BP-2003-30280F
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GIDLEY TOWN ROAD
DRAWN BY: BNP APPROVED BY: RJR • CIVIL ENGINEERING P.O. BOX 1088
• LAND SURVEYING J50 BEDFORD ST.
DATE: JUNE 5, 2002 PROD. NO. 6960101 �� LAKEVILLE, MA 02734
AS-BUILT.dwq DWG. • ENVIRONMENTAL PRIME E1VGl�VEt=R1111G TEL: 508,947.0050
DWG. NO.: ASSESSMENT FAX: 508.947,2004
DESCRIPTIO
4
ELEVATION
PROPOSED
ELEVATION
ACTUAL
4' INV. AT BUILDING
45.54
(a)47.5. (b)4Q5.2
4" INV, AT SEWTIC TANK (IN)
44.00
45.45
4" INV. AT SE TIC TANK (OUT)
43.75
45.20
4' INV. AT PU
P CHAMBER (IN)
43.59
44.78
4" INV. AT PU
P CHAMBER (OUT)
43.34
45.61
4" INV. AT DI
. BOX (IN)
49.99
51.53
4INV. AT DI
. BOX (OUT)
49.82
51.37
4' INV. AT BE
INNING OF FIELD
49.77
51.34
4" INV. AT EN
OF FIELD
49.60
51.18
VERTICAL DATUM IS ASSUMED.
1, RICHARD
. RHEAUME, P.E. OF PRIME ENGINEERING, INC.,
HEREBY CE
TIFY THAT THE SUBSURFACE DISPOSAL SYSTEM
HAS BEEN
ONSTRUCTED IN COMPLIANCE WITH 310 CMR 15.000,
THE APPRO
ED DESIGN PLANS AND ALL LOCAL REQUIREMENTS
AND THAT A
Y CHANGES TO THE DESIGN PLANS HAVE BEEN
REFLECTED
9N THE AS -BUILT WHICH IS HEREBY BEING
SUBMITTED
O THE DARTMOUTH BOARD OF HEALTH.
RHEAUME, P
tMHARO
J.
RHEAUM6
No. 28373
CIVIL
DESC
IPTION
I.D.
FROM ®
FROM
1.500 GAL
TANK COVER
1
32.6
22.8
1.500 GA4
TANK COVER
2
35.6
24.5
1.500 GA4
TANK COVER
3
40.7
26.6
1,000 GA
PUMP CHAMBER
4
46.8
30.9
1,000 GA
. PUMP CHAMBER
5
51.4
34.2
DISTRIBUTION
BOX
6
110.5
85.6
FIELD
7
101.2
77.0OF
FIELD
8
104.3
88'1OF
ECORNEROF
FIELD
9
121.8
104.OF
E94.9.
FIELD
10
119.2
3-,
13
SHT. NAME
51 GIDLEY TOWN RAAD
DARTMOUy, AA SEPTIC SYSTEM AS L lUILT
MR. LEONARD GON�ALVES LOCATION PLAN
DARWUTH, MA
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2003
RESIDENTIAL
2.1 Owner of Record:
De t�/�ICZ�I ei 6")V1
Name (print)
2.2 Authorized Agent:
Contact Address
Phone Number
Name (print) Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
TPicable ❑
Licensed Construction Supervisor
umber
Address
n Date
Signature Telephone
3.2 Registered Home Improvement CAntractor:
cable ❑Are you a Home Improvement C" ontractor subjectto (780 CMR-6)Are you claimin exetrf If no, go to tg ptton from the requirement? ❑ yes ❑ n
If yes, submit the
required affidavit!
Company Name
Address Registration Number (if none, state Elnone❑)
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 Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
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
RS WHO
TO PERFORM
D BE
109.1.1 Licensing of ConstructiFOR on Supervisors: Except for those structures goveevrn d by ConstruBtion Control in Se SecLE FOR THEIR OWN tion CT
effective July 1,1982 no
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 forLicensing
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 engges 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 og are applying under this section sign below:
Signature:_ 1%
Your ci—h-
--- -.w.-,,,...... � — losponsinutties, 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 ConstructR. 2003
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 COMPENS;iTIUIN INSURANCE AFFIDAVIT (MGL C 152 & 251
Workers Compensation Insurance affidavit must be complete(
will result in the denial of the issuance of the building permit.
