BP-2002-25122RESIDENTIAL 2002 RESIDENTIAL
2002
SECTION.2 - PROPERTY OWNERSHIP / AUTHORIZEDAGENT -
2.1 Owner of Record y
Name (print) _
Contact Address Phone Number
2 2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number Q
Address 6�� � M
Expiration Date 0t
Signature Telephones��+� Z�
3.2 Registered Home Impr vetnet Contractor:
Not Applicable ❑
Are you a Horne 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 t
Registration Number (if none, state "none")
Address
Sig %'cure Telephone
Expiration Date
3.3 For Resddential et ode fork Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
H-bine Improvement Contractors Registration, One Ashburton Place -Room 1301, Boston, ,If 4 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 engges 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) ,�vho owns a parcel of land on which he/she resides or intends to reside, on
which there is, otr is intended to be, a one or t-,vo family dwelline, attached or detached structures accessory to such use and/or farnl 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 Construct"
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. Failure to provide thhis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* addition airs ❑chimey/ f❑ we odstove
(eitergy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition -
(shed/garage) no. of windows_ doors_ (specify below): (specil`fy below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths Z t
Two Family: no. of bedrooms unit 1 no. of baths unit l
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): C) 46
❑ 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 Proposed Work:
_
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Building `
l p O
'?. Electrical
3. Plumbing
4. Mechanical (HVAC)
bf
5. Total = 0 + 2 + 3 + 4)
* Estimated Total S /t5,po0
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please p int
I, as Owner of the subject property hereby authorize 6hil—to6w_d
to act on in all matters relative to work authorized by this building permit application.
V-half
/6
Signatur f Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I, o & c , as Owner/Authorized Agent hereby declare that the statements and ir0formation
�Czl�t° g
on the foregoing app cation are true and accurate, to the best of my knowledge and belief.
Signed under the pains d penalties of perjury.
t
t
Signature of Ow r/ uthor&d gent- Date
C„bidg.lonns,BldCLapp.res.wpd Page 2- Rev. January 19. 2001 C:.blde.torins B1dgapp.res.Nv pd I ., t. ? Rev;.11anuary 19, 2001
RESIDENTIAL
`2002 RESIDENTIAL 2002 ,
❑FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE 8c NON-TRANSFERP.qBLE
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 nays 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. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature: Date:
SECTION 9 - APPLICANT NOTIFICATION
Applicant inforrpe4 of abov Da Time: Clerk:
Comments:
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: S
Less Application Fee: $ 25.00
/IV
Balance: S
-Remaining
TOTAL FEE: 's3 Gross Area - New Construction total sq. ft. S�"7
Gross Area - Alteration total sq.'ft.
Permit Issued To-
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
DATE RECEIV,/rED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
..fi.:a...- 508-910-1820 FAX 508-910-1838
APPLICATION TO CO,NSI R T, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWTLLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: `
BUILDING PERMIT
DATE SENT FOR REVI V:
NUMBER:
DATE ISSUED:
JUL2 '4 2002
OK TO ISSUE - SIGNATURE: DATE
'
B ilding Commissioner/Inspector uildings
Zoning District: Proposed User Zone: O B ❑ A ❑ V Outside Flood Zone ❑ Aqurifer Zone '--►
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elee. ❑ IEnergy Report
Appeals Health _ Affidavit Card Sent: Cut Off Folllow-up*
❑ Fire ❑ 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: 0 t `2 4 2002
Energy Report: Signature: Date:
v
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work beingpeiformed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑lino
1.1 Property Address:
1.2 Assessors Plat & Lot Number:
Platte Lot=....
Nearest Cross Street:
Subdivision Name:'
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Histcoric Commission?
Total Land Area Sq. Ft.:
yes ❑ no Date:
1.4 Water Supply(MGL c40 S 54):
1.5 Sewage Disposal System:
1, unicipal❑ Private Well
❑ Municipal On S ta-Disposal System
C:\bldoonns\Bldgapp.res5rpd Page 4 Rev. January 19, 2001 C:\bld,,.forms\Bldgapp.res.wpd Page I Rev. January 19, 2001