BP-57369SECTION 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 Sig
Applicant informed of
Comments:
Date:
Time:
Less Application Fee: $25.00
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
ES
Date:
Clerk:
Remaining Balance: $
If
J �n�-le/L -�7G
❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 PLICATION FEE IS NON RE-FUNDIBLE & NON -TRANSFERABLE
DATE RECEIVECY _ :> • ' `-
�9 DARTMMiOUTH BUILDING DEPARTMENT
N= 400 Slocum Road, P.O. Box 79399 ?.
Dartm th MA 02747 2 �`1.� 2 P11
-
l°�. yY 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 DWELLINIG
T IS ,SECTION "FOR OFFICIAL USE ONLY
Zoning Review: Signaturk- �.Q ' �'�� Date: -'7— ?2- f o)/
Energy Report: Signature: Date:
Fire Chief. Signature: Date:
Board of Health: Signature: Date: La
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of wont being performed:,
Front Yard
Side Yard
Rear Yard
.4 Water Supply (MGL o4O s54):
Municipal ❑ Private Well
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ Site Disposal System
3�
-0�7A<w S---
1:1 CONSTRUCTION PLANS 1:1 SITE PLAN ❑ENERGY RE PORT
2
2.1 Owner Record:
IS Tr�',j�. C�-
Name (print)
2.2 Authorized Agent:
Name (print)
3
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address:
'<MIPIAUTHORIZED AGENT =
r l
Contact Address
Contact Address
J Signature: Telephone:
V3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ N,
. If No, go to the next section!
O Are you claming exemption from the requirements? ❑ Yes ❑ No
V If Yes, submit the required affidavit!
Company Name:
Address:
Not Applicable ❑
License Number:
Expiration Date:
Not Applicable ❑
CNIis-
Phone Number
Phone Number
Registration Number (if none, state "none"):
- - - i umpi rune: Expiration Date:
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 thef work myself. (�
Owners Name (print):
Signature:
By signing the) a
Date: I I 'L�i 1 t)
3.4 Homeowner Exemption - One & Two Family Only
uiat mere win oe no eligibility to the Guaranty Fund
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 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.
you are applying under this sectio"ign below:
Signature:
certain
SECTION 4 - WORKER'S COMPENSATION 'INSURANCE AFFIDAVIT (MGL C 152 § 25)s
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 ❑ Alteration ❑ Chimney/Fireplace ❑ WOOdstove/Pellet Stove
❑ New Construction` ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Dermolition
(Energy report required) No. of windows _ Doors _ (Spe!cify 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:
o e1 ,13
-_-,"SECTION 6 - ESTIMATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit amplicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4)
SECTION 7A- OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
as Owner of the subject property hereby authorize
to act on my behalf, i a m tte relative to work authorized by this building permit application.
Signature of Owner, Date
` SECTION 713= OWNERIAUTHORIZED AGENT DECLARATION-,, .
as Owner/Authorized Agent hereby declare that the statements rand information
on the foregoing application a true and accurate, to the best of my knowledge and belief.
Sign tl under the pains and penalties of perjury.
91— 41,
Ignature of Ow, r/Authorized Agent Date
mcivamg out not necessarily limited to, general