BP-4741411 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
11 SPECIAL PERMIT (Per 780 CMR 111.13)
1. Date plan reviewed: $25.00 APPLICALTION� FEE IS NON IIIE-FlUTIND.A.111LE A NON-Tlftz'kNSFEIRABLE
2. DENIED (see project review worksheet):
ATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
Date:
3. HOLD
400 Slocum Road, P.O. Box 79309
Reason:
4. HOLD subject to Zoning Board of Appeals action: Date: Dartmouth, MA 02747
•
508-910-1820 Fax: 508-910-1838
Comments: Date: !6 Phone. www.town.dartmouth.ma.us
APPLICATION TO C;ONSTRUCT, REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS �SECTION FOR FFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBE
Inspectors Signature:
Date: DATE SENTT
FOR REVIEW:
—0 DATE ISSUED:
SECTION 9 -APPLICANT NOTIFICATION
Applicant informed of above: Date- Time: Clerk: O.K. TO ISSUE -SIGNATURE: DATE: Z
Comments:
A Zoning District: -S /-,N- Proposed Use: Z I one: VI/C El B 0 A 13 V Aquifer Zone:
—SECTION 10 - OFFICE/INSPECTOR'S -NOTES THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
Less Application Fee: $25.00 0 Board of 0 Board of 0 Cons. 0 Demo 0 DPW 0 Elec. 0 Enerc
Total Permit Fee: $ o 0 Remaining Balance: $ or 0 Appeals Health _�y Report
Commission Affidavit Card Sent: Cut Off Follow-up*
Other $ Amount $ 0 Fire 0 Gas 0 Planning 0 Sewer Card 13 Water Card 0 Zoning 0 Other-
Chief
Cut Off Board Cut Off Cut Off -
TOTAL FEE: Gross Area - New Construction total sq. ft. *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT,
Gross Area - Alteration total sq. ft. DEPARTMENTA APPROVAL
Permit Issued to: '),0 Alg W 're S, Zoning Review: Signature: _5
e 11, 1-41 9 0 Date: /Xc /C
-Z )
Yo 1-,4 416> Energy Report: Signature: Date:
atur::7�
Fire Chief Signature: Date:
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES Board of Health:
tyrSignature:
I'/ eo ter./ -2 0, C, 0 Date:
`5' 0 Conservation Commission: Signature: Date:
C_ ife <__ �_ Other: Signature: Date:
41
Brief description of work being performed. L C tj
SECTION I - SITE I FORMATION
1.1 Property Address: 0'k ) 1.2 Assessors Map & Lot Number:
Nearest Cross Street: Map �_ Lot
Subdivision Name: 1.3 Historical District 0 Yes
NFL o
Total Land Area Sq. Feet: Has application been submitted to the Historic Comrmission?
0 Yes 0-f43_ Date:
1.4 Water Supply (MGL c40 s54):
0 Municipal 0 Private Well 1.5 Sewage Disposal System:
El Municipal �e Disposal System,
ID CONSTRUCTION PLANS EISI-rE PLAN 1-1 ENERGY REPORT
RESIDENTIAL
VV
W
Z
W
U
J
LL
O
a.
O
U
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1�Owner Record:17
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
69 P``ogs
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: u`p� (` `� {'
License Number:
q
Address: d e_e 1
Expiration Date: h c/
Signature: ! Telephone:
3.2 Registered -Home Improvement Contractor: WtM T3
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: (`
Registration Number (if none, state "none"):
1 � dh� t Gq-3
Address: �O
Signature: Telephone:
Expiration Date: /Q %
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 am a Homeowner performing all the work myself.
Owners f4ame (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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 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 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
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 responsible for code compliance. (see Appendix of 780 CMR R5.2.1 ,rs)
SECTION 4 - WORKER'S COMPENSATION
INSURANCE AFFIDAVIT (MGL c 152 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted
with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached: QYcls' ❑ No
SECTION 5 - DESCRIPTION OF PRO
OSED WORK (Check all applicable)
Deck ❑ Pool ❑ Repairs ❑ Alteratior
❑ Chimney/Fireplace ❑ Woodstove/Pellet `Stove
❑ New Construction* ❑ Accessory Bldg.
❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ Addition ❑ Replacement window/door
❑ Demolition
(Energy report required) No. of windows _ Doors
(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 Ba
hs Unit 1
No of Bedrooms Unit 2 No. of Ba
hs Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (sr
ecify):
city):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (Sp
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil
Other
/Ibescription of proposed work:
/ / '
t
s
SECTION 6 - ESTIMATED
CONSTRUCTIO14 COS
Item
Estimated
Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4)
SECTION 7A - OWNER
AUTHORIZATION
to be completed when owner's agent o
( p g
contractor lies a for building
applies g permit)
(Please Print)
61A-t,—%
�1
I, L iCgA,! L. 1aIetl- —,as Owner of the subject
property hereby authorize
to act on m behalf, in all matte relative to work authorized by this b
jilding permit application.
Date
Signatur of Owner
SECTION 7B - OWNER/AUTHO
IZED AGENT DECLARATION
\
Xm
C as Owner/Author
zed Agent hereby declare that the statements and informiation
on the foregoing application are true and accurate, to the best of my
nowledge and belief.
Signed under the pains and penalties of perjury.
1a�la-7
Date
Signature of Owner/Authorized Agent