BP-460313DO OWNER SIGN - OFF
I, the undersigned, am the ownerof 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 requested.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 times 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
Signature -�'
The
Date
act and is signed under the pains and penalties of perjury.
Who is authorized to pickup the permit at the Building De artment? {please Drina if, ithi `7 A
Address% %r 12225 57Phone d' s —.9
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR HOME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control
in Section 127.0, 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 accordarce w.`h the rules and regulations promulgated by the BBRS entitled
RLIe's 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 heishe 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
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that anv
licensed Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see
2.15.2 of section 5)
1500 COST
Cost of Improvement
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other
TOTAL �eooeq' PO
/Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration .required,
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal V
Declaration required.
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 dwelliing will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 34011.10 for
residential and Articlo 8 lu: commercial) =- -
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periotils of time.
Describe
500 CONSTRUCTION PLANS
None submitted. Why?
- Submitted, usually three sets required. Four sets for food service uses. Number of sets submitt�.d
600 SITE PLAN
❑ Not required, why? —
Zubmitted When? = Previously, date 'J4ith this application
700 UTILITIES
Water supply - required y yes _ no, public ? _ yes _ no, on site well? _ yes _ no),
existing? _ yes _ no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supiply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _' yes _ no, public sewer V yes _ no
private septic - on -site _ yes _ no. Submit copy of permit as soon as available.
r,
800 MECHANICALS & PRIMARY FUEL
Architect/Engineer - project supervision and reports
- 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
900 SPRINT LERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, plans provided, plans 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
H-ndicap spaces - required _ yes _nn. If yes, how many as a part of the total 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.
1100 IDENTIFICATION (print or type except as noted)
Current owner -name
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.
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 andl not
reproductions.
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Company name�L.,J ���'/ 0 c�'✓�%��
Address
Phone number
s
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and' 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 to ntext section!
Are you claiming exemption from the requirement? Yes No V If yes, submit the required aiffidavit!
Ren_odel contractor name (please print) � �. 20S (4 0 %'o�1'f
Address 13 e5l;'
Registration number (if none state "none") Ix- �(p
Phone number % / �° / 7S
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS 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
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1600 TO THE APPUCANP/REIrERRAL AND APPROVAL
Date of Application submission
Plat Lot Street Aquifer Zone
Owner
Owner mail address
Owner phone #
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REOL��D
SUBMLSSIONS.
® TAX COLLECTOR ❑ Approved HOLD By
Date
13 Board of Appeals ❑ Approved By
Date
17 Conservation. Commission ❑ Approved By
Date
13 D.P.W. Water 'I Approved By O D.P.W. Sewer ❑ Approved By
Date
13 D.P.W. Cross Connection u Approved By
Date
17 Treasurer (Bond) 13 Approved By
Date
" 13 D.P.W. Engineering ❑ Approved By
Date
-3 Board of Health (well) :3 Approved By
Date
O Board of Health (septic) 1 Approved By
Date
o Board of Health (food service) 2 Approved By
Date
13 Planning Board (parking) :1 Approved By
Date
N FIRE DISTRICT (I - II -III) Approved By
Date
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BUILDING DEPARTMENT APPROVAL:
O ZONING
13 BUILDING INSPECTOR/BUILDING COMMISSIONER
a CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construction/ alteration/demo sewage disnneal
[Alter/add interior walls] [add rooms] [add footprint] water supply - public/private well
[pool] [garage/shed/deck] [game court] [food service] I
Describev�=-- X
a /,�
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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
TOWN OF DARTIVIOUTS : BILDING DP.RT'1VIE.lT'
:TELEPHONE .508-M-0720 FAX 508.999-f 738
APPLICATION FOR ZONING AND BUILDING PERMIT
bssUruetiom
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 homs to assist as necessary. N/A should be inserted for those se-tions
which do not apply. A properly completed application will help avoid —necessary. delays. Nde: )Ei6 Sees not tef�a�i�
(for oWme we only) ❑ FOUNDATION' ONLY
Total Cost $ Received Bp_ Date Rec'd� j�'�
Less Application Fee $ 5
Total Permit Fee Permit # Iss;w d Date
100 LOCATION OF PROJECT
TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT 3 LOT I ZONING DISTRICT
OTHER ZONING OVERLAYS DISTRICTS, if applicable �
NUMBER &STREET [N Z1_� D k / I`/ f,
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME �r-J
PREVIOUS TENANT / OWNER tla me 6 /v/)V/ � e )7S
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
THIS SECTION NOT APPLICABLE
Single family - number bedrooms number baths
,a
Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2 _
Accessory apartment Total gross sq. ft. -
C Accessory structure:
Garage - detached - attached to dwelling, dimensions L W
n iu Carport - detached - attached to dwelling, dimensions L W i
�1
Shed- dimensions L W
9 Deck - dimensions L W
C Gazebo - dimensions L W
(� Swimming pool above ground in -ground Size
G Chimney - number of flues
C7
— ••..uuatu.e--LsCu-tWUV `equWe-nspecuon pnor to Installation , new (provide manufacturers The following section for official use only.
instructions). Location(s) (list) INSPECTORS' REVIEW
C Fireplace(s) - (includes flue) List location(s) ' Date plan reviewed /
y
C Game Court -.describe (include overall dimensions) 30 days to review period expires
C Tent, Trailer (Mobile Home) or Other - describe x C OK to issue date
300 C011mr c AL - PROPOSED Plaonc /USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES J OK to issue subject to requested submittals (see project review worksheet) date
C THIS SECTION NOT APPLICABLE DENIED see project review worksheet date '
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the C HOLD reason
Code) elate
C HOLD Subject to Zoning Board of Appeals action
n Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Comments
C Business office, assembly with less than 50 occupants - indicate Medical or other professional (see Code Inspectors signature DO 19a�
Section 303.0) -
C Educational -structure for training including child day care for those over 2 years 9 months (see Code Section Applicant informed of above - Date time staff (fax, phmne, in person)
304.0)ssss*ss*sssss*sssssss*s*ssssss*ssssssssss*s*ssssssssssssssssssssts*ssssssssssass*ssssss*ssssrs**sssssssss*s
C
Over six months since approved for issue - DEEMED abandoned! Factory /Industrial _ (see Code Section 305.0) Advise applicant. Hold 90 days for return then dispose if not picked up.
C High Hazard - (see Code Section 306.0)
El Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Mercantile - retail stores (see Code 308.0)
C Residential - three or more family, hotel (see Code Section 309.0)
C Storage - includes garages (see Code Section 309.0)
C 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?
C Other
Describe the proposal briefly, INCLUDE rumber of dwelling units and bedrooms or occupant load as applicable,
also existing condition
400 TYPE 00 CONSTRUCTION OR WORK TO BE PERFORMED
l
New Construction ion 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
C 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.fL) Yes No (see Code Appendix 1)
APPLICANT TO PROVIDE
Inspector - _
Dante
C Advised applicant Date Time staff (by phone, fax or in persom)
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OFFICEUNSPECTORS NOTES
0
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
Comments/notes on permit
2