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BP-11493Residential 1999 Residential ❑ FOUNDATIG'NONLY 1999 1. Date plan reviewed: r��v��" r 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(see project review worksheet): Date: 5. DENIED (see project review worksheet): Date: 6. HOLD reason: Date' 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: 19. Inspector's Date: �n DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED !Q m LL 400 Slocum Road, P.O. Box 79399 o c Dartmouth, MA 02747 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING; Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Property Address: 1.2 Assessors Plat &Lot Number: [ Nearest Cross Street. Plat ..3� Lot-�_ Subdivision Name: 1.3 Historical District ❑ yes fib-rM 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: 15'MunicipaID Private Well 'Municipal 0 On Site Disposal System p Name (print) Contact Address 'phone number c:\wpwin\forms\?bldgapp.res Page 4 January 20, 1999 c:\wpwin\forms\bldgapp.res Page I Jamuary 20, 1999 Residential ` ' .. 1999 Residential 1999 2.2 Authorized Agent: Contact address NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licenised Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 Name (print) CMR R5.2.15) Telephone SEG"I J1.fN::.�:; . .MPE1�1t1TI . > :..... ...................... ,:::.::_...:.:.:....:......... T.. 11'CAL........................:.:::.:::.::::::.:... ................. .:. .. _ ...... ... . A7 FEDAt?I ................... ..............................:.:.: ......................... :::::.:::.................................:....±G41Sx1tt 1C...xUIY.SI1:Ri CS........................:::::............................:.:..................... 3.1 Lice Cons;;:.;; cti sa5eA tru o Supervisor: ­xx Not Applicable ❑ Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide t{his affidavit Licensed Construction will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no pupemsor License Number _..... . itON,5..:D> SCRTPTI4N.:4 .1' ap4S1 > ;.W t2 : checlz.alt. a : ;1 cable .:::::'::: . F ) Address es Signature Telephone Expiration p Date ........:.::::::::.......::.::....::::... ::..: ...... .........:..:;.;..:.::... «,,,:,:::::::.;::;;::;.::.;:<;;:::::::.;,,:.::::.;::;:>:.;;>:>:;>;:•:;.;:.;;�:<;<>;•.>:�>:�>:>:::<.>:;;;:>:;:«;;:;>,::>::>:;.>:<;;<::«:;;:;:;:»:> «c;:::i>.;:::<::,:<::<::<:;::;;::;::>::;><;. i ❑ new �ddition ❑ alteration ❑ repairs ❑ chimney/fireplace ❑ w©odstove construction* 3.2 Registered Home Improvement Contractor: Not Applicable ❑ ❑ deck ❑pool ❑ accessory bldg. ❑replacement window/door ❑other ❑ de-molition Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no (shed/garage) no. of windows_ doors_ (specify below): (speciify below): If no, go to the next section! Are you claiming exemption from the requirement? ❑ yes ❑ no * If new construction, please complete the following: Ifyes, Submit the required affidavit! Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit 1-no. of baths unit 1 Company Name Registration Number (if none, state "none") no. of bedrooms unit 2 no. of baths unit 2 Address Brief Description of Proposed Work:' Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED TERED CONTRACTORS O S DO NOT HAVE E ACCESS TO THE GUARANTY _ ::::::...:::::.:... :.:.::: . STIC3iv..: �i ES.TT1vT TET:C#��iYSTRTI i If tN.:CO :::::::...:..:::.::, >'::;.>::>::::: S [.:::.:..............;::>:::<:>::»;>... _ ::::::.:::::::::::.:::::...::...:::::.:.:.......::. ;::.;;;:.;:.::::::::::::::::::::......:::.::::.;:.:;.;::;;;;:.;:.;:.;:.:;;::::::::;.:::::::::::.::::::;.;:.;::::::::;;;;:::::..:..................................... .................... . ..........................::::::::::::::::.:::. :..:.:...... FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 Item Estimated Cost ($) to be completed by permit applicant 1. Building Owners Name (print) 2. Electrical Signature 3. Plumbing by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund 4. Mechanical (HVAC) Date 3.4 Homeowner Exemption 5.Total=(1+2+3+4) - One & Two Family Only Estimated Total U--6a, FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE S ONSIB LEFOR THEIR OWN PROECT JECT E�TION 7A OVIIER �4113Tiit1Rl1t1T1Q1�1XX ...... ............::.::.:..............:........:::.:.::::::::::..::::::::::.:::.<.:::::.....:::::..:::.......::::::::.:.....:.::::::.:::.::::::::...::::::::..::::::::.......:::......::.:::::....:..::::..:::::::::.::.:::::.........................-........ tci:ao.eiY ,::.::.:...,:...:::.;:::.:::.....:::.. :::>::;.::>:::>::>>:>::>::>::;:;.::::::::;:.>: to lcted:�vire�t . :::::::::::.:::::.:::.:::.:................xvn esr:a: a �nt;ar::eontrato.r.;:a 11es::fn:a�uildin .; .::.............................:::::::::::::.............................g........................:.:::::::::::::.#1:::::::::.....................................)....::::::::::::::::::::::::::::::::::::::::::.:::::. ...........................::::::::.:::.:::.:.::::::.:::.:::.::::::::.:::::....................................:::::::::.::::.::::::::P ..1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, ........ :.:...............................::::::::::.:::::::::::... (pleas print) 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 I, / , as Owner of the subject property hereby authorize with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. to act on my' a in all re five to work authorized by this building permit application. Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this Sig eb section; provides that if a Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. Date For the » Purposes o s section only, a Homeowner is de Y, fined as follows: Person(s) on s who owns a arcel () of land on which he/ P she ;: ..: <>,:.::::.:: .... 1 C. i 7a:.:. W1�tE .AI3Ti _.......... :.;:.;;:.:;:.;:.;::;.;:::::.:::..:.:.;:.;:.;.;::.>:.:.:::::.::::.:::::.:.:............tN...........U...........R.............RY D.A NT:DIv .T,Ai: ;....................................................................... ...C.............CCll�l:::::::::::::::::::.::,:::::.:::::::::::::::::.......................:. resides o intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ,......::::::::::::....................................::::::._:::::::::::::::.:......................................................:::::._.::::::::::::::::. I 6 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 4el , as Owner/Authorized Agent hereby declare that the statements and infiformation a Homeowner_ on the foregoing a licatio re true and accurate, to the best of my knowledge and belief. If you are applying under this section sign below: Signed uanc Signder the pains ipenalties of perjury.� Signature: Pri Nam Your signature carries certain responsibilities, including but not necessarilylimitedto, general liability f Signature of Lyer Aut orize A ent Date c:\wpwin\f6rms\b1dgapp.res Vage 2 January 20, 1999 c:\wpwin\forms\bldgapp.res Page 3 Japivary 20, 1999 7. r FOMESS CIPAVEL CUVAa 10 96 VWM CMFACr KM 4pc4mcmmRzmsLO" 70 WIM V47M r wowwacmim v 8 "L FMT V*PM SAIP'llwit r 6111AVIIIII. MAN COMM= FLOOR FLAN roaoraYrumr HOT rri�o�inrlr.+vlw —I WATER HEATER, PER CODE FOLNDATION FLAN 3 BOWL POTTING SINK, e w • PER b, CODE MM& 8W= 21-LL BEAM VP VA. Ov. 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