BP-15837RESIDENTIAL 2000
NO
TICE
Tr CE TO
LIC
ENSED CONTRAC
TORS:
ORS: Theit Building
Code g provides i+xt 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)
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: Dyes ❑
no
... 5 bIySCR.tPTI N.£IF i'22 .POSEtI W oi2r :......::.... I.tettale..:.::..:::...::...::.::..
.
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/
(energy report required) (energy report required)
❑ woodstove
fireplace
deck ❑ Pool ❑acaccessory rYbl bldg. ❑ replacement
ent wind ow/do or ❑ other
demolition
(shed/garage) no. of windows doors (specify below
(specify below)
* If new construction, please complete the following:
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):
❑ 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
ref Description of Proposed Work:
7'0
Owe C--'a k,- `+��'-i^�1�3i. cq
i�
.:..
Item Estimated Cost ($) to be completed by permit applicant
1. �30din
2. Electrical
, 3. Plumbin -
". Mechanical HVAC
5 Total (1 + 2 + 3 + 4) *Estimated Total $ Y1?
I(please print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
C:\bldg.forms\Bldgapp.res.wpd Page 3
Rev: January 13, 2000
RESIDENTIAL 2000
�1 apE ary t irr �►tf,
2.1 O er of Record: �Qb��
��
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
..
SEGFfQ Y .;* CQ]\TSi 1LIFCTi . N'SEItYICES .:=::c::>:: ':...
. .....:. .
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 ❑
I
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming
g 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
3.3 For Residential Remodel Work Only
I
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY'IFUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727t<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 11, 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 Reguilations 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 intendis 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.
f y u are applying under this section sign below:
c
attire:
Yo r signature carves certain responsibilities, including but not necessarily limited to, general liability
i
C:\bldg.forms\Bldgapp.res.wpd Page 2 [Rev. January 13, 2000
RESIDENTIAL
❑ FOUNDATION ONLY 2000
:�6b.UU AJVPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERAMLE
nouTH DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road P.O. Box 79399
N
o y ' Dartmouth, MA 02747�
`�h° 508-999-0720 FAX 508-999-0738
APPLICATIONTO O C ().NS 9"RUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I.,.,
Zoning Review: Signature:
Date: I.
Energy Report: Signature:
Date: a
Fire Chief: Signature:
Date:
Board of Health: Signature: k
Date:
Conservation Commission: Signature:
Date:
Other: Signature: —Z
Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes U11101,
1.2 Assessors Plat & Lot Number:
V
'erty Address: 'Yk `cam, 0 S Ls3 ,rPlateLot
Cross Street: L cz�.J
�S division Name: 1.3 Historical District O yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic,,(Commission?
❑ yes ❑ no Date:
'1 _44ater Supply (MGL c 40 § 54): 1.5 Se �e Disposal System:
Municipal Private Well ❑ Municipal;' On Site Disiposal System
C:\bldg.forms\B7dgapp.res.wpd Pa-e 4 Rev. January 13, 2000
C:\bldg.fonTis\Bldgapp.res.NN-pd
Page 1
�R�ja :ary ]3, 2000