BP-62937..' sECTiO[ls';.ilsr�1=TCR`RE1IEVLCOPJiMENTs
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1. Date plan reviewed: APR 9 9A
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Vote Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
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Pace 4
REST DES I Al ❑ Approval in Part (Per 780 CMR.5111.13) ,_„
t DATE -RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 A ' 12 V11, 12: tl3
z Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
-
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: A X �'��.Gh Date: APR 21
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date: ,
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: 0>�vu,� t VI (,P ( /o.►:e "J'(A> �Y "7.,' hmr/(
1.1 Property Address: 6,1 5 0�� 1.2 Assessors Map of Number -
Lot Area (sf.) Frontage Map a_ Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
.1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal rivate Well ❑ Municipal On Site Disposal System ❑ Yes ❑ No Date:
® CONSTRUCTION PLANS ❑ SITE PLAN ® ENERGY REPORT
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SEGTIflN 2!E=<'OwNERSHIP1AUTHORIZED
AGENT;
.PRfl?Ri
2.1 Owner Record:
.-� 5
Name�pnnt) f
Contact Address Phone Number
6k—Z —
2.2 Author' ed Agent:
Name (print)
Co tact Address Phone Number
,,SECTION3=sCOhdSTRUGTION;SERiIICES
3.1 Licensed Construction Supervisor/Specialty License :`
License Number:
Company Name/Contractor Name:' it
L
Address: r
Expiration Date:
a
Signature: ---Z Telephone: C3 —
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3.2 *Registered Home Improvement Contractor. t
Not Applicable ❑t
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"):
(�
Address: 6(�
Signature:1,4 �Telephone: - (i
Expiration Dater — --
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ l am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individus
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Constructioi
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowne
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on whic
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more tha
one home in a two-year period shall not be considered a Homeowner
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached:' es ❑ No
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace
❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding
❑ Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ Addition ❑ Replacement window/door
❑ Demolition
(Energy report required) No. of windows Doors
(Specify below)
*If new constrt,iction, please complete the following: •
Single Family: No. -of Bedrooms ''_ . Nd. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 -
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit) A
❑ None of the above to be provided '
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
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SECTI011 & =: ESTIMATED CONSTRUCTION COST . Z,;„, ,,, .. .. .,
Item
Estimated,Cost ($) to..be�completi?d by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
(Please Print)
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
/) n 1Jsi�'aC _ / .
Signature of
Date
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are tr and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
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