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BP-2003-287572003 RESIDENTIAL 2003 RESIDENTIAL SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: Contact Address Phone Number Name (print) 2.2 Authorized Agent: Name (pri Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 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 subje t t If0 CMR 6). ❑ yes ❑ no no, go to the next section! Are you claiming exemption from the require n ❑ yes D no If yes, submit the required affidavit! Company Name Registration Number (if none, state "none") Address Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTO S O NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: istr tiot On s I urton Place - Room 1301, Boston, MA 02108, (617) 727-8598 ` Home Improvement Contractors R;Ig Owners Name (print) ' 1 Signature by signing the above, �tte hlme 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 ava,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 Licensin_^_ 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 dweiline, 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. Failur to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Qryes 0 no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* addition r(,— ❑ 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 I no. of bedrooms unit 2 no. of baths unit 2 e Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): e Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): c HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) e None of the above to be provided F, Hot Water: Gas Electric Fuel Oil Other Work: Brief Description of Proposed .� r d SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. ?iuildint1_111* 2. Fhctrical 3. PI-mbing 4.1i.chanical (HVAC) 5 00 - 5. Total = (1 + 2 _ 3 + 4) * Estimated Total $ f �j G �G • i� ' SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) .,(phase print) as Owner of the subject property hereby authorize I , to act on my behalf, in all matters relative to work authorized by this building permit application. Sicnature of 0��-ner Date SFCTIO'S 7B - OWNER/AUTHORIZED AGENT DECLARATION 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. Signed under the pains and penalties of perjury. C Date Signature of Owner/Authorized Agent \bldg.fonns\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:`.blde.fomis\Bldgapp.res.wpd Page 3 Rev. January 19, 2001 RESIDENTIAL 2003 RESIDENTIAL 2003 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE SECTION 8 - INSPECtTOR' REVIEW/COMMENTS 1. Date reviewed: b plan 2. 30 days to review period expires: 3. to issue date: _OK 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: S SECTI 9 - ICANT NOTIFICATION Applicant informed o ov to Time: Clerk: Comments: SECTION 10- OFFICEVNSPECTOR'S NOTES / Total Permit Fee: $ / Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL. FEE.; 0® Gross Area -New Construction total sq. ft. T ( Gross Area - Alteration total sq. ft. t s 53X, s•s� Permit Issued T � SECTIO 11- ADDITI NAL COMMENTS/SKETCHES =A>11ECEIVED DARTMOUTH BUILDING DEPARTMENT �5 400 Slocum Road, P.O. Box 79399` Z Dartmouth, MA 02747 �(J✓'`�"" , H" J = 508-910-1820 FAX 508-910-1838 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: DATE ISSUED: OK TO ISSUE - SIGNATURE: DATE B ilding omm Sion 1 nsp�ecto of Yuildings Zoning District: Proposed Use:a� Zone: E C F1T3 ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW d.,❑ Elee -' ❑ Energy Report Appeals Health Affidavit --Card Sent: Cut Off -Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Server 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: w i loop Date: ® - 8 Z Date: Energy Report: Signature: 1/ Fire Chief: Signature: ' s�' Date: t�� �cc P1' Board of Health: Signature: Date:,,01 Conservation Commission: Signature: /.� Date: Other: Signature: Date: Description of work being performed: SECTION I - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 2 yes ❑ no 3AAnx 1.2 Assessors Plat & Lot Number: 1.1 Property Address: // y �A, / Plat Lot - Nearest Cross Street: z,. [C C1doWJ 9 1.3 Historical District ❑ yes no Subdivision Name: G ei %� Has application been submitted to the Historic Commission? Total Land Area Sq. Ft.: ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: © Municipal❑ Private Well ❑ Municipal 2-On Site Disposal System C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 C:\b1&.forms\B1dgapp.res.wpd Page I Rev. January 19, 206