BP-61700.$may.
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❑ Approval in Part (Per 780 CMR. 5111.13) R 71 N - D
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1. Date plan reviewed:
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S25. 0 A-PPLICATIOD-1 IEEE IS NOP-a' _ � Yt�' 1 'TTA!�S. EP.t
DATE RECEIVED
D,�RTMOUTH eUIL�°�� i7����Ti�'����
cl :. �`ml��' 10 AIN p^ '12
400 Slocum Road, P.O. Box 79399
x_ Dartmouth, MA 02747
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Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma. us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TVVO FAMILY DvVELLING
f02 � T 1S SEC110iv FOf2 OrF1CIAI, E15c OILY,
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x IIDPW Q1ec L7Eergy e ort:
QSoardof�� ,O Sar�ct af, ,, II Cons L7 L7emo
Appeals Health 4Gomm�ssion �{ Afidartard Sens Cu Dff Foil tiu up
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r\` ❑Fire; f !]Gas '�Q;;Pfannr�'g � Sewe' Gail � �D�VVate Gard � �"�E��Zng � � '®�Other,� ���,'
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IEQtJLFiES..IISPEGTOR. l�(il BEFO.i THE U E
TOTALFEE:
F E.
Gross Area New
_Construction s . ft.
_,. >
_ ...,..
Gross Area - Alteration total sq. ft.
Permit Issued to S ro
Zoning Review: Siggnature:
Date: NOV 1 0. 010
Energy Report: Signature:
Date:
Fire Chief: Signature:
Date:
.:-a�w.-.. .:a.- �, .,.. � . . , . ..:...._... , .:,
., _,-.. - _ �cGTiC#t�I
.... _.. � ..,=ems ................
Board of Health:. Signature:
'. i
Date:
Conservation Commission; Signature:
Dater
-
Other: Signature:
Date:
Brief description of work being performed.
PORT
CONSTRUCTION I PLAN SITE E PLAN ENERGY EA
�7 3 Page4
Page 1
r.
2.1 Owner Record
Name (print)
Contact Address
Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address
Phone Number
�
3.1 Licensed Construction Supervisor/Specialty License :
License
Z 1_
l
Company Name/Contractor Name:41
--Number.-
Address: + ,.
Expire
ion Date:
Signature: Telephone: -;k
a ,
3.2 Registered Home Improvement Contractor:
NotA
plicable ❑
r
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? $'Yes ❑ No
Are you claming exemption from the requirements? ❑ Yes O No
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration
Number (if none, state
Address: `.
Signature: �, Telephone: ' �,1--2_r -9 2
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.
_...,
r Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston,
MA 02108, 617-727-8598
❑ i am a Homeowner performing all the work myself..
Owners Name (print):
Signature:
B signing the above, the homeowner that there will be no to
Y 9 9
he uar G an Fu d .... -•
h' ,
Date:
3.4 Homeowner Exemption - One & Two Family Only
-
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR
OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 1
16.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition
involving the structural elements of building
o structures unless e o she is licensed in accordance with the rules and regulationspromulgated e e
r unl h r h rb the BBRS entitled Rulesand
9 Y
_ -a
Regulations s�o Licensing � u b
g n for Li n ing Constr cfi i '
Supervisors.
• .
Exce tion: An Homeowner performing work forwhich a Building Permit is required shall be exempt from the provisions of this
P Y _P 9 9 q p P
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: Persons who owns a parcel of land onwhich he/she
p p y, O pre
s' '
ides 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 Ilability
�� 1�,..4 OR�cR,.S. QfIr El S i:.ICP t S 1PAt AF
r provide this
Worker's Compensation insurance Affidavit must be completed and submitted with, this application. Failure fo
P PP
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: VYes ❑ No
011�-
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. VRoofing/Siding ❑ Other
(Energy
e t9' report required) (Shed/Gera e
) (Specifybelow)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
*If new construction, please complete the following:
Single Family: No. of Bedroom 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):
0 HVAC (combined unit) -primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
El None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed:wor1k: Gam( '
s.: c 3 �+ e.
L �t�i�t� ,ta. St l� � ':�..� ;' L:a � ti�fQ
>, S � 3E T A� E . STR.�
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2.Electrical
3. Plumbing _
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
a
'JT
rvheE�: C,oTwIOner.,: s=_<a Qe rt t -c.E
Mf•.- Rc oAn. lOrti.x..O
....
_
�bcjEdtn etl._, .,.
_.._ (Please Print) 1
I, P" Fr ( ' k 6ti Ihnej Owner of the subject property hereby authorize Azez,a-r , X, n�..ag� �✓
to t on my behalf, in all matters relative to work authorized by this building permit application.
Ile
Signature of Owner Date `
IXGEt�fi=C3ECT_ARA1'EL�I�
I,'0a. as Owner/Authorized Agent hereby declare that the statements and information
a
on the foregoing application are true 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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