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1600 TO THE APPLICANP/REFE UL L AND APPROVAL
Date of Application submission
Plat Lot Street Aquifer Zone
Owner
Owner mail address
Owner phone #
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or appr•ovaI for your
proposed project. CONTACT ITEM FOR RF[u1rpM SIIBMISSIONS.
® TAX COLLECTOR = Approved:: HOLD By
❑ Board of Appeals = Approved By
❑ Conservation Commission E. Approved By
❑ D.P.W. Water — Approved By ❑ D.P.N. Sewer = Approved By.
❑ D.P.W. Cross Connection = Approved By
Date
Date
Date
Date
Date
❑ Treasurer (Bond) ❑ Approved By
Date
❑ D.P.V. Engineering _ Approved By
7 Board of Health (well) = Approved By
❑ Board of Health (septic) - Approved By
❑ Board of Health (food service) = Approved By
❑ Planning Board (parking) = Approved By
Date
Date
Date
Date
Date
0 FIRE DISTRICT (I Approved By
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BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construcriow alterationidemo sewage disposal - public:private
[Alter:add interior walls] [add rooms] [add footprint) water supply - publiciprivate well
[pool] [garage shed/deck] [game court] [food service]
Describe
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have anv
questions please advise. If any reason to withhold the requested permit is found. please advise. Your assistance and
cooperation is appreciated.
The Building Department - Date sent for review By
TOWN OF DARTMOUTHT BUILDING DE.RT
TELEPHONE 508-999-0720 FAX 5O8-999-4738
APPLICATION FOR ZONING AND BUILDING PERMIT
Instructions
The applicant shall complete this application to the best of their ability prior to submission. leaving no item unanswered. The
Department staff will be, available during regular business hours to assist as necessary. N/A should be inserted for those sections
which do not apply. A properly completed application will help avoid unnecessary delays. Nolen Fling fees mA tda�ielie:
(for ogee aae only) "'MUNDATTON ONLY
Total Cost $ Received By Date Reed 1
Less Appbcation Fee $ 0?-
Total Permit Fee f Permit # Lssoed Date
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT � LOT. ZONING DISTRICT "- " ✓
VTHER ZONING OVERLAY DISTRICTS , if applicable
UMBER & STREET
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TENANT / OWNER
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
= THIS SECTION NOT APPLICABLE
= Single family - number bedrooms number baths
= Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
= Accessory apartment Total gross sq. ft.
= Accessory structure:
= Garage - detached - attached to dwelling, dimensions L W
= Carport - detached - attached to dwelling, dimensions L W
= Shed - dimensions L W
Z Deck - dimensions L W
= Gazebo - dimensions L W
= Swimming pool above ground in -ground Size
_ Chimnev - number of flues
woodl ve - used (will require impecdon prior to installationo, new (provide manufacturers
instructions). Location(s) (list)
= Fireplace(s) - (includes flue) List location(s)
_ Game Court - describe (include overall dimensions)
= Tent, Trailer (Mobile Home) or Other - describe
300 COMMERCIAL - PROPOSED PROJECT/USE . INCLUDING THREE FAMILY OR MORE
AND EXEMPT USES
- THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED See
Code)
.. ) ( the
- Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
_ Business - office, assembly with less than 50 occupants - indicate :Medical or other professional (see Cod
Section 303.0) e
— Educational - structure for training including child day care for those over 2 years 9
304.01 months (see Code Section
- Factory Industrial - (see Code Section 305.0)
— High Hazard - (see Code Section 306.0)
f - Institutional - hospital, nursing home. infant day care (see Code Section 307.0)
s
- Mercantile - retail stores (see Code 308.0)
s - Residential - three or more family, hotel (see Code Section 309.0)
_ Storage - includes garages (see Code Section 309.0)
_ Utility & Miscellaneous Structures - i t
►ncludes tents and agricultural structures (see Code Section 311.0)
= New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning Bv-law section 3
_ Tent or Trailer - temnorary purpose?
_ Other
Descrtbe the proposal brie$}, INCLUDE
-umber
also existing condition of dwelimg Qnits and bedrooms oroocu t
pran load as appU=bk,
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFoRM[ED
= New Constracdon and/or Addition - total gross square feet
(For commercial only total gross cubic feet) - indicate
It will be considered new constructio
alteradonls). n if there an increase in square footage in addition to anv
If project is an addition to existing structure - Total gross square feet of existing _
= FOR COMMERCIAL, ONLY �
WW this project be subject to CONSTRUCTION CONTROL (over 35.000 cu.ft.)
see Code section 127.0). Designer to submit Yes — No. (If ves
�S'iIl this project require P Code Synopsis.
e4 Peer review lover 400.000 cu.ft.) "es
APPLICANT TO PROSE No (see Code Appendix I)
The following section for official use only.
INSPECTORS, REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
OK to issue subject to requested submittals (see project review w.orksheet) date
— DENIED see project review worksheet date
HOLD reason
date
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature
Applicant informed of above - Date
Date a._ �-� --F J
staff (fax, phone, in person)
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Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector
Date
Advised applicant Date Time staff (by phone, fax or in person)
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OFFICEUNSPECTORS 75(0.
