BP-2004-35795RES-ENTIAL
l 2004 RESIDENTIAL 2004
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2.1 Owner of Record:
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Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
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3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number {if none, state ❑ none❑)
Address
Signature Telephone
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Expiration Date
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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
wnersName (print) -ek f`
Signature
b signing the above e ome owner acknowledges that there will be no li ibilt to the Guaranty Fund
Y g g g g Y Y
Date
1
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS 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 116.0, 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 entitled Rules and Regulations for Licensing
Construction Supervisors.
Exception: An Homeowner performing
onnm work for which a Building Permit is required shall be exempt from the provisions of this sect: P Y P � g 9 P P on, 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: Persons) 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 applying unde is s cfion sign below:
Signature:
Your signature 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 Appendix of 780 CMR R5.2.15)
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Workers 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
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::i.:. �,ae,° i;u�u�lai&assaL,e�PaP@IPI�`,.wt,�
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑pool ❑accessory Bldg. ❑replacement window/door ❑other ❑demolition
(shed/garage) no. of windows_ doors_ (specify below): (specify below):
* 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 (specify):
❑ Air conditioning (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: -r
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�.Th ,0 1WN& ,rw e c@rP' Item Estimated Cost ($) to be completed by permit applicant
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�. RlP.ctrinal
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d Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) * Estimated Total $ �pnr, cry
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(please print)
I, 14A,, as Owner of the subject property hereby authorize
to act on y h n all matters relative to work authorized by this building permit application.
Signatu e of ner Date
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I, �&' as Owner/Authorized Agent hereby declare that the statements and information
on foregoing application are true and accurate, to the best of my knowledge and belief.
Si d under the pains and penalties of perjury.
Signat re of Owner/Authorized Agent Date
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RESIDENTIAL--
2004 RE
AL - 2004
❑ FOUNDATION ONLY ❑ FOUNDATION ONLY
$25oo APaaacATao FEE as NON-REFUNDABLE NON -TRANSFERABLE A� a.acA oN FED asoN -REFurqonLvoimil°k'm sa'rRAAzar€
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1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to ZoningBoard of Appeals action:
PP Date:
8. Comments:
9. Inspector's Signature: Date:
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licant inform pp b e�rDat . Time • Clerk-
Comments:
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Total Permit Fee: $ ess A lication F e• � Re pp maining Balance: $
TOTAL FEE
: Gross Area -New Construction total sq. ft.
Gross Area Alteration total sq. ft.
Permit Issued To: e1P_00
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DA MOUTHBUILDING DEPARTMENT
DATE RE EIVI✓L
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400 Slocum Road P.O. Box 79399.26
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Dartmouth, MA 02747
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508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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S iE,.d,.P SCte i, Pea ,'RJ" 7J[i m,i i$rx gxeiEilro'�m� d �� " m Deus .,lm'ai
Zoning Review: Signature: Date:
Energy Report: Signature: Date: z
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signatur . Date:
Other: Sign/are: re: Date:
Description of work being performe[� N jm
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W.. l.�m ties MA,
NU I R OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: �s ❑ no
1.1 Property Address: % Z j 2ss e(b Ml js Pot
1.2 Assessor 1 t & Lot Number:
Plat 2- IF- Lot -
Nearest Cross Street: 9!$
1.3 Historical District Eg-pes ❑ no
Subdivision Name:
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
❑ yes �rl� Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal T'Private Well
❑ Municipal W<n Site Disposal System
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