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BP-335932004 RESIDENTIAL ❑ FOUNDATION ONLY S2S-00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE SECTION $ —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): 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 APt(1IAJ:Ayr NOTIFICATION Applicant info of above ate Tines Comments: r Cler SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $ 00 1 Less Application Fee: $ 25.00 Remaining Balance: $ 02 , oc TOTAL FEE: , OD Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To: SECTION 11 - ADDITIONAL COMMENTS/SKETCHES .s� //©cf /0 : 0 0 JJ 3 // � Y a G� 12 RESIDENTIAL U2004 N ATION ONLI' $25.00 APPLICATION FEE IS NON-REFUNDABLE NON-TRANSFERABME DARTMOUTH BUILDING DE ARTMENT a , T-,DATE RECEIVED 0 y, o — _ 400 Slocum Road, P.O. Box 79399 ";' Dartmouth MA 02747 j~ 508-910-1820 FAX 508-91 -1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE R DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOI l OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT U BE;}IV I DATE SENT FOR REVIEW: .ai->�I DATE ISSUED: r OK TO ISSUE - SIGNATURE:vl DATE` Buildin nimissioner r ildings Zoning District: 5 oposed Use: Zone: ❑ B A ❑ V Outside Flood Zone 0 Aquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of oard of Con. Corn. ❑ Dei no ❑ DPW ❑ Elec. ❑ Enerrgy Report ppeals Health Affidavit Card Sent: Cut Off Follow, -up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Otbwr Chief Cut Off / Cut ff ! Cut Off Review* * REQUIRES INSPECTOR'S RE 4 EW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTA PROVAL Zoning Review: Signature: r Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: / d! �'10 Ll B and of Health: Signature: `A Date: Conservation Commission: Signature: Date: Other: Signature: Date: t Description of work being performed: 1 SECTION I - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.2 Assessors Plat & Lot Number: 1.1 Property Address: Plate 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: ❑ Municipal /Private W 11 ❑ Municipal /On Site Dis ,posal System C:\bldg.fe-ms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003 C:\bIdg.forms\BIdgapp.res.wpd Page 1 Rev. January 1, 2003 RESIDENTIAL 2004 SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: 5-0-8'65(6 —! � Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address 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: 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! Not Applicable ❑ Phone Number 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 Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 i Owners Name (print s Signature by signing the above, the ho e owner acknowledges that there will be no eligibilty to the Guaranty Fund Date 3A 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 Homeo-wrier 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 RESIDENTIAL 2004 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Consttruction Supervisor, whether or not they have taken the permit are respor sible for code compliance. (see Appendix of 780 CMR R5.2.155) SECTION 4 —WORKER'S COMPEN ATION INSURANCE AFFIDAVIT (MGL c 152 & 251 Workers Compensation Insurance affidavit must be compi eted and submitted with this application. Failure to proviide this affidavit will result in the denial of the issuance of the building per it. Signed Affidavit Attached: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) 'new construction* ❑ addition (energy report required) (energy report required) ❑ deck ❑ pool ❑ accessory bldg. (shed/garage) * If new construction, please complete the following: Single Family: no. of bedrooms no. c ❑ alteration ❑ repairs ❑ chimney/ fireplace ❑ replacement window/door ❑ other no. of windows_ doors_ (specify below): baths U woodstove 1:1 demolition ((specify below): Two Family: no. of bedrooms unit 1 no. o baths unit 1 no. of bedrooms unit 2 no. o 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, alectricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, pror ane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric -uel Oil Other Brief Description of Proposed Work: N Z-1 SECTION - 6 ESTIN14TED CONSTRUCTION COSTS Item I I Estimated Cost ($) to be completed by permit applicant 5. Total = (1 + 2 + 3 + 4) *Estimated Total $ .j Opd _ O o SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) please p.nt 1,— , as Owner of the subject property hereby authorize to act half, in all matters relative to work authorizei I by this building permit application. Sign ure of Owner Date SECTION 7B - OWNERj AUTHORIZED AGENT DFCLARATION T, �9o�Y l�?- 77�d/� $ , as Owner/ kuthorized Agent hereby declare that the statements and iinformation on the foregoing application are true and accurate, to the bes of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Ow*er/Authorized Agent Date C:\bldg,fo-:ns\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd I Page 3 per___