BP-23139RESIDENTIAL
2002
RESIDENTIAL
2002
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
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:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
S. Comments:
Date:
9. Inspector's Signature:
Date:
ECTION 9 - APPLICA T OTIFICATION
Applicant inf ei of abov te: Ti �`� Clerk:
Comments: Alt
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: S
Less Application Fee: $ 25.00
Remaining Balance: S
TOTAL FEE: _— Gross Area - New Construction total sq. ft.
Gross ArgdgAlteration total sq. ft. )
Permit Issued To- I _e %
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
In
C"
❑ FOUNDATIW'" ONLY
$25.00 APPLICATION FEE IS NON-r.EFUa�DABLE be NON -TRANSFERABLE
;urH •.•
DARTMOUTH BUILDING DEPARTMENT
t� 400 Slocum Road, P.O. Box 79399
-DATE RECEIVED
'
Dartmouth, MA 02747
f_`<__€ 1
113 : L17
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 Pc�/��
DATE SENT FOR REVIEW: _
NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: h 1. Ll DATE'—c --
Buildi g Co issionernnspegor o u'Idings
Zoning District: SR.6Proposed Use: Zone: ❑ B A ❑ V Outside Flood Zone ❑ Aquifer Zones
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 / Cut Off / 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:
Description of work being performed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
�/ v
p4e
1.2 Assessors Plat & Lot Number:
1.1 Property Address: S 1 vyb FDl�L 'Dr
Plat Lot_=-
Nearest Cross Street: LAN
1.3 Historical District ❑ yes no
Subdivision Name:
Has application been submitted to theiiistoric Commmission?
Total Land Area Sq. Ft.:
9 Date:
❑ yes no
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ On Site Disposall`System
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RESIDENTIAL
2002 RESIDENTIAL 2002
SECTION 2 - PR6PERT"1'-3WNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
t.)0"�e2 )S6r1 CSkoY6L('
1
jr% n ��,WycoKcbr 1717,9 -036a
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
�-
�
f
C—d 5hA,yA)6nJ - hosrfoAfs Cone
Nalne (print)
Contact Address Phone Number
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:
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 1�no
If yes, submit the
required affidavit!
Company Name AW0 11j C6i2 71't0
Registration Number (if none, state "none")
� 1 j�606-
Address 'd 3 13 re w 4c r 10 f l�l%
_ _
Signature Cgt4, �rf7J Telephone
Expiration Date 7L 7 (�2
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 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 familv dwelline, 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 provide tthis affidavit
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 ❑ alteration ❑ repairs ❑ chimney/ ❑ wioodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. 'replacement wI dow/door ❑ other Eldlemolition
(shed/garage) no. of windows 7' doors (specify below): (spe Tify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms- no. of baths
Two Family: no. of bedrooms unit I no. of baths unit I
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, 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:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (I + 2 + 3 + 4)
* Estimated Total $
i
SECTION 7A - OWNER AUTHORIZATION t
(to be completed when owner's agent or contractor applies for building permit)
(please print) j /�
e ` 1ex T , as Owner of the subject property hereby authorize ��l� eti 35 n re, n
I, J e94
to act on ehalf, ' a mat`ters relative to work authorized by this building permit application.
pf 0 ,
Igna re of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I, , as Owner/Authorized Agent hereby declare that the statements and iinformation
on the fo egoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
t'
Fee Q2—
nat re of Owner/Authorized Agent Date
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