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
COmments/notes on permit
-Y,iS
1300 OWNER SIGN - OFF
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
Name /C C7Y
Signature
The above signature is my v untary act and is signed under the pains and penalties of perjury.
Date
Who is authoriz
.gd to pickup the permit at _iQthe Building Department? !lease o..
Address 15,S
p 9
Phone f o ,�� ' 3 O fie. Q of
1400 HOMEOWNER E)MWFTION - ONE & TWO FAMMy ONLY
FOR HOME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Constrvct'on Supervisors: Except for those structures governed by Construction Control
in Section 127.0, effective July 1, 1982, no individual shall be engaged in directly supervising
construction, reconstruction, alteration, repair, removal or demolition involvingthe structuralpersons engaged it
structures, unless he or she is licensed in accords-ce with the rules and regulaons promulgated bents B RS buildingsorRules and Regulations for Licensing Constriction Supervisors. y the BBRS enti, ed
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this sectioc only, a "Home Owner" is defined as follows: Person(s) who owns a parcel of land
on which heishe resides or intends to reside, on which there is, or is intended to be, a one or two family dwelUn , attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner.'
If you are applying under this section sign below:
Signatures
Your signature carries certain r ponsibilities, including but not necessarily limited to, 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
2.15.2 of section 51
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1500 COST
Cost of Improvement
S
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other 3
TOTAL
r V d
= Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration required.
_. Moving - (Provide copy of D.P.W. moving license)
from where (plat/lot or address)
to where (plat/lot or address)
Type of structure
Number of dwelling units Number of bedrooms per dwelling unit
— Re -roofing - (for existing only, is included in new construction)
Number of square feet Number of layers ah-eady existing
Number of layers when complete
A separate disposal declaration REQUIRED
Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for
residential and Articl, 8 ft- commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
_ None submitted. Why?
= Submitted. usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
❑ Not required, why?
= Submitted When? = Previously, date C With this application
700 U UXITE,S
Water supply - required _ yes ,_, no, public ? _ yes _ no, on site well,, _ yes _ no,
existing? _ yes _ no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes _ no, public sewer _ yes _ no
private septic - on -site _ yes _ no. Submit copy of permit as soon as available.
800 MEC IANICA S & 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)
None of the above to be provided
Hot Water Gas Electric
Fuel Oil Other
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, _Plans provided, plans not provided, why?
Not required, not to be installed, Why?
1000 YEQUIRM OFFSTREgI• PARIONG for ZONING & Architectural Access
NOT APPLICABLE
= Parking Plan submitted To = Building Department Planning Board Date submitted
Number of spaces -indoors --
outside total provided
H-ndicap spaces - required _ yes _no. If yes, how many as a port 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.
1100 IDENTIFICATION (print or type except as noted)
Current owner - name/$ -
address / � � .% . �/� �
phone #
If corporation. officer in charge
Architect/Engineer - for overall design
Company name Cad RiG `�
Address ( Vd = L / ` S ��
c� 'I+ C �RD
Phone number _ r- Q --
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all cans, affidavits and
reproductions. other documents SHALL BE originals and not
Archdtet ineer - Project saPwrision and reports
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all DIMS, affidavits and other documents S
reproductions. HALL BE originals and not
General Contracto tf Homeowner, tate homeowner here then complete section 1300)
Compan• ----
Address
Phone number
Construction Supervisors license number
NOTE Signatures and seals on all Wans, affidavits and other documents SHALL HALL BE originals and not
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes _ No — If no go to next section!
Are you claiming exemption from the requirement? Yes _,No _If yes, submit the required affidavit!
Ren_Ddel contractor name (please print)
Address
Registration number (it none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE 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
Plat #23
Lot #20
q�
TOWN! OF MPI T",11UTH
E, � L
s Q Copy Ct This indorsed
Plan Must Be Kept On Site
Plat #28 Durinq Construction
Lot #93 no Date (fAR � 4
z
0
/
w 35' Ta3SG
� N
01
v
J
72'
121'
Plat #28 sy
Lot #92 F�
24 TREE O S3034'09"E
EL.-33.67 22.44
—Cop
S85 36'55"E
30:85, 165.77' 30.00'
� S 35'26'12" E
L0r#1
100,286 S.F.
2.30 ACRES
(FR.=209.33')
Plat #23
Lot #20
I certify that the foundation
shown on this plan is in
compliances with the applicable
Zoning By —Laws in the
Town of DARTMOUTH.
Lane
Dee}ruc{ion f
136'
R =
L -
Correia's Engineering Inc.
LAND SURVEYING
8 Grinnell Street
South Dartmouth, MA. CIVIL ENGINEERING
02748-2314 SUBDIVISIONS
TeWphone (508) 996-6052 SITE PLANS
Fax (508) 979-5949 AS BUILT PLANS
Joseph E. Correia III Pres. & Joseph E. Correia IV VP.
Plat #28
Lot #88
AS -BUILT
FO UNDA TION PLAN
in
DAR TM UTvT, MA .
prepared for
MIKE L OPES
Scale 1 " = 60' MARCH 19, 1999
FILE#96-0099 PJD