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2.1 Owne Recor
n
jv� J", k—
Name '(print)
Contact Address Phone Numbe
2. A Age
6thordzed
Name (print)
Contact Address Phone
Number
NOONAN N ERV ES"�_
3.1 Licensed Construction Supervisor/Specialty License :
License Number:
Company Name/Contractor Name:
C
Address:
Expiration Date:
Signature: Telephone'
®
P
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
y
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
F
Are you claming exemption from the requirements? ❑ Yes ❑ No
L
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"):
C
Address:
E
`Signature: Telephone:
Expiration Date:
N .
. 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: .
improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8593
tS�Home
6
e ' ❑ i am a Homeowner performing all the'work myself.
Owners Na (pn t): L� �ANrjel
Signature: 9 n
6 si nin t above, the homeown a howled es that there will be no eligibility to the Guaranty Fund
y, 9 9 9 9 h' tY
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involvingthe structural elements of bulildin
9
or structures unless he o she is licensed
n r h. Ir n d m accordance with the rules and regulations o ,r mul ated b the BBRS entitle e
promulgated y d Rules Regulations for Licensing Constructioi
9 9
Supervisors.
Exception: An Homeowner performing work for a Building
p y p g h uilding Permit is required shall be exempt from the provisions of this section; provides that if a Homeowne
j«
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor i
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 whit
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
tha
one home in a two-year period shall not be considered a Homeowner
If you are appl 'ng under this section sign below:
c
Signature: 6,
Your signature carries c responsibilities, including but not necessarily, limited to, general liability
,.: <..:. w' .,::v.GC.+t I�,�i:.4 ,-i/:�.QR : C ... ..J...lr ,. -., .:.... .. ... ..,:. -- .: -:,, .,,`.%,: ;,..:. � ,_;s, t . ..�,,:•,.
_.... .� .. ,. ,_.:,..
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to preov!de this
afdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Ye ❑ No
�
;.,, ScGTION 5UESCRIPI f0! QF PP..:OPOSEi? itlt7>RK.; Gheck aiC.a`r 'lieaf5le rv,
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ iM7oodstove/Pellet Stove
❑ New Construction"' ❑ Accessory Bldg. ❑ Roofing/Siding
Ober
er
(Energy report required) (S-rpec'
fy below)
Q Addition ❑ Repl2Cernent.window/door ❑ DJemolition
(Energy report required) No. of windows Doors (Specify below)
I
*If new construction, please complete the following:
Single Family: No. of Bedrooms qo. 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, elE ctricity, other(specify):
fy) ;
0 Boiler (heating) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
None of the above to be provided
❑ Hot Water: GasElectric Fuel Oil Other
Description ofproposedMork: j � CIAILLI T i �s
x � a <.:
�P
Item Estimated Cost ($) to be completed by permit Eapplicant
1. Building
2. Electrical
3. Plumbing _y
4. Mechanical (HVAC)
5. Total (1 + 2 + 3 + 4) L{
t f � SECT10 .7A- OlritN�R-A:U 5l-t E�I�ATIOT�[
(Pie e P nt) i
alai as Owner of the subject property hereby authorizP-7r, lei
-.
to a my behalf, in all matters relative to work authorzed by this building permit application.
Sign of Owner Date
.,>
s �. G .T►ON 7er.._ow 1=�rAl�Tl-�a>�! o , . , .. �.. ._AfsElVg`J3ECI=AT�,4.�^lQp.4 iY .,.,. z..
�•� „4�' �{G,/G->�s�%"' as C wner/Au thorizedAgent hereby declar
e that the statements;, -and information..
on the foregoing application are true and accurate, to the best of my knowledge and belief.
LSiLed ndtpain n pe alties of p '
dignatur of Own /Aut orized Agent' DEfte
I
rage �
Page 3
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1. Date plan reviewed: OCT 2 6 2010
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: !� Date:
4. HOLD subject to Zoning Board of Appeals action: bate:
Comments
Inspector's Signature: Date:—OCT 2 6 2019
L�i EM3 iOT'.t Fti.etlT1�Q7Y M L ._.;. .t2. »`u,3r" Fiu,dF °gym ,.;,diaF.
Applicant informed of above: Date: Time: Clerk:
Comments:
Less Application Fee: $25.00 Remaining Balance: $
Total Permit F'ee: $
Other $ Amount $
TOTAL FEE: / :I S Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to
i
i
Page 4
a
Z'BEN 74
❑ Approval in Part (P gr 780 CIV,'R.5111.13) r- �L1325.00 APPLICATION FEE IS
g r
NON P.E_v�fNDAELE
DATE REICMIEED
DARTMOUTH BUILDING DEPARTMENT
CH 15 P,
�� 7 400 Slocum Road, P:O. Box 793 9 I "
_ Dartmouth, MA 02747
k� 4 Phone: 508-910-1820 Fax: 508-9 0-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT. REPAIR. RENOVATE OR DEMOLISH A ONE OR Two FAmn Y nwm I_INr,
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.... ...gin.. .r. ...:...._ , �$� ,r,
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1.1 Property Address: 1��_W title <!X ?k f NI ,
1.2Assessors Map & Lot Number:
Lot Area (sf.) C^P �;' Frontage
Map `_ Lot- �—
Required Provided
1.3 Historical District ❑ Yes No
Front Yard C
Side Yard '
`7
Year Built
:Rear Yard Ci
.
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54):1
1.5 Sewage Disposal System:
Has application been submitted to the Historic Commlission?
Municipal KPrivate Well
❑ Municipal Qn Site Disposal System
❑ Yes ;`No Date:
CONSTRUCTION PLANS SITE PLAIN LJ ENERGY RFEADOIRT
. V &-I'
1 ��1 /