BP-59634SECTION 12 - ESTIMATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1, Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Off -Street Parking
6. Total = (1 + 2 + 3 + 4 + 5) Estimated Total Cost Including Labor: $
SECTION 13A - OWNER AUTHORIZATION {"
(to'be completed when owner`s agent or contractor applies for building p'ernut)
Plea rint)
4to
as Owner of the subject property hereby authorize -Ilfl,* Gat'ji �e°'
a t gA my be If, i II ma ers relative to work authorized by this building permit application. I
Signature o c0 er Date
SECTION 13B - OWNER/AUTHORIZED AGENT DECLARATION
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.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
SECTION 14 - INSPECTOR'S REVIEW/COMMENTS
1. Date Plan Review:
2. 30 Days to Review Period Expires:
3. OK to Issue Date:
4. Per 780 CMR 111.1 Rejection Letter Sent:
5. HOLD - Reason: Date:
6. HOLD - Subject to Zoning Board of Appeals Action:
7. Comments:
8. Inspector's Signature Date: APR 1 2 2010
ACTION 1 APPLICANT NOTIFICATION
Applicant informed of o Dat Time:
Comments:
SECTION 1-OFFIC'EIINSPECTO 'S NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE:/�" ` Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. /a -VC,
Permit Issued to:44�„���
CONIDIERCIAL
$25.00 APPLICATION FEE IS NON BE-FQN"ABLE A NON- 1{t(S'"kAB_.
DATE•REG-EIVED
-'o„TN. DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
T;
Phone: 508-910-1820 Fax: 508-910-1838
•..,,h_ 64_��
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING(including 3 or more family dwellings)
DEPARTMENTAL APPROVAL
APR 7- 2010
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chief.
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed: Gc%,
"a6t , Zr.14f6,dla4�
1.1 NU ER OF PLANS SUBMITTED: 1.2 SITE PLAN SUBMITTED: ❑ Yes ❑ No
1 Property Address: //OD /€' u� �f ��t�r r j�f {� 1.4 Assessors Map & Lot Number: 7�
Map _ .Lot
Nearest Cross Street: wcct'�A %zi%
-' � 1.5 Water Supply (MGL c40 s54):
Business Name: ro oez�/ - ��ja5l"z C,;/ .2 ❑ Municipal ❑ Private Well
Business Phone #: a ,3 G .2 yY/
1.6 Sewage Disposal System:
Total Land Area Sq. Feet: ❑ Municipal ❑ On Site Disposal System
.1 Owner Record:
f: /-Z!O-U7 f'r2et Ors 2 f c 7' � I . all
Name,t"nrint) Contact Address Phone Number
�2.2 A�ized Agent:
Name (print) I Contact Address Phone Number
Page 4 Page 1 Revised 9/09
SECTION 3 ,- CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: �'J v-e— v►' 4
License Number:
Address: � , f'e_ 1--r.40-i- - ,ff4O}
Expiration Date:
�����6
Signature: Telephone:
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(MGL c 152 §,25)
Worker's 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 (MGL 152 Section 25A).
Signed Affidavit Attached: 'IFes ❑ No
SECTION 5 - DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑ New Construction ❑ Addition ❑ Repairs ❑ Accessory Building (Shed/Garage/Other)
❑ Other (Specify Sec. 6) ❑ Demolition ❑ Sign ❑ Replacement window/door
No. of Windows Doors
❑ Fire Protection
SECTION 6 - PROPOSED PROJECT USE -'INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
The following descriptions are based on the Massachusetts State Building 7th Edition, Code Article 3, as noted. See the Code.
❑ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0)
Describe:
❑ Business - office, assembly with less then 50 occupants - indicate Medical or other professional (see Code Section 304.00)
❑ Education - struction for training including child day care for those over 2 year 9 months (see Code Section 305.0)
❑ Factory/Industrial (see Code Section 306.0)
❑ High Hazard (see Code Section 307.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 308.0)
❑ Mercantile - retail stores (see Code Section 309.0)
❑ Residential - three or more family, hotel (see Code Section 310.0)
❑ Storage - including garage (see Code 311.0)
❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
❑ New Tenant - for any of the above, please indicate (see Code Section 110.0)
❑ Tent or Trailer - temporary
Purpose?
❑ Other:
Describe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
condition (if extra space is needed, attach an additional sheet):
SECTION 7 - TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
❑ New construction and/or Additional (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ Yes ❑ No
If Yes, see, Code Section 116.0 Designer to submit Code Synopsis in additional to original plans and if existing building Section 3402.1.1
Will this project require Peer Review (over 400,000 cu ft.) ❑ Yes ❑ No (see 110.11.1 Code)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR.
❑ Demolition* - describe structure:
❑ Trench Permit Required? ❑ Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq.
❑ Moving* - (provide copy of DPW moving license)
*Type of structure: from where (map/lot or address):
to where (map/lot or address): number of dwelling units:
number of bedrooms per dwelling unit:
❑ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged)
EGRESS dimensions must be maintained.
❑ Temporary structure and uses - includes, when allowed, new tenants, trailers, tents and the like and only for limited periods of time.
Describe:
SECTION 8-MECHANICAL&;PRIMARY FUEL
❑ 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) Roof Top Unit (RTU) New ❑ Replacement ❑
❑ None of the above to be provided Mechanical Ventilation ❑
❑ Hot Water: Gas Electric Fuel Oil Other
SECTION 9 -SPRINKLERS AND/OR' FIRE :PROTECTION •3 COPIES OF. PLANS AND NARRATIVE REQUIRED
❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why? Narrative Submitted? ❑ Yes ❑ No
SECTION 10 -;REQUIRED OFF-STREET PARKING (for and Architectural Access
( 9 )
❑ Parking plan submitted to: Building Dept. Planning Board Date submitted
Number of spaces indoors outside Total provided
Handicap spaces - required Yes No if Yes, how many as a part of the total required 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.
SECTION 11 - IDENTIFICATION <.
11.1 Architect/Engineer -for overall design
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans. affidavits & other documents SHALL BE originals and not reproductions.
11.2 Architect/Engineer - project supervision and reports
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
11.3 General Contractor
Company Name:
Address:
Phone #:
Construction Supervisors License Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
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