BP-19595-01RESIDENTIAL
2001
RESIDENTIAL 2001
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2.1 Owner of Record:
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Name (print)
Contact Address Phone Number
72
me (print) Contact Address Phone Number
0r1-II 1NJ-UVNV )IK I]ON NEKVIU'S
3.1 Licensed Construction Supervisor: I Not Applicable ❑ '
Licensed Construction Supervisor _J��16S License Number 12)
Addresses 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 %I
Address
1 5 1Registration Number (if none, state "none")
Signature Telephone 013 Expiration Date
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
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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
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 § 25)
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*
(energy report required)
❑ deck "pool
❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) fireplace
❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ replacement window/door
no. of windows doors
no. of baths
Two Family: no. of.bedrooms unit 1 no. of baths unit I
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
,�4T—d1 r l 4, r n .,ems Q. ... i_
❑ other ❑ demolition
(specify below): (specify below):
-' SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbing
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)
(ple print)
1,
, as Owner of the subject property hereby authorize
to n my eha in all
a ers ati a to w r aut orized b is building permit applicatio
.
Ignature of Owner
Date
SECTION B - OWNE A HORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoin ppli at
are true and accurate, to the best of my knowledge and belief.
Sig der the aln and
pen_aLties of per u
Signat e of Owner/Authorized Agent-
Date
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Rev. January 19, 2001
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Do., T--..--
RESIDENTIAL
2001
_ SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
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):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signatur
Date:
SECTION -APPLICANT NOTIFICATION
Applicant informed of a ove Date: 1,14111Time: Clerk:
Comments:
SECTION 10- OFFICEINSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE:Gross Area - New. Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To -
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
-RESIDENTIAL 2001
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-RE'N"UNDABLE & NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED
iro _ 400 Slocum Road, P.O. Box 79399
.� �. Dartmouth, MA 02747
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTI N FOR OFFICIAL USE ONLY Y r
RECEIVED IL
BY:_ BUDIN z
DATE SENT FOR REVIEW: a
L =
NUMBE .T . .
1,DATE'IS UED• -
=�'MAY tip=
OK TO ISSUE SIGNATURE: �" w DAT w
i Commis loner/Inspector of Buildings:�� x:
Zoning District: Proposed Use: ' .„y .Zone: @'C ❑ B :❑ A V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED
❑ Board of ❑Board of Mon. Comr ❑ Demo r X ❑ DPW y x ��x ❑ Elec.; ❑Energy Report
Appeals Health Affidavit x Card Sent Cut Off Follow up*
• a. T w:=y::.`C'"" x mow- x'i ,r.+"` 1, ,rh t -
a i s x rn
❑ Fire ❑Gas ❑Planning Board* ' ❑Sewer Card ❑Water Card , _ ❑Zoning ❑ Other
Chief Cut Off .,- :. / Cut Off / Cut'`OffReview* `'
*. REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMTT.
DEPARTMENTAL APPROVAL'- � * '
Zoning Review: Signature: DAY 0 2 Tor
Energy Report: Signature: Date:
Fire Chief:
Board of Health:
Conservation Commission:
Signature:
Date: S _.S —C
Other: Signature: Date:
Description of work being performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Pla of Number:
1.1 Property Address:—�iF� ((lam � Pl� Lot` -
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1 1.4 Water Supply (MGL c 40 § 54):
Municipal❑ Private Well
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal Zen Site Disposal System I
ia�a�.
f
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