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BP-2001-21612Y C \ t \ 1 I \ \ 1 \ I \--------------J 1 \ I 1 \ 1 I J I r` V / z J . (< I C/) I z .m � o io I 0 I = I i \ I 1 \ I I I I x k -------------------- __ ___________ _ _ FIRST FLOOR S.F. NEW EL:0'-0" SECTIONS a1 1/4' = 1'-0' 1 '-4" NSALVES ROMAO.SANTOS JULY 7.2001 Al All la///Frrl ✓' /i�j // IJ FIRST FLOOR F.F. % r �% //�. . % './ ' EXISTING EL: 0'-0" I I ELEVATION AT COURTYARD 1/4"- V-0" A.1 GONSALVES ) t; i),7- FIRST FLOOR S.F. NEW EL: 0'-0" ROMAO.SANTOS IIULY 7.2001 MYERS CE SIMPLEX CONTROLLER WITH ALARM MOUND INSIDE DWELLING HIGH, MEDIUM AND OFF FLOATS INV. EL - 43.59_ ALARM ON--� EL - 40.68 PUMP ON - EL - 40.38 PUMP OFF ---- EL - 40.01 (MERCURY FLOAT SWITCH, TYPICAL) INLET - SET TANK ... .. �- STONE OR APPRIOVED LEVEL BASE �- ACCESS COVER (TO BE BROUGHT TO GRADE) 102 " F L1 2" BALL VALVE SCH. 80 PVC I I 2' SCH. 40 CROSS WITH CLEAN -our CAP /! 0 0 1/4 WEEP HOLE IN DISCHARGE PIPE l + t 2" BALL CHECK VALVE SCH. 80 4' I 'PULP OR APPDROVED EQUAL I 24" DU+M. COVERS L----------_j '*-BOT. ELEV. - 39.34 PLAN SET ON 6" OF CRUSHED STONE CROSS SECTION 1.000 GALLON PRECAST PUMP CHAMBER 0'-6- I (( t C I I 24" DLA. COVERS NOT TO SCALE 5'-8' PRECAST CONCRETE COVER RAISED TO WITHIN 6 INCHES OF GRADE WITH BRICK AND MORTAR. )UTLET GAS BAFFLE CROSS SECTION 1,500NOTPRECAST SEPTICTAN TO SCALE DESIGN_ DATA DESIGN FLOW: 3 BEDROOMS x 110 GPD/BEDROOM = 330 GPD SEPTIC TANK: 330 GPD x 2.0 = 660 GALLONS 1,500 GALLON (MIN.) TANK REQUIRED SOIL ABSORPTION SYSTEM: PERCOLATION RATE <2 MIN./INCH (CLASS I SOIL) DESIGN LOADING RATE = 0.74 GPD/SF LEACHING AREA REQ'D = (330 GPD) = 446 SF 0.74 GPD SF 600 S.F. MIN. REQUIRED BY DARTMOUTH BOH USE: 0.5' DEEP X 18' WIDE X 34' LONG FIELD LEACHING AREA PROVIDED: 18' X 34' = 612 SF > 446 SF REQ'D DAILY FLOW CAPACITY: 612 SF X 0.74 GPD/SF = 453 GPD > 330 GPD REQ'D �:G v(10 ti�vei _ / J _ Pit Y e l J LOCU$ �c cem lu Gidley3 Comer (Z\ 00 LOCUS PLAN SCALE. 1 "=2WV't 60' ELEVATION SCHEDULE: DESCRIPTION ELEVATION 4" INV. AT BUILDING 45.54 40 INV. AT SEPTIC TANK IN 44.00 4 INV. AT SEPTIC TANK 0 43.75 4 INV. AT PUMP CHAMBER IN 43.59 2" INV. AT PUMP CHAMBER 0 43.34 2" INV. AT DIST. BOX IN 49.99 4" INV. AT DIST. BOX OUT 49.82 4" INV. AT BEGINING OF SAS 49.77 4' INV. AT END OF SAS 49.60 ELEVATION AT BOTTOM OF SAS 49.10 GROUNDWATER ELEVATION 44.10 MAP 32, LOT 37 AREA: 321,776 SF THERE ARE NO WETWJDS WITHIN 200' OF ANY OF THE PROPOSED IMPERVIOUS LOT COVERAGE: 1.5$ IMPROVEMENTS AS CONFIRMED BY THE DARTMOUTH CONSERVATION COMMISSION OFFICE UNDER THE A-1 INSPECIION FORM PROCEDURE. 5' LIMITOF UNSURABLE ` ► 17V 48 SOIL REMOVAL TO PROPERTY LINE .... _ _.... ....... _...,,, -- 47- 356't �- VENT TO PROPERTY LINE PROPOSED 0-BOX _ . - \ . TP 187't Y TO PROPERTY LINE . _--- t00Z RESERVE AREA BENCHMARK: SPIKE SET IN r'. CEDAR TREE ELEVATION - 48.54 0p PROPOSED`',.1,000 GALLON PUMP CHAMBER 0 \ / PROPOSED IAOO GALLON SEPTIC TANK PROP.