BP-20702%
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EXISTING WATERWE'
WITH STUB
EXISTING
HANDHOLE
i BOX
w . � ` +y' ,� � U j:. ,4; r EXISTING CULVERT SITE BENCHMARK:
EXISTING I NAIL SET IN 24"TREE
SEWER STUB ELEV.=84.17 (NGVD)
4
Ax C� LINES O T 3
'
1024 S. F.
un
1 Ac. 1.79 cl
)
PARCEL B
(OPEN SPACE)
EXISTING
'BARN
it
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T.O.F.=7 .2
of HO
t
Ni
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SITE U
SCALE I
LEGEND
90 E)
PRO,
FH
RL
(EXISTING)
I
(PROPOSED)
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-----7E— BIURIE.
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--- T&C—TELEPHC
RESIDENTIAL
M(11
SECTION 8 - INS ECTO4'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 wor heet : Date:
5. DE rojec iew worksheet): r
`
Date:
6. :`
Da te: Q
�Hseuabsoect
7. to Zonin Board of Appeals action:
Date:
8. Comments:A• ��Ok
9. Inspector's Signature: i
a e:
SEC*ON 9 - APPLICAN TIFICATION�
Applicant informed of aboveate: I Time: L�: "� j
Clerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
-T
,✓
Total Permit Fee: $ / i,7
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: dl� dross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To* x -3 07
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
SS Y19/a / &&'�e,
i
/j)A-
RESIDENTIAL S u e , 2001
❑ FOUNDA" 'ION ONLY
$25-00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERA313LE
DARTMOUTH BUILDING DEPARTMENT
;o 400 Slocum Road, P.U. Box 79399
DATE RECEIVE D
Dartmouth, MA 02747
`.:.'6 ° =' 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEL'LIT4G
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: /
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:1
/-� �.
DATE ISSUED:
OK TO ISSUE - SIGNATURE: t ' ,DATE
Buildin Co issio er/Inspector of Buildin
Zoning D>Istrict: Proposed Use: Zone: 054 ❑ B ❑ A T Outside Flood Zone ❑ Aquifer lone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo . ❑ DPW ❑ EIr c. ❑ Eneergy Report
I Appeals Health - Affidavit = _ Card Sent: Cut 1ff Folloiw-up*
I ,
-
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card J Zoning 7 Othier
_
IChief Cut Off / Cut Off / Cut Off Review*
I
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPAY�TMENTAL APPROVAL . .
Zoning Review: Signature: Date:
aergy Report: Signature: Date:
-.
Fire Chief: Signature: Date: ® -
IBoard of Health: Signature: A) 6Date:
Conservation Commission: Signature:4, f/✓��
Other: Signature: -
Description of work being performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1. I Property Address: �-r..v
1.2 Assessors Plat &Lot Number:
�� ��
Plat— Lot-3
Nearest Cross Street:0 Gye A RI -1
1.3 Historical District ❑ yes §no
�900 /
'
Subdivision Name: Ali o x F6 , - M
Total Land Area Sq. Ft.: � � : 000 rj F
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
1.4 Water Supply (MGI:, c 40 § 54):
,- Municipal❑ Private Well
unicipal ❑ On Site Disposal System I
/ k
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RESIDENTIAL
2f)(11
SECTION 2- PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
l i3
e w l Q .�, � •+ r� �
R) 116 7 N t l? i -2 2
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVT ES
3.1 Licensed Construction Supervisor:
Not Applicable.
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
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 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
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
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, 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 Homeowner shall act as supervisor.
For the purposes of this seetion only "Homeowner" is deft d as fo ws: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intpnded to be, a e or two famil detached
_ ell' , attacW or structures accessory to such use and/or farm structures. A person who constructs
more than one horn a two- y period shall not c idered 14o
If you are applying u is section sign b
Signatu C s�
You gn, ure es certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
2001
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructtion
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 tibis 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* ddition ❑ alteration ❑ repairs ❑ chimney/ ❑ wo,odstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dennolition
(shed/garage) no. of windows doors (specify below): (specify below):
* 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
� c4r
1 a4 �� 2
/ov
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildiniz
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (I + 2 + 3 + 4)
* Estimated Total $
SECTION 7A - OWNER AUTHORIZATI
(to be completed when owner's agent or contractor applies for 6ildia'gpermity-
(please rint)
as Owner of the subject property hereby authorize
to act o ehalf; in al work authorized by this building permit application.
7— J �V
atu O er Date 1
SECTION - OWNER(AUTHORIZED AGENT DECLARATION
- �7 , as Owner/Authorized Agent hereby declare that the statements and infawmation
on the foregoing applec 'on are triie an ccurate, to the best of my knowledge and belief.
S ` fed nd
,1g p,iIs and pe erjury.
atuKe^wn&i4uth Ized Age Date
Z 111X
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