BP-2002-25548100.5
0#i V = 100.5
(A)
100.3
�„ SANDY LOAM
100,0
LOAMY SAND
98.5
24"
98.5
97.0
00ARSE LOAMY
SAND
100.a
o»
ELEV,
�A)
100.3
6„
SANDY LOAM "
100.0
LOAMY SAND `.
98.5
24"
98.5
(C)
97.4
COAgSE LOAMY
SAND
r
RESIDENTIAL �UUZ
'n-V C F 'V 1%1TT A T. 2002 - a
1\iJ IJ iL
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: P62 Lr r`� � � � � �
Not Applicable ❑
Licensed Construction Supervisor
License Number � 6 ys7
Address j tt. ,5� 7
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Contractor subject to 780 CMR-6)? "❑ yes 2 no
Are you a Home Improvement J (
If no, go to the next section!
Are you claiming exemption from the requirement? ` ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name J-"atfl ' Z-7 r �
Registration Number (if none, state "none")
Address -r f i'
Signature �`.a.�-� .�. 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, 11A 02108, (617) 727-8598
Owners Name (print)
Slgnatu;: e
by signing the above, the homeowner 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 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
Constraction Supervisors:
r from the provisions of this section; provides that if a
Permit is required shall be exempt Exception: Any Homeowner performing work for which a Building q P
Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
Far 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 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
NOTICETO 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 13)
INSURs
SECTION 4'- WORKER S COMPENSATION ANCE AFFIDAYTs
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ nso
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicabl e t
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ 10 woodstove
(energy report required) (energy report required) fireplace
Eldeck ❑ pool ❑ accessory bldg. Elreplacement window/door ❑other , G'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 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 Description of Proposed Work: -
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicatnt _
1. Buildin
2. Electrical
3. Plumbing
4. Mechanical HVAC
* Estimated Total (�
5. Total = (1 + 2 + 3 + 4)
SECTION 7A OWNER AUTHORIZATI
(to be completed when owner's agent or contractor
's cila e� i Y
(please print)
, as Owner of the subject property hereby authorize
to act on �myehaf, in all ma ers relative to work authorized by this building permit application
Sion f Owner f Date
.- r AM
WN
"_' N- `
NE --
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION%
I w wner/Authorized Agent hereby declare that the statement, and information
a-o
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature wner/Authorized Agent IDate
C•`hld,� iFnrms\Rldannn res.wnd Paee 2 Rev. January 19, 2001
C:\bldg.f'ornis\Bldgapp.res.wpd Page 3 Rev. January 19, 2001
2002 RESIDENTIAL 2002
RESIDENTIAL
❑ FOUNDATION ONLY
` Y SECTION 8 - INSPECTOR'S REVIEW/COMMENTS $25.00 APPLICATION FEE IS NON-REFUNDABLE d� NON-TRANSI'ERASLti�
.n .
DATE RECEIVED
1. ` Date plan reviewed.
DARTMOUTH BUILDING DEPARTMENT
2. 30 days to review period ex
pires. j y
1 :° Y � ��' ; 400 Slocum Road, P.O. Box 79399
3. OK to issue date: - Dartmouth, MA 02747
Date: ='
..:, ��.� �YY:
4. OK to issue subject to requested submittals(see project review worksheet): 508-910-1820 FAX 508-910-1838
5. DENIED (see project review worksheet): Date: -
'APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Date:
6. HOLD reason:
THIS SECTION FOR OFFICIAL USE ONLY
7. HOLD subject to Zoning Board of Appeals action:
Date:
8. Comments:
RECEIVED BY: BUILDING PERMIT
DATE SENT FOR REVIEW:
0 NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: C ; DATE
Date: E/ i✓ uildmg missioner/Inspect r of Build' gs
9. Inspector's Signature:
s k -s PPLICAN IFICATION F '' r'
ECTION 9 A Zoning District: roposed Use: Zone: l❑ B ❑ A Outside Flood Zone ❑ Aquifer Zione
Applicant informed of above Date: Time: Clerk: THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
_ �. ❑ Elec. ❑ Ener
p
Report
ort
Comments. Board of❑Board of❑Con. Com. ❑ Demo ❑DPW Follow ut
Appeals Health Affidavit Card Sent:'Cut Of
,
h SECTION 10- OFFICEVNSPECTOR'S NOTES Other❑Fire ❑Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑
Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ Cut Off / Cut Off Review*
Chief Cut Off
TOTAL FETE: ; co Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. ' �`
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Permit Issued To
4' ; , Date:
Signature:
Zoning Review:
,..
4 �_ s SECTION 11-ADDITIONAL COMMENTS/SKETCHES Date:
- Energy Report: Signature:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Date:
Conservation Commission: Signature:
Other: Signature:
Description of work being performed:
SECTION 1 SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
P ` 1.2 Assessors Plat & Lot Number:
1.1 Property Address: r° % Ra SId,15 M Plat 13 Lot rFZ -
Nearest Cross Street:
1.3 Historical District ❑ yes
Subdivision Name:
4 � a Has application been submitted to the Historic; (Commission? .
Total Land Area Sq. Ft.: ❑yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal[] Private Well ❑ Municipal ❑ On Site Disposal System
v
.A
Page 1
uaiy 2001
Rev.Jan
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