�, 1-BEDROOM ADDITION EXISTING Ist `�-- 48- I \ DRINKI G AT CESSPOOL EXIST. ) 2-BEDROOM DWELLING I SILL EL 50. EXIST. PRIVATE 49 DRINKING WATER1 I SUPPLY WELL 1 1 ` \ I I � 1 l J' if cow low vpw SCALE: 1 "=200' 30 TOWN READ GIDL.EY 0 30 60 90 Scale 1 " = 30' LEGEND ---------49 --- ------ ---- EXISTING CONTOURS - --'- PROPOSED CONTOURS ® PROPOSED SPOT ELEVATION TP-1 OBSERVATION HOLE LOCATION EDGE OF BITUMINOUS PAVEMENT W PROPOSED WATERLINE OUTLET TEE TO BE FITTED WITH GAS B ANO 29') 4" Z�DVC SCH. 40 = 45.54 AT HOUSE) 4" PROP. 1.500 GAL PRECAST CONCRETES TANK 20' MIN. TO BUILDING 2" CLEAN WASHED PEASTON'E RANGING FROM 1/8" TO 1/2" AND FREE FROM IRON, FINES AND DUST 3.0' 60 1 GRADE COVER AT SEE PUMP CHAMBER DETAIL FOR C,RADE FLOAT SETTINGS 21 2! SOR EL 49.99 d'" DISTRIBUTION BOX PROPOSED 1,000 GAL PRECAST CONCMETE PUMP CHAMBER SEPTIC SYSTEM PROFi NOT TO SCALE ]VIDE T FIRST 2' TO BE LEVEL 2x SLOPE (MID•) �� 2" OF 1/s" TO 1/2' VENT e'0NE 4" PE!=. PIPE 4" SOLID PVC SCH. 40 S-0.0( EL - 49.60 , I S-0.005 18VX34'LX0.8''IFI� i I 6" OF 1-1/2* OF WA<HED STONE - 49.10 I EL -49.77 L I REMOVE UNSUITABLE SOT:. dt: REPLACE 1 WITH CLEAN FILL IN ACCORDANCE WITH I ---- - CMR 15_25.'��3) - --) EL - 49.82 DEPTH TO GROUNDWATER 5' MINIMUM GR61NDWATM ELEV. - 44.10 W,_-D ON TP-1 NOTE 1. THE CONTRACTOR SHALL NOTIFY THE LOCAL BOARD OF HEALTH AND PRIME ENGINEERING, INC. AT LEAST 48 HOURS PRIOR TO REQUIRED INSPECTIONS. 2. BENCHMARK IS SPIKE IN CEDAR TREE, ELEVATION = 48.54 (ASSUMED DATUM) FlNI4 GRADE: 3. HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS 0l THE SEWAGE DISPOSAL FIELD 51.9 51Z� DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. (SE_ PLAN VIEW' 4. NO FIELD MODIFICATIONS TO THE SEWAGE SYSTEM SHALL BE MADE WITHOUT PRIOR WRITEN APPROVAL BY THE THIS' DRAWING) ENGINEER AND THE LOCAL BOARD OF HEALTH. z 5. UNLESS OTHERWISE NOTED ALL SYSTEM COMPONENTS SHALL BE INSTALLED I� ACCORDANCE WITH TITLE V ORDINARY* OF THE STATE ENVIRONMENTAL CODE DATED MARCH 1996, AND ANY APPLICABLE LOCAL RULES. BACKFILL' M 6. SEPTIC TANK,' PUMP CHAMBER AND DISTRIBUTION BOX SHALL BE MANUFACTURED BY J&R PRECAST OR APPROVED EQUAL. 50.27 7. B TO GROUT ILE GASKETS AND OUEE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE D 0 N I I 49.77 STRUCTURES IN ORDER TO PROVIDE A WATERTIGHT SEAL. MORTAR ALL INLET A\D OUTLETS NOT USED ON ALL CONCRETE STRUCTURES. I 8. THE IRST TWO FEET OF EACH LINE EXITING THE DISTRIBUTION BOX SHALL E LEVEL. �0 1 I ; - REMOVE UNSUITABLE SO �- 49.27 L dt REPLACE WITH CLEAN FILL I 9. THIS SYSTEM IS NOT DESIGNED TO ACCOMMODATE A GARBAGE GRINDER. 5' MIN- 5' IN ACCORDANCE W 310 CMR 15.255(3) PIPE CONFCIRMIINNG row 10. SYS'�EM COMPONENTS TO WITHSTAND H-10 LOADING CRITERIA. \_ --------------- ------------------� ASTM D 27'29-12 MAX. WATER TABLE EL 44.10 11. FLOOD ZONE LINES ARE APPROXIMATE ONLY, BASED ON THE FLOOD INSURkNCE RATE MAP OF THE TOWN OF- DARTMOUTH, COMMUNITY-PANNEL NUMBER 250051-022-E, REVISION DATE JULY 2, 1992. 12. PROPERTY LINE INFORMATION BASED ON PLAN OF R. SWAIN GIFFORD-ESTATI. SITUATED AT CROSS SECTION Ai START OF LEACH FIELD NONQUITT-DARTMOUTH, MASS, DATED DECEMBER 1922, BY FRANK M. METCALF, C.E., NEW BEDFORD, MASS No`r TO SCALE 13. THERE ARE NO KNOWN WELLS WITHIN 200 FEET OF THE PROPOSED LEACH FIELD. 