BP-2001-20287I
1?F CTT1Ti'NTT S T ,
2001 RESIDENTIAL
2001
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SECTION 2 - PROPERTY OAWWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
4dAe 13 /0
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Dame (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (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? O yes ❑ no
If yes, submit the
required affidavit!
Company Name
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:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
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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
4ildings 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
v?rhich 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.
1ff'you are applying de this section si n b
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 licens;zd Construction'
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR,IR5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 2a-S)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure tth provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes Cp no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify below)): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit l 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):
1:1 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. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
*Estimated Total s3 �d
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
I, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7B - OWNE A THORIZED AGENT DECLARATION
I%!,�✓�17 Aogr—U , as Owner/Authorized Agent hereby declare that the statennents and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and Xnalties of perjury.
sigri f Owner/Authorized Agent ate
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RESIDENTIAL
2001
SECTI//ON 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: t
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. DENT,ED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature: --
Date: Cv 0
CJ SECTIOfN 91- C T NOTIFICATION
pAPP
Applicant informed f o e /Date: /� 1, Time:
Comments: �
Clerk:
SECTION 10- OFFICEVNSPECTOR'S NOTES
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Total Permit Fee: $ 0
Less Application Fee: $ 25.00
Remaining Bala Lc- $/
TOTAL FEE: !lam .03 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq, ft.
Permit Issued To• Y / ' �
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
;t
RESIDENTIAL 2001
❑ FOUNDATION ONLY
$25 00 APPLICATION FEE IS NON-REFUNDABLE do NON-TRANsrERAM;LE
— ouTH.. DATE RECEIVED.
DARTMOUTH BUILDING DEPARTMENT
3 ' 400 Slocum Road, P.O. Box 79399
Z Dartmouth, MA 02747..
508-910-1820 FAX 508-910-1838
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