BP-922713.1 Licensed Coi
Address: K1
�u�eivtsor.' yvi� 'vt �/ Not Applicable ❑
1 License Number:
Expiration Date:
Telephoner V/-t0Y1-10I'll
Worker's 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 (MGL 152 Section 25A).
Signed Affidavit Attached: 'es ❑ No
�.�.: SEMI I[%f 5 rSCRIp t Tile7F.itf�PCEflff3l+.{Cfie-lfalt"gip lieble
Q New Construction - ❑ Addition
[repairs ❑Accessary Building (Shed/Garage/Other)
❑ Other (Specify Sec. 6) a Demolition ❑ Sign ❑ Replacement window/door
❑Fire Protection
No. of Windows Doors
7-7
a: C�It�PiOI��sD I�I�E}EC I iJSE tLUAIRiG THkREEF,1C,3t €fi P1911-01 tJS The following descriptions are based on the Massachusetts State Building &th Edition, code Article 3, as noted See the Code.
o Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0)
Describe:
❑ Business - office, assembly with less then 50 occupants indicate Medical or other professional (see Code Section 304.00
❑ Education- struction for training including child day care for those over 2 year 9 months }
Y (see Code Section 305.t))
❑ Factory/industrial (see Code Section 306.0)
❑ High Hazard (see Code Section 307.0)
❑ Institutional - hospital, nursing home, infant day care (see Code, Section 308.0)
❑ Mercantile - retail stores (see Code Section 309.0)
❑ Residential - three or more family, hotel (see Code Section 310.0)
❑ Storage - including garage (see Code 311.0)
❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
❑ New Tenant - for any of the above, please indicate (see Code Section 105.1)
❑ Trailer - temporary
Purpose?
Describe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
condition (if extra space is needed, attach an additional sheet):
F.
F
❑ New construction and/or Additional (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ Yes' ❑ No
If Yes, see Code Section 107.6.2 Designer to submit Code Synopsis in additional to original plans and if existing building Chapter 34.
Page 2
I❑ Demolition* - describe structure:
0 Trench Permit Required? o Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CMR 7.00,%t seq.
❑ Moving* -(provide copy of DPW moving license)
*Type of structure; " from where (map/lot or address):
to where (map/lot or address): number of dwelling units:
number of bedrooms per dwelling unit:
❑ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enharged)
EGRESS dimensions must be maintained.
❑ Temporary structure and uses - includes, when allowed, new tenants, trailers, tents and the like and only for liimited periods of time.
Describe:
❑ Furnace (hot air) - fuel gas (natural or propane); fuel oil, electricity, other (specify):
❑ Boiler �Iieating) - fuel gas, (natural or propane), fuel oil, electricity, other (specify):
11 VAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit) Roof Top Unit (RTU) New ❑ ` Replacemient ❑
❑ None of the above to be provided Mechanical Ventilattion ❑
❑ Hot Water: Gas Electric Fuel Oil Other
❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why?
Narra#ive'Submiitied? ❑Yes. ❑ No
11.1 ArGhitect/Engineer for overall design
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductii-0ns.
11.2 Architect/Engineer - project supervision and reports
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductiolns.
11.3 General Contractor
Company Name:
Address:
Phone #:
Construction Supervisors License Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductiol7iS.
Page 3
_ _ 8EG1'I(3P
Item
1. Building
2, Electrical
3. Plumbing
4. Mechanical (HVAC)
5. -Off-Street Parking
6. Total = (1 + 2 + 3 + 4 + 5) - Estimated I Cost Including Labor: $ /a w
COWKENCIAIL
licant $25-00 APPLI[C T)[ON FEE IS NON RE-FUN-01 LlE NON-TIMANSFEBLE
(Please Print)
I
as 0 erOA 'ilding
ct property hereby authorize
P P Y Y
to act on my behalf, in all matte vela#' e o rk .. thori is bermit a lication,
P PP
Signature of Owner Date
T F
` SECTION 1,�8 a, ._ RIAtJi'�tOF�IZIvD AG€�T:DgCLAR�TtOE2 ` ;
�-
, , as Owner/Authorized Agent hereby declare that the statements and Information
on tote fore oin a licati n ar true and a rate, o
9 9 RP e, t the best of my knowledge and belief.
Signed un
der nder t e pains and i<aI#Ies of er u
P I rY
C7T
Signatu er/Authorized Agent date
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $_'
Other $ Amount $
Gross Area - New Construction total sq: ft.
Gross Area - Alteration total sq. ft. a
` v
Permit Issued to: � � ;�? �''� ` L,�°t. ����
i
r
1,Y31 ,
Page 4
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road,
. Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
I66:'
A�BUILDI'NG
www.town,dartmouth.ma.usAPPLICATION
TO CONSTRUCT, REPAIR, RENOVATE OR -DEMOLISH A COMMERCE(including3ormorefamilljdwellings)
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lnmgs�r4lr�S Ming$,L yy $ x
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Fire E}Gas QI'lanrung <�-- iI�uewer.Cafd � ®77Vaterf:�arff E}�csning MEIi3�ie��°
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fEi7)RS7NSPECTfJRSREVI3fE`tIEtSIJf(CE{?PAPERMIT
-=
DEPARTMENTAL APPROVAL
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature:'Date:
Signature: Date:
Signature: Date:
Brief description of work being performed. (dam Ulf./
` �
�
1.2 Assessors Lot Number:
1.1 Property Address: I 1 �� lkk' 1 1 4 ��� �
x
Map Lot
Nearest Crass Street:
1.3 Water Supply (MGL c4O s54):
Business Name:
❑ Municipal ❑ Private Well
Business Phone #:
1.4 Sewage Disposal System:
Total Land Area Sq. Feet:
❑ Municipal ❑ On Site Disposal System
-
2.1 Owner Record:
Name (print)
Contact Address PhoneJNumber
2.2 Authorized A ent:
Name (p(nt}
Contact Address Phone,lNumber
110 - '07
CCavori 0
Debris Removal
per N10L 0,40 Sec. .54
Page 1 Revised 10/11