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BP-24576RESIDENTIAL 2002 RESIDENTIAL Z002 SECTION 2 ZPROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: T o cos � ng�cusellS �1 � I Io C&-ntact Address Phone Number Name (print) 2.2 Authorized Agent: - SCI Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION 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 ` Tno If no, go to the next section! Are you claiming exemption from the requirement? ❑ yes ❑trr5 If yes, submit the required affidavit! Company Name e57 5h /0- J1 nCIO "J V �)4 © r Registration Number (if none, state "none") IbS-3f 0 Address 34, stiled1oJ /( iv ?.eAll",/ Signature r" Telephone&(f N„2ff Expiration Date 7 /? O Z 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, 19S2, 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 NOTICE TO 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 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 this 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/ ❑ woodstolve (enet j, report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. KI replacement window/door ❑ other ❑ demoliti6n (shed/garage) no. of windows doors (specify below): (specify belimw): * If new construction, please complete the following: Sinole Family: no. of bedrooms no. of baths Two Family: 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: �0— llau. � 6lJA06cc) SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. Building 2. Electrical 3. PlumbinL, 4. Mechanical (HVAC) 5. Total = (1 + 2 + 3 + 4) * Estimated Total $ 3ao. c."i SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (p e print) I �y(�yp c�Cx,.�o� , as Owner of the subject property he authorize S� to act on behalf, in all ters re t' e to work authorized by this building permit app 'cation. Signature of Owner v ate SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION I , as Owner/Authorized Agent hereby declare that the statements and informtation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. S' (Y nre Owner/Authorized Agent Date C:`:bld!,.forms\Bldgapp..res.wpd Page 2 Rev. January 19. 2001 C.'v.bldg.forms,Bldgapp.res.wpd P aee 3 Rev. Januatry 19, 2001 RESIDENTIAL 2002 - - - RESIDENTIAL 200� SECTION 8 - INSPECTOR'S REVIEW/COMMENTS ❑FOUNDATION ONLY NON-T $25.00 APPLICATION FEE IS NON-REFUNDABLE & RANSFERABL 1. Date plan reviewed: E 2. 30 days to,review period expires: o 'rti: i .. _ DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 3. OK tQ issue date: rW 400 Slocum Road P.O. Box 79399- 4. OK to issue subject to requested submittals(see project review worksheet): Date: z ` Dartmouth, MA 02747 , 5.. DENIED (see project review worksheet): �, a 2_rr �t I Date: 508-910-1820 FAX 508-910-1838 1 6. HOLD reason: Date: APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY -7. HOLD subject to Zonjng Board of Appeals action: LY DWELLING Date: THIS SECTION FOR OFFICIAL USE ONLY 8. Comments: II 9. Inspector's Signature:- JUN Date: SECTIO 9 - PPLICANT NOTIFICATION Applicant info e o a ove Date Time: Clerk: _ .:. //l/ EYE► 1� Comments: SECTION 10- OFFICE\INSPECTOR'S NOTES Total Permit Fee: 1 Less Application Fee: $ 25.00 TOTAL FEE- � Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To Remaining Balance: S SECTION I I - ADDITIONAL COMMENTS/SKETCHES 9 2002 RECEIVED BY: DATE SENT FOR REVIEW: OK TO ISSUE - SIGNATURE: BUILDING PERMIT NUMBER: DATE ISSUED• DATE JUN 1 9 2002 ,R-UiVding Commissioner/i/Inspector of Bu din s Zoning District: Proposed 4eA-� Zone: Pl ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas Chief Cut Off ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other / Cut Off / Cut Off Review* * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERIMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: `�— Date: Energy Report: Signature: Date: Fire Chief- Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Description of work being performed: SECTION 1- SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Property Address: %D�/ MillPd 1.2 Assessors Plat & Lot Number: i1tSej 50 �cu'fvvtacc�tl. Plat / Lot - Nearest Cross Street: 1.3 Historical District ❑ yes ❑ no Subdivision Name: Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal❑ Private Well ❑ Municipal ❑ On Site Disposal System C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. Janunr}' 19,'001 C:' 1dg.forms\Bldgapp.res.wpd Po 1