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BP-83569SECTION 8 -INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: Applicant informed of above: Date: Comments: SECTION ANT N Time: Date: Z Z `/, , - I Clerk: RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13) $25.00 APPLICATION FEE IS NON RE-FU° snAIR'<.F A NnN.TRAN.CFRiRA7t7T DATE;RECEIVED r o� 9s:_ DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 ° I E Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 •-... lfifi4 ��f " www.town.dartmouth.ma.us L APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIN(a THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY. ""+ BUILDING PERMIT NUMBER O.K. TO ISSUE - SIGNATURE: Zoning District: Proposed Use:- Zone [B'C ❑ B ❑ A .❑ V AquiferZorie. THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ' ❑Board of ' ❑Cons. ❑Demo ❑DPW ~ ❑ Elec ❑ Energy Report" = Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up* ❑ Fire .. - ` ❑ Gas' ❑ Planning ❑ Sewer Card ❑ Water Card - ❑ Zoning ❑ Ofther Chief ��' Cut Off Board = Cut Off CufOff *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature, Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Brief description of work being performed. SECTION 1 -SITE INFORMATION 1.1 Property Address: lT t%� eb1 I/Z L/ 1.2 Assessors Map & Lot Number. Lot Area (sf.) Frontage Map Lot Required Provided Front Yard 1.3 Historical District ❑ Yes ❑ Nei Side Yard Has application been submitted to the Historic -(Commission? Rear Yard - ❑ Yes ❑ No Date: 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal Syrstem ❑ CONSTRUCTION PLANS SITE PLAN ❑ENERGY REPORT RESIDENTIAL SECTION 2-'PRC-PERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Reco d: pbcl 3 (-�-oLevli 97ll.5`1D Name (print) Co. ctAd ess Phone Number 2 Authorized Agent: >t In S �Y l 3,? � R�� si ,�� s� 9 Name (print) Contact Address Phone Number SECTION 3 -CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: - Not Applicable ❑ j Licensed Construction Supervisor: t,� V I P De I4 f / License Number: S © Y Address: � kea, �T IN t'f f -7 Expiration Date: � Signature: Telephone:_a� 997s/ 3 3.2 Registered Home Improvement Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? EYes ❑ No If No, go to the next section! Are you claming exemption from the requirements? ❑ Yes ❑ No If Yes, submit the required affidavit! Company Name: Pe_v0v\ 4 c Registration Number (if none, state "none"): Address: �j� _1_ CR��f� S� G/c1 �. 7 Signature: Telephone: q�� 3 Expiration Date: l�Lll ,12 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, 617-727-8598 ❑ 1 am a Homeowner performing all the work myself. Owners Name (print): Signature: By signing the above, the homeowner acknowledges that there will be no eligibility 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 5108.3.5 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 iin 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 persons) 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: Signature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 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: -EYVes ❑ No SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable) - ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pe!llet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding X10ther (Energy report required) (Shed/Garage) (Specify below)) ❑ Addition ❑ Replacement window/door ❑ 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 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 ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Description of proposed work: Re- B C-1 t ospit� podr_4 pW Yf s1l h f.C-t1h SECTION 6 -ESTIMATED CONSTRUCTION COST Item Estimated Cost ($) to be completed by permit applicant: 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total = (1 + 2 + 3 + 4) C�Caii. SECTION 7A -OWNER AUTHORIZATION .. (to be completed when owner's agent or contractor applies for building permit) (Please Print I, iS:Jtas Owner of the subject property hereby authorize e c to act o + y behalf all,�alk�rs elative t work authorized by this building permit application. Signa r w er . Date / V / SECTION 713- OWNER/AUTHORIZED AGENT DECLARATION I, - 1a'1A z v Z'4s. as Owner/Authorized Agent hereby declare that the statements and inffarmation on the foregoing application are t ue and accurate, to the best of my knowledge and belief. Signe n the pains and penalti perjury. Signature of Owner/Authorized Abeht Date