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CONTRACTOR IS RESPONSIBLE TO
:
ASSURE ALL CONSTRUCTION TO
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MEET ALL BOCA AND LOCAL AND/OR
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271 i
2002
2002
RESIDENTIAL
RESIDENTIAL
_ OWNERS AUTHORIZED AGENT
SECTION 2 PROPERTY OWNS
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
(see Appendix of 780 CMR R5.2.15)
>y
Supervisor. whether or -not they have taken the permit are responsible for code compliance.
2.1 Owner of Record:
INSURANCE AFFIDAVIT (MGL C 152 § 25)
`` t
_ SECTION 4 - WORKER'S COMPENSATION
Address � Phone Number
0
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to providf,, this affidavit
�(print)Contact.
Name
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
2.2 Authorized Agent:
5 OF PROPOSED WORK (check all applicable)
SECTION -DESCRIPTION
Phone Number
❑ new constnlction* ❑addition ❑ alteration Elrepairs` ❑ chimney/ ❑11woodstove
fire lace
Name (print)
Contact Address
(ever �' report required) (energy report required). p
SECTION 3 - CONSTRUCTIO\ SERVICES
❑ deck El pool ❑accessory bldg. ❑replacement window/door ❑other ❑1(demolition
3.1 Licensed Construction, Supervisor:
Not Applicable ❑
(shed/garage) - no. of windows_ doors_ (specify below): (sppecify below):
Licensed `construction Supervisor
License Number
* If new construction. please complete the following:
Address - _
Expiration Date
Single Family: no. of bedrooms —no. of baths
Signature Telephone
Two Family: no. of bedrooms unit l no. of baths unit l-
3.2 Registered Home Improvement Contractor:
Not Applicable El
no. of bedrooms unit 2 no. of baths unit 2
fuel (natural or fuel oil, electricity, other (specify):
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑.yes G no
❑ Furnace (hot air) - gas propane),
lcrt other s eci f
fuel oil, electricity, )
e Y _ propane), (specify):
raj or Y
❑ Boller (heating) fuel gas (natural p p ),
fuel, natural gas, propane, electricity, other (specify):
If no, go to the next section!
❑ HVAC (combined unit) - primary
Are you claiming exemption from the requirement? ❑ yes ❑ no
❑ Air conditioning - (separate unit)
If yes, submit the
❑ None of the above to be provided
Other
required affidavit!
❑ Hot Water: Gas -Electric Fuel Oil
Registration Number (if none, state "none")
Bi-ief Description of Proposed fVork: ` c L.�" 1�L�Je� (3nc
a, hr'<'t3P=
Company Name
t rt
(j b, it 0, r
Address
Signature Telephone
Expiration Date
SECTION- 6 ESTIMATED CONSTRUCTION COSTS
3.3 For Residential Remodel Work Only
Item
.Estimated Cost($) to be completed by permit applicantt
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY" FUND:
1. Building
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 7?7-SJ98
2. Electrical
11 6 ® _
3. Phllllblila
60
Owners Name (print)
-k. Mechanical HVAC
5. Total = (l + 2 + 3 + 4)
Estimated Total S `
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
SECTION 7A -OWNER AUTHORIZATION
Date � �
(to be completed when owner's agent or contractor applies for building permit)
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
(please print) _
h as Owner Of the subject property hereby authorize
109.1.1 Licensingof Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
removal or demolition involving the structural elements of
to act on mV behalf, in all matters relative to work authorized by this building permit application.
shall be er;gaged in directly supervising persons engaged in construction, reconstruction, alteration. repair,
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
Date
Construction Supervisors.
• Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a
An Ho
Exception: p _
Y
Si*nature of Owner
N
7B OWNER/AUTHORIZED AUTHORIZED AGEN DECLARATION
Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act assupen tsor.
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
e purposes of this se
For thy,
SECTION -
as Owner/Authorized Agent hereby declare that the statements
�,1�-,..�— � �md information
«<o family dwelline `attached or detached structures accessory to such use an farm structures. ,� person who constructs
which there is, or is intended to be, a one or ty
I, �i�.1��
foregoing application are true and accurate, to the best of my knowledge and belief.
more than one home in a two-year period shall not be considered a Homeowner.
on the
If you areapplying under t section sign below:
Signed under t epauls and penalties of perjury.
%1
Signature -
Your sig ature carries certain responsibilities; including but not necessarily limited to, general liability
Your
Dalte
Signature o Owner uthorized Agent
n.;,, t,,.��,,: tq "I1111
Page 3 Rev. January 19, 2001
�`��J,Ia„ t „mr,Rl�l �.uniJl'5.��'Dll - - -
RESIDENTIAL
2002 RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSMIRABLE
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:'
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
Date:
5a DENIED (see project review worksheet):
Date:
6_ HOLD reason:
Date:
7. HOLD subject to Zoning Board of Appeals action:
Date:
S. Comments:
9. Inspectors Signature:
Jg eZ 5 2002
SECTION 9 - APPLICANT NOTIFICATION
3 .plicant informed of above Date: Time: Clerk:
i omments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee:
Less Application Fee: S 25.00
Remaining Balance: S Y
TOTAL FEE: Gross Area - New Construction total sq. ft. - f
Gross Area - Alteration total sq. ft.
Permit sued To•
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
C- i q.,.{<> rea wnd pnn'o 4 Rev_ Linivirv.
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
7
400 Slocum Road, P.O. Box 79399--
-7 .. Dartmouth, MA 02747
508-91.0-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY (DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
_
DATE ISSUED:
U N 2 5 2002
OK TO ISSUE - SIGNATURE: DATE
P
Bu�ildin"g Commissioner/Inspector of B '(dings
Zoning District:-A—ProposUdse: / � Zone: C ❑ B ❑ A ❑ V Outside Flood Zone ❑ Xquifer Zone -
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elee. ❑ Energy Report
ppeals Health Affidavit Card Sent: Cut Off Follow-up*
r..
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card i ❑ Other
Chief Cut Off / Cut Off / Cut Off t iew*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL 4
Zoning Review: Signature: Date::
Energy Report: Signature: Date:ifUN 2 5 2007
Fire Chief:. Signature: Date::67`47-0
�
-�
�
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: �-�
1.2 Assessors Plat & Lot Number:
Plat
Nearest Cross Street: k'5 Lk(ni.
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
11
Has application been submitted to theJ Historic Commission?
Total Land Area Sq. Ft.:
p yes ❑ no Date:: -
1.4 Water Supply (MGLe40 5 54):
1.5 Sewage Disposal System:
❑ Municipal Private Well
❑ Municipal Orn'Site Disposal System
Pnt>e 3 Rev. January 19, 2001