BP-2004-34193L17
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PISTRICT
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YOUR DaWu\�Q MUST V� K"'T
AT THE BUILDING DURK0 T"
PPIOGRESS OF TH'S WORK.
EUjjLjyNG DEPARTMENT
r,ONO-TUSE SIZE AND DEPTH
jg5THp,"�CTION IS REQUIRED BI-FED.O19E
F Cot4CRETE IS POUR
LzUILDING DEPARTMENT
:TOWN OF DART"'117 H
RECOW) PLAt!
f, Cs p if W., T 41 S E n d C"T T c
Plan Must B KEPt 011 SitO
Darin, Duct 0'.
NG RF
STOPPING .
FIRE I gilREMENT
d walls -.�nd floors shall be
Flonetrations o1ru rate ), preventing the
s,.jaled with a material c,-'Pat"� ad
nar,,sage of jja-�jjcs and ha
t gz% .3ses when subjected
Test Standard EPIsdilc
the requirements Of the
Fir StOP s ASTM, E-61 4.
.0
1"L
LOD F- �L;Ao�.
11
C)An7rV OZ7 :71 IOU
C j
i ST R1
FIR= -QTQPP1NrJ REQUIREIAE
Penetrations thru rated %vzalls and floors shall be
p
sealed with a material r.rb!e ofl
pac,sc,ge of flames and w-ion subjf*eventingacthet��.,
to the requirements of V5 jest Standard erpedllc�
for Fire StofA- ASTM-E-81 4.
OF DJARTMICUTH
nECORD PLAT!
A Copy (Y1, This Endc=m".a
Plan Must Be- rept On
Duriv, " ft, 0;W_
SONO-TLIZE SIZE AND DEPTH
IWPECTION IS REQUIRED BEFOF'E
THE CONCRETE IS POURED,
Iv-
Ir-
,UILD!'40 DEPARTMENT
Tjr,i CO D-t-t—Mr-C
VjU.rA Di Wwa 14JST 2=5 XPPT
AT THE rpmbiNa DURING THE
Pr=p!:S OF TWS WORK
CU!LDM DEPARTMENT
Torm eg Dartmaten
J 1 L 3 G \/,
HIT, u0i",
)I, IN q-0 11
V
L'A' t---1
yt":l- 0 "
AT I(E FLnLOING DUr-.IN 3 THE,
3,r'i'►.° S OF THIS WORK.
ir!J MIG DEPARTMENT
11 `-- 1 C)" le I So 1- ,Z 91 01 _
Svc. gm6rc
2->P.'a (� lVe/L
1-2.
\ ' en
f «�
t a1 'p"Vd
=- I ��
nl�W J%CI.nI�- w4•M1 wf-Xty-�.
a 12Ktb
0 6EAC146 WALL
c o'-.3-t,.. V j / trot i V—
A VT, & ,
zt— ol1
ISTRICT
k S 30
FIRE STQG R�QI,IlRIr�4�Y
Rf'
Pcnetrations thru rated walls and floors shall be
sealed with a matori l caps bls of preventing tht-
paswge of flame: an hot gasses when sub;l0ded
to the requirements of the Test Sfanderd €tic
for Ftm St AS'i'AR- -b1 4.
IAAIrA
,C-Xi41,
eln
L
",,- -r, -
RF,SIDENTIAL
2004
RESIDENTIAL
2004
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
% to a� r�.isr dl� ��e�h e �m� r.¢-lire J
�5 / 6c&::Se 76CIZI, 21 i
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor � /�w 1
License Number 0-U7;,ro
Address �) ,� o 2 ��
Expiration Date
Signature Telephone 1�-a-q-NJ
3.2 Registered Home Improvement Contractor: 1/G% !! SrW)k
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? in 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 �.f i�'l��.v
Registration Number (if none, state ❑ none[])
l o Li sr �J
v s'
Address 4� /f
SignatureA' Telephone �1
Expiration Date
3.3 For Residential Remodel W Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
Y
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
F Owners Name (print)
Signature
'.y 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 ef:gaged 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 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
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 responsible
for code compliance. (see Appendix of 780 CMR R5.2.15,)
SECTION 4 — WORKER'S COMPENSATION
INSURANCE AFFIDAVIT (MGL C 152 § 25)
e
ted and submitted with this application. Failure to provltde thts affidavit
Workers Compensation Insurance affidavit must be compl
will result in the denial of the issuance of the building pen
it. Signed Affidavit Attached: ❑ yes ❑ no
SECTION 55 - DESCRIPTION OF
PROPOSED WORK (check all applicable)
❑ new construction* "addition
m"alteration ❑ repairs ❑ chimney/ E3 woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg.
