BP-30865RESIDENTIAL 2002
FOUNDATION ONLY
❑
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE
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 werkehee±l = Date:
4 ;
6. HOLD reason: -,; Date:
7. HOLD subject to Zoning Board of Appeals.4tion: Date:
8. Comments:
1 9. Inspector's
Applicant is
Comments:
of above
0.3
Time: 3`�` —
Clerk: =!??!
Total Permit Fee: $ /00' 00 1 Less Application Fee: $ 25.00 Remaining Balance: $ �S D
TOTAL FEE: 1W , 0 0 Gross Area - New Construction total sq. ft. � S�
Gross Area - Alteration total sq. ft.
I Permit Issued
Gam`
4 )'
i
rY
,{ J
C_
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON-TRA1
RABLE
2003
CAb1dg.forms\B1dgapp.res.wpd Page 4 Rev. January 1, 2003 CAb1dg.forms\B1dgapp.res.wpd Page 1 Rev. January 1, 2003
RESIDENTIAL
2003
RESIDENTIAL
2003
2.1 Owner of Record:
Name (print)
2.2 Authorized Agent:
Name (print)
124 S lades Corner IZ�. 9_0906.1396
Contact Address Phone Number
S oq ` n-i O ms k
C6niacf Address -k,
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address 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
Address
Signature
Telephone
Phone Number
Registration Number (if none, state ❑ none❑)
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
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 p 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 i or is intene, 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 ome in a two- s considered a Homeowner.
If you are
Your signature carries certainifcngo�ities, including but not necessarily limited to, general liability
INOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction I
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2 15)
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
❑ new construction* b"addition ❑ alteration ❑ 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 Pr osed Work: Ad A p p e a s+ 5 i U e✓ b P ST � a�
r %, ei/nlf_L-J — ,1-,1i- /_ry tar Ij
Item Estimated Cost ($) to be completed by permit applicant
1 Rnildinv -* 30 O 6 Z) , O-6
F.lectriral p D O O d
S
Date
as Owner/Authorized Agent hereby declare that the statements and information
on t regomg plication are true and accurate, to the best of my knowledge and belief.
Si ed unde in an perjury.
�63
Signature of Owner/Authorized Agent i Date
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd
Page 3
Rev. January 1, 2003
12
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VADING DEPAM-71NT
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FIRE STOPPING REQUIREMENT
Ponstrations thru rated wak's and floors shall be
seated with a material capable of preventing the
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to tho requirements of the Test Standnrd specific
for Flro Stops ASTM-E-$14.
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CIALDN i DEMRTWIEW
FIRE SMPPING REQUIREMENT
Penetrations thru rated YjaUs and floors shall be
sealed with a material capable of preventing th(
page of flamos and hot gasses when su*ctec
tO the requirements of the Test Starx:t,-rd tpecific
for Fire Stops ASTM-E-814,
TOWN OF DARTMOUTH BUILDING DEPARTMENT
This plan has been reviewed and accepted as a record copy of work proposed
to be performed in compliance with 780 CMR 6TH Edition. The owner,
applicant/agent and/or architect/engineer is responsible for insuring final
compliance with the above -mentioned code notwithstanding any errors or
omissions in the record plan. Any change in owner, license contractor
or engineer must be peorted to this office im diately. Any change in
plan must be sub med/to is offi in a tim manner.
Signature
Date //,,
C.C. DFSj.qN �'�'�p���ON Norte nMMnon AZusr i, 2003
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12" CONGI�S MOM
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AT THE BUILDING DURING THE
ES8 OF THIS WORK.
vim,�A DEPARTMENT
Tmm dI mrtm,%
60140-TUBE SIZE AND DEPTH
IRISPECTI I IS REQUIRED BEFO
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WILDING DEPARTMENT
Tom of Dar ftWh
TOWN OF WT (NJTK
RECORD W21
A Copy Of This Lrdrr d
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FILE OU1
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C.G. DESIqN
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floors shall be
p�tlons thru rated MU, � preventing tttL
sealed with a r:Iaterlal cape titer#
passage of fiamos and hot gasses whenr ific
to the requirements of �1 Test Stand
for Fir^. Stope ASTM E
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51.UHV-AVMON nA,fmou N AUGUST' I, 200