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:SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
ROAN Clzm ei '-wile lr4),,4•, _�wezpr-TffC
PC, C f 70 s Y0
Name (print)
Contact Address Phone Number
SECTION 3 -,CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: ftlr1 C�
License Number: i',-% QO
Address: j (feN L7l R-
Expiration Date: r
%07
Signature: w Telephone: �� - 990-2 J(%
g/f V
3.2 Registered Ho Improvement Contractor: 12 o 6S / ��/ ylo2 0)0
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
�/
Company Name: Q •e Cht - i
registration Number (if none, state "none"):
Address: ) Q 3 L Je
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
El I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
bate:
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 enraged 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.
Exceptiorr_ 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 Co
a provides in the Rules and Regulations section that amy licensed Constructio
Supervisor, whether or not they have taken the permit are re
ponsible for code compliance. (see Appendix of 780 d•AR R5.2.15)
-:',SECTION 4 -WORKER'S COMPENSATION
INSURANCE AFFIDAVIT (MGL c 152 § 25)
Worker's Compensation Insurance Affidavit must be comp)
ted and submitted with this application. Failure to provirae this
affidavit will result in the denial of the issuance of the building
permit. Signed Affidavit Attached: ❑ Yes !❑ No
SECTION 5 - DESCRIPTIONS
OF PROPOSED WORK (Check all applicable) '. .
❑ Deck ❑ Pool Repairs
0 Alteration ❑ Chimney/Fireplace ❑ Woodistove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg.
❑ Roofing/Siding ❑ Other -
,(Energy report required) (Shed/Garage)
(Speciify below)
❑ Addition ❑ Replacement wir
dow/door ❑ Demcilition
(Energy report required) No. of windows
Doors _ (Speciify below)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No.
f Baths
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, electric
ty, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electrici
, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, elec
tricity, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric
Fuel Oil Other
S/6r
Description of proposed work: -P
; L �c �c �c��oAj
J
4
=. SECTION 6 - E
TIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit ainplicant
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
SECTION 7A
-OWNER AUTHORIZATION
(to be completed when owners
agent or contractor applies for building permit)
(Please Print)
00W )
A 16 A) ~ aim g: S
I t , 0 d 10-11 e 1 n P_ 10L v P as Om
ner of the subject property hereby authorize .1
,
to act on my behalf, in all matters relative to work authoriz
d by this building permit application. iadf li✓ C� em T(I Y S L,)tq/ I tI
)
Dat
Signature of Owner
SECTION 7B - OWN
R/AUTHORIZED AGENT DECLARATION
I, 94 ��J��� t J�4 as Owner/Authorized
Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the
best of my knowledge and belief.
Signed under the pains and penalties of perjury.
el A
li , ner, ^ .
3 / a,!1
Date
Signature of Owner/Authorized Agent
SECTION 8 -' INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD Date:
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date:
EC ION 9 -APPLICANT NOTIFICATION ,
Applicant informed of abo e: Time: Clerk:
Comments:
SECTION 10 OFFICE/I,NSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $25.00 3� eve% Remaining Balance: $—
�' .S � p d
.. Other $ Amount $
TOTAL FEE: -- �yl t%✓ Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: ,S'%7f c f s S T,¢'L G ✓ it' -z / s✓ C /fir, ��-
SECTION 11 = ADDITIONAL COMMENTS/SKETCHES
❑ SPECIAL
$25.00 APPLICATION FEE IS
I/T (Per 780 CMR 111.13)
BE -FUNDABLE & NON-TPiANSFEIII AMI.T
OUTo -N DATE RECEIVED
DARTMOUTH BUILDIN DEPARTMENT r
' 400 Slocum Road, P.O Box 79399
4 (li
.2 y Dartmouth, MA 02747
Phone: 508-910-1820 Fa : 508-910-1838 s E
l6 4 'r
www.lown.dartmouth.ma.us
APPLICATION TO CONST T, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DIINELLING
• THIS SECTION FOR OFFICIAL USE ONLY
1
RECEIVED BY: '- / F f ,.,,
BUILDING PERMIT NUN't8ER-.
DATE SENT FOR REVIEW: DATE'
A
I 5" nfif
TE ISSUED:
,
O.K. TO ISSUE -SIGNATURE.. z DATE. -
Zoning District: Proposed Use: Zone: ❑ C - ❑ B ❑A ❑ V . Aquifer Zone::
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:, `
O Board of . ". ' O Board of,- :. ID Cons.", A IDema :. ', fl DP1N ` , . C] Etec..: .:, ,.; :. p Energy _ ...
Appeals Health Commission - Affidavit Card Sent: Cut Off "`; Follow Rp port : ,.
0 Fire ; .,;' ❑ Gas p Planning, Sewer Card 0 Water Card ❑ Zoning
e.
Chief Cut Off Board Cut Off Cutoff
.. "
`0 Other.:.`.,
*REQUIRES INSPECTOR'S RE IEW BEFORE THE ISSUANCE OF A PERMIT.
DEPA TMENTAL APPROVAL .,..>. .
Zoning Review:
Energy Report:
Fire Chief:
Board of Health:
Signature:
Signature:
Signature:
Signature:
Conservation Commission: Signature:
Other:
Signature:
Brief description of work being performed:
SECTIOq 1 Z.Z IVE INFORMATK)N
1.1 Property Address:
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Feet:
1.4 Water Supply (MGL c40 s54):
❑ Municipal ❑ Private Well
❑ CONSTRUCTION PLANS
Date:
Date:
Date:
Date:
te:
ate:
1.2 Assessors Ma & Lot Number:
Y�
Map Lot �-
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the 'Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal S=Site
❑ Municipal Disposal System
SITE PLAN ❑ ENERG`�` REPORT