BP-39364RESIDENTIAL
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review
worksheet): Date:
3. HOLD
reason: Date:
4. HOLD subject Zoning Board of Appeals action: Date:
Comments: �� 1'J`^ ��J �t.0 ,,(i,.c.� -d'�
Inspector's Signature:
Date:
SECTI N LICANT NOTIFICATION
Applicant informed f 16e
Comments:
Date: U Tim � " l Clerk:
L�
SECTION 10- OFFICE NSPECTOR S NOTES
� 1
Total Permit Fee: $ 3 ��
Less Application Fee: $ 25.00_
�
Remaining Balance:
TOTAL FEE: ��[�� �� Gross Area - New Construction total sq. ft. / e2-'
Gross Area - Alteration total sq. ft.
Permit Issued To•wz�
SECTION 11 —ADDITIONAL COMMENTS/SKETCHES
r
RESIDENTIAL
❑ FOUND4TION ONLY
$25.00 APPLICATION FEE IS NQN. EFUNUAiRi.r A. 1vA1v_R+saa�arcrr�a�r
"•" �i T •i
DARTMOUTH BUILDING DEPARTMENT
't 400 Slocum Road, P.O. Box 79399
> =.DATE RECEIVED .
Dartmouth, MA 0274
f ` ', rs. ,o
1 t�
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVA
E OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: ; , � �,
BUILDING �
IT PERM ,
DATE SENT FOR REVIEW: J j
NUMBER:,,
-
DATE ISSUED• t
OK TO ISSUE - SIGNATURE: GG DATE
But di Of w
Zoning DistrictmProposed Use,: LW --- Zone: C{
A ❑ V Outside Flood Zone Aquifer
Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo
0 DPW ❑ Elec. ❑ Energy TReport
Appeals Health Affidavit
Card Sent: Cut Off Follow-ups"
❑ Fire ❑ Gas ❑ Planning ❑ Server
&rd ❑ Water Card ❑ .. ❑ Other
Chief Cut Off Board* I Cut Off
/ Cut Off Zoning
REQUIRES INSPECTOR'S REVIEW
BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMEN`.FAL APPROVAL
Zoning Review: L2 �! Signature:
Date:
Energy Report: �✓ �'� Signature:
Date:_ —4 <
Fire Chief: Signature
J
Board /� �igna ��✓`'
Date: !
t
of Health:
�, _.
Conservation CoNr,.m:ssion: Signature:
Date: c
Other: Signature:
Date:
Description of work being performed:
SECTION 1- SITE
INFORMATION
NUr,/F-R OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1�
1 Property Address: 7'% 1rVfJaDCDe(K D/� D
1.2 Assessors Map &Lot Number:
Map _ Lot -
Nearest Cross Street: ^11-15 lra4p
woopCCeK /QDA
Subdivision Name: Ga T V p[i+•T33
1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: t� /
oT 3f
Has application been submitted to the Historic Cornmission?
yes ❑ no Date:
.4 Water Supply (MGL c 40 § 54):
1 Sewage Disposal System:
1t/J7-/ `
C:\bldg.fbnns\Bidgapp.res.wpd
Page 4
Rev. January 2005 C:,bldg.forms\Bldgapp.res.wpd
P gel
Rev:, January2005
RFCTT)F,NTTAT.
RESIDENTIAL
-SECTION 2 - PROPERTY R4,4MP I AUTHORIZED AGENT
Owner of Record:
f le-111;10yti -7-7-1O/t9113
�'7 G�OUI�L�OC'K /Pl1.9e1i
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION N U ION ER S
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:
"ESTIONS OR COMPLAINTS call or write:
Home Improvements Contractors Registration, One Ashburton Place -Room 1301, Boston, MA 02108, (617) 727-8598
`✓ N��7 "N ]LZJ
Owners Name (print?
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date~�(o
3. 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
shill be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuildings
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 Constriction
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that ifa 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 applyingunder this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
>✓
v
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 res ponsible
for code compliance. (see Appendix of 780 CMR R5.Z.15)
SECTION 4 - WORKER'S COMPS
SATION INSURANCE AFFIDAVIT (NIGL C 152 § 25)
pleted and submitted with this application. Failure to provide this
Workers Compensation Insurance affidavit must be corr
affidavit will result in the denial of the issuance of the b
ailding permit. Signed Affidavit Attached',: ❑ yes ❑
n
0
SECTION 5 -DESCRIPTION
OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition
❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy r ort require
fireplace
❑ deck ❑pool accessory bldg.
❑replacement window/door ❑other ❑demolition
(shed/garage)
no. of windows doors (specify below): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no
of 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, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel
bil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas,
ropane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric
Fuel Oil Other
Bri -Description of Proposed Work:
SECTION - 6 ES
IMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicaint
1. Building
2. Electrical
3. m in
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimate
Total S c,
SECTION
A -OWNER AUTHORIZATION
(to be completed when owner
s agent or contractor applies for building permit)
(please print)
1, , as Owner
of the subject property hereby authorize
by this building permit application.
Date
to act on my behalf, in all matters relative to work authorized
Signature of Owner
��Ny /h-Oi1ls , as 01
vner/Authorized Agent hereby declare that the statements and information
e best of my knowledge and belief.
oo on the foregoing application are true and accurate, to tf
Signed under the pains and penalties of perjury.
Signature of O er/Authorized Agent
Late
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 2005
C:\bldg.forms\Bldgapp.res.wpd
Page 3
Rev. January 2005