BP-41204RESIDENTIAL
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Inspector's Signature: J 71 _ t Date:
SECTION 9-APPLICANT NOTIFICATION
Applicant inform o P//�
DateComments: / 1w ^
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Rev. January 2005
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❑ FOUNDATION ONLY
S2S.00 APPLICATION FEE IS NON-REFUNW?ABLE & NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT
}�
DATED
-'�+•QE�T.
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
ZM5 SEP -8 PM 3� 52
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TAA'O FA -,I ILY DWELLING
�N FOR OFFICIAL USE ONLY,
RECEIVED BY:<
BUILDING
PERN TiT
-
DATE SFN'I FOR REVIEW:
a
NU.IIBER _
' r Yin
DATE ISSUED: E
OK TO ISSUE - SIGNATURE: _ l` j
DATE - 1
Zoning District: y, Proposed Use: Zone: Cl C 0 B ❑ A ❑ Y Outside Flood Zoncr--lAduifer
Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
I
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DI'R"
0 Elec. 0 Energy Report
Appeals Health AffidaNit ' Card Sent:
Cut Off FollovN-up* l
❑ Fire ❑ Gas ❑ Pianninu ❑ Sewer Card ❑ Water Card
❑ ❑ Other
Chief Cut Off Board* ! Cut Off i Cut Off
Zoning
* REQUIRES INSPECTOR'S REVIEiV BFFORI THE ISSUANCE OF .A PERN11T.
DE P AR F:M ENT VL APPROVAL
Zoning Review: j9Signature:
Energy Report: Signature:
Date:
Fire Chief: Signature:
Date:
Board of Health: Signature: i
Date: _
Conservation Commission: Signature:
_Date:_—
Other: Signature:
_Date: ____
�/
_Description of work being performed:_/%7�',,"�C�/7C� `S�y ��r%'i ��? �'
���
SECTION I - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address:
1.2 Assessors Ma of Number: -
Map Lot
Nearest Cross Street:
Subdivision Name: (i! Cox 70el"3
1.3 Historical District Cl yes
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal Sys
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2.1 Owner of Record:
j s 7�2/? 417 P 5 - .33 5 "
Name (print) - �" "
2.2 Authorized Agent: Contact Address Phone Number
r
Name (print)
Contact Address
Phone Number
' 1 r
R ... �..
3.1 Licensed Construction Supervisor. Not Applicable ❑
Licensed Construction Supervisor 15 fF n`/5' e License Number Q -7 4? -
Addressa Y,? �Cus�r� t 11P / K �GIJ Q� O.rz Expiration Date
Signatur Telephone I'%�%/ �� //;)/off OD
3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes .Q`
no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes El no
If yes, submit the
required affidavit!
Company Name Clete Jk- Tr'/� Cep /$ Registration Number (if none, state "none")
Address o?a y 0 C%�� /2f,
Signature Telephone SDI?' 9W//`1 �f
Expiration Date oZ -2- 7)-60 (�o
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
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 116.0, effective July 1, l
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuilding 1982, no individual
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.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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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)
a ..
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide th��yes
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached:: ❑
_. n
az�. _.�� �; ... , _..�� <„ .tip ;_ . ,,. _ ,� , � .. � . o
❑ new construction* ❑ addition
(energy report required) (energy report required)
❑ deck C�pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs ❑ chimney/
fireplace
❑ replacement window/door ❑ other
no. of windows_ doors (specify below):
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):_
El Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
El Air conditioning - (separate unit)
None of the above to be provided
Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
%e
Item
5.Total =(1+2+3+4)
❑ woodstove
❑ demolition
(specify below):
Q', '00r) /f'7
Estimated Cost ($) to be completed by permit applicanit
* Estimated Total $ -X70pc c-) , r7 ` ,
(please pri tt
1, ' ' C ��'� �0 �e ��S , as Owner of the subject property here
by authorize Cleal-
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 3 ' 6`5-
Date
r (.C1 G 7-P2 7-00 ( , as GwR ar4Authorized Agent hereby declare that the statements anld 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
$ • 30 0,6
Date
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