BP-18021RESIDENTIAL
2000
RESIDENTIAL
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 worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature:
Applicant informedib�
Comments: CC
-4-0-- Ax;�- - J1__
5 VA
Date:
Date:
Date:
Date:
Date:
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE dot NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED
9�
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
2000
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date:
Fire Chief: Signature:
Date:
Board of Health: Signature: AJ
! Date:
Conservation Commission: Signature:
Date:
Other: Signature:
1
Date:
�/� ,� Q
WAIIJ
Description of work being performed:( JA&AA?J (_�
9C1-1! t1-�[ _
NUMBER OF PLANS SUBMITTED:
L I Property Address: ,R a kx—
Nearest Cross Street:(
Subdivision Name: �� �' f�y1,�
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
l�tunicipal ❑ Private Well
SITE PLAN SUBMITTED:
❑ no
1.2 Assessors Plat & Lot Number:
Plat I Lot
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Com mission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
2 unicipal ❑ On Site Disposal System
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Rev. Januiary 13, 2000
RESIDENTIAL
IAL 2000
Slt CTt(?!S 2 rtUPERT�' QWNEi;SHtP! At`T1�d1i#Eb ACENT
2.1 Owner of Record: y/ A k ,41e
Sc�bikC�l1�iy-
2.2 Authorized Agent:
Name (print) Contact Address
Phone Number
I
d �� '�.„� �►� c a hs (�M ,�
Name (print) Contact Address Phone Number
SEG I iLihJ. .» a 'irR CTIO.N: SERi 1cEs
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number l �l
Address Expiration Date
Signature TelephoneqqyllqA
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 ',rsidential 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
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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 1 16.0, effective July I, 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 dwellinn , 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 nit 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
RESIDENTIAL
NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction,
Supervisor whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
■ • fl
bldg. ❑ 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 (specify):_
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: ,, —,.,_ _ ,
4
2000
❑ other ❑ demolition
(specify below): (speciAl lhelow):
Item I Estimated Cost ($) to be completed by permit applicant
5. Total =(1 +2+3+4)
* Estimated Total
as Owner of the subject property hereby authorize l '/ eo- T
to act o lf, m all ma rs rel tiv work authorized by this building permit application
��Ii3IG't�
Signature o wn Date
I, as Owner/Authorized Agent hereby declare that the statements and information
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 Agent
(-�H 611 t-61MAI
AI
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