BP-18046Dartmouth Building .Department
400 Slocum Road P.O. Box 79399 Dartmouth, MA 02747
508-999-0720 PAX.50-999-0738
IZION N-G REVIEW,
Plat: Lo Street '1 C
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Subdivision Name: , i - _ Lot#
Owner's Name -TM71
Designer: ¥
¢y
Contact Person:"``
71
Designer's Specialty: ofessional Engineer= € Surveyor
Sanitarian ❑ Other ❑
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RESIDENTIAL 2000
RESIDENTIAL 2000
FOUNDATIOj-J ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERAMILE
DATE RECEIVED',,`
�M, s DARTMOUTH BUILDING DEPARTMENT _
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 M ,
sy 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLUNG
Zoning Review:
Signature: ` _
s� atj: 6 :20,
Energy Report: -
Signature:
NOVbfie2-000
Fire Chief:
Board of Health:
Signature: 1114 a
Signature
Date:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 111yes ❑ no
1.2 Assessors Plat Lot Nu ber:
1.1 Property Address: jT � � �? da le �l Plate Lot _-
Nearest Cross Street: lcj �
Subdivision Name: 1.3 Historical District 0 yes X no
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Ctmmission?
(� ��
0 yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal Private Well ❑ Municipal :K On Site Disposal System
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Rev. January 13, 2000
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Rev;:,JJanuary 13, 2000
RESIDIENTIAL
2.1 Owner of Record: —
c/ � , Z�',� l '56J A>A00, RAY)
Name (print) Contact Address
2.2 Authorized Agent:
Name (print) Contact Address
.....................
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor 6 ),2 /-f, A 8_LioencP N,imhPr n 491 je_
f IvIlf
Address 1 1 v. —�
f `ei
Expiration Date
y �y�
9 �
Signature Telephone 179� _ J 2 0
3.2 Registered Home Improveme t Contractor:
Not Applicable ❑
Are you a Nome Improvement Contractor subject to (780 CMR-6)? Xyes ❑ no
If no, go to the next section)
Are you claiming exemption from the requirement? ❑ yes iN no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
AddH'ess 0 t +
Signiat21re 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)
Signature
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 OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, 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, 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 a two-year period shall not be considered.a Homeowner.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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Workers Compensation Insurance affidavit must be completed and submitted with this application. ail re to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ves ❑ no
❑ new construction* addition ❑ alteration ❑ repairs ❑ chimney/ 131,woodstove
(energy report required) (energy report required) fireplace
deck ❑ pool X accessory bldg. ❑ replacement window/door ❑ other ❑l(demolition
( /garage) no. of windows doors (specify below): (speecify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
j
Two Family: no, of bedrooms unit I 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:
< ®X >0Y)
-e" 00�Y � � c°C Vto �. � P C�"'
Item Estimated Cost ($) to be completed by permit applicant
1. Building C. 066 00
2. Electrical -r�3n
J. 1 tuilluili
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) * Esti»rated Total $ rr000 0
(please print)
1, as Owner of the subject property hereby authorize g Ake
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 7 Date
/..............
I, %t) ®T�e'Y as Cyr/Authorized Agent hereby declare that the statements and in�'Tormation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
0- r> , ,%
Signature ofr/Authorize Agent ate
I
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