BP-35302FILE COFY
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ELIZA (50) WIDE) LANE
150.00'
LOT 4A
U?
40,000 +/- SO. FT.CN
`cO 0.92 ACRES
LOT 5 1
EX/STjNG
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TRIM"F DAVITHOU
Cora Of This Endorsed
Plan east Be Kept r Site \
ruction
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Dut1r � �.`oc� d3n
Date
I
RESIDENTIAL
2004
�16
�i
2.1 Owner of Record:
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
�'
Contact Address Phone Number
Name (print)
"1§ g fig"s -�
A ..m
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 n 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 (Vk_V, Zr' qc,
Registration Number (if none, state El
C'
Address )
Signature Jelephone < �
Expiration Date GC,
3.3 For Residential Remodel Work
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)
Sigh atuare
by signing nine the above,g 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
Construe fion 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 persons) 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
• onstructi tensed C
ED CONTRACTORS. The Building Code provides m the Rules and Regulations section that any h �on
NOTICE TO LICENSED g
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
m . �
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide tl!his affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
e
1.
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❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ wcoodstove
(energy report required) (energy report required) fireplace
❑ deck pool ❑ accessory bldg. . replacement window/door ❑ other Eldmolition
� g ❑
(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: r . SIR W 4kk 4t dti t ti
1
01
Item Estimated Cost ($) to be completed by permit applicant
1 Rnildina
Flertrirnl
I Phimhinu
4 Merhnnirnl (HVAC)
5. Total = (1 + 2 + 3 + 4) * Estimated Total $ I—boCj ti CS@>
(please rint
1 s , as Owner of the subject property hereby authorize eI3, Qbi��
to act o alf, ' all tters ative to work authorized by this building permit application.
Sig ture of Owner Date
P a _
EmuMI w
�' _ e• ._ - efte
area e a s��
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ktJ + ItA� 5�Q_s as Owner/A on ed Agent hereby declare that the statements and irnformation
on the foregoing application are true and accurate, to the bes of my owledge and belief.
Signed under the ains and penalties of perjury.
Signature of Owner Authorized Agent Date,
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Rev. January 1, 2003
RESIDENTIAL 2004 RESIDENTIAL 2004
❑ FOUNDATION ONLY ❑ FOUNDATION FEEIS ONLY
$2500 APPLICATION
_ - TI N FEE IS 1 ON- EFUNDA LE' NON-TRANS$NON-REFUNDABLE A LE NOW -TRANSFERABLE A LE $25.00 APPLICATION _ _ _ _
�.... avP
1. Date plan reviewed: Cam%
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet):
5. DENIED (see project review worksheet):
6. .HOLD reason:
Date:
Date:
Date;
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
Dater
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Applicant info d _ f above Date: Time erk:
Corments: es
ssON 00,� � s �
Total Permit Fee:$�
Less Application Fee: $ 25.00 Remaining Balance. $
TOTAL FEE: Gross Area - New Construction total sq. it.
Gross Area - Alteration total sq. ft. , f
Permit Issued To:
�N
ouTa
t1ATE DART. ! , led
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 2(1 4 ItU - 6 iI 10 F, 7
` Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIN!;
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Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: CJrC lf4,1 9LyCt_- Date: ds A
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed: `1 f 2Rifv
Wall "TO
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NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑Mo
i ` t? jA- L.N -
1.1 Property Address:
1.2 Assessors Plat & of Number:
Plat 411 Lot
Nearest Cross Street: �T
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Hist(Nric Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal Private Well
P
❑ Municipal �_On Site Disposal System
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