BP-575911. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3:.HOLD
Reason: l—� Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Applicant informed of above:
Comments:
Total Permit Fee: $ 7 J
TOTAL FEE:
Permit Issued to:
Date:
Time: / ?C� , i' "
Less Application Fee:
Other $ Amount $
Date:
Clerk:
Remaining Balan $
Gross Area - New Construction total sq. ft.
r:rncc Aran - Altarntinn tntal sn_ ft_
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
e25_(1t► APPLICATION FEE IS NON ]RE -FUNDABLE & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT RECEIVED
4r 'N� 400 Slocum Road, P.O. Box 79399`' '� 0TH1-PT.
z y Dartmouth, MA 02747 9 AUG 9.�
Phone: 508-910-1820 Fax: 508-910-1838
^. 1664`,�•�
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Signature:
Energy Report:
Signature: _
Fire Chief.
Signature: _
Board of Health:
Signature: _
Conservation Commission:
Signature: _
Other:
Signature: _
Brief description of work being performed.
1.1 Property Address:
Lot Area (sf.)
Required
Front Yard
Side Yard
Rear Yard
1.4 War Supply (MGL c40 s54):
Municipal ❑ Private Well
Provided
Dater=[fit
Date:
Date:
Date:
Date:
Date:
Assessors t Number: 7t&�
Map Lot
1.3 Historical District 0 Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal Syste
❑ Municipal On Site Disposal Systerm
El CONSTRUCTION PLANS 1:1 SITE PLAN 1:1 ENERGY REPORT
M
2.2 Authorized Agent:
Name (print)
3.1 Licensed Construction Supervisor /Specialty License
Licensed Construction Supervisor /Specialty License
Address:
Signature: Telep
3.2 Registered Home Improvement Contractor:
Contact Address
0 Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ Ni
S. If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
VIf Yes, submit the required affidavit!
Not Applicable ❑
License Number:
Expiration Date:
Not Applicable ❑
Phone Number
Company Name: Registration Number (if none, state "none'):
Address:
Signature: Telephone: Expiration Date:
P
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, 617-727-85-Q
e' I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
Date:
0
inat mere Will be no eligibility to the Guaranty Fund
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1.198Vof
shall be engaged in directy supervising persons engaged In construction, reconstruction, alteration, repair, removal or demolition involving the structural eleor structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for LicensSupervisors.
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
engages a person(s) for We 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 Wo-year period shall not be considered a Homeowner.
If you are applying under this section
Signature:
SECTION 4 WORKER'SCOMPENSATION INSURANCE AFFIDAVIT (MGL`6 152 § 25)
Worker's 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)
❑ Deck ❑ Pool ❑ Repairs ❑ eration ❑ Chimney/Fireplace ❑ Woodstove/Pelllet Stove
❑ New Construction" ❑ Accesso Idg. ❑ Roofing/Siding ❑ Other
(Energy report required) (She arage) (Specify below))
❑ Addition Replacement windo cor ❑ Demolition
(Energy report required) No. of windows Doors _ (Specify below)
"If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
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
❑ Air conditioning : (separate unit)
❑ None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil -
ON.
Other
I Item I Estimated Cost M to be completed by permit applicant I
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total= (1 +2+3+4) 0i
(Please Print)
I, , 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
76
Date
I, ct v t• v , as Owner/Authorized Agent hereby declare that the statements and informfation
on a foregoing application are true and accurate, to the best of my knowledge and belief.
igned under pal and penalties of perms __
Agent
VZ ZY0
Date
rncwaing but not necessarily limited to, general