SECTION 5 .DESCRIPTION OF PR
❑ new construction*
(energy report required)
❑ deck ❑ pool
❑ addition
(energy report required)
❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
no. of bay
Two Family: no. of bedrooms unit 1
no. of bal
no. of bedrooms unit 2no. of bat
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, ele
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, elec
❑ HVAC (combined unit) - primary fuel, natural gas, propane,
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric__
Fuel
Brief Description of Proposed Work: IV 1
Item
1 Rnildino
? Flertrirnl
I Phimhina
4 MPrhnnirnl (IIVAC)
5.Total =(1+2+3+4)
(please print)
to act on my
of Owner
SECTION - 6 ESTIMATED
* Estimated Total
submitted with this application. Failure to provide thiis affidavit
Signed Affidavit Attached: ❑ yes ❑ no
;ED WORN (Check all ar►rilir��1,1„1
alteration ❑ repairs ❑ chimney/ ❑ w
fireplace otodstove
replacement window/door ❑ other ❑ demiolition
J. of windows_ doors_ (specify below): (specify below):
unit 1
unit 2
city, other (specify):
:ity, other (specify):
'etricity, other (specify):
t----- Other
COSTS
Cost N to be completed by permit applicant
SECTION 7A - OWN0 AUTHORIZATION
(to be completed when owner's agent or ontractor applies for building permit)
as Owner of the subject property hereby authorize
all matters relative to work authorized by thil building permit application.
SECTION 7B - OWNER/
on the foregoing application are true and accurat, as Owner/Author
e, to he best of my
Signed under the pains and penalties of perjury.
Z2
Date
AGENT DECLARATION
Agent hereby declare that the statements and informattion
wledge and belief.
Signature of Owner/Authorized Agent
Date
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Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd
RESIDENTIAL
❑ FOUNDATION ONLY
S25-00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
20W2
SECTION S - INSPECTR'S REVIEW/COMMENTS
/�
1. Date plan reviewed: � v 3
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
Date:
"SECTION 9 - A P fICANT NOTIFICATION
Applicant informed of above Date: Time:
Comments:
Clerk:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ 7j - 00
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: �� Gross Area - New Construction total sq. ft.
Gross Area - ation t t 1 sq. ft.
Permit Issued To.
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
UJ cal `l ,(� ,' ()
RESIDENTIAL 2003
❑ FO Uj VDATION ONLY,.
$25.00 APPLICATION FEE IS N N-REFUNDABLE & NON-TRANSFERFA%BLE
` r`rnT
°"T"".
, M9y DARTMOUTH BUILDING DEPARTMENT
N
DATE RECEIVTED
416
o = 400 Slocum Road, P.O. Box
79399
Dartmouth, MA 027,17
508-910-1820 FAX 508-
10-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVAT I
OR DEMOLISH A ONE OR TWO FAMILY DWELLING;
THIS SECTION FpR
OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUM!f;ER: `t d
' ?
DATE SENT FOR REVIEW: A/
DATE ISSUED:
OK TO ISSUE - SIGNATURE:
lit
? DATE
Buil tng Co si
ertinspector of ild ngs
Zoning District:.- -- - Proposed Use://X�'- Zone
C ❑ B ❑ ❑ V Outside Flood Zone ❑ Aquifter Zone
TH FOLLOWING A
NCIES SHOULD BE NOTIFIED:
❑ Board of C" -oard of Con. Corn. ❑
?
emo ❑ DPW ❑ Elec. ❑ 11,nergg Report
Appeals �- ealth A
idaw Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑
Sewer Card ❑ Water Card ❑ Zoning ❑ Gather
Chief Cut Off iGut
Off ! Cut Off Review*
* REQUIRES INSPECTOR'S I
EVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL
APPROVAL
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date:
Fire Chief: Signature:
Date:
Board of Health: Signature:
P - Date:
�ry
"
J-e e(Date:
Conservation Commission: Signature: I-
-
Other: Signature:
Date:
Description of work being performed:
SECTION
I - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: acs ❑ n10
1.2 Assessors Plat &-Lot Number:
1.1 Property Address:
Plat4P _�2 Lot' -
Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
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:
Private
Well
❑ Municipal L/On Site IDisposal System
El Municipal
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