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OF D. RIUMUTH
RECORD Pl.Arl
A Copy Of This Endorsed ;
Plan klust Be Kept Qn Site
}p During Construction
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RESIDENTIAL
2.1 Owner of Rec rd:
Name (print) Contact Address
2.2 Authorized Agent:
Name (print)
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
Contact Address
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
Address
Signature Telephone
3.3 For Residential Remodel Work Only
RESIDENTIAL
'il AC NT NOTICE TO LICENSED CONTRACTORS: The Building Code provid
Supervisor, whether or not they have taken the permit are respons
SECTION 4 - WORKER'S COMPENSA
(! Workers Compensation Insurance affidavit must be comple
Phone Number affidavit will result in the denial of the issuance of the buil(
Phone Number
Not Applicable ❑
License Number
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place -Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name inO e"O it I n r U,0-AP-,ne-74*
`fin o za-
Signature
/1 r7 by signing the above, th9111" ner acknowledge t there will be no eligibilty to the Guaranty Fund
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 indirectly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuildings
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
enga_es 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 j section sign below:
Signature: +
Your signature carries certain responsibilities, lig but not necessarily limited to, general liability
SECTION 5 - DESCRIPTION OF
❑ new construction* ❑ addition
(energy report required) (energy report required)
❑ deck ❑ pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms no.
in the Rules and Regulations section that any licensed Constlpuction
e for code compliance. (see Appendix of 780 CMR R5.2.15)
:)N INSURANCE AFFIDAVIT (MGL C 152 § 25)
I and submitted with this application. Failure to provie4e this
.g permit. Signed Affidavit Attached: ❑ yes ❑
n
0
WORK (check
❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
fireplace
❑ replacement window/door ❑ other )'demolition
no. of windows doors_ (specify below): (specify below):
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, electricity, other (specify):_
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, pro ane, 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
404, p.c-/H i 7 ,
TED CONSTRUCTION
Item I I Estimated Cost ($) to be completed by permit applicantt
5. Total = (1 + 2 + 3 + 4) - I * Estimated
SECTION 7A - OWNER AUTHORIZATION
(to he completed when owner's Pgent or contractor applies for building permit)
(please print)
as Own of the subject property hereby authorize
to act on my behalf, in all matters relative to work author zed by this building permit application.
Signature of Owner Date
I d It , as O er/Authorized Agent hereby declare that the statements Mnd information
on the foregoing application ar rue and accurate, to the best of my knowledge and belief.
Signed under the pains and enalties of perjury.
Signature of Owner/Authorized Agent l
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Rev. January 2005
Page 2 Rev. January 2005
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RESIDENTIAL
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review
worksheet): Date:
3. HOLD
reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Date:.S'
SECT14 9 AP ICANT NOTIFICATIO'
Applicant informed qCabove
Comments:
Date: Time Cler
SECTION 10- OFFICVINSPECTOR'S NOTES
Total Permit Fee: $ %�5_0. 00
Less Application Fee:
Remaining Balance: $
TOTAL FEE: y.'�1" ��
Permit Issued To'IL-os
c
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
or
/'r�X 2G'"vCX- t.
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
RESIDENTIAL
❑ FOUNDA 710LV ONLY
$25.00 APPLICATION FEE IS NON-REic UNDABLE NON -TRANSFERABLE
DARTMOUTH BUILDING DEPA
TMENT
`DATE RECEIVED
4-
(��9 400 Slocum Road, P.O. Box 79
399
Fr ey ` Dartmouth, MA 02747
n .F
1,111 9: 59
508-910-1820 FAX 508-910-
838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE
R DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR O
FICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER: 3�
DATE ISSUED: oS
OK TO ISSUE - SIGNATURE:
s, LL DATE
BuildingOfficial-
Zoning District: 'roposed Use: 1 Zone: C
B ❑ A ❑ V Outside Flood Zone❑Aquifer
Zone 1-7>
THE FOLLOWING ENCIES SHOULD BE NOTIFIED:
❑ Board of . Board of ❑Con. Com. Cl Demo
❑ DPW ❑ Elec. ❑ Energy Reptort
Appeals Health Affidavit
Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning ❑ Sewer Card
❑ Water Card O ❑ Other
Chief Cut Off Board* ! Cut Off
1 Cut Off Zoning
* REQUIRES INSPECTOR'S REVIEW BE
FORE THE ISSUANCE OF A PERMIT.
DEPARTMENT
APPROVAL.
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date:
I
Fire Chief- Signature:
Date:
of Health: Signature:
Date: l QS
Conservation Commission: Signature:
Date:
Other: Signature:
Date:
Description of work being performed:
j
f. U -7 u p j } &-s
SECTION I -SITE
NFORMA'TiON
NUMBER OF PLANS SUBMITTED:
ITE PLAN SUBMITTED: ❑ yes ❑ no
-'g2
1.1 Property Address: -5 ? �
�
Nearest Cross Street: J' /S� -
Subdivision Name:
Total Land Area Sq. Ft.:
Assessors Map & Lot Number: i
MapQ
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commiission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c
.5 Sewage Disposal System: '
f �
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