Loading...
BP-31302RESIDENTIAL ❑ FOUNDATION ONLY 4t7c_nn A1PpL1iC1XT1lnN FEE IS NON-REFUNDABLE & NON -TRANSFERABLE 2002 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: X: 3 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: Date, �r_ SE N 9 - APPLICANT NOTIFICATION 4,0 Applicant informed of aj ve ate: I Clerk: Comments: l// KV SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $ 6E V-1 �� Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE:60a` 1ileld Gross Area - New Construction total sq. ft. �/ /Gross Area - Alteration total sq. ft. -/ — Permit Issued To-. %�t.evtrlCJC e� //J Y-CL- / (:7- 6 45LbL:ze6- SECTION I - ADDITIONAL C4MMENTSISKETCHES GCi�6 ✓iP 0 -" RESIDENTIAL 2003 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE Q 9s DARTMOUTH BUILDING DEPARTMENT Q N 3 DATE RECEID 400 Slocum Road, P.O. Box 79399 2�?3 r T 2 % 1 11: 29 Dartmouth, MA 02747 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT NUMBER: DATE SENT FOR REVIEW: DATE ISSUED: OK TO ISSUE -SIGNATURE: DATE Bui i Commissioner/Inspector of Buildings /' Zoning Distriet> Proposed Use: P Zone: C ❑ B ❑ A ❑ V Outside Flood Zone 1''. Aquifer Zont:s THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑ Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other Chief Cut Off . 1 Cut Off J Cut Off Review* * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: �escription of work being performed: '-7.c, ^�na c / e) SECTION 1 - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes 19-ne- 4. 1.2 Assessors Plat & Lot Number: Property Address: Platte Lot - Nearest Cross Street: Subdivision Name: Historical District ❑ yes Eno Y Has application been submitted to the Historic Comttnission? Total Land Area Sq. Ft.: ❑ yes ❑ no Date: ,1.4 Water Supply (MGL c 40 § 54): 5 ,Sewage Disposal System: �nicipal ❑ Private Well X F MiMnicipal ❑ On Site Disposal';System C:\bldg.forms\Bldgapp.res.wpd Page 4 i Rev. January 1, 2003 e C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 1, 2003 RESIDENTIAL 2003 RESIDENTIAL 2003 SECTION 2 - PROPERT`_' OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record;— 771 Name (print) Contact Address ' - Phone Number 2.2 Authorized Agent:yS l /-? G f Contact Address Phone Number Name (print) SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor � License Number V4:: jP ' Address C Expiration Date s/, Signature Telephone cjS '?,5 3.2 Regist Home Improvement ntractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? 43y"es ❑ 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 __" e_ -7anvc6-- , Registration Number (if none, state ❑ none❑) ,.3/v��_, �__ Address o,, 50c-. 14 Signature t, Telephone %d 3 y Expiration Date 3.3 For R ential 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 10,9.1.1 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 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 and submitted with this application. Failure to proviide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: D-yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition ❑ alteration repairs ❑ chimney/ cl woodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. &`ieplacement window/door ❑ other © demolition (shed/garage) no. of windows 1Q doors_ (specify below): (`specify below): * If new construction, please complete the following: Single Family: no. of bedrooms . T 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 ❑ F rnace (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, electricity, 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: pp � 0,4 acv C,Z .4 -1 SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ($) to be completed by permit applicant 1 Rnilrlino 'i Flartriral 1 Phimhinv d Mprhnnirnl (NVAC') 5. Total = (1 + 2 + 3 + 4) * Estimated Total SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) I,�4fLC' Sfj , ,,9 w —as Owner of the subject property hereby authorize "� ���' C4 2:-n,,-2 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7B - OWNF,R/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent hereby declare that the statements andl information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. O Signature of Ovpi5VA,,d6rized Agent Datr C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3 1Rev. January 1, 2003