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BP-13948RESIDENTIAL 1999 SKCI710N 8 -INS-PEC.TORJSREVIEIV/COiNIMEiTS. 1. Date plan reviewed: 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(see project review %vorksheet): 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 Signature: Fr Applicant infb7Fd of Comments: /V i I, Total Permit Fee: S TOTAL FEE: 50;� Pen -nit Issued To - Date: 4 7 Time: Clerk: ........ .. O�ICEVNSPECTOWSIJNOTES Less Application Fee: S 25.00 Remaining Balance: S—— Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. SECTION 11, - ADDITIONAL CONIMENTSISKETCHES. r RESIDENTIAL FO NDA TION ONLY $25.00 APPL16 U ION FEE IS NON-REFUNDABLE DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED ic 400 Slocum Road, P.O. Box 79399 1A_�^';30 -_ •= y""Dartmouth, MA 02747 508-999-0720 FAX 508-999-0738 97 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 199( Zoning Review: Signature: UU 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: SECTION' t- SITE INFORMATION : —.. ... ................. NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 0 yes 0 no 1.2 Assessors Plat & W Number: 1.1 Property Address: Plat Lo Nearest Cross Street: Subdivision Name: 1.3 Historical District 0 yes Ono Total Land Area Sq. Ft.: Has application been submitted to the Historic Coirnmission? 13 yes 0 no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: 0 Municipal 0 Private Well 0 Municipal 0 On Site Disposal System --t r%% III 7='.' ":_� znrr %'s " 2 2 �_ —1 RESIDENTIAL 1999 '110RIZED AGENT RESIDENTIAL 199 2.1 Owner of Record: xt-q �e. , aL Name (print) 2.2 Authorized Agent: Name (print) rr 998- ,/opt Contact Address Phone Number Contact Address Phone Number 13.1 Licensed Construction Supervisor: I Not Applicable ❑ I Licensed Construction Supervisor I License Number Address Signature Telephone 3.2 Registered Home Improvement Contractor: Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ ves ❑ no If no, go to the next section! Are you claiming exemption from the requirement? ❑ yes ❑ no If ves, submit the required affidavit! Company Name A ldress Signature Telephone 3.3 For Residential Remodel Work Only Expiration Date Not Applicable ❑ Registration Number (if none, state "none") Expiration Date PERSONS CONTR-ACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Nome !ntprovement Contractors Registration, One Ashburton Place - .Room 1301. Boston, MA 02108, (617) 727-8598 Owners Name (pr:nt) Signature by signing the above. the home owner acknowledges that there will be no eligibiity to the Guaranty Fund Date :.4 Homeowner ENemption - One & Two Family Only FOR HOMEOWNERS WHO (\TEND 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 1 16.0, effective Jul- 1. 1982. no individual shall be engaged in directl% 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 Licensine 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 ,his section only. a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which heishe resides or intends to reside, on which there is. or is intended to be. a one or hNo famil, dwelling, attached or detached structures accesson to such use andlor farm structures. A person who constructs more than one home in a mo-year period shall not be considered a Homeowner. If you are appl ing under this section sign below: Signature: certain responsibilities, including but not necessanl limited to. general liability Signature NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Consttruction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15; SEC TioN 4 » WORKER'S CONIPENSATI©N INSURANCE.:A F.ID VIT 4G- C Workers Compensation Insurance affidavit must be completed and submitted with this application. Fa lu e to providle this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ no SECTION 5 —DESCRIPTION OF PROPOSED WORK (check affapplimble) ❑ new ❑ addition ❑ alteration ❑ repairs ❑ chimney/fireplace ❑ woodstove construction* ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door other ❑ demolition (shed/garage) no. of windows doors (specifv below): (Sp)ecifV below): * If new construction, please complete the following: 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 Brief Description of Proposed Work: A Item I Estimated Cost (S) to be completed by permit applicant 5. Total = (I + 2 + 3 + 4) I * Estimated Total S 7 O O (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 I. as Owner/Authorized Agent hereby declare that the statements and iinformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties m%;r Signature: fY vner,,Authorized Agent /Date