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BP-34010RESIDENTIAL ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE RESIDENTIAL 2004 ❑FOUNDATION 9NLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE SECTION 8 — INSPECTOR'S REVIEW COMMENTS 1. Date plan reviewed: i 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: �o ,' ECTION 9 - APPLICANT NOTIFICATION Applicant informed of above Date: Time: Comments: Clerk: SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE: ��E%5 - 00 Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To �� •� r ' h�Cz' f - Gil SECTION 11 - ADDITIONAL COMMENTS/SKETCHES T M;. DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED " Yi 400 Slocum Road, P.O. Box 79399 ; r" r��: 2.) Dartmouth, MA 02747 _ 1664 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLIISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT NUMBER:3 V0 DATE SENT FOR REVIEW: 1 DATE ISSUED: OK TO ISSUE -SIGNATURE: _ ra DATE uildiri" ormnissioner/Inspeetor of Buildings Zoning Districtfi Proposed Use: Zone: t❑ B OIA ❑ V Outside Flood Zone Aquifer Zone THE FOLLOWING AGENCIES SHOI LD BE NOTIFIED: ❑ Board of 1 Board of ❑ Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas Q Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other Chief Cut Off t Cut Off / Cut Off Review* * REQUIRES INSPECTOR'S REVIEW BEF04 THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: i Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Description of work being performed: SECTION 1. - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Property Address: 135_l ti 0MCo C l,"— 1A 1.2 Assessors Plat & Lot Number: Plat �3 Lot- �-^ Nearest Cross Street: 1^ i S �'e l2 �C�. Subdivision Name: 1.3 listorical District ❑ yes ❑ no ,r1 m as application been submitted to the Historic Comissiorn? Total Land Area Sq. Ft.: 0 yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: // ❑ Municipal Private Well ❑ Municipal 0'On Site Disposal Systerm C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 1,,:2003 RESIDENTIAL 2004 RESIDENTIAL '2004 SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: Name (print) 5NM e_ Contact Address Phone Number 2.2 Authorized Agent: Contact Address Phone Number Name (print) 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: e ! 'r-1 d A)R P- C l s O 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 Nh te-C.1 S O 1 e yZ 1 5 e 5 _L N C Registration Number (if none, state ❑ none❑) Address To 13 01�- 6 S © Signature Telephone50'6-763-11'50 FExpirationDate .0 LS 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 Owners Name (print) Signature by signing the above, the home owner acknowledges that there will be no eligibilty 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 engw-es 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 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 R5.2.15) SECTION 4 — WORKER'S COMPENSATION INSURANCE AFFIDAVIT (mGL c 152 § 25) Workers Compensation Insurance affidavit must be completed andsubmitted with this application. Failure to provide this aff`idavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition ❑ alte ation ❑ repairs ❑ chimney/ ❑ woodst©ve (energy report required) (energy report required) fireplace ❑ deck �ol ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolitiion (shed/garage) no. o windows_ doors_ (specify below): (specify be?low): * 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 a 't 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 oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, elec ricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: dd� SECTION - 6 ESTIMATED CC NSTRUCTION COSTS Item Estimal ed Cost ($) to be completed by permit applicant 1 Rni1dina F.lertrirnl i Plnmhina 4 Merhnnirnl (HVAC') 5. Total = (1 + 2 + 3 + 4) * Estimated To a Q , 6z) $ SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent orcontractor applies for building permit) s�oo , as Owner of the su ject property hereby authorize(;G2��? Kacoeh fin 1 matters relative to work authorized by thi building permit application. Date wner SECTION 7B - OWNER/AUTHO D AGENT DECLARATION T D b YL— , as Owner/Authori zed Agent hereby declare that the statements and informattion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page Rev. Januatry 1, 2003