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Box 79399 � Dartmouth, MA 02747 508-999-0720 FAX 508-999-0738 c— APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DNVY'ELLING Zoning Review: Signature: C%� Energy Report: Signature: Signature: / Fire Chief: y � Board of Health: Signature: Conservation Commission:Signature: Other: Signature: Description of work being performed: Date: %`7 Date: Date: Date: Date: NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ mo 1.2 Assessors Plat &Lot Number: I 1.1 Property Address: /_'{ /�,y,�/c'f3ifr'� %A Al, bi9,6" Plat__gg Lot�_- Nearest Cross Street: 9U55ii5C_S /tL , c1% f-t'1NE Subdivision Name: 1.3 Historical District ❑ yes [ no Total Land Area Sq. Ft.: / " �� , Has application been submitted to the Historric Commission? j ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: 1z'Munici al ❑ Private Well P ❑Municipal E�On Site .Disposal System 1999 RESIDENTIAL E'vT1IAI RESID SECT1t?N Z — pTtopr R'r 11 OWE I FRS111PI:aETTROR1ZED AGi NT 2.1 Owner of Record: r r Name (pant) Contact Address Phone Number 2.2 Authorized Agent: Name (Print) Contact Address Phone Number SEGT7fl `CQ\5 i Ri C £iE)�I SER(`10E5 3:1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone .).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 Name Registration Number (if none, state "none") Address Signature Telephone Expiration Date P { 3.3,Fc,r Residential Remodel Work Only PERSONS CONTRACTI:,,G WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home lmprovement Contractors Registration, One .4shburton Place - Room 1301, Boston. UA 02108, (617) 727-8598 Owners Name (print) Signature by sianin2 the above. the home owner acknowledges that there will be no eligibiin to the Guaranty Fund Date 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPOMME FOR THEIR OW-N PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structuresgoverned 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 MRS 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 rivo 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. f are appi. nder is section sign \ ature: V Your signature carries certain responsibilities, including but not necessarily limited to. general liability If - Rules and Re ul,ations section that any licensed Con struction .NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the $ Supervisor, whether or not they have taken the permit are responsible for code compliance.,;(see Appendix of 780 CMR R5.2 15) SECT101�! 4 WORKER' CO�1PEi�SAT10NV ti�i ilRr1M +�` fDAv (I�iG ; c 15 25j I Workers Compensation Insurance affidavit must be completed and submitted with tfhis application. Failure to>provide this affidavit will result in the denial of the issuance of the building permit. Signed AffiiAavit Attached: ❑ yes ❑ no EGTC© I DE$fR3I'TIQ� Q F PRDPOSED XVO.Ri (c:titeck all applicable) ❑ new ❑ addition C"alteration ❑ repairs ❑ chimney/fireplace E'"woodstove construction* ; .. n ti re lacement indow doorr ❑ other ❑ demolitio ❑ deck [I pool ❑accessory bld�. d p ( shed/garac,e) no. of windows doors - (specify below): _(specify below): * If new construction, please complete the following: J Single Family: no. of bedrooms no. of baths 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): Cl Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specirfy): ( g Q propane, electricity, other � eci ❑ HVAC (combined unit) - primary fuel, natural gas, p p ty� (.P fy) Cl Air conditioning - (separate unit) ❑ None ofthe above to be provided 0 'Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: EGTiO� .;.0 ESTIIIXTED Ct�+�S TREICTIE COSTS �. Item Estimated Cost (S) tco be completed by permit applicant 1 I. Building • 2. Electrical 3. Plumbing 4. Mechanical (HVAC) d $ 5. Total = (1 + 2 + ; + 4) *Estimated Total _. ,Si�nature of (Uwnevautnortzea t�gent