BP-2005-40127jtENWEIN 11AI, ti
"ram
i
r
2.1 Owner of Record:
xr(1r'o�us '(an��.ct-evl����ke. N �R dog
Name (print) Contact Address Phone Number
2.2 Authorized Agent;
j Name (print)Contact Address Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor
License Number,
Address Expiration Date
j Signature Telephone
j 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? El yes ❑ no
If yes, submit the
required affidavit!
.Company Name
Registration Number (if none, state "none"`I
Address
Signature
- -- Telephone Expiration Date J
'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, M,4 02108, (617) 727-8598
Owners Name (print
llawaL U0etn wt
KDa7t'
atu:by s.gnmg the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
f
3.4 IlomewNmer Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
1tD9.1.1 Licensing ofConstruction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
involving the structural elements ofbuildings
r construction, reconstruction alteration, repair, removal or demolition inF o g
shalabeengaged indir ctlysupervismgt-ersonsergagedin
orstructures, 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.
EStception: Any Homcowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engag
es a person(s) for hire to do such work, that such Fictne-owner 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 witch
there is, or is intended to be, a one or two fam lv iwalhng, 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 si atfii're carries certain responsibilities, including but not necessarily limited to, general liability
i
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 2005
RESIDENTIAL
that an licensed Constriction
'n the Rules and Regulations section y
Building Code provides I gu
LICENSED CONTRACTORS`. The B g p
NOTICE TO L
R .2.15
ix of 780 CMR 5
' whether or not the have taken the permit are responsible for code compliance.. (see Append a)
Supervisor, Y !
G'
� ?l
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provl,de this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes El
n
0
RESIDENTIAL
RESIDENTIAL
0 FOUNDATION -ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABL
&N® N SFERAO L
�-
1: Date plan reviewed: � �.S ,:
�
:...........�
,i� e�
, -'E'
sizrFr. '
t DA RECEIVED
2 RENTED (see project review
z_
DARTMOUTH BUILDING DEPARTMENT _
�
works'.heet):
Slocum R P.O.m
400 m o O Box 7 399
d, r
,. i
i
Date:F
a ,
�;
HOLD
Dartmouth, MA 02747
3
508-910-1820 FAX 508-910-1838
-
,reason:
Date:
4. HOLD subject to Zoning Board of Appeals action:
Date:
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINrG
g-^ I, , .
Comments:
v+
�/
T E:, i u
.T7rU a^��si try n:,.n�c�.•iz:�,-rx.�. .. �a. _._.. ..c _ N. ... , . �r ..;. ,».� a- a.�,,`i�i`�.,ti,.�.. ... .:,::... �.� _>..� ,��-.�..��^. .,_._._.�=r.�1 �,.x�.Y;�,i�, ....,•;�✓i .. �. •._�_ _v_.� .�
�_
_
Date: 7 �r
-
Inspector's Signature:
,rSECTTO - ()TIF ICON
p
Applicant, informed o ab v lr;ate: d Tim/
-' Clerk. -
Cotximent,:
t,
ws
yYy �'+ z
., 'e i,.A.n lex^F >t•91 sF "^.9`j/ES...,+ >tf F X..E/LYC;T % NOT s� /
„gip, %EI , ✓., :.., �, ft N 1
.. ,, .
�
/$
Total Permit Fee: $ O 0C9 Less Application Fee: $ 25.00
Remaining Balance: !�
TOTAL FEE: 0,0 Gross Area -New Cohstniction total sq. ft. 'K
S 6 C a /`:T
Gross Area -Alteration total sq. ft.
Permit Issued To - ,2 L I/ �" x C. G ivy
IAI C C0/2%�
8-6
ONOl1VTENTE....;:;....
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