BP-19021, 11[-XL
2001
RESIDENTIAL
2.1 Owner of Record:
Name (print)"! 1' r ✓�,_ V�
Agent:
Name (print)
SECTT N -
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
RSHiP / AUTHORIZED AGENT
%30 5U)Ob'.S -a �s✓�
.51 -6))01Zv?3o It -g
Contact Address
�� `/yu
Phone Number
Contact Address Phone Number
CTION E VI ES
Not Applicable ❑
License Number
Expiration Date
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
Are you claiming exemption from the requirement? If ❑'ye to❑ t he next section!
If yes, submit the
required affidavit!
Not Applicable ❑
Company Name
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:
QiJESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
cam"
Own6rs Name 1p'nt).--Signatnre.
by s g the above, the home 9ner 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 dwenl , attached or detached s
shall not be considered a Homeowner. ttvtures accessory to such use and/or farm structures. A person who constructs
more than one home in a two-year period
If you are applying under this section sidn below- / / ►\
lities, including but not necessarily limited to, general liability
2001
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. Fa
ilure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicabl )
❑ new construction* ❑ addition ❑ alteration
(energy report re uired ❑repairs ❑chimney/ ❑ woodstove
q ) (energy report required) fireplace
❑ deck ❑ pool acc -bl ❑ replacement window/door ❑ other
❑ demolition
sh 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, others (specify):_
o HVAC (combined unit) - primary fuel, natural gas, propane, electricity,(p)
• Air conditioning other (specify):_
- (separate unit)
o None of t�above to be provided
• Hot Water: Gas Electric Fuel Oil
Brief�Description of Proposed Work: Other
SECTION - 6 ESTIMATED CONS-7-TRUCTION COSTS j
Item Estimated Cost ($) to be completed b
P y permit applicant
5.Total =(1+2+3+4) * ,
Estimated Total $ 6 (N
SECTION 7A - OWNER AUTHORIZATION ;
(to be completed when owner's agent or contractor applies for building permit) -
(please print)
, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
SE TT N 713 OWNERAUTHORIZ M, AGENT DE MARA[TON
I' , as Owner/Authorized Agent hereby declare that the statements and "information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signefunder the pains and penalties of verhev.
of er/Authorized Agent
C:'.bidc. f'ormslBldgapp.res.wed
Page 2
Rev. January 19.2001
C:`,bldg. forms\Bldgapp.res. wpd
P— 1
I?FCTTIF.NTTA I ,
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):
Date:
5. DENIED (see project review worksheet):
Date:
6. HOLD reason:
Date:
7. 1JOID suugbjectt to/�Zoning Board of Appeals action:
Date:
8.G011P'A !s:`Z.C<Il-� -cT9 -
_ v 11_/1�-('� /0
e 4:6
-�
V. Insp ctor's Signature:
Date: 0
CTIO'' 9-/APPLI AN NOTIFICATION
q
4 Applicant inforped of aboye te: ) d" Q Time,
1
Clerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: S
1 Less Application Fee: $ 25.00
Remaining Balance:
TOTAL FEE: Gross Area - New Construction total sq. ft. CPO
Gross Area - Alteration total sq. ft.
x��' ✓/1 �- ��
/r`�'y%p
Permit Issued To
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
-
i1S
R15
RESIDENTIAL
❑ FOUNDATION ONLY 2001
$25.00 APPLICATION FEE IS NON -(REFUNDABLE & NON -TRANSFERABLE
-DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
e
Dartmouth, MA 02747
'.
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: (
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:_ _Lem �
DATE ISSUED:
DATE
OK TO ISSUE - SIGNATURE:
Building Com ssioner/Inspector of u dings
Zoning District:y/Proposed Use: Zone: ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING SHOULD BE NOTIFIED:
AGENCIES
❑ DPW ❑ Elec. ❑ Energy Report
❑ Board of E3'Board of QCon. Com. ❑ Demo
Appeals Healthi ^ L f; �L, Affidavit Card Sent: Cut Off Follow-up*
ire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
2
/J
Board of Health: Signature: Date:
Signature:.-� 'C �� �� Date:
Conservation Commission:
Other: Signature: Date:
Description of work being perfors:ed:
SECTION I - SITE INFORMATION /✓
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: Ef yes ❑ no
1.2 Assessors Plat &Lot Number:
1.1 Property Address: c v J �`+� z 5 C� f`1�f s ')', Y ?
Plat_ Lot�-
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
S
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.: f
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
Municipal❑ Private Well
❑ Municipal 6 Site Disposal System
C:Pa_e 4 Rev. January 19. 2001
C:Abldg.forms',Bldgapp.res.wpd
Page 1
Rev. January 19.2001
4 onj
'kp
gk;'g
N 8.50 - 07'- 1 e-w
RD.
TG1;'7,1' Cr"* DA-R'Tlr'C71CUTH
K'""n'
'41030 P1,1kKI
A Copy Of This Endorsed
Plan Must Be Kept On Site
Dudn,rf Construetion
Date
13J
AS BUILT FOUNDATION PLAN
IN
DARTMOUTH, MA.
(FLAT 28 LOT 95)
OWNED BY
ISAAC J1,1R. 8 COLLEEN S. THOMAS
SCALE 1 11 =401 MAR. 22, 2001
ALLEN D. QUINTIN, P. L.S.
28 COSTA ST. N. DARTMOUTH, MASS.