BP-44030SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: / r' Date: 0
AE;CTJ0)Q9 -APPLICANT NOTIFICATION
Applicant informed ofabove- Da e: Time' Clerk;
Comments: Ok�7
- SECTION 10 - OFFICE/INSPECTOR'S NOTES
y
Total Permit Fee: $ �� •n
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
TOTAL FEE: 30,o E'� Gross Area - New Construction total sq. ft. A
Gross Area - Alteration total sq. ft. /tt'/9
Permit Issued to: / IV S % G L AJ M F /T % /)-?,I Al F ,F,(e d_7—
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES = `
d i /✓1 �/ .S
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
S2S.00 APPLICATION FEE IS NON R -] Vl%-DABLE R N TRA1%'SFEItABLE
DATE RECEIVED
DARTMOUTH BUILDING DEP RTMENY `
400 Slocum Road, P.O. Box 79399
:o x' �xs# tr l,r
,Z Dartmouth, MA 02747..r :< i- l 36
N:
°X Phone: 508-910-1820 Fax: 508- 10-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT NUMBER: D3U
DATE SENT FOR REVIEW. 7 DATE ISSUED.
O.K. TO ISSUE =SIGNATURE:
Zoning District: 48
Proposed Use-P rS
Zone: EiK ❑ B ❑ A ❑ V
Aquifer Zone:
S�
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of oard of
❑ Cons ❑ Demo
❑ DPW _
-❑ Elec.
❑ Ene[rgy Report..'
Appeals Health
- Commission Affidavi
Card Sent
Cut Off
Folltow-up
❑ Fire, O Gas
❑ Planning ❑ Sewer i
and ❑ Water Card
0 Zoning'-
❑ Othrar `
Chief , = Cut Off
>...: Board Cut Off
- Cut Off
"REQUIRES INSPECTOR'S REVIEW BEFORE
THE ISSUANCE OF A PERMIT.
DEPARTMEN
AL APPROVAL
Zoning Review: Signature: z(JaJ/ _�uu :� Date: �/•2 ��C" el
Energy Report: Signature: Date:
Fire Chief: Signature: _„ Date:
01 Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed.
.. SECTION 1 - SI
E INFORMATION
.1 Property Address: 3 I Woo)i co k- li✓TI\
1.2 Assessors Map & Lot Number:
Nearest Cross Street:
Map 3 Lot
Subdivision Name:
1.3 Historical District ❑ Yes ❑ No
Total Land Area Sq. Feet: 0 1000Has
application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
jy.4 Water Supply (MGL 0 s54):
m:
.5 Sewage Disposal SFn
❑ Municipal rivate Well
❑ Municipal Site Disposal Symitem
❑ CONSTRUCTION PLANS
❑ SITE PLAN
❑ ENERGY REPORT
l/
0
0
f�
RESIDENTIAL
_ SECTION 2 - PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
C15,09)
1'4 (C M&t_ -t
13 l 0oclixodc. <L�) 63LI -OW7
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES -
3.1 Licensed Construction Supervisor: r
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address: '}'�
4
Expiration Date:
I N )67
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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
A '�-
Registration Number (if none, state "none"):
Address: 2 0 2�'�Ck
Signature:d1v L,--- Telephone Q -SSA 7
Expiration Date:3 ZW_ a �X_
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
❑ 1 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
a
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 tNs 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 ir the Rules and Regulations section that any licensed Confstruction
Supervisor, whether or not they have taken the permit are responsible for ode compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION IN
URANCE AFFIDAVIT (MGL c 752 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted
with this application. Failure to ovide this
affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached: 'es ❑ No
SECTION 5 -DESCRIPTION OF PROPO
ED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration
❑ Chimney/Fireplace 64Woodstove/Pellet Stovne
❑ 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 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 (speci
):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ 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
1
Description of proposed work: 1/j}�l
=-. -SECTION 6 -ESTIMATED CONSTRUCTION
COST
Item
Esti
iated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
-: SECTION 7 - OWNER
UTHORIZATION - .:..
-(to be completed when owner's agent or c
ntractor applies for building permit)
(Plea`sg� Print)
.'4"',Rk wo[E L_ 6A0 PAr(a2 as Owner of the sub
ect property hereby authorizer .Rj ��)'% l n
to act on my beha Vinalmatters relative to work authorized by this builc
I-- _'e2���
ing permit application. /
____ 4/ /,F /o
Date
—
Signature ollner
SECTION 7B - OWNER/AUTHORIZED
AGENT DECLARATION
t " as Owner/Authorize
Agent hereby declare that the statements and informaticin
on the fo egoing applic ion are true and accurate, to the best of my knowledge
and belief.
Signed n7eresins and penalties f perjury.
Date
Signature o r/ u ed Ag t
I Ilk
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ASTM E1509 •'Mobile Home -Approved
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60 lbs .
Fuel
Wood Pellets
lower Size
135 efm_
Outside Air Size
2-3/8°
Weight'
250 lbs -
Height
32-1/2't
Depth
—
20-1/2"
Venting Size
3" Pellet Vent Pipe
Feed Rate
3 4 lb. hi. (minimum)
6-lbs./hn (maximum)
Clearance to Combustibles
Side
10 tt
Center of Flue to Floor
7.75"$
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T
Corner Installation
Front View
352 Mountain House Road
Halifax, PA 17032
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C-�Ce CJ�a.�ne �u�viod
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F-- 20.5" -
fll=-
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This way, no energy is wasted by
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r
After your set teml
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in the room drops
Advance will incre,
If an outside door
room temperature
the Advance will it
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And, if the outside
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f the temperature
ven slightly, the
e its flame level.
opened and the
rops rapidly,
rease its fire in
mperature drop.
emperature rises
;d, the Advance
ut down but
• the room
it drops again.
80° .................................. ....
70°
600 .................................
50..
Advance r" Others
In addition to adjusting temperature
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