BP-48136 47-57SECTION
12 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildirg
G' 0.6
2. Electrical
3. Plumb ng
4. Mechanical (HVAC)
5. Off -Street Parking
6. Total = (1 + 2 + 3 + 4 + 5)
Estimated Total Cost Including Labor: $ P e Yeo , G-r
SECTION 13A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please P-int)
as Owner of the subject property hereby authorize
to act or my behalf, in all matters relative to work ay horized by this bui ing permit application.
Signature of Owner Date
SECTION 13B - OWNER/AUTHORIZED AGENT DECLARATION
["N/� 4-*S B A. , as Owner/ uthorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my ge and belief.
Signed under the pains and penalties of perjury.
/Z 2z f C .7
Signature of Owner/Aoorized Age t ate
SECTION 14 -INSPECTOR'S REVIEW/COMMENTS
1. HOLD reason:
Date:
2. HOLD subject to Zoning Board of Appeals
Actio r Date:
3. Comments:
4. Comments:
5. Inspector's Signature: Date:
_. SE TION 1 -APPLICANT NOTIFICATION
Applicant 'nformed of above: Dat, . Time: !',���'" ! Clerk:
Commerts f ic , // I
SECTION 16 - FICE/INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee-$25,ho'.
Other $ Amount $
Remaining Balance:($
TOTAL F=E: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
COMMERCIAL,
$25.00 APPLICATION FEE IS NON IIIE-FIFNI?`ilILE Jlk NON-TRiVINSkEBABLE.
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DATE RECE NED
DARTMOUTH BUILDING DEPARTMENT
r`. 400 Slocum Road, P.O. Box 79399
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T! Dartmouth, MA 02747
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Phone: 508-910-1820 Fax. 508-910-1838
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www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL
BUILDING (including 3a Inore family dwellings)
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBI�R
DATE SENT FOR REVIEW: ' i '' r f
DATE ISSUED:
O.K. TO ISSUE - SIGNATURE: Y ✓ - _ DATE:
$uilding Commissioner/Inspector of Buildings
Zoning District: "'Proposed Use: _�� Zone: 121'115+6 B ❑ A ❑ V Aquifer Zone:_.
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑ Cons. ❑ Demo ❑ DPW ❑ Elec_ ❑ Energy Report
Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑Zoning ❑ Other
Chief Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPAPffiAENTALAPPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: tg,:
Brief description of work being performed:
SECTION 1 - SITE INFORMATION
1.1 N MBER OF PLANS SUBMITTED:
1.2 SITE PLAN SUBMITTED: E7 (es ❑ No
� .3 Property Address: y/Jf1h'Ti'7041 if L'vNJu 1.4 Assessors Map & Lot Number',
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_
Lot ' 1
Nearest Cross Street: Map -
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usiness Name:, /9/'I£,Pd/u CvNS% • otR®or-TNG Ca = Z7,y4-.
1.5 Water Supply (MGL c40 s54):
siness Phone #: i $ & y3 4 0 C"C/ ❑ Municipal ❑ Private Well
Total Land Area Sq. Feet:
1.6 Sewage Disposal System:
❑ Municipal ❑ On Site DisPvlsal System
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 wner Record:
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Name (print) Contact Ad ss Phone Number
2. Authorized Agent.
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Contact Address Phone Number
Name (print)
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Ccnstruction Supervisor:
License Number:
Address:
Expiration Date:
Signature: Telephone:
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(MGL c 152 § 25)
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: ❑ Yes ❑ No
SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ New, construction ❑ Addition ❑ Repairs ❑ Accessory Building (Shed/Garage)
❑ Othe• (Specify Sec. 6) ❑ Demolition ❑ Sign ❑ Replacement window/door
No. of Windows Doors
SECTION 6 - PROPOSED PROJECT USE '-INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
The following descriptions are based on the Massachusetts State Building 6th Edition, Code Article 3, as noted. See the Code.
❑ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0)
Descriibe:
❑ 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 (see Code Section 305.0)
❑ Factory/Industrial (see Code Section 306.0)
❑ High Hazard (see Code Section 307.0)
❑ Institutional - hopsital, 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 110.0 and Zoning By -Law Section 35)
❑ Tent or Trailer - temporary
Purpose?
❑ Other:
Describe the proposal briefly, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
(if extra space is needed, attach an additional sheet):
lcondition
O a - (�,
10
SECTION 7 - TYPE OF CONSTRUCTION_ OR WORK TO BE PERFORMED
❑ New const%,ction 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 c� 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 Ccce Section 116.0 Designer to submit Code Synopsis in additional to original plans.
Will this proje t require Peer Review (over 400,000 cu ft.) ❑ Yes ❑ No (see 125.0 Code & Appendix 1)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR.
❑ Demolition* - describe structure:
❑ Moving* - (provide copy of DPW moving linense)
*Type of structure: from where (plat/lot or address):
to where (plat/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 enlarged) E,'_-;RESS
dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered as an alteration, : itherwise will
be included in new construction. (see Code Section 3603.21 for residential and Article 10 for commercial).
❑ Temporary structure - includes, when allowed, trailers, tents and the like and only for limited periods of time. Describe.
SECTION 8 - MECHANICAL & PRIMARY FUEL
❑ 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
SECTION 9 - SPRINKLERS AND/OR FIRE PROTECTION
❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why?
SECTION 10 - REQUIRED OFF-STREET PARKING (for Zoning and Architectural Access)
❑ Parking plan submitted to: Building Dept. Planning Board Date submitted
Number of spaces indoors outside Total provided
Handicap spaces - required yes no if yes, how many as a part of the total required number
Is Route 6 (State Road) entrance permit required? yes no if yes, has it been issued? yes no
Submit copy of application and/or permit as soon as available.
SECTION 11 -IDENTIFICATION
11.1 Architect/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 reproductions.
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 reproductions.
11.3 General Contractor
Company Name: 61U (° oN 5 f o4 iE'r?oFZ-N G- 6
Address: i'H -S /9i1.Z cge) , /�. <= z 7 V I
Phone #: _� - S D S-- G y p n c J
Construction Supervisors License Number:
Note: Signatures and seals on all plans affidavits & other documents SHALL BE originals and not reproductions.