15. AN AUDIBLE ;AND VISUAL ALARM SHALL BE PROVIDED. PUMP TO BE ON SEPARATE CIRCUIT FROM ALARM. 16. PUMP AND APPURTENANCES TO BE INSTALLED AND LOCATED ACCORDING TO MANUFACTURES INSTRUCTIONS BUOYANCY CA CU IONS 1,000 A N TANK: AND LOCAL BUILDING AND WIRING CODES. DOWNWARD FORCE: WEIGHT OF EMPTY 1,000 AL. TANK = 8,000 LBS. PROVED EQUAL 17. PUMP SHALL CONSIST OF MYERS MODEL SRM4 SUBMERSIBLE PUMP (OR AF )• PUMP SHALL WEIGHT OF SOIL ABOVE TA K: BE RATED AT 4/10 HP AND SHALL HAVE A 2" DISCHARGE. THE PUMP SHALL OPERATE FROM A 115 VOLT, 142 CF OF SOIL X 110 L /CF OF SOIL = 15,700 LBS. 11.5 AMP, SINGLE PHASE, 60 HERTZ POWER SUPPLY. DOWNWARD FORCE = 8,00 + 15,700 = 23,700 LBS. 18. CONTRACTOR TO ENSURE LIQUID IN DISCHARGE PIPE FLOWS BACK TO PUMP CHAMBER AFTER PUMP BUOYANT FORCE: (ASSUME TANK FULLY SUBMERGED IN WATER) CYCLE. VOLUME OF DISPLACED WA ER = 180 CF BUOYANT FORCE = 180 C X 62.4 LB/CF = 11.300 LB 19. PUNIP CONTROL PANEL SHALL CONSIST OF MYERS CE SIMPLEX ELECTRICAL CONTROL PANEL (OR APPROVED 23,700 LB > 11,200 LB DOWNWARD FORCE > BUOYANT FORCE) EQUAL). PUMP CONTROL PANEL TO BE LOCATED INSIDE PROPOSED DWELLING. BUOYANCY CALCULATIONS 1 500 CALL ON TANK: DOWNWARD FORCE: WEIGHT OF EMPTY 1,500 GAL TANK = 12,000 LBS. WEIGHT OF SOIL ABOVE TA K: 93.9 CF OF SOIL X 110 /CF OF SOIL = 10,326 LBS. DOWNWARD FORCE = 12,0 0 + 10,326 = 22,326 LBS. BUOYANT FORCE: (ASSUME TANK FULLY SUBMERGED IN WATER) VOLUME OF DISPLACED WA ER = 357 CF BUOYANT FORCE = 357 C17 X 62.4 LB/CF = 22,277 LB 22,326 LB > 22,277 LB (OWNWARD FORCE > BUOYANT FORCE) 5 - 5' DU. PUMP DESIGN: I REQUIRED HEAD = FRICTION LOSS t ALTITUDE CHANGE f STATIC PRESSURE CH NGE 15' L ALTITUDE CHANGE = 49.99 - 40.01 = 9.98' FRICTION LOSS = 2.9' STATIC PRESSURE CHANGE = 0 REQUIRED PUMP HEAD = 0.0' + 2.9' = 12.9' PUMP PERFORMANCE CURVE (MYERS MODEL SRM4): HEAD (FT) 3 10 13 19 _OW (GPM) 95 60 35 0 SOIL TESTING AND PERC TEST PERFORMED BY ROBERT REGO OF PRIME ENGINEERING, INC:. AND WITNESSED BY DARTMOUTH HEALTH AGENT, SUE GRIFFIN ON 6 27-01 SOIL SOIL HORIZ. COLOR TP-1 DEPTH dam• SOIL HORIZ. SOIL COLOR TP-2 DEPTH ELEV. 0 47.10 0 47ZO A 10YR 5/3 SANDY LOAM A IOYR 5/3 SANDY LOAM 10" 12" Bw IOYR 6/6 SANDY LOAM 24" Bw IOYR 6/6 SANDY LOAM 30" e 36" 44.10 C7 2.5YR 7/4 LOAMY SAND T 40" 43.97 4:5" BOTTOM CF PERC HOLE 66" Cz 2.5YR 7/2I M/C SAND 1 1 120" 37.10 ESTIMATED HIGH GROUNDWATER ELEV. - 44.10 DESIGN PERC RATE = 1" IN <2 MINUTES NOTE: LAYERS A, B, AND C1 TO BE REMOVED ANC UNSUITABLE SOIL TO BE REMOVED TO A DE OF 5'-0" BEYOND THE LIMITS OF THE SOIL C 2.5YR 7/41 M/C SAND 1 1 120" 37.30 ESTIMATED HIGH GROUNDWATER ELEV. - 43.97 DESIGN PERC RATE - 1" IN <2 MINUTES REPLACED WITH CLEAN FILL IN ACCORDANCE WITH 310 CMR 15.255(3). TH OF 30" TO 66" INCHES BELOW GRADE :AND TO A DISTANCE ABSORPTION SYSTEM. 15 • :•A NOTE: DISTRIBUTION BOX SHALL I COMPLY TO MINIMUM REQUIREMENTS -+ OF 310 CMR 15.232. 