BP-16951RESIDENTIAL 2000
❑ FOUNR1 TIO�'V ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
`oETti DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
,o 400 Slocum Road, P.O. Box 79399 t .
el 5
Dartmouth, MA 02747 I'
508-999-0720 FAX 508-999-0738 t
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: /� �,Q.�ie bt-
Nearrst Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
Z Municipal ❑ Private Well
SITE PLAN SUBMITTED:
1.2 Assessors Plat & of Number: _
Plat ' Lot�-
1.3 Historical District ❑ yes Ono
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal 0 On Site Disposal System
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RESIDENTIAL
2000
RESIDENTIAL
2000
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1 cTION �- hRQpEltt Y arv�,r4 ttsHtP 1 arrnoRtzEtj ,Vt; ANT
2.1 Owner of Reco d:
I (� [L nh
Name (print) ..
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
....:: :. ..
CO : CQ i CTiQ, SERT'aCES;...:.
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 ❑ no
If no, go to the next section!
Are you claiming 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 Resid--ntial Remodel Work Only
PERS( NS 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, 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 ! ire 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 interded 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 signatur certain resp ibdities, 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 Constructiion
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
IWorkers Compensation Insurance affidavit must be completed and submitted with this application. Fail re to provide thiis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ no
❑ new construction* qVdition
(energy report required) nergy report required)
❑ deck ❑ pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
❑ alteration ❑ repairs ❑ chimney/ ❑ wo)odstove
fireplace
❑ replacement window/door ther ❑ de.
P
demolition
no. of windows doors �sp ci below : s ecit belowfY ) (P fY )'
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit I no. of baths unit I
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: _ A
Item I Estimated Cost ($) to be completed by permit applicant
5. Total = (I + 2 + 3 + 4)
* Estimated Total
q
(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
Date
0
I, , as Owner/Authorized Agent hereby declare that the statements and inpormation
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 Agen Date
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