BP-31391600 TO THE APPLICANT/REFERRAL AND APPROVAL
Date of Application subr�mission 1 j n -7
Plat Lot//treet -
Owner
Aquifer Zone
Owner mail address
Owner phone# .4717) 4/ Z
OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT TEEM FOR RFnz>iftpp S-pg WS-
® TAX COLLECTOR `Approved _ HOLD By Date
❑ Board of Appeals _ Approved By Date
❑ Conservation Commission G Approved By
O D.P.W. Water _ Approved By 13 D.P.W. Sewer _ Approved By
❑ D.P.W. Cross Connection _ Approved By
❑ Treasurer (Bond) ❑ Approved By
❑ D.P.W. Engineering ❑ Approved By
-3 Board of Health (weln :!At proved By
❑ Board of Health (septic) _ Approved By
❑ Board of Health (food service) ^ Approved By
❑ Planning Board (parking) _ Approved By
Date
Date
Date
Date
Date
Date
Date
Date
Date
19 FIRE DISTRICT (I - II -III) _ Approved By
Date
BUILDING sssssssss
BUILDING DEPARTMIIVT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SLT.MMARY:
new construction/ alteration/demo sewage disposal - public/private
[Alter/add interior walls] [add rooms] [add footprint] water supply public/private well
[pool] [garage/shed/deck] [game court] [food service]
Describe
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department - Date sent for review
By
g
TOWN OF DARTMOUTH'TW. BUG D PAR�N
TELEPHONE .508-999-0720
FAX.,508-999-473,5
APPLICATION FOR ZONING AND BUILDING PERMIT
Instrnedom
The applicant shall complete this application to the best of their ability prior to submission, leaving no item ®answered. The
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted for those sections
which do not apply. A properly completed application will help avoid unnecessary delays. Noft Fimg iee is not tee I iI
(for office use only) ❑ FOU IDATION ONLY
Total Cost $ Received By % Date Ree'd `
Less Application Fee $"���- . . -�
Total Permit Fee S Permit # Lssned Date ;j /� 7
100 LOCATION OF PROJECT
TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT LOT �d'� ZONING DISTRICT
OTHER ZONING OVERLAY D
NUMBER & STREET
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
if annlienhle
or BUSINESS NAME P / OWNER rc�&> [,)e "1— Lo- (cam r P P6")
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
THIS SECTION NOT APPLICABLE
Single family - number bedrooms number baths
Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. ft.
Accessory structure:
Garage - detached - attached to dwelling, dimensions L W
Carport - detached - attached to dwelling, dimensions L W
Shed - dimensions L W J�
Deck - dimensions L W
_ Gazebo - dimensions L W
Swimming pool above ground in -ground Size
Chimney -number of flues
v - - • ---� a....uuaa�;�LLf CI3
instructions). Location(s) (list)
C Fireplace(s) - (includes flue) List location(s)
C Game Court -describe (include overall dimensions)
❑ Tent, Trailer (Mobile Home) or Other - describe
300 COMMERCIAL - PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
2 Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Section 303.0) -
Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
C Factory / Industrial - (see Code Section 305.0)
High Hazard - (see Code Section 306.0)
L Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Mercantile - retail stores (see Code 308.0)
L Residential - three or more family, hotel (see Code Section 309.0)
E Storage - includes garages (see Code Section 309.0)
Utility & Miscellaneous Structures - includes tents and gricultural structures (see Code Section 311.0)
C New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
C: Tent or Trailer - temporary purpose?
Other
Describe the proposal briefly, INCLUDE r umber of dwelling units and bedrooms or occupant load as appficab je,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
New Construction and/or Addition - total gross square feet
(For commercial only total gross cubic feet) indicate
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
If project is an addition to existing structure - Total gross square feet of existing
FOR COMMERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes No. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
° Will this project require Peer review (over 400,000 cu.ft.) Yes No (see Code Appendix 1)
APPLICANT TO PROVIDE
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INSPECTORS' REVIEW
Date plan reviewed /
30 days to review period expires
_I OK to issue date
OK to issue subject to requested submittals (see project review work sheet) date
DENIED see project review worksheet date
HOLD reason date
HOLD Subject to Zoning Board of Appeals action
Comments
n
Inspectors signature
MateJUL 141997
Applicant informed of above - Date time staff (fax, pibone, in person)
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Over six months since approved for issue - DEEMED abandoned?
