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BP-2005-39602to ID ON x • LO), it v i n*o B 0 �t 10 TS jTTS �.J% Li .- W Z Y 0 W 17 �=0 a 0 c �i w i w =� N w•Ww o W cr- in J-. P, 9... t 7 3 . _ Jj ,- JI CD Z m Cc=- or - � o WUJ �Lo va RESIDENTIAL RESIDENTI AL 2.1 0,Amer of Record: K\1)tU (' . f, p1q kLEPE elElu o2 Si Glug,I -row p RD # 5o8 6360d q Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number U N 'FRVI E.' 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Re`istered 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") Address Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: ( JESTIIONS OR COMPLAWTS call or write: Home Improvement Contractors Registration, One Ashburton Place - Room 1301,-Boston, MA 02108, (617) 727-8598 Owners Name (print) -v��v Signature signing the above, the home owner acktWwledges that *there will be no eligibilty to the Guaranty Fund Data 3.4 Homeowner Exemption - One & Two Family Only FOR IIO1VTOWNERS wIIO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 Licensing of Construction Superivisors: Except for those structures governed by Construction Control in Section 116.0, effective Jury 1, 1982, no individual shall be engaged in dit ectly snpervi6ngpersons engaged in construction, reconstruction, aiteration, repair, removal or demolition involving the structural elements ofbuildings or stmctures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulatiors 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, ter 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, ir&ding but not necessarily limited to, general liability V NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor, whether or not they have taken the permit are responsi le for code compliance. (see Appendix of 780 CMR R5.2.15)) SECTION 4 - WORKER'S COMPENSAT ION INSURANCE AFFIDAVIT (MGL G 152 § 25) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to providle this affidavit will result in the denial of the issuance of the build ng permit. Signed Affidavit Attached: ❑ yes ❑ n 0 SECTION 5 -DESCRIPTION OF IIROPOSED NVORK (check all applicable) ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ Nwoodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door other ❑ diemolition (shed/garage) no. of windows doors (specify below): (spe-cify below): * If new construction, please complete the following: Single Family: no. of bedrooms no. of t aths Two Family: no. of bedrooms unit 1 no. of aths unit 1 no. of bedrooms unit 2 no. of aths unit 2 ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): _ o Boiler (heating) - fuel gas (natural or propane), fuel oil, c lectricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propz ne, 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: FpA) C F-M E iU� " /Mt2mt A b 4 SECTION - 6 ESTINI TED CONSTRUCTION COSTS item Estimated Cost ($) to be completed by permit applicant 1. Buildin 2. Electrical 3. Plumbing 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) * Estimated To.tal $ ©tom °0 SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) I, , as Owner f the subject property hereby authorize d by this building permit application. Date to act on my ell , i matters relative to work authorizc Signature of ��ic as Owner Authorized Agent hereby declare that the statements and information t of my knowledge and belief. on t e foregoing application are tr nd accurate, to the b S' tied under the pains and penalties of perjury. l Signature of Ovmer/Authorized Agent Date C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 2005 C:\bldg. forms\B idgapp.res.wpd Page 3 Rev. January 2005 RESIDENTIAL SECTION 8 - INSPECTOR'S REkIEWICOMMENTS 1. Date plan reviewed: G 2. DENIED (see project review worksheet): Date: 3. HOLD reason: 4. HOLD subject to Zoning Board of Appeals action: Comments: Date: Date: Inspector's Signature: Date: We � SECTIO -APPLICANT OTII<ICATION ^ " , Appli�nt informed of above Comments: Date C/ � e Tim. Cl• SECTION 10- OFFICE\INSPECTOR'.S NOTES Total Perna; Fee: $ -5'6 Less Application Fee: $ 25.00 Rema.ning Balance: TOTAL FEE: Gross Area - New Construction total sq. ft.__ Gross Area - Alteration total sq. ft. Per. it Issued To* % 6' C) e _) S f r � f %i� r /" S C am✓ t y c- f Li ?,G i✓' 7 - / J t G /'y S-0 l 7 J-o C6,a✓;' ✓p✓9SS �5 o/c t71-✓ Cc,-,e _2193 SECTION 11 - ADDITIONAL COMMENTS/SKETCHES RESIDENTIAL 61�h6u In., ^ ❑ FO UN OATION ONLY �� $25.00 APPLICATION FEE IS NONL REFUNDABLE & NON -TRANS �RABIW .E � DARTMOUTH BUILDING D PARTMENT DATE RECEIVED 400 Slocum Road, P.O. Bo 79399 Dartmouth MA 027 7 its t 508-910-1820 FAX 508- 10-1838 APPLICATION TO CONSTRUCT, REPAIR, REND ATE OR DEMOLISH A ONE OR TWO FAMILY DWELLJING T S ECTION R OFFICIAL, USE ONLY RECEI� ED SY: f BUILDING PERMIT NUMBER: i 2"" J X DATE SENT FOR REVIEW: LSLL DATE ISSUED: OK TO ISSUE - SIGNATURE: DATE" B ilding Official ,- Zoning Distrietsg roposed Use:Zone: C ❑ B ❑ A ❑ V Outside Flood Zone❑Aquifer- Zore THE FOLLO,VING AGEPf:IES SHOULD BE NOTIFIED: a l ❑ Board of :. oard of . OCon> Corn. ❑ De o ❑ DP 4V ❑ Elec. ❑ Ener gyReport . Appeals Health Affida, it Card Sent: Cut Off Follow -;op* ❑ Fire ❑ores ❑Planning ©Se: r Card ❑ Water Card ❑ ❑ Othe r i Chief Cut Off Board* rcut Off f Cut Off Zoning REQUIRESINSPECTOR'S RE VV BEFORE THE ISSUANCE OF A PERMIT. DEPARTNI ENTAL APPROVAL Zoning Review: Signature: 11 �c/ Date: (Q 6? Energy Report: Signature: Date: —.i Fir Chief: Signature: Date:_ card of Health: Signature:. L— / !ice �Si Date:,_ Conservation Commission: Signature: _ Date: Other: Signature: Date: - Description of work being performed: - -- �7/1/�' S " SECTION 1 SITE INFORMATION - NNLMBF.R OF PLANTS SUBMIT IrED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.2 Assessors Map & Lot Number: t 1.1 Property Address: — Map (?� Lot G- `' — Nearest Cross Street: Subdivision Name: 1.3 Historical District ❑ yes no Total Land Area Sq. Ft.: I,'as application been submitted to the Historic, (Commission" ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): i 1.5 Sewage Disposal System:FJ 51 C C:\bidg.fonms,Bldgapp.res.wpd Page 1 Rev. January'_'00" C:�bldg.for :�s\Bidgapp.res.�vpd Pate 4 Rev. January 2005 2