BP-2002-22724UqV" I.1H—N' F 1 A 1
20U1 RESIDENTIAL
2001
SECTION 2- PROPERTY OWNERSHIP AUTHORIZED A ENT
O&-
2.1 Owner of Record:
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-It V 7 R6ss4L^16(s -12a 0/0ff
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
j-7i"--
Name (print)
Contact Address Phone Number
U ECTi N 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: ` j ` "12 C
Not Applicable ❑
Licensed Construction Supervisor
License Number 0V, 03
Address _X��L-( aa3
Expiration Date
0�
Signature
Telephone
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3.2 Registered H me Improvement Contractor:
Not Applicable O
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 `Kno
If yes, submit the
required affidavit!
Company Name { P C
Registration Number (if none, state "none")
`0 k, y
Address 0 ,,- ltJIvl ae- C?j3ll
Signature Telephone 50�-�J �`%��
Expiration Date
3.3 For Reside ial 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
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 - 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: 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
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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)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c_ 152 §.2-
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 ,
SECTION 5 -DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition t alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) 1&,mo4�t 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 l
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:��
SECTION - 6 ESTIMATED CONSTRUCTION COSTS` Qt?!�
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildiniz
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit);
(please rint)
c property hereby authorize 1411d%1) IJt'It
I, a , as Owner of the subject p p rty y
to act on m beh, half i all matters relative to work authorized by this building permit'applicatiQn.
- 2—
Signature of Owner Date
SECTION 7B -OWNER/AUTHORIZED AGENT DE L RATI
I i Ltd /vv t , as Owner/Authorized Agent hereby declare that the statements and information
� 1
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
144
Signature owner/Authorized Agent Date
Rev. January 19, 2001
„..may,-_ . _� �_ -- ❑ FO UNDA TION ONL Y
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: r/
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:
S. Comments:
9. Inspector's Signature:
Date:
SECTION 9 - A PLICANT NOTIFICATION
y
Applicant informed a e D te: Time: r Clerk:
PP
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ 00- 0
Less Application Fee: $ 25.00
Remaining Balance: $ - 1 06
TOTAL FEE: Gross Area - New Construction total sq. ft.
r
Gross Area - Alteration total sq. ft. IVY
Permit Issued Tn-_ 62z6&-7W
SE TI 11= ADDITIONAL COMMENTS/SKETCHES
$25.00 APPLICATION rEE IS NON-REruNDADLE do NON-TRANSFERADLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box i9399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING P
DATE SENT FOR REVIEW: NUMBER” =
DATE ISSUED:.
OK TO ISSUE -SIGNATURE:7IDATE
uildin ommission nspect r o Buildings
�� z
�.,� _
Zoning District: 5 `�Yroposed Use: Zone: C ❑ A ❑ V Outside Flood Zone Q Aqu><fer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑Board of ❑Con. Com. ❑Demo '❑ DPW Repoli
Affidavit
-Card Sent:
Appeals Health A - F Cut Off Follow up*
i c
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑Zoning QOther
Chief Cut Off / Cut Off 7 Cut Off - Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT, a
DEPARTMENTAL APPROVAL x ,
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1- SITE INFORMATION ` # ' t
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
1.1 Property Address: 1 7 /ys Plat , Lot -
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
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 System:
unicipalD Private Well ` ❑ Municipal � On Site Disposal System
e 1 Rev. January 19, 2001
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