BP-56283RESIDENTIAL
JtG f IUN 2 - PROPERTY'OWNERSHIP/AUTHORIZED'
AGENT
r2.�1Owner Reco ;-
n
Name (prints
Contact Address Phone Number
2.2 Authorized A ent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor: ' 1�0$er'°T- r ,44 e-s-
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address: 5 3(a '�� �1✓%►/`� ��
Expiration Date:
`' s— (�
Signature: P Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)?;lb Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ,j:(No
If Yes, submit the required affidavit!
Company Name:�lr'rl. �� 0, M
Registration Number (if none, state "none"):
Address:Ct i �r '► h�
Signature: Telephone: fs
Expiration Date: --Q
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:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
v ❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
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 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: 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 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 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 liability
� - , re— 5 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.
Signed under the pains and penalties of perjury.
Sig ture of Owner/Authoci ed Agent Date
SECTION 8 -INSPECTOR'S REVIEWICOMMENTS
RESIDENTIAL ❑ Approval In Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON RE-�LNDABLE
1T ,ry��WrEIVED
Jv!14 Hi
DARTMOUTH BUILDING DEPARTMENT s e
400 Slocum Road, P.O. Box 793994 ` ;? —2 AM 9- i
cz. Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
~-- www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
/-?z5 Signature:
Zoning Review:
Energy Report: Signature:
Fire Chief- Signature:
Board of Health: Signature:
Conservation Commission: Signature:
Other: Signature:
Brief description of work being performed:
Date:
Date:
Date
Date:
Iv
Date:
� Date:
SECTION 1 - 511 t rrvrvrcmK i w�.
1.1 Property Address: I / '7 1.2 Assessors Map &Lot, Number.
Map L
Lot Area (sf.) Frontage
Required Provided
1.3 Historical District Yes ❑ No
i
Front Yard
Has application been submitted to the Historic Commission?
Side Yard Yes ❑ No Date:
Rear Yard
1.5 Sewage Disposal System:,
1.4 Water Supply (MGL c40 s54):
unicipal ❑Private Well
PM
❑Municipal /� On Site Disposal System
V\
0 CONSTRUCTION
PLANS 0 SITE PLAN ❑ ENERGY REPORT