BP-9876$00 A4ECHANICAIS & PRIMARy FUEL
Furnace (hot air) - Fuel gas (natural or propane), fuel oil, electricity,other s (pacify)
Boiler (heating)- Fuel gas (natural or propane), fuel oil, electricity, other (specify)
HVAC (combined unit) - Primary fuel, natural gas, propane, electricity, other (specify)
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 PA ICING - for ZONING & Architectural Access
NOT APPLICABLE
- Parking Plan submitted To = Building Department L Planning Board Date submitted'
Number of spaces - indoors outside total provided
Handicap spaces - required _ yes _no. If yes, how many as a p1rt of the total requited number.
Is Route 6 (State Road) Entrance permit required? yes no If yes has it been issued yes = no
Submit copy of application and/or permit as soon as available.
1100 IDENTIFICATION (print or type except as noted)
Current owner - name w i
address
phone # (D
If corporation. officer in charge
ArchitecVFAm#neer 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.
Archifi3t1E1k9meer - project supervision and reports
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.
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Company name 410 Lyn e (p R E'
Address
Phone number
Construction Supervisors lice
nse nu
mber
mbar
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals 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
If no go to next section!
Are you claiming exemption from the requirement? Yes _No Zifyes, submit the required affidavit!
Ren_ ,)del contractor name' (please print)
Address
Registration number (it 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) 727-8598 L
Owners name (print)
Signature
Date %'
1300 OWNER SIGN - OFF
I. the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -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
six months after the last inspection if work has begun and that the permit may be extended for six months if no work is
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
/f Zoning).
Name /,?
Signature
The abo ture is my voluntary hcta=nd�
is signed under the pains and penalties of perjury.
Date
Who is authorized to pickup the permit at the Building Department? (vlesse prinn A / �
Address Phone 7-
1400 HOMEOWNER EIMAPTION - 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 by Construction Control
in Section 127.0, effective July 1, 1982, no individual shall be 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 enti!'ed
Rules and Regulations for Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall he 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 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
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signs a carries certain responsibilities, in ding but not necessarily limited to, general liability
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NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations 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
Items to be installed but not included in the above cost: Electrical 5
Plumbing
HVAC
Other
TOTAL
- Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
Demolition - describe structure
Ga
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration req uired
= Movin„ - (Provide copy of D.P.W. moving license) Type of structure
from where (plat/lot or address)
to where (plat/lot or address)
Number of dwelling units Number a" y oms V.,r dweiling unit .
Re -roofing - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
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 f,._ 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
❑ of required, why?
reviously date `'With this application
Submitted When. ._ P _ :
700 UTILITIES
- no public ? es no, on site well' Zyes no,
Water snppky required _yes _ , p Y
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 eyes no. Submit copy of permit as soon as available.
= Woodstove - used will require ins
( eq inspection prior to installation), new (provide manufacturers
The following section for official use only.
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instructions). Location(s) (list)..
INSPECTORS' REVIEW _
= Fireplace(s) - (includes flue) List location(s)
Date plan reviewed
Game Court - describe (include overall dimensions) _
days to review period expires
30 -�.
_ Tent, Trailer (Mobile Home) or Other - describe
OK to'issue date
300 COMI ERCIAL'- PROPOSED PROJECTIUSE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
OK to issue subject to requested submittals (see project review worksheet) date
THIS SECTION NOT APPLICABLE
= DENIED see project review worksheet date
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
HOLD reason date
Code)
= HOLD Subject to Zoning Board of Appeals action
_ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Comments
-office,
Business assembly with less than 50 occupants -indicate MedicaI or other professional (see Code
Inspectors signature ®' Date
Section 303.0)
= Applicant informed of above - Date time staff (fax, phone, in person)
_ Educational -structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
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Over six months since approved for issue - DEEMED abandoned!
Factory ,' Industrial - (see Code Section 305.0)
Advise applicant. Hold 90 days for return then dispose if not picked up.
= High Hazard - (see Code Section 306.0)
Inspector Date
- Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Advised applicant Date Time staff (by phone, fax or in person)
_ Mercantile - retail stores (see Code 308.0)
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=Residential -three or more family, hotel (see Code Section 309.0)
OFFICEUNSPECTORS NOTES
Storage
- includes garages (see Code Section 309.0)
TOTAL FEE
= Utility & Miscellaneous Structures - includes tents andagricultural structures (see Code Section 311.0)
Gross area - new construction Total Sq. Ft.
New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 3S'
i
alteration Total Sq. FL
Tent or Trailer - temporary purpose?
Permit is issued to
— Other
Describe the proposal briefly, INCLUDE -amber of dwelling units and bedrooms or occupant bad as applxabl�
Comments/notes on permit
also existing condition
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400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
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_ New Constriction 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
alteration) s).
If project is an addition to existing structure - Total gross square feet of existing
- FOR COMMERCIAL 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 Pees- review lover 400.000 cu.ft.) Yes No (see Code Appendix I)
-APPLICANT TO PROVIDE
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1600 TO THE APPLICANT/REFERRAL AND APPROVAL
Date of Application submission rl len
Plat 26n_ Lot Lb4 Street r
Aquife�Zone
Owner
Owner mail address
Owner phone #
OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REOi`MED SUBMISSIONS.
s TAX COLLECTOR Z Approved HOLD By Date
❑ Board of Appeals Approved By Date
❑ Conservation Commission Approved By Date
❑` D.P.W. Water = Approved By 13 D.P.W. Sewer - App ved By Date
❑ D.P.W. Cross Connection Approved By Date
❑ Treasurer (Bond) ❑ Approved By Date
❑ D.P.W. Engineering Approved By Date
-1 Board of Health (well) _ Approved By Date
❑ Board of Health (septic) Z Approved By Date
❑ Board of Health' (food service) — Approved By Date
❑ Planning Board (parking) Approved By Date
s FIRE DISTRICT (I - II - III) Approved By Date
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BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTOR/BUILDING CO1i1`IISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUM114ARY:
new constructions alters ' ]demo sewage disposal public/private
[Alter add interior walls] [add rooms] [add footprint] water suppiv publiciprivate well
[pool] [garage/shed/deck] [game court] [food service]
Describe t. �X �}
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 Buiidinz Department- Date sent for review Bv
TOWN OF DARTMOUTABUI1XV4G::-DEP RTMENT
TELEPHONE 508-999-0720 SAX: 508-999-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Iasnvdiom
The applicant shall complete this application to the best of their ability prior to submission, leaving. no item ®answered. 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. I!I<s6es6 fee in not'-'ar
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT LOT ZONING DISTRICT
OTHER ZONING OVERLAY DISTRICTS , if applicable
NUMBER & STREET
NEAREST CROSS STREET
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SUBDIVISION NAME & LOT #
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3
or BUSINESS NAME
PREVIOUS TENANT /OWNER/e d
200 RESIDENTIAL - PROPOSED PROJECT one & two familyresidence 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. ft.
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