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BP-29621RESIDENTIAL ❑ FOUNDA ION ONLY $25.00 APPLICATION FEE IS NON- EFUNDABLE & NON-;TRANSFERABLC; nuTR.3" (15z ' i " DATE RECEIVED P . 1A DARTMOUTH BUILDING DEPA TMENT �"` 400 Slocum Road P.O. Box 79 99 f T- _'` 11: 24 a =, v.' Dartmouth, MA 02747 508-910-1820 FAX 508-910-1 38 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR EJEMOLISH A ONE OR TWO FAMILY DWELLING i B ❑ A ❑ V Outside Flood Zone SHOULD BE NOTIFIED: ❑ DPW ❑ Elec. Card Sent. Cut Off 2003 ' REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERNM. , DEPARTMENTAL APPROVAL $P awoq' Q Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: s Date:7 Z Conservation Commission: Signature: Date: Other: Signature: Date: Description of work being performed: SECTION 1 - S ,INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: D-<es ❑ no 1.1 Property Address: (&Zowf) F\J 1.2 Assessors Plat & Lot Number: Plat Lots_, .� Nearest Cross Street: 1.3 Historical District ❑yes �o Subdivision Name: 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 ii, Private Well ❑ Municipal 19`6n Site Disposal System C:\bldg.forms;Wdgapp.res.wpd Page 4 Rev. January 1, 2003 C:\bldg.forms\B Rev..JJanuary 1, 2003 RESIDENTIAL 01i VERST, / 2.1 Owner of Record: T A S i SGY1 f, !�✓l Cf i Name (print) 'J f-tti PC : l tp �fr� *1 2.2 Authorized Agent t r•, i Name (print) 3.1 Licensed Construction Supervisor: !j(Zdnt Licensed Construction Supervisor Addresso S "_ Signature :3.2 RegisteredHome Improvemt Co trnot_, y 2003 Contact Address --- ?7 Phone Number Contact Address Telephone 956 3 320 Phone Number Not Applicable ❑ License Number o` 3'3dJ� Expiration Date fo d� Not,Applicable ❑ Are you a Home Improvement Contractor subject to (710 CMR-6)? ❑ yes ❑ no Are you claiming exemption from the requirement? If no, ' go to the next section! Yes ❑ no If yes, submit the Company Name required affidavit! AQ2o�N P�I.S Address Registration Number (if none, state ❑ none❑) Signature `` Telephone 3.3 For Iles ential Remodel 4rk Only 33ZQ Expiration Date PERSONS CONTRACTING QUESTIONS OR COMPLAINWITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS To THE GUARANTY FUND: TS call or write: Irome ImProvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108 6 Owners ]Name (print) 7% 227-8598 v Signatur; by signing lthe above, the home owner acknowledges Date that there will be no eligibilty to the Guaranty Fund 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS 109.1.1 Licensing of Construction SupeWHO INTEND TO PERFORM WHO Except for those structures governed b Cons shall be engaged in direct] Supervising BE RESPONSIBLE FOR THEIR OWN PROJECT Y P g persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural buildings or structures, unless he or she is licensed in accordance with the rules and regulations promulgated b the BB Y Construction Control in Section 116.0, effective July] 1982, no individual Construction Supervisors. Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the elements of Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as sue Y RS entitled Rules and Regulations for Licensing r. For the purposes of this section only,a " provisions of this section; provides that if a ,Homeowner" is defined as follows: Person(s) Who ownsoa parcel of land on which he/she resides or intends to reside which there is, or is intended to be, a one or two farm] dwelling,attached or detached structures accessory to such use an more than one home in atwo-year period shall not be considered a Homeowner. and/or farm structures. A person who constructs If you are applying under this section sign below: Your signature carries certain responsibilities, including but not necessarily limited to, general liability :\bldg.forms\Bldgapp.res. wpd Page 2 RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: T�elrig CodeSupervisor, whether or not they have takrmit are in the Rules and Regulations section that any licensed Cons'it fe for code compliance. (see Appendix of 780 CMR R5.2.l1-g Inv TArcit,i', _ ss u�,�,Avrr (MGL c 152 § orkers Compensation Insurance affidavit must be com leted and submitted with this application. wlll result in the denial of the issuance of the building Pe t. Signed Affidavit Attached: Fail ure to Ono ` SECTION 5 DESCRIPTION O PROPOSED WORK (check aIi applicable) ❑ no ❑ new construction* P ), ❑ addition �� „ (energy report required) ❑ alteration ❑ repairs ❑ chimney/ (energy report required) i�❑ ❑ deck `a' pool ❑ �_ fireplace accessory bldg. ❑ replacement window/door ❑ (shed/garage) no. of windows doorsother _ © � * If new construction, please complete the following: (Specify belo): — w(�Sp Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit 1 no. of bedrooms unit 2— no. of no. of ❑ Furnace (hot air) - fuel gas (natural ot:propane), fuel oil, ❑ Boiler (heating) -fuel gas (natural or propane), fuel oil, e ❑ HVAC (combined unit) -Primary fuel,'natural gas, propa ❑ Air conditioning - (Separate unit) ❑ None of the above to be provided ❑ Hot Water: Gases_ Electric_ Ft Brief Description of Proposed Work: �% Cf Item hs unit 1__ hs unit 2 aricity, other (specify): ricity, other (specify): electricity, other (specify): Oiler_ Other �'%'►'11nlum ��rnm1w6 ��L sated Cost ($) to be completed b Y permit applicant S.Tot al=(1+2+3+4) � Estimated Total $ Q,— SFCTynv �.` _ „ ., I,t,( sot4 11 vxtc7IJ.AGENTI)ECLAI2ATION as Owner/Authorized rized A on the foregoing applicgent hereby declare that the statements and inforim� ation are true and accurate, to the best of Si �Uner e tes of perjury. IT Y knowledge and belief. r� P J rY Of Owner/ Agent Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd