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BP-20598RESIDENTIAL 2001 RESIDENTIAL 2001 A 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): Date: 5. DENIED (see project review worksheet): Date: 6. HOLD reason: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Signature: Date: ;SECTTION 9 - APPLI ANT N FICATION Applicant inforaieo of ab ve Date: Time: / Clerk: _ Comments: � SECTION 10- OFFICE\INSPECTOR' NOTES t Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE: ,30 o Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To - CLI_ r _ c� SECTION 11-ADDITIONAL COMMENTS/SKETCHES ba o Orr,, a.r, , -pd . � f J o C�Y' ca'a t'Oafv t e4V--* sc accx>D C _ _ 3 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDA' 8LE do NON -TRANSFERABLE .--��TH; •. DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 ±o x; - • \?3G ' -- �•' Dartmouth, MA 02747•',� , 508-910-1820 FAX 508-910-1838 / ' '';'' APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Zoning Review: Energy Report: Fire Chief. Board of Health: Conservation Commission: Other: S ignature: Date: Signature: Date: Signature: Date: Signature: Date: Signature: Date: Signature: Date: Description of work being performed: SECTION 1- SITE INFORMATION NUMBER OF PLANS SUBMITTED: I SITE PLAN SUBMITTED: ❑ yes — Rno 1.2 Assessors Plat & Lot Number: 1.1 Property Address: b �+2J ►SPX' Plat Lot_ Nearest Cross Street.lf��� ��j ► ") . is Subdivision Name: Total Land Area Sq. Ft.: 1.4 Water Supply (MGL c 40 § 54): ❑ Municipaall?Private Well W 1.3 Historical District ❑ yes ❑ no Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.5 Sewage Disposal System: ❑ Municipal -K On Site Disposal System ,C:\bide:forms\Bldgapp.res.wpd__. _ ___ _ - - Page 4 Rev. January 19,-2001 C:\bldg. forms\B Idgapp. res.wpd Page 1 ! u (� (q ��'� Rev. January 19, 2001 RESIDENTIAL _ 1� I� - ° t� `9� 2001 RESIDENTIAL 2001 t SECTION 2-- PR P^RTY 0WNER HIP AUTHORIZED AGENT i 2.1 Owner of Record: 1 (© r%� Ps Name (print) Contact Address Phone Number 2.21 Authorized /Agent: �JiGL ft1,(`n�S 7t 1)rl�'�T W� V Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVTCES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number CS 066,669 Address ?G -br 1 MA, Expiration Date Signa TelephonelJ� re 3.2 Registered Home Improvement Co actor: i )&O ,P Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)?\,�Lyes ❑ 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 �,J AC-L Y, r 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 FUND: QUESTIONS OR COMPLAINTS call or write: Honte 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 dwelline, 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 (see Appendix of 780 CMR R5.2.15) Supervisor, whether or not they have taken the permit are responsible for code compliance. 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* ❑ addition ❑ alteration 1. repairs ❑ chimney/ ❑ woodstove (energy report required) (energy report required) 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): ❑ 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 Item Estimated Cost ($) to be completed nt 1. Building 2. Electrical 3. Plumbin 4. Mechanical (HVAC)_ 5. Total = (1 + 2 + 3 + 4) * Estimated Total $ E 71ON — WNER A ORIZATION actor applies for building permit) o be comp eted when owner's agen r cont (please print) I, of t subject roperty hereby authorize to act on my behalf, in m ers relative or t orized y this buildin permit application. Signature of Owner Date E i N 7B- A TH RIZED DECLARATION I, f , as Owner/A rized Agent hereby declare that the statements and information on the foregoing pplicatio re true and urate, to the of my knowledge and belief. Sig e under the p ins an , penalties of per Sign of Owner/Authoriz d A ent Date C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.forrns\Bldgapp.res.wpd Page 3 Rev. January 19, 2001 __ � � ,. .�.,,, 7 ,_ a : _. ; r..� °� .._._ , . ,_: _. � , �. b ,. q. `. ` _, .. :. c: _ _ .. a - , ,. i r .. r � .,, i .. i t- , f .. I _. :. %1[AiStAA7 // _ __ Er.; , p _, � � � _ ; .�, J r I N � ' I 1 I " � i .:r , �..