BP-40867SECTION 8 —INSPECTOR'S REVIEW/CODINIENTS
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):
5. DENIED (see project review
worksheet):
6. HOLD
reason:
7. HOLD subject to Zoning Board of Appeals action:
S. Comments:
Date:
Date:
Date:
Date:
2005
Date: O S
T=NOTIFICATION
Time: Clerk:
C:\bldL.forms\Bldgapp.res.tivpd Page 4 Rcv..Iunc ?6, 2003
RESIDENTIAL 20Q%5
❑ FO UNDA TIOT T10,VLY
$25.00 APPLICATION FEE IS NON -RE ABLE & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT .13 , _,
400 Slocum Road, P.O. Box 79399 L 1
1.1 Property Address/, -
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
4 Water Supply (MGL c 40 5 54):
❑ Municipal Zrivateell
C:Abldg.forms,Bidgapp.res.N�pd
1.2
1.3
Page t
A ONE OR TWO FAMILY DWELLING
Date:
Date:
Date:
Date:
Date:
r
PLAN SUBMITTED: ❑ yes
assessors PI t Number:
Plat V Lot /
'I Q'.0
❑ no
storical District ❑ yes ❑ no
application been submitted to the Historic Commissiorn?
yes ❑ no - Date:
wage Disposal System:
❑ Municipal ❑ ntQ" S Disposal Syste=
Vo[It
I t4R7eJune 26,,"2003
RESIDENTIAL 2005
.. SF Mn IROP
LSHIP I AXITIH
2. Owner of Record:
Name (print) Contact Address N �-L-)fWt7 ki -t, O'a7 (Phone Number
2.2 Authorized Agent:
1 I
r3l
me (print) Contact Address Phone Number
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!
f7cqmpany N
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:
Holne Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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, 3Keffective July 1, 1982, no individual
s all be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
Supervisors.
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
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 oatllows: 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 riv i1 wellin , attached r deta hed structures accessory to such use and/or farm structures. A person who constructs more than
one home in a two-year period hal of be onsidered Home er.
if you are applying under this s tion sj n below:
Signature•
our signature.carries certain responsibilities, including but not necessarily limited to, general liability
a:
C:\bldg.fornns\Bldgapp.res.wpd Page 2 Rev. June 26, 2003
RESIDENTIAL 2005
EsuopT
CE To LICENSED CONTRACTORS: The Building Code pro ides in the'Rules and Regulations section that any licensed Coinstruction
rvisor, whether or not they have taken the permit are resp nsible for code compliance. (see Appendix of 780 CMR R5.2;215)
Workers Compensation Insurance affidavit must be comr leted and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the bu Ilding permit. Signed Affidavit Attached::❑ yes ❑ no
SECTION S -. DE5CRIPTIO1�I,fF
k
PROPOSED WORK (cHecalippIible0,
�.
❑ new construction*
❑ addition
❑ alteration ❑ repairs
❑ chimney/
10 woodstove
(energy report required)
(energy report required)
fireplace
❑ deck
ool
Y
❑ accessory bldg.
❑ replacement window/door
❑ other
10 demolition
-
(shed/garage)
no. of windows doors
(specify below):
((specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. Jf baths
Two Family: no. of bedrooms unit 1 no. f baths unit 1
no. of bedrooms unit 2 no. f 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, pro ane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric uel Oil Other
Brief Description of Proposed Work: r
Item
Estimated Cost ($) to be completed by permit applicant`
15. Total = (1 + 2 + 3 + 4) I * Estimated *tal $ , ;oj7%j 460 t�
f, F)N-1
on the foregoing
Signed underlie
Signature
are true and
Authorized
C:\bldg.forms\Bldgapp.res.wpd
perjury.
as Ownet Authorized Agent hereby declare that the statements andl information
e bet of my knowledge and belief.
- l7 O0 S-
Date
Page 3 Rev. June 26, 2003
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