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1600 TO THE APPLICANI'1REFERRAI, AND APPROVAL
Date of Application submission
Plat Lot t Street
u a, Aquifer Zone
Owner
Owner mail address
Owner phone #
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REQUrM b'>QBMLSSIONS.
in TAX COLLECTOR = Approved — HOLD By I
Date
❑ Board of Appeals = Approved By I
Date
❑ Conservation Commission C' Approved By I
Date
❑ D.P.W. Water _ Approved By_ ❑ D.P.W. Sewer _ Approved BY--L
Date
❑ D.P.W. Cross Connection a Approved By I
Date
❑ Treasurer (Bond) ❑ Approved By
Date
❑ .P.W. Engine-� .ing = Approved By - I
Date
i
Hoard of Health (well) Z Approved By 2%,41,t, 6 I- j (
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_
Date
—�
❑ Board of Health (septic) 7 Approved By
Date
❑ Board of Health (food service) = Approved By (
Date
❑ Planning Board (parking) Approved By (
Date
s FIRE DISTRICT (1 - II - IITj — Approved By I
Date
BUILDING DEPAR'IWENT APPROVAL:
❑ ZONINIG
❑ BUILDING INSPECTOR/BUILDING COMMISSIONER
Cl CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construction/ alteratia /demo sewage disposal -public/private
[Alter,add interior walls] [add rooms] [add footprint] water supply - public/private well
[pool] [garage/shed/deck] [game court] [food service]
G�-4Describe f
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department - Date sent for review _ By
TOWN. OF DARTMOUTH BUILD NG DEPARI EN
TELEPHONE 508-999-0720 FAX: 548-999-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Instroctiom •
The applicant shall complete this application to the best of their ability prior to submission. leaving no item anon: veered. The
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted for those sections
which do not apply. A properly completed application will help avoid unnecessary delays. Ne1s- lit, fee ii..trefim&H -
(far otToe am only)
N ONLY
Total Cost � � Received By Date Reed
Less Application Fees
Total Permit Fee t_ Permit #< Issued D2te-9LZL
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT LOT �_ ZONING DISTRICT°
OTHER ZONn,'G ')VEkLAY DISTRICTS , if
applicable ,p
NUMBER & STREET l t�. { �, y w�--�� � Ag
NEAREST CROSS STREETS
SUBDIVISION NAME & LOT # - —
or BUSINESS NAME
PREVIOUS TENANT /OWNER �1�
200 RESIDEN,11AL - PROPOSED PROJECT - one & two family'residence only
= THIS SECTION NOT APPLICABLE
= Single family number bedrooms number baths
= Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. M
= Accessory structure:
-- Garage - detached - attached to dwelling, dimensions L W
= Carport - detached - attached to dwelling, dimensions L W
Shed -dimensions L W
= Deck - dimensions L W
= Gazebo - dimensions L W
— Swimming pool, above ground in -ground Size
= Chimney - number of flues —
= Woodstove - used (will require inspection prior to installation), new (p vide manufacturers
instructions). Location(s) (list)
= Fireplace(s) - (includes flue) List location(s)
= Game Court - describe (include overall dimensions)
Tent, Trailer (Mobile Home) or Other - describe
300'C011QMi MCIAL - PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MOkE AND EXEMPT USES
THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
= Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Des ribe
= Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Section 303.0)
= Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
= Factory 1 Industrial - (see Code Section 305.0)
— High Hazard - (see Code Section 306.0)
— Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
= Mercantile - retail stores (see Code 308.0)
— Residential - three or more family, hotel (see Code Section 309.0)
= Storage - includes garages (see Code Section 309.0)
= Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
= New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
Tent or Trailer - temporary purpose?
= Other
Describe the proposal briefly, INCLUDE -amber of dwelling units and bedrooms or i pant load as applieble,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED '
= New Construction and/or Addition - total gross square feet
(For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition to any
alterationis).
If project is an addition to existing structure - Total gross square feet of existing
FOR COIIUMIERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes No. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400.000 cu.ft.) Yes N (see Code Appendix I)
APPLICANT TO PROVIDE
The following section for official use only.
