BP-510000 SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON IIE-FUNDABLE &i NON-THANSFEIBAIBLE
o� H DATE RECEIVED
�M DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road P O Box 79399
'•o
-Z Dartmouth, MA 02747
`°�•. ,hb, Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH ALONE OR TWO FAMILY DWELLING
Zoning Review: Signature: `�/L `t-� "Gt Date:
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:
1.2 Assessors Map & Lot Number:
Map o.2 Lot 0-
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site Disposal System
1-1 CONSTRUCTION PLANS ❑SITE PLAN El ENERGY REPORT.
RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructior
SECTION 2 = PROPERTY OWNERSHIP/AUTHORIZED
AGENT
.1 Owner Record:
97 ' �5b
Contact Address Phone Number
Name (print)
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
= .SECTION 3 -,CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address:
Expiration Date:
J Signature: Telephone:
i
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
1 Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration Date:
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
❑ 1 am a Homeowner performing all the work myself.
Name'nt):i/ivbre:
Vatus .
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
f FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
/all
e engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
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 Construction
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 Homeowner
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 which
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 than
one home in a two-year period shall not be considered a Homeowner.
If you are appl under this section b o
Signature:
Your signature carries certain responsibilities, including but not necessarily I
invited to, general liability
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
"::SECTION 4 -.WORKER'S COMPENSATION' INSURANCE AFFIDAVIT (MGL c 152's§ 25)
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: ❑ Yes ❑ No
-- v^ ^-- JLV t I%J11 J - LJGa7VRlr I1%all Vs- _rRVCVJ GU YYVRR �VtlCf.cIS: �111 .[I
❑ Deck 0Pool ❑ Repairs ❑.Alteration : ❑ Chimney/Firepla
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding
(Energy report required) (Shed/Garag
❑ Addition ❑ Replacement wr d w/door
(Energy report required) No. of windows/l1 Door
CC %�
*If new construction, please complete the following: —�
Single Family: No. of Bedrooms No. 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)
❑ None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
Description of proposed ork:
A
Chimney/Fireplace
Estimated Cost M to be
❑ Woodstove/Pellet Stove
❑ Other
(Specify below)
❑ Demolition
(Specify below)
(Please Print)
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.
Signature of Owner/Authorized Agent
Date
it applicant