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector
:Date
Advised applicant Date Time staff (by phone, fax or in person)
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OFFICEVNSPECTORS NOTES
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration
Permit is issued to
Comments/notes on permit .
Total Sq. Ft.
1300 OWNER SIGN - OFF
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -and correct and that the permit recpaested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and'that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three tunes by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
Name t
( P-e n
Signature L
The bove signature ^is my voluntary act and is signed under the pains and penalties of perjury.
Date A, 3 t `% % /
Who is authorized to pickup the Permit at the Building Department? (ease r;nt1
Address 7 Vtc (�C V �/ a �qr(p�� L°Cs(�i P Ur LCt t., ✓< G
• Phone �' / — yJ
1400 HOMEOWNER F.XEMMON - ONE S, TWO FAMILY ONLY
FOR 1101ME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109-1.1 Licensing of Construction Supervisors: Except for those structures governed b in Section 127.0, effective July 1, 1982, no individual shall be engaged in directlsupervisingy Constructionsen Control
construction, reconstruction, alteration, repair, removal or demolition involving the strucural ele�ts of b ding o
structures, unless he or she is licensed it accordance with the rules and regulat!ons promulgated by the B.3RS entitled
Rules and Regulations for Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Home Owner" 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 dwellin , attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner.
If you are appiying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necess
arilv mited to
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NOTICE TO 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
2.15.2 of section 51
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1500 COST
Cost of Improvement
Items to be installed but not included in the above cost:
Electrical $
Plumbing
HVAC
Other
TOTAL
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration requit-ed,
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration regau ed.
Moving - (Provide copy of D.P.W. moving license) Type of structure
from where (plat/lot or address)
to where (plat/lot or address)
Number of dwelling units Number of bedrooms per dwelling unit
— Re -roofing - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
= Replacement doors and windows _ (for existing only) (only where doors and windows exist and will not. be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will ibe
considered as an Alteration, otherwise will be included in: new construction. (see Code section 3401.10 for•
residential and Articl. 8 fc: commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of throe.
Describe I will be using the
u :5ti� `Ecitior,
500 CONSTRUCTION PLANS ❑ 6t h Ed i t i on
None submitted. Why? of the State Guild: rnq cpap
/submitted. usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
❑ Not required, why?
1/9ubmitted When? = Previously, datet ith this application
700 UrUXI'IES
Water supply -required _yeso, public ? ✓ yes _ no, on site well? _yes _ no,
existing? _ yes _ no
If required and not existing have necessary permits been issued? _ no _ yam, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, whem
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes 1no, public sewer yes _ no
private septic - on -site _ yes _ no. Submit copy of permit as soon as available.
A
900 MECHANICALS & PRIMARY FUEL
= Furnace (hot air) - Fuel gas (natural or propane), fuel oil, electricity, other (specify)
C 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
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, --plans provided, Elplans not provided, why?
- Not required, not to be installed, Why?
1000 REQUIRED OFF-STREET PARKING - for ZONING & Architectural Access
NOT APPLICABLE
Parking Plan submitted To = Building Department [] Planning Board Date submitted
Number of spaces - indoors outside total provided
Handicap space.- - required _ yes _no. If yes, how many as a part of the tota-' required number.
Is Route 6 (State Road) Entrance permit required? yes no If yes has it been issued yes no
Submit copy of application and/or permit as soon as available.
1I00 IDENTIFICATION (print or type except as noted)
Current owner - name P(j t'4 •(_ L IrC r e e
address
phone #
If corporation, officer in charge
Architect/Engineer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
Architect/Engineer - project supervision and reports
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals rand not
reproductions.
General Contra (if Homeowner, st ' homeowner here then complete section 1300)
Company name
Address
Phone number
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals aind not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes _ No _ If no go tto next section!
Are you claiming exemption from the requirement? Yes _No _If yes, submit the required affidavit!
Ren_odel contractor name (please print)
Address
Registration number (ir none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCIESS TO THE
GUARANTEE 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)
Signature
Date
4