BP-50463SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD sub, ect to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
Inspector's Signature: �Z�
Date: 7 i'
OF
SECTIONS --APPLICANT NOTIFICATION
Applicant informed of above: Date: Time:
Comments:
Clerk:
SECTION 10 - OFFICEIINSPECT NOTES
Total Permit Fee: $ /.S S • C',
/'S
Less Application Fee: $25-00 / S S C' c
Other $ Amount $
Remaining Balance:
TOTAL FEE: / S , C- �� Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: 44,0 c ,,/ Oc- 0 /7 if t 41.4- k, Ig ";71z
dt) X ye JA/6/4C't�,v Stv/, i�if�./� i'�r�[
c/S ei'L'o rc4A-1_5 -7 "?,4-Al�'�9
�?�` X i% fnor._ r%�� {f
SECTION 11 -ADDITIONAL COMMENTSISKETCHES
Ofi
E�
0od
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
.4?5-00 APPI'IACATION FEW iC NON HF.FJ?N"AnJF, A- N�N.Ti3lATfiFF,�AP3i,�c
DATE RECE:,.tED
MoGTH..
t'Q J N
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
_7,.' to 25
Dartmouth, MA 02747
.... ,664
Phone: 508-910-1820 Fax: 508-910-1838
;if
www.town. darmouth. ma. us
APPLICATION TO CONSTR CT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWE:-.LING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBE..::4
C'
DATE SENT FOR
REVIEW: l
DATE ISSUED:
O.K. TO ISSUE - SIGNATURE:
DATE: "" L L '
Zoning District:
r ,
�' /` �' Proposed r.
Use: _ Zone:
!�ti ❑ B ❑ A El Aquifer Zone:
THE FOLLOWING AGENCIES
SHOULD BE NOTIFIED:
❑ Board of
❑ Board of ❑ Cons. ❑ Demo
❑ DPW ❑ Elec. .1 Energy Report
Appeals
Health Commission Affidavit
Card Sent: Cut Off Follow-up"
❑ Fire
❑ Gas ❑ Planning ❑ Sewer Card
❑ Water Card ❑ Zoning Other
Chief
Cut Off Board Cut Off
Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPAR,TMENTAL APPROVAL
/
Z`7
Zoning Review:
Signature: /lam ''
Date:
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission: Signature:
Date:
Other:
Signature:
� �1�
Brief d scription of
work being performed:
SECTION 1-- /S'ITE INFORMATION
.1 Property Address: (� /r'�J / Q y 1.2 Assessors Map & Lot Number: "" f
Nearest Cross Street: �/ //C//� Map Lot -
Subdivision Name: I't1lC C OX ��_?!?I
Total Land Area Sq. Feet:
1.qt Wate upply (MGL c40 s54):
I / Municipal ❑ Private Well
1.3 Historical District ❑ Yes ZI No
Has ' plication been submitted to the Hi::toric Commission?
JO Yes ❑ No Date:
5 Sewoge Disposal System:
C9`Municipal ❑ On Site Dispc::;al System
❑ CONSTRUCTION PLANS ❑SITE PLAN El ENERGY REPORT
RESIDENTIAL
SECTION 2 =PROPERTY OWNERSHIP)
2y1 Owner Record:
1/f Y/)-,z 0.7j�
(prino
2.2 Authcri.zed Agent:
IZED AGE
Phone Number
Name (print) �09 Z/ 2 79
Contact Address Phone Number —
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
(n Address:
._. Expiration Date:
LLJ Signature: Telephone:
Z 3.2 Registered Home Improvement Contractor:
UJ
V Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
If No, go to the next section!
LL Are you claming exemption from the requirements? ❑ Yes ❑ No
0 If Yes, submit the required affidavit!
>-FAdEdress:
ny Name:
Telephone:
Not Applicable ❑
Registration Number (if none, state "none"):
Date:
3.3 For Resicential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Hcr, ae 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 srgrnng t1lie a ve in Qeov1n"ki1uwieages that there will be no eligibility to the Guaranty Fund
Date: (�/�� ///
Homeowne, Exemption - One & Two Family Only
i 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 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.
IIf you are applying under this section Sig
Signature
r
responsibilities, 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 Constructior
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CN,I -� R52.15)
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: ❑ Yes m No
i
❑ Deck ❑ Pool
❑ New Construction•
(Energy report required)
❑ Addition
(Energy report required)
5 -DESCRIPTION OF PROPOSED
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows_ Doors
*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
'Description of proposed work:
UKK (Check all applicable)
❑ Chimney/Fireplace
❑ Roofing/Siding
Other
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item 1. Building Estimated Cost ($) to be complete
2. Electrical
3. Plumbing
4. Mechanical (HVAC) G
5. Total=(1+2+3+4) `
SECTION 7A - OWNER AUTHORIZATION
(Please Print) (to be completed when owner's agent or contractor applies for building permit)
1, , 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.
❑ Woodstr:we/Pellet Stove
❑ Other
(Specify );elow)
❑ Demolitiuin
(Specify (below)
bignature Ot Ownet
Date
:<int
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
Z &ems , as Owner/Authorized Agent hereby declare that the statements and reformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains an3l1p�2nggies of perjury.
C�^i
Date
Signore of