3 - 5' 6k INLETS BACKWASH OF WATER BOARD OF HEALTH STAMPS PURFICATlON OR THIS SYSTEMIS NOT CONSTRUCTION OF -HIS DESIGNED FOR GARBAGE SEPTIC SYSTEM MUI T BE FILTRATION DEVICES MAY GRINDER WHIRLPOOL COMPLETED WITH T REE NOT BE DISCHARGED TO OR OTHER HIGH �','�TER (3) YEARS OF THE D WE 'THIS SEPTIC SYSTEM 3i 0 CMR 15.004 (0) USE DEVICES, OF APPROVAL _ BOARD OF HEALTH STAMPS p.FPFt0 Q,D of -. THE AppRo-SAL Y BOARD OF HEALTH INISPECTION mCo y�� OOEI OTG��pATH7tS(QFF6CE Q tM r,� UI EXCAVATED 11F�N EL T1IE •ttlj;.i�a.D �'vp` t..'4 o BY ATs ' &z EFFECTIVENESS o ANY Zo wrwko�S DART„BOOTH &IOCO Os ;�[,^„ r�l L �' O xIS MUST NOT BE P.E. STAMP . •..AR, SUBSURFACE SE DISPOSAL SYSTEM a� PICHARD yG` OWNER: LEONARD GONSOLVES, DARTMOUTH, MA i uz3. + C RHEAUME ASSESSORS MAP do LOT. MAP 32, LOT 37 1 3 c� No. 28373 - CIVIL DARTMOUTH, MA STREET LOCATION: 51 GIDLEY TOWN ROAD, G/STEM FS'y/0N AL ENGINEERING FIRM: P.L.S. STAMP PRIME ENGINEERING ENGINEERS AS -BUILT CIVIL ENGINEERING •LAND SURVEYING •ENVIRONMENTAL ASSESSMENT A �1 P.O. BOX 1088 350 ORD STREET LAKEVI MASSACHUSEITS 02347 i��{`11'Y & CERTIFICATION TEL_ (5088947-0050 r•'+� (5088)947-2004 STATEMENT REQUIRED DATE: JULY 31, 2001 REVISED: SEPT. 16, 2001 CONTACT PERSON: BOB REGO, p3IME ENGINEERING, INC. ;.._.- ADDRESS: P.O. BOX 1 o,%, MA TELEPHONE: (508) 947-0050 SEP 1 8 C-\PRO.r_-'M\SEPTIC\DkgrMOUTH\GIDLEY TOWN\CIDLEY TOWN -DWG RESIDENTIAL 2001 RESIDENTIAL 2001 SECTION 2 - PROPERTY WNERSAIP / AUTHORIZED AGENT 2.1 Owner of Record: /j to�?4 /— J / / e, o nl,¢ Ra[ (SON SA k ej r1 �-4 4 Fry- jut 4 Name (print) Contact Address Phone Number 2.2 Authorized Agent: Ae � -TT -,f 9 F L 7SW Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 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") 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: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors One Ashburton Place - Room 1301, Boston, AM 02108, (617) 727-8598 /Registration, Owners Name (print) / e o -vt A R r9-lu e t $ignature by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund Date 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 in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings 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 dwelline, 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 s ction sign below: Signature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construcltion Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide tihis affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* [tiddition 11 alteration ❑ repairs ❑ chimney/ ❑ wroodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. replacement window/door ❑ other ❑ &;molition (shed/garage) To. of windows doors (specify below): (speeiify below): * If new construction, please complete the following: Single Family: no. of bedrooms no. of bai hs Two Family: no. of bedrooms unit 1 no. of ba hs unit 1 no. of bedrooms unit 2 no. of ba hs unit 2 ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, el ctricity, other (specify): ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fue Oil Other Brief Description of Proposed Work: +K ,1' T •nIS ey 1 ,i,,, J T" SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. Buildine 2. Electrical 3. Plumbiniz 