BP-9095Dlrt. RM. KIT.
FA til . R M
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eD• RM.
800 MECHANICAIS & PRIMARY FUEL
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)
77 None of the above to be provided
Hot Water Gas Electric Fuel Oil Other
goo SPRINKLERS FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
n v
Required, --plans provided, plans not provided, why?
Not required, not to be installed, Why?
1000 REQUIRED OFFSTR= 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 spaces -required _ yes _no. If yes, how many as a prt of the total required number.
Is Routeb (State Road) Entrance permit required? yes no If yes has it been issued yes no Y,.
Submit copy of application and/or permit as soon as available.
1100 IDENTIFICATION (print or type except as noted)
Current owner - nameiz
address` L K e'avv
i phone #
If corporation, officer in charge
Architect/Engineer - for overall design
Company name
I
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.
Arc eer - 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 and not
reproductions.
General Contractor (if Homeowne , state homeowner here then complete section 1300)
J ••
Company same
Q
Address
Phone number
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 gto to next section!
Are you claiming exemption from the requirement? Yes —'No _If yes, submit the requiired affidavit!
Ren_odel contractor name (pleaseyrint)
Address
Registration number (if none state "none")
Phone number
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) 7�27-8598
- wners name (print) Cl e't
Signature
Date
i
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 requested -be issued.
Further i understand that the permit will expire in six months from the xP � date of in
sue,
if
six months after the last inspection if work has begun and'that the no work is begun is
egu permit may be extended for six mont
hs if no work '
anticipated if I uest is
request such an extension in writing. I understand that the permit may be e
written request I understand that o Y extended only three times b
q once the permit expires a new application Y
P pp may be required, including fees and current
other requirements (including Zoning).
Name
Signature
The above signature is my voluntary act and is signed under the pains and penalties of perjury.
Date
Who is authorized to picku t�}e permit at the Building Department? (alense grind
Address 1�1.?�,.� IC�� 7
�z � � � � Phone
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMH,Y 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 accords-ce with the rules and regulations promulgated by the BBRS entitled
Riles and Regulations for Licensing Constrn.ction 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 O Amer 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 dwellin
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in, attached
two-year period shall not be considered a Home Owner.
you are applying under this section sign below:
ignature A,
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE ',li'O 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 5)
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1500 COS7
Cost of Improvement
Items to be installed but not included in the above cost: Electrical 5
Plumbing
HVAC
Other
TOTAL
= Alteration of existing,. no increase in gross square feet. A separate Refuse Disposal Declaration., required.
= Demolition - describe structure
i
Number of dwelling units Number of bedrooms A separate Refuse Disli,osl
Declaration tequirsd.
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 ewill not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwellting will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3404.10 for
residential and Artici- 8 fi._ commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
Z.- No submitted. Why?
i
Submitted, usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
❑ Not required, why? -
Submitted When? = Previously, date ^With this application
700 UI HXIUS
Water supply - required — yes — no, public ? yes _ no, on site well? v 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 supp,'!y, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required — yes no, public sewer _ yes — no
private septic on -site yes — no. Submit copy of permit as soon as available
Woodstove - used (will require inspecd,�n prior ?) installation), new (provide manufacturers
instructions). Location(s) (list)
Firepiace(s) (includes flue) List location(s)
G me Court describe (include overall dimensions)
r )
Tent, Trailer (Mobile Home) of othe,r;L describe "
300 COMMERCIAL - PROPOSED PROJECT/USE INCLUDING THREE FAMX3,OTED)
USE
i
THIS` SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Buildingee theCode)
Assembly - restaurant, lounge, theater, school,etc. (see Code Sectio
= Business - office, assembly with less than 50 occupants - indi Medical or other professional (see Code
Section 303.0) -
Educational, -'structure for training including child da are for those over 2 years 9 months (see Code Section
304.0)
Factory / Industrial - (see Code Section 30 )
High Hazard (see Code Section 306.