❑ replacement window/door ❑ other 11:1 demolition
(shed/garage)
no. of windows_ doors_ (specify below): ((specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. c
f baths
Two Family: no. of bedrooms unit 1 no.
f baths unit 1
no. of bedrooms unit 2 no.
f 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: �< %% D �-
�'� Log m - u F
"� 7"i rcrc
SECTION - 6 ESTINIATED
CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1 Rnilrlina
F.lrrtrirnl
i Phimhino
�(
d MPrhnnirnl (HVAC)
5. Total = (1 + 2 + 3 + 4)
* Estimated
Total $ OJ d_0'0
SECTION 7
- OWNER AUTHORIZATION
(to be completed when owner'
agent or contractor applies for building permit)
(please print)
/
I, 1e6n /¢h� �dyt�fi4 w�1 , as Owner
of the subject property hereby authorize
zed by this building permit application.
Date
to act on my behalf, in all matters relative to work authorJ
Signature of Owner
SECTION 7B - OW
R/AUTHORIZED AGENT DECLARATION
as Ow
er/Authorized Agent hereby declare that the statements and information
best of my knowledge and belief.
on the foregoing application are true and accurate, to the
Signed under the pains and penalties of perjury.
4/2
Signature of Owner/Authorized Agent
Diate
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Rev. January 1, 2003
RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE
SECTION 8 — INSPECTOR'S RFVTFW/VnNncrtVNTQ
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
5. DENIED (see project review worksheet):
6. HOLD reason:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments
RESIDENTIAL
❑ FOUN ATION ONLY
$25-00 APPLICATION FEE IS NO -REFUNDABLE & NON-TRANSFERAMLE
DARTMOUTH BUILDING DEPARTMENT = DATE kh�EIVEL) Q � N
400 Slocum Road P.O. Box 79399
� tEl ...t
y;
Dartmouth, MA 02747 7' `' — t:' i 10: 42
508-910-1820 FAX 508-91 -1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE
THIS SECTION FC
RECEIVED BY: L
DATE SENT FOR REVIEW:
OK TO ISSUE - SIGNATURE: !i L
9. Inspector's Signature: Date: ? Zoning District:- oposed Use: _Lone:
SECTION 9 A L ANT NOTIFICATION � THE FOLLOWING AG]
Applicant informed ab ata: �� ime: Clerk: ❑Board of JBoard of ❑ .Cone. 01
Comm; nts: Appeals lth A ff
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ / Less Application Fee: $ 25.00
TOTAL FEE: /,35. 00 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Is�gl�dxa 'r
❑ Fire 0 Gas
Chief Cut Off
Remaining Balance: $ //a. ��
SECTION 11 - ADDITIONAL CdMMENTS/SKETCHES
7,///0
"�- r416 V7
* //, 5 - , z "
C:\bldg.fonns\Bldgapp.res.wpd Page 4
Rev. January 1, 2003
Zoning Review: a X
Energy Report: 0/L
Fire Chief: *
Board of Health:
Conservation Commission:
Other:
Description of work being,
B DEMOLISH A ONE OR TWO FAMILY DWELLING
OFFICIAL USE ONLY
BUILDING PERMIT
DATE ISSUED:
DATE 7/ !I C'
of
❑ B ❑ A ❑ V Outside Flood Zone 0 Aquifer
> SHOULD BE NOTIFIED:
❑ Planning Board* ❑ Sew r Card
/ Cut Off
* REQUIM INSPECTOR'S RE
DEPARTMENTA
Signature:
Signature:
Signature:
1 �
Signature:
Signature:
Signature:
rformed:
SECTION 1 -
NUMBER OF PLANS SUBMITTED:
1.1 Property Address:_
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.
2004
❑ DPW
❑ Elee.
❑ Energy Report
Card Sent:
' Cut Off
Follow: -up*
❑ Water Card
❑ Zoning
❑ Oth(-•y
/ Cut Off
Review*
BEFORE THE ISSUANCE OF A PERMIT.
%tOVAL
Date: Wvv
Date:
Date:
Date: L
Date:
Date:
Es
SITE PLAN SUBMITTED: M11yeS ❑ no
1.2 Assessors Plat & Lot Number: r
Plat-1 .2— Lot Z
1.3 Historical District ❑ yes CJ no
j14 Has application been submitted to the Historic CQ)mmission?
yes eno Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
Municipal k'Private Well ❑ Municipal 1? n Site Disposal System
C:\b1dg.f6rms\B1dgappAs.wpP6 1 - — Page 1 �
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