Loading...
BP-23936RESIDENTIAL 2002 RESIDENTIAL SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 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): Date: 5. DENIED (see project review worksheet): Date: 6. HOLD reason: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Signature: Date: 1 ?002 SECTION 9 - APPLICANT NOTIFICATION Applicant informed o ove Dat : rQ Time: Clerk: Comments: SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee:.S Less Application Fee: S 25.00 Remaining Balance: S _ TOTAL FEE: Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To- qG SECTION 11 - ADDITIONAL COMMENTS/SKETCHES /q C':`blde. forms' Bldppp.res.wpd Pa(e 4 - Re\.;;:nuar P).N)iiI ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-: ErUNDABLE ac NON -TRANSFERABLE DARTIIOUTH BUILDING DEPARTMENT - .., DATE RECEIVED 400 Slocum Road, P.O. Box 79399 — Dartmouth, MA 02747 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: DATE SENT FOR REVIEW: OK TO ISSUE - SIGNATURE: BUILDING PERMIT NUMBER: DATE ISSUED: 2002 ' DATE MAY Q 1 20p� of Buildi ies Zoning District:_& Proposed Use: one: P< ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone «---- THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Repmrt Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other Chief Cut Off / Cut Off / Cut Off Review* * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT DEPARTMENTAL APPROVAL a Zonin- Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: / Date: Conservation Commission: Signature: /V Date: Other: Signature: Date: Description of work being performed: SECTION 1 - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Propene Address: Vk L y D R 1 U Nearest Cross Street: 1.2 Assessors Plat & Lot Number: Plat 38 Lot 10 --t 3 i Subdivision Name: G U 6- F t4lit.- STA Tlr 5 1.3 Historical District ❑ yes 9 no Total Land Area Sq. Ft.: _ 5-o7t LJ 14 D Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: X%IunicipalO Private Well 14unicipal ❑ On Site Disposal Sysitem RESIDENTIAL 2002 RESIDENTIAL SECTION 2 - PROPERTY ONV`1ERSI'!D AUTHORIZED AGENT 2.1 Owner of Record: Zs3 S al LE L Ao P-A AA &"crJ V A L,,ci D f-%vtiz- Sc, j--4 DA V- x Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTTON 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,Narne 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 Owners Name (print) �• 2cE Qt Signature EaZ4,ou-t� 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 OW PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section l 16.0, 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, oa- 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 Dome in a two-year period shall not be considered a Homeowner. If you are applyiing under this section sign bel Signature: -�t4- Your signature carries certat responsibilities, including but not necessarily limited to, general liability 2002 NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructiion 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 Nis affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ wotbdstove (energy report required) (energy report required) fireplace 2/deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ detmolition (shed/garage) no. of windows doors (specify below): (specit?y below): * If new construction, please complete the following: Single Family no. of bedrooms no. of baths Two Fantilv: 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: DernD e ctJ4-1 % � � I S � CZ I 01 « K. 20 ,s i argj SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ($) to be completed by permit applicant 1. Buildina 2. Electrical 3. Plumb11IQ 4. Mechanical H\'AC 5. Total = (1 + 2 + 3 + 4) * Estimated Total $ 'ZQDO 00 SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) 1, , 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 - OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent hereby declare that the statements and infOinnation on the foregoing plicai on are true and accurate, to the best of my knowledge and belief. Signed under the gins and penalti s f perju 1 —©Z- Signature of 0\vner/Autklirizecl Agent Date ('•V,LIu Inrmc\Rl�gn�nn — -nd Pa(,P ? Rov 1:wir!re 19 ''001