BP-33689RESIDENTIAL
❑ FOUNDATION ONLY
LS.UU AYYLiGAWIUN FEE i, 1VVN-KEFVW1JA13LE & NUN-TKANSFEKASLE
2002
1.
Date plan reviewed: .- /// /U 5�--
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:
5.
DENIED (see project review worksheet):
Date:
6.
HOLD reason:
Date:
7.
HOLD subject to Zoning Board of Appeals action:
Date:
8.
Comments:
9. Inspector's
Applicant informed 9} above
Time: l0: W
;0.
Total Permit Fee: $ 6'" ! Ved Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE: Gross Area -New Construction total sq. ft. —'—
Gross Area - Alteration total) sq. ft. _/
Permit Issued Tot i7, v-f,� �,t� 7rP�l �P_ yy1 P f, 7`Gr✓r�'IC�c�,g / ' ��.
r'J
RESIDENTIAL ❑ FOUNDATION ONLY_ °?
$25.00 APPLICATION FEE IS NON-REFUNDA�ILE NON -TRANSFERABLE
" DATE RECEIVED
DARTMOUTH BUILDING DEPART MINT
400 Slocum Road, P.O. Box 7939, 5 1b
+ Dartmouth, MA 02747
64
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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:
NUMBER OF PLANS SUBMITTED:
1.1 Property Address
NearestCross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat &Lot Number: �7 j
Plata Lot / / -
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
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❑ Municipal ❑ Private Well
Page 1
❑ Municipal ❑ On Site Disposal System
Rev. January 11, 2003
RESIDENTIAL
2003
R F.PUDENTT A T .
20)0ly
Y
2.1 Owner of Record:
Name (print)
2.2 Authorized Agent:
Name (print)
7Le
n 1
� t
Contact Address U Phone Number
Contact Address
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Constriction Supervisor License Number
Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes tta-tfo
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes m�i<o
If yes, submit the
required affidavit!
Expiration Date
Not Applicable ❑
Phone Number
Company Name Registration Number (if none, state ❑ none❑)
Address
Signature Telephone 60�'�pz( � �7 Expiration Date /7
3.3 For Residential Remodel Work Only _
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
IQUESTIONS 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 Licensin- of Construction Supervisors: Except for those structures governed 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 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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
INOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction I
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: ❑ yes ❑ no
❑ new construction* ❑ addition
❑ alteration ❑ repairs
❑ chimney/
❑ woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg.
! replacement window/door
❑ 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 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 p
Brief Description of Proposed Work:
Item I Estimated Cost ($) to be completed by permit applicant
im
4 Mernnmrni "v ,,
5. Total = (1 + 2 + 3 + 4) 1 *Estimated Total $���
se print)
as Owner of the subject property hereby authoriz
left my b fXinattcrs felxtivr-to work authorized by this building permit application.
ature of canerDat
as Owner/Authorized Agent hereby declare that the statements and information
on ttTie foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under e pains and penalties
,mot., _ C 171 /ll
Agent
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