INSPECTORS, REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
OK to issue subject to requested submittals (see project review worksheet) date
DENIED see project r_=view worksheet date
HOLD reason
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature
date
Date q--v - 9 F'
f
Applicant informed of above - Date time staff (fax, phone, in person)
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Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Date
Inspector
Advised applicant Date Time staff (by phone, fax or in person)
OFFICE\INSPECTORS NOTES
1 c:7
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
Comments/notes on permit
1300 OWNER SIGN - OFF -
- lion of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
I. the undersigned, am the owner of record or authorized lessee (provide documentati n) and I have reviewed
— Demolition - describe structure 4e Q
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this Number of dwelling units Number of bedrooms A separate Refuse Disposal
application is time -and correct and that the permit requested. be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or motion required'
six months after the last inspection if work has begun and that the permit may be extended for six months if no work is � Moving - (Provide copy of D.P.W. moving license) Type of structure
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
from where (plat/lot or address)
Name
to where (plat/lot or address)
Signature 1�1 Number of dwelling units Number of bedrooms per dwelling unit
The above signature is my voluntary act and is signed under the pains and nalties of perjury. -,• '
Date -)A I lPAs<� �1-i /�" — Re -roofing - (for existing only, is included in new construction)
Who is authorized to pickup the permit at the Building Department? (please print)
Address Phone
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR HOME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures governed J Construction Control
in Section 127.0, effective July 1, 1982, no individual shall he 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 Constmetion Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is requirej shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Home Owner" is defined as follows: Person(s) who owns a parcel of land
on which heishe resides or intends to reside, on which there is, or is intended to be, a one or two far ilv dwelling, attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner. I
If you are applying under this section sign below: ���
. 11 P ...
Signature �
(
Your signature carries certain responfibilities, including but not necessarily limited to, general liability
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NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regui'ations section that any
licensed Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see
2.15.2 of section 5)
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1500 COST
Cost of Improvement g ��p►'P'�
Items to be installed but not included in the above cost: Electrical 5
Plumbing
HVAC
Other
TOTAL $
Number of square feet
Number of layers when complete
A separate disposal declaration REQUIRED
Number of layers already existing
— Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling, will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for
residential and Articl- 8 ft.: commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
= None submitted. Why?
= Submitted. usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
0 Not required, why?
- Submitted When? = Previously, date ^ With this application
J 700 UTEL rTEES
Water supply - required _ yes A-S"O, public ? _ yes _ no, on site well? _ yes _ no,
existing? _ yes _ no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes _ no, public sewer _ yes _ no
private septic - on -site _ yes _ no. Submit copy of permit as soon as available.
800 bEECHAANICALS do PRIMARY FUEL,
Archift cUEngmeer - project supervision and reports
= 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)
--L—
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
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, --plans provided, plans not provided, why?
Not required, not to be installed, Why?
1000.REQUIRED OFF-STREET PARE3NG - for ZONING & Architectural Access
= NOT APPLICABLE
= Parking Plan submitted To = Building Department Zi Planning Board Date submitted
Number of spaces - indoors outside total provided
H-ndicap spaces - required _ yes _no. If yes, how many as a p-irt of the total required number.
Is Route 6 (State Road) Entrance permit required? yes Y no If yes has it been issued yes = no �.
Submit copy of application and/or permit as soon as available.
1 00 IDENTIFICATION (print or type except as noted)
Current owner -name
address L� ��- IA 5Efj` Adf )C
phone # G (3 (o — 62 3 R
If corporation, officer in charge
Architect/Engineer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as "
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions. - 4
M
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Company name " t,,. 4 z
Address A -If V ig t'lI ei i0.
Phone number 9q7 - ell
Construction Supervisors license number 6- -z 1 6CQ 4
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE e.iginals and not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes No _ IY no go to next section!
Are you claiming exemption from the requirement? Yes No _If yes, submit the required affidavit!
Remodel contractor name (please print)
Address
Registration number (if none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration
One Ashburton Place - Room 1301
Boston, MA 02108
(617) 727-9598
Owners name (print)
Signature
Date