BP-2005-38901,ESIDENTIAL
RESIDENTIAL
f GENr
2.1 Owner of Record:
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4,64,l
Name (p rint) CoIZ r 1 l�1'/:�� Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
de
3.1 Licensed Construction Supervisor:
Not Applicable
Licensed Construction Supervisor Kz O % Y, H c n re -
License Number rl Q y
Address f i S+ 501ty\
Expiration Date
(10"
Gam{
Signature f, Telephone,rff�
3.2?4;stered Home I p ov ent Contractor:
Not Applicable El
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 A s k Registration Number (if none, state "none")
Address
'Expiration Date O -- 0
Stgnat'ure -` / ALelephone � p � 24 -- V fo
3.3 For Res ential Remodel Wor 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)
Signar rse
b signing the above the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Y �g g
Date
ne & Two Family 3.4 Ho�teowner Exemption - O y 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 ofbuildings
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 u person(s) for hire to do such work, that such Homeowner shall act c 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 ' tached 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 applyinf under this section sign elow:
t1
Signature,:WVt<: 1
Your signature carries certain responsibilities, Lluding but not necessarily` limited to, general liability
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ twoodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify below): (spexcify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms 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
❑ 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 Descri tion of P posed Work:
Ab"C(%1S C4 �aay
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
C
3. Plumbingi
4. Mechanical AC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $
� , � �; �otrl Iett�d
wvlletl own a cn COriti`at;torwa s�"ttr 13w1d _� e
(please print)
as Owner of the subject property hereby authorize ;4
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
e, /,•i
,I
1W�.
as Owner/Authorized Agent hereby declare that the statements and 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.
f t (,/>/1/L' i 1
Signature of Owner/Authorized Agent Date
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Rev. January 2005 C:\bldg.forms\Bldgapp.res.wpd
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,Rev. January 2005
RESIDENTIAL
RESIDENTIAL
❑ FOUNDATION ONLY,
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�25.®Q� APPE�ECATI®lOT F
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1. Date plan reviewed: U
DARTMOUTH BUILDING DEPARTMENT
ATE`IZE -EIVED
�
2. DENIED (see project review -
400 Slocum Road, P.O. Box 79399
� .Fry
wo7ksheet): Date:
Fes.`°�t
, F Dartmouth, MA 02747
�8
3. HOLD
k�� 508-910-1820 FAX 508-910-1838
reason: Date:
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELIIL'ING
4. HOLD subject to ZoningBoard of Appeals action: . Date.
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Comments:ma
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Inspector's Signature: Date:
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f Date. � �
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A hcant informed ov fs� Time. Clerk.
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Comments:
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Total Permit Fee. $ Less Application Fee. $"2h7T� Remaining Balance.
TOTAL FEE: Gross Area -New Construction total sq. ft.��
yaf • •..�� s , .�i,,�'RE.Q�IFLES T� ,:,. �: R S ���g �iti I�'�,I�N� ¢,- B � � ..
Gross Ar -Alteration total sq. ft,,;,
AL API�I2O
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Permit Issued To•
Zoning Review: 9 Signature: Date: ' v
Energy Report: Signature: Dater
W. J,. - r . I D AL'., M NT KET , ✓ \
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Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
r:2 \ ,xg SECIO ,t ,,,,SITS
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NUMBER OF PLANS SUBMITTED:
¢ h k.
IFCl2� �k)N, .
,. .. .., NC' 9
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SITE PLAN SUBMITTED: ❑ yes ❑ no
C:\bld .fonns\Bld a .res. d
S S rP �? ?ale 4 Rev. January 2005
1.1 Property Address: a�` /
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
Assessors Map& Lot Number-
Ma Lot
p
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic,(Commission
❑ yes -' ❑ no Date:
1.4 Water Supply (MGL c § 54):
1.5 Sewage Disposa S stem:
67
� 0� .
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