Institutional hospital, nursing me, infant day care (see Code Section 307.0)
Mercantile - retail stores (s Code 308.0)
Residential - three or " ore family,'hotel (see Code Section 309.0)
Storage include garages (see Code Section 309.0)
Utility & M* ellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
New to nt for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
- Te or Trailer- temporary purpose?
ther
Describe the proposal briefly, INCLUDE - umber of dwelling units and bedrooms or occupant bad as applicable,
i
also existing condition
400 TYPE OF NSTRUCTION OR WORK TO BE PERFORMED
— New Construction and/or Addition total gross square feet
II M.
(For commercial only total gross cubic feet) - indicate
It will he 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 COMMERCIALONLY
Will this project be subject to CONSTRUCTION CONTROL (over35,000 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 I)
♦ DDT T f` A li i` T!1 DD 1AXTY" V .
The following section for official use only."'
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
OK to issue subject .to requested submittals (see project review worksheet) date
DENIED see project review worksheet date
HOLD reason date
HOLD Subject to Zoning Board of Appeals action'
Comments
Inspectors signature Datte EN 7 19
Applicant informed of above Date time staff (fax, ph(nne, 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 IT;ate
Advised applicant Date Time staff (by phone, fax or in pers(bn)
OFFICE\)NSPECTORS NOTES
TOTAL FEE
Gross area - new construction 3 7 Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to .,—i-+��t�7'�'�`r`►——.'''?°r�`C^.�/l!/l/lil '7'': �^��—� z
r
Comments/notes on permit
I
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1600 TO `i'IiE APPLICANTJREFERRAL AND APPROVAL
Date of Application submission'
Plat ; Lot j Stre
ram.' 1 ( Aquifer Zone i
Owner i' d .. o 16i CA
Owner mail address.{
Owner phone #
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OTHER ENVOLVED AGENCIES -'The following agencies
require separate jurisdictional
permits or approval for your
proposed project. CONTACT TIUI FOR Rg(NT>7Qyp
SiIBIMiISSION3-
TAX COLLECTOR _ Approved i' HOLD By
Date
o Board of Appeals.= Approved By
!%
Date
4 ❑ onservation Commission-C-Approved By
Date
Q D.P.W. Water Approved By ❑ D.P.W. Sewer - Approved By
Date
❑ D.P.W. Cross Connection a Approved By
Date
❑ Treasurer (Bond) ❑ Approved By
Date
❑ D.P.W. Engineering Approved By
Date
ard of Health (well) Approved By
D00ard
Date
of Health (septic) = Approved By
Date
❑ Board of Health (food service) = Approved By
Date
❑ Planning Board (parking) 7 Apprvvesi B
Y Date
;FIRE DISTRICT ( II - fIr) — Approved By Date
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BUILDING DEPARTMENT APPROVAL: ,
❑ ZONING
o BUILDING INSPECTOR/BUILDING COMMISSIONER
a.: ffi
❑ CONTROL CONSTRUCTION'aFFIDAVTT,
PROJECT SUMMARY:
new construction/ alteration/demo sewage disposal - publiciprivate
f.Alt,er;add interior walls' [add rooms] [add footprint] water supply - public/private well
[pool] [garage/shed/deck] [game court] [food ervice]
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 anv reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
1-�
The Building Department -Date sent for review By _4
TOWN OF DARTMOUI'R`SUI MViG.-DEPAR NT.
TELEPHONE .508-999-0720 FAX..* 508-999-0`738
APPLICATION FOR ZONING AND BUELDING PERMIT
Instructions
The applicant shall complete this application to the best of their ability prior to submission, leaving no item unanswered. T`he
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted for those seoitions
which do not apply. A properly completed application will help avoid unnecessary delays. Am in not refiwA T61&_
(for office use only) �.- • SUN �9NLY
Total Cost Received By � Date Reed
Less Application Fee - -
Total Permit Fee �� Permit # Issued Date
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT .3 ( LOT ZONING DISTRICT
OTHER ZONING OVERLAY DISTRICTS , if applicable
NUMBER & STREET i9 ( - T11
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TENANT / OWNER
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 i
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
Deck - dimensions L W
Gazebo - dimensions L W
Swimming pool above ground in -ground Size
Chimney - number of flues
V 0OR