BP-2004-24329RESIDENTIAL
2004
2.1 Owner of Record: yq A1,qt-/)
Name (print) Contact Address
Phone Number
2.2 Authorized Agent:
Name (pri7777,76 —nt) Contact Address
N eW GFbFD� Phone Number
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 Expiration Date
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY F
QUETIONS OR COMPLAINTS call or write: UND:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - p 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 I I6.0, effective July 1,1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition invo
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 lving the structural elements of
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 follow
s: 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 dwellin 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 shal not be considered a Homeowner.
If you are applying unis sect i%srgn
Your L---� n
C:\bldg.forms\Bldgapp.res.wpd
responsibilities, includi but not necessarily limited to, general liability
Page 2 Rev. January 1, 2003
RESIDENTIAL 2004
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that Construction
Con any licensed Constr Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR tr
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
0 "-17-
❑ new construction* ❑ addition ❑ alteration ❑ repairs
(energy report required) (energy report required)
❑ chimney/ ❑ woodstove
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):
11 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: / iY fat
• a
l- ` d
Item Estimated Cost ($) to be completed b p y permit applicant
1 Rnilrlino 00
Rlrntrical .►►—�
I Phtmhino
4 Me.rhanirnl (14VAC') ------
5 Total (1 + 2 + 3 + 4) * Estimated Total $
' � a
(please riot)
I' �'(Z L as Owner of the subject property hereby authorize
to act on ehalf a ters relative to ork authorized by this building permit applicati
Signature o wrier Date
n ��
a
a _
yam $ � � a
a� .xa. . es,R
I' as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si under the pains and penalties of perjury.
S gn�ature of O ner/A orized Agent
Date
C:\bldg.forms\Bldgapp.res.wpd
Page 3
RESIDENTIAL 2004
❑ FOUNDATION ONLY
-',. $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
RESIDENTIAL 11� �Q _ 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NOX-REFU DA L NO -'P SF ... LE
1. Date plan reviewed: Cep
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 Zoning Board of Appeals action: Date:
t
8. Comments: ";
9. ' Inspector's Signature: Date:
,p
Applicant inform d b ve t Tim Cle
Comments: �t
.g• ,., :..„u
, ,
Total Permit Fee. $ �Z
Less Application Fee. $ 25:00 _Remaining Balance. $
TOTAL FEE: Gross Are - n
�� a New total sq. ft.
Gross Area - Alteration total sq. ft.�---
Permit Issued To:Zz
N.
3
fige�° ro •,y''
RECEIVED
E
DARTMOUTH BUILDING DEPARTMENT
_.. DATE
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, IR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Zoning Review: Signature: Date:
Energy Report: Signature: Date: s_
Fire Chief- Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
.P :. �m�I
„ '
OF PLANS SUBMITTED:
1'E PLAN SUBMITTED: ❑ yes ❑ no
!NUMBER
(, of A%dltil AD %� (�, "
1.1 Property Address.�
1.2 Assessors Plat & of Number:
3�j
Plat Lot
Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no.
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal Syst
❑ Muni j,
'cipal
❑Plivate Well
n - ❑ On Site Disposal System
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