BP-21189SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
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):
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:
Dater
SECTION 9 - APPLICANT NOTIFICATION
Applicant informed of above Date: Time: Clerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $
ca
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
�s
Permit Issued To- 2— ire —
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
7-3
1
P(I-
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
-
DARTMOUTH BUILDING DEPA.RTM'r'I'NT
o 400 Slocum Road, P.O. Box 79399
DATE RECEIVED
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
EV
DATE SENT FOR RIEW
NUMBER: oZ�
DATE ISSUED•
OK TO ISSUE - SIGNATURE: DATE 401--o
B ing Corn missioner/Inspgs ector of Buildin
Zoning District: Proposed Us : &�
Zone: ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW lec. ❑ Energy Report
Appeals Health Affidavit Card Sent: C t off Follow-utp*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: _Date:
Board of Health: Signature: d ,(x�u Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
//
Description of work being performed: &42w 1 i
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1 L-
1.2 Assessors Plat &Lot Number:
1.1 Property Address: ni
Plat Lot - -�
Nearest Cross Street: T _U Gee e
Subdivision Name: v v " 1 C_ d k r-A RN
1.3 Historical District ❑ yes ❑ no
%
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.: �
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
Municipal❑ Private Well
�unicipal ❑ On Site Disposal System
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2.1 Owner of Record:
2001
RESIDENTIAL
2001
- ZA
Name (print)
lam- al.,-t...-L
Name (print)
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
Iq W/4-,fix t-A-1 &a8- 3gl- 160,;6
Contact Address Phone Number
P0 5136 7
Contact Address Phone Number
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
nogo to
Are you claiming exemption from the requirement? If ❑'yes ❑tno next section!
If yes, submit the
required affidavit!
Company Name
I Address
Signature
3.3 For Residential Remodel Work Only
Telephone
Not Applicable ❑
License Number
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT •E ACCESS TO THE GUARANTY FUN
QUESTIONS OR COMPLAINTS call or write: D:
Hone 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 1, 1982. no individual
hall be engaged in directly supervising persons engaged in construction, reconstruction, alteration. repair, removal or demolition involving the structural elements of
,uildings 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
'onstruction 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
lomeowner engages a person(s) for hire to do such work, that such Homeowner shall act as super isor.
For the purposes to this 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
hich there is, or is intended to be, a one or two famil_ v d_wc,,m attached or detached structures accessory to such use and/or farm structures. A person who constructs
ore than one home in a two-year period shall not be considered a Homeowner.
you are applying under this section sign below:
gnature:
Your signature carries certain responsibilities, including but not necessarii} limited to, general liability
NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructivtn
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers 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)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/
(enetgl report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door
(shed/garage) 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
11 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: -1 ,
Item
5.Total=(1+2+3+4)
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
❑ other
(specify below)
❑ wOO(dstove
�mc)lition
(specify below):
0
Estimated Cost ($) to be completed by permit applicant I
* Estimated Total
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
1,— La--,4g� A t c 5,-A.) as Owner of the subject roe hereby authorize e,.., to ac � property rh' Y .t3 13 �A?r�d•v
Y in all matters relative to work authorized by this building permit application.
Signatu of Owner �S - 7- G I
Date
' 1� o - wl�t✓ A TH RiZED A ENT DE LAR Ti N
I, & --' / r., T , as Owner/Authorized Agent hereby declare that the statements and informattion
on t e foregoing appl cation are true and accurate, to the best of my knowledge and belief.
Si ne e nde pains
g� P ies of perjury.
'A
rized Agent
-2 7-0
Date
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