Loading...
BP-51545❑ SPECIAL PERMIT (Per 780 CMR 111.13) $25.00 t+PPLIWATION FEE IS NON IIIE-FUNDABLE O, NON-TRANSFEUXI3LE _ DATE RECEIVED o H DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 =.Z Dartmouth, MA 02747 1664� Phone: 508-910-1820 Fax: 508-910-1838 2 � ;., r 2% 1 www.town.dartmouth.ma.us.JL 14, APPLICATION TO CONSTRUCT. REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING =nergy Report: Signature: :ire Chief: Signature: 3oard of Health: Signature: 'onservation Commission: Signature: )ther: Signature: Brief description of work being performed. 1.1 Property Address:/ t3C„tt- t? h P /Ill 'e Rd Nearest Cross Street: ( ©C (c — O - %� Lc /V e e Subdivision Name: Total Land Area Sq. Feet: /e 0-&A-0— Date: Date: Date: Date: Date: 1.2 Assessors Map && Lot Number: Map cR z Lot 1.3 Historical District ❑ Yes ❑ No Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Vmunicipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ CONSTRUCTION PLANS ❑ SITE PLAN ENERGY REPORT RESIDENTIAL - NOTICE TO LICENSED, CONTRACTORS, The Building Code provides in the Rules and Regulations section that any licensed Constructio SECTION 2 -PROPERTY ROPERTY OWN -; Supervisor, whether - - HORIZED`AGENT, .. , ..,.. " " p ether or not they filave taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) 'SECTION 4 O WORKER S COMPENSATION INS MGL•c 152 25 2.1 Owner Record: ( § ) K _ /4 / �>' 'e /0 C4 O�- reel^ >i lle '6 Worker's Compensation Insurance Affidavit must be completed and submitted With this applica�fion. Failure to provide thl PTV'7 Name (print) Contact Address Phone Number affidavit will result in the denial of the issuance of the building permit. Signed AfidaVit: Attached: ❑ Yes ❑`Nov- '1-1`=. +. 2.2 Authorized Agent: .. , SECTION'5 :� DESCRIPTION OF PROPOSED WORK (Check all .app (print) Contact Addlicable)' Name Address Phone Number ❑ Deck ❑ Pool ❑Repairs ❑ Alteration 0 Chimney/Fireplace o ❑ Woodstove/Pellet Stove ..::-SECTION3 -CONSTRUCTION SERVICES < 3.1 Licensed Construction Supervisor: Not Applicable ❑ ❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ "Other 1 :r• " (Energy reportrequired) (Shed/Garage) (Specify below) Licensed Construction Supervisor: License Number. `y. ^ ❑ Addition VI*Replacement window/door ❑ Demolition, Address: �// �..� Expiration Date: (Energy report required) No. of windows J 0 Doors _ (Specify below) - .: LW Signature: Telephone: co Z 3.2 Registered Home Improvement Contractor: Not Applicable ❑ *If new construction, please complete the following: ; Y V,Lii L) Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No Single Family- No. of Bedrooms No. of Baths ` ..I If No, go to the next section! LL. Are you claming exemption from the requirements? 0 Yes ❑ No Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 If Yes, submit the required affidavit! No of Bedrooms Unit 2 N6 of Baths Unit 2 ` Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): %' Company Name: ❑ Registration Number (if none, state "none'): 1„❑Boiler (heating) -fuel gas (natural or propane), fuel oil, electricity, other (specify): Address: ❑ HVAC combined unit - primary fuel, natural as, propane, electricity, other ( ) P � rY 9 P P Y, Signature: ❑ Air conditioning - (separate unit) 9 Telephone: Expiration Date: ❑None of the above to be provided --r x' :`'-'.f 3.3 For Residential Remodel Work Only ❑ Hot Water: Gas Electric Fuel Oil "Other PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: Description Of proposed work: ylol QUESTIONS OR COMPLAINTS call or writer Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598 3 ❑ ' 1 am a Homeowner performing all the work myself. Item Owners Name (print): 1. Building �y n 2. Electrical Signature: (" �.[X A --"-a 3. Plumbing By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund 4. Mechanical (HVAC) Date: J � 7 5. Total = 0 + 2 + 3 + 4) 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 dwelling, 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 n-of necessarily limited to, general liability Estimated Cost ($) to be completed by permit applicant lease Print) ,,. ..... �; 1, as Owner of the subject property hereby authorize to act on m be al , in atters relative to work authorized b this building Y y g permit Signature of 0 r Date r as Owner/Authorized Agent hereby declare that the statements and information n 4the foregoing application are true and accurate, to the best of my knowledge and belief. i Si ned under the pains and penalties of perjury. ignature of wrier/Authorized Aaent na+o