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) * Estimated Tota $ SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agenll�t or contractor applies for building permit) (please print) I, 4eZ) j ARtC( f: I , as Owner of / he subject property hereby authorize �i r�p erT r%.F to act my behalf in all tters relative to work authorized y this building permit application. Date Signature of Owner SECTION 7B - WNER A ' II HORiZED A ENT DE LARATION / as Owner/A ithorized Agent hereby declare that the statements and iinformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date C:\bldg.fomms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.fonns\Bldgapp.res.wpd Page 3 Rev:. January 19, 2001 RESIDENTIAL 2001 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: - 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(see project review worksheet): Date: 5. DENIED (see project review worksheet): Date: 6. HOLD reason: _ Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Signature: - Da PT 0 4 00 t SECTION 9 - APPLICANT NOTIFICATION Applicant informed of above Date: '- Time: Clerk: Comments: SECTION 10- OFFICE\INSPECTOR'S NOTES Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ j_- TOTAL FEE: �a-��b ° Gross Area , New'Constructiori total sq. ft. Z o" Gross Area - Alteration total sq. ft. Permit Issued To- SECTION 11- ADDITIONAL COMMENTS/SKETCHES RESIDENTIAL 2001 ❑ F0UNDAT'ION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFI> ;RABLE i DARTMOUTH BUILDING 400 Slocum Road 11.0. DEPARTMENT Box 79399 DATE RECEIVED Dartmouth , 508-910-1820 FA A 02747 508-910-1838 - APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY IDWELLING THIS SE TION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT DATE SENT FOR REVIEW: NUMBER: DATE ISSUED• OK TO ISSUE - SIGNATURE: DATE OCT 0 4 2001 ildingCom issioner/Inspecto of Buildings Zoning District:��roposed Us :1 ne: ❑ C 1� ❑ A ❑ V Outside Flood Zone ❑ Xquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIE ❑ Board of ❑ Board of ❑Co Ce?% ❑ Demo ❑ DPW ❑ Elec: ❑ Energy Report Appeals Health - Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other _ Chief Cut Off / Cut Off / Cut Off Review* * REQUIRES INSPECTOR S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: z,,5A OCT 0 4 2001 Date: Energy Report: Signature: J OCT 0 4 2001 Date: Fire Chief- Signature: Date: �fl �- 1 n Board of Health: Signature:( Date: Conservation Commission: Signature: Z d L Date: Zz Other: Signature: Date: _ Description of work being performed: SEC ON 1 - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes `❑ no _ 1.1 Property Address: �/ s��sy. 1�S 1.2 Assessors Platt & Lot Number:411 !� Plat Lot V Nearest Cross Street: Subdivision Name: 1.3 Historical District ❑ yes Erno �C' Total Land Area Sq. Ft.: ' Has application been submitted to the Historic Commission? ❑ yes ®no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal& Private Well ❑ Municipal 0 On S''ite Disposal System a,ib\Q.", Page 1 Rev. January 19, 2001 G C:\bMg, forms\B Idgapp.res.wpd Page 4 Rev. January 19, 2001 C:\bldg. formslBldgapp.res.wpd