BP-4313472 F.CTT)F.NTT A T .
7.
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): Date:
5. DENIED (see project review
worksheet): Date:
6. HOLD
reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature:
Applicant i;
Comments:
Total Permit Fee: $ 47D I Less Application Fee: $ 25.00
TOTAL FEE: itJr—� Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued
,q�rt bf tf6d/C
c
AED
Date: 2 —
Remaining Balance: $ 9 ;�.
i
e6
I
Gcs�
use
2005
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RESIDENTIAL 2005
❑ FOUN ATIONONLY
-----___-- - _--
$25.00 APPLICATION FEE IS NON- FUNDABLE & NON-T.".ANSFERABLE
DATE OFIVtD)
DARTMOUTH BUILDING DEPARTMENT fat
400 Slocum Road, P.O. Box 79399
�3� Dartmouth, MA 02747 ! `� ? !
1 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRU4, REPAIR, RENOV�TE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Signature:.
Energy Report:
Signature:,
Fire Chief:
Signature:.
Board of Health:
Signature:
Conservation Commission:
Signature:
Other:
Signature:
Description of work being performed:
Date:
Date:
Date:
Date:
Date:
Date:
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
,/ 1.2 Assessors Plat of Number:
1.1 Property Address: / �� 6jmj oz o k !� Plat
Nearest Cross Street:
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
.4 Water Supply (MGL c 40 § 54): .5 Sewage Disposal System:
❑ Municipa101rivate Well ❑ Municipal 9 /Onite Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. June 26, 2003
I
RESIDENTIAL
2005
0
�.,Ty
1 a..,
of Record:
V20wner
r-P /
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
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:
QUESTIONS OR COMPLAINTS call or write:
Nome 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
: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 pu-poses 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 int—ended 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 no be considered a Homeowner.
If you are applying µnder this section sign below.
Signature:
You signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL 2005
NOTICE TO LICENSED CONTRACTORS: The Building Code provides 1 a 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)
Workers Compensation Insurance affidavit must be cc
affidavit will result in the denial of the issuance of the
❑ 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. of
Two Family: no. of bedrooms unit 1 no. of
no. of bedrooms unit 2 no. of
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil,
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, c
❑ HVAC (combined unit) - primary fuel, natural gas, propz
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric F
Brief Description of Proposed Work:
I A/)/) /i 'I 1-7 /r
Item
and submitted with this application. Failure to provide tlhis
permit. Signed Affidavit Attached:❑ yens ❑ no
alteration ❑ repairs ❑ chimney/ ❑ wct�odstove
fireplace
replacement window/door J other ❑ de:molition
1. of windows_ doors_ (sp cify below): (specify below):
is unit 1
is unit 2
:tricity, other (specify):_
ricity, other (specify):
electricity, other (specify):
Other
Cost ($) to be completed by permit applicant
4. Mechanical HVA
5. Total = (1 + 2 + 3 + 4) I * Estimated Total 1 $ , <j---(
(please print)
I, , as Owner of subject property hereby authorize
to act on my behalf, in all matters relative to work authorized b this building permit application.
Signature of Owner = Date
I, / (cl/ , as Owner/A
the fore oing application are true and accurate, to the best c
Signed under the pains and penalties of perjury.
Signature e Owrier/Au`thorized Agent
ized Agent hereby declare that the statements and information
knowledge and belief.
Date
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