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BP-2004-36343RESIDENTIAL 2004 $(?lY-4I"ElltY 1iVNR IiP` A17Ti1RI� AMEN pa m 2.1 Owner of Record: G.� Name (print) Contact Address Phone Number 2.2 Authorized Agent: Contact Address Phone Number Name (print) a ECI©N = tQNSfiRCJ�IiiAIE124ICES 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 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 Registration Number (if none, state ❑ none❑) tkddress Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: ,QUES ONS OR COMPLAINTS call or write: X Improvement Contr actors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 wite Name (pkt Signature by signing the above, the acknowledges hat there w4 1 be Ao elf bilty to the Guaranty Fund Date ZbIldings omeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 9.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1,1982, no individual e engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of 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 not necessarily limited to, general liability RESIDENTIAL 2004 NOTICE TO LICENSED CONTRACTORS: The Building Code rovides in the Rules and Regulations section that any licensed (Construction Supervisor, whether or not they have taken the permit are r sponsible for code compliance. (see Appendix of 780 CMR Rf5.2 15) _ SECTION 4 — WORKER'S'COM EN5ATION INSURANCE AFFIDAVIT (MGL C 152 .e.., w Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to rprovide this affidavit will result in the denial of the issuance of the buildingpermit. Signed Affidavit Attached: ❑ yes g no ❑ new construction* ❑ addition (energy report required) (energy report req, ❑ deck ❑ pool ❑ accessory bldg. (shed/garage) * If new construction, please complete the followin; Single Family: no. of bedrooms Two Family: no. of bedrooms unit 1 no. of bedrooms unit 2 ❑ Furnace (hot air) - fuel gas (natural or propane), ❑ Boiler (heating) - fuel gas (natural or propane), ❑ HVAC (combined unit) - primary fuel, natural € ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Brief Description of Proposed Work: Item � F.1Petriral 5.Total =(1+2+3+4) 1 * ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove fireplace ❑ replacement window/door ❑ other ❑ demolition no. of windows_ doors_ (specify below)): (specify below): no. of baths no. of baths unit 1 no. of baths unit 2 Iel oil, electricity, other (specify):_. el oil, electricity, other (specify): >, propane, electricity, other (specify): Fuel Oil Other t J% • / . / _�1 -A, �. I Estimated Cost M to be completed by permit applicant Total $ / ©Q 0, d (please print) I , a Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work ithorized by this building permit application. Signature of Owner Date I,D &^ I -ed klor ( ap-- ' I/ s Owner/Authorized Agent hereby declare that the staterments 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. cs Signature of Owner/Authorized Ag Dat C:\bld forms\Bld a res.w d Rev. January 1, 2003 rAhlda fnrmsVRldeann.res.WDd Page 2 Rev. January 1, 2003 g• g pp• p Page 3 RESIDENTIAL 2004 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON REFUNDABLE -M! N-TRANSFERABLE r)AR DAB°R!C;EIVED, a DARTMOUTH BUILDING DEPARTMENT' +o 400 Slocum Road, P.O. Box 9399 2v, -7 ti 1 9: 12 Dartmouth, MA 02747 508-910-1820 FAX 508-910 1838 APPLICATION TO CONSTRUCT, REPAIR, REXOVATE OF DEMOLISH A ONE OR TWO FAMILY DWELLING Zoning Review: Sigr Energy Report: Sigr Fire Chief: Sigr Board of Health: Sigr Conservation Commission: Sigr Other: Sigr Description of work being performed: NUMBER OF PLANS SUBMITTED: 1.1 Property Address:-j Nearest Cross Street: Subdivision Name: Total Land Area Sq. Ft.: d SITE PLAN SUBMITTED: ❑ yes ❑ no f 1.2 Assessors Pla t Number: Plat Lot�- cA 1.3 Historical District ❑ yes ❑ no Has application been submitted to the Historic Coommission? ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): ❑ Municipal Kprivate W 1.5 Sewage Disposal System: ❑ Municipal Site Disposal System Re�anuary 1, 2003 C:\b1dg.forrns\B1dgapp.res.wpd Page 4 Rev. January 1, 2003 C:\b1dg.f6r<ns\B1dgapp.res.wpd Page 1