BP-2002-24003RESIDENTIAL
2002 RESIDENTIAL 2002
SECTION 2 - PROPERTY OWNERSHIP l AUTHORIZED AGENT
2.1 Owner of Record:
Name (print) Q %
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? ❑ 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:
QIJESTIONS OR COMPLAINTS call or write:
Nome Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, .WA02108, (617) 727-8598
1
Owners Name (print) D 6 K--ITS!
Signature,�'�t1�i
by bn the'above, the home owner acknowledges that there will be no eligibiltyto the Guaranty Fund
'
Date
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWE 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 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 Homeowner.
If you are appIlying under this section n ow:
Signature:
Your signature carries ce tam -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 Construrdtion..
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,tihis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes El no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
El new construction* ❑ addition alteration ❑ repairs ❑ chimney/ ❑ w,coodstove
(enei-D� report required) (energy, report required) fireplace
El deck ❑ pool El accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows - doors - - (specify below): (specjifybelow):
If new construction, please complete the following:
Sin -le Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 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):
El Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Ivork:
/
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
- Item
Estimated Cost (S) to be completed by permit applicant
1. Budding
2. Electrical
3. Plug mbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Esthnated Total ' $ ,4
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
uildin g permit application.
g P pp
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I .. ,.
as Owner/Authorized Agent hereby declare that the statements and ttnformatton
Oil the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and s of perjury.
%penalt'
of OwnerlAirthorized Agent
Sigriatur
C:Abldg.foriiis\[$pdgapp.res.wpd Page 2 Rev. January 19. 2001 C^b'�1 "irns\Blrlgapp.ic�.�cp�i
Page 3 Rev-
JJanuary 19, 2001
n1[7CTTIU\TTTA T
2002 RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
y_L u1 y SECTION 8 -INSPECTOR'S REVIEW/COMM
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 workslieet):
6. HOLD reason:
Date:
Date:.
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments
Date:
9. Inspector's Signature:
SECTIO 9 - APPLICANT NOTIFICATION
MAY
ate: 7 �
Applicant inforn d f a ve, ate: Time:/Mw Clerk:
Comments: _ �. �;
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00'
Remaining Balance:
TOTAL FEE:® Gross Area New Construction total sq. ft.
Gross Area - Alteration total sq. ft. �47�
Permit Issued Tom- j
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
j
LIN
z7 DATE.RECEIV_ED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road P.O. Box 79399
_
Dartmouth, MA 02747
&.. U.Tl
ss
✓'
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLRNG
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: A
®
BUILDING PI;RNIT
DATE SENT FOR REVIEW
NUMBER:
DATE ISSUED:
OK TO ISSUE -SIGNATURE: DATE MAY �� . �
B i Commission r/Inspe or of Buildings
Zoning District: Proposed Use. one: C ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer done _
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Enemy Report
Appeals Health Affidavit Card Sent: Cut Off Follow;=up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Othe!r
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
nergy Report: Signature: Date:
Fire Chief: Signature: Date:
r
Board of Health: Signature:" _ Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:' ;.
Description of tivork being performed:
SECTION 1 -SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address: 9r��s-e.�/�
1.2 Assessors Plat of Number: /f)
Plat Lot
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Has application been submitted to the Historic (Commission?
Total Land Area Sq. Ft.:
❑ yes , no'' Date:
1.4 Water Supply (MGL c 40 5 54)/:
1.5 Sewage Disposal System:
® Municipal❑ Private Well
❑ Municipal N(On Site Disposal System
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