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BP-27372DATE 3_3_0.3 REVISED EDWARDHHELLE LUTH 3 Iric, IZA LANE KENNETH R. FERREIRA ENGINEERING, INC. ` DRAWING Nurv�rBER STOCKDRAFTING FORM NO. 101-EI 46 FOSTER STREET, NEW BEQFORD, MA. 02740 E 3 0 03 2 R-L A-N SEAL E . I/-/ _ 1'-= 0�qx Tor:! OF am? Bum AT THE ®UlLDIrlG Dl1RINQ PROGRESS OF THIS WORK.TI A C f 'CIS rs7 euE�D€N®DEPARTMENT Plan fea /tB at 11 Tc" & Dartmouth @"r n > On FIB mpFiEmiC- RFOUlRFMENTNO Penetrations thru rated walls and floors shm1I be � sealed ti ith a rrtefer[F! c ,P. �,le of pro entin the. ��r� r s Built ��. VeY PIMA be Passage Of flame -sr an-d clot when sub', t d sl)-b"y it-ted tO the Building to the requirements of the Test Standard spi-.A is Dept. prior to for Fire Snaps ASTNi-E-814. call�n8 for ��dation inspection or fUl'tllcr cOnstruction. Osec> SCALE: Il� - l ! APPROVED BY: DRAWN BY Z f RESIDENTIAL 2002 SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: Fd 1Z (I lane Name (print) Contact Address Phone Number 2.2 Authorized Agent:. 90 7 ( d��i� s l ©w,,,l Name (,print) _ Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed COIIStruction Supervisor: Not Applicable ❑ Licensed Construction Supervisor �� " License Number C'S O Address r19 A41 Expiration Date /05 Signature Telephone ! %�7^ got 3.2 Registered Home Improvement Contractor: Not Applicable Are you a Home Improvement Contractor subject to (7SO 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! l Company Nat17e Regisirarion Number (if none, state "none") Address Signature Telephone J ExpirationDate 3.3 For Residential Remodel Work Only PERSONS'CONTRACTING WITII UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Hon )ie lmpro ,enrent Contractors R(cgistratiori: Oae .dshbitrtoIIPlace - Roorit 1301. Boston..1L4 02108, (617) 7?7-8595 Owners Name (print) fi Signature / by signing the above, the home owner acknowledges tliat there will be no eligibilty to the Guaranty Fund Da'ie 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 shall be engaged in (directly supervising persons engaged in construction. reconstruction, alteration. repair, removal or demolition involving the structural elements of buildings or stntctutes, 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 A.mv Homeowner performing work for which a Building Permit is required shall be exempt front "the provisions of 11 this section: provides that if a Hotteo\aner cin adzes a person(s) for hire to do such work, that such Homeowner shall act as supervisor. For theptnpo,as 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 dwellin , attached or detached structures accessory to such use and or fans structures. A person who constructs more than one honne in a two-year period shall not be considered a Homeowner. If p'ou are appl, iai, a ider this sect on sig below: I Signature:. Your signature carves certain responsibilities, including but not necessarily limited to, gencrai liability RESIDENTIAL 2002 .oTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construcliion 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' COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25) Workers Compensation Insurance affidavit must he completed and submitted with this application. Faiil_4ve to provide thiis affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: _ Ryes ❑ no SECTIONN5 - DESCRIPTION OF PROPOSED WORK (check all applicable) �addition new construction* CY❑ alteration ❑repairs ❑ chimney/ ❑ w(oodstove Iener(rr report required) (ener-y report required) fireplace n deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other . ❑ deimolition (shedlgarage) no. of windo%vs doors (specify below): (speciffy below): v If new construction. please complete the following: Single Family: no. of bedrooms no. of baths Tvi o 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): = Boller(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 !� ALL- ZZ SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. Buildill� c` Electrical f� hltlinblllL? "- ''. Mechanical (HVAC) �. Total = (1 -r 2 - 3 + 4) 301000 * Estimated Total $ 30 000 SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) 1. / / ��/'i �r-�'� as Owner of the c�y�/1 subject property hereby authorize l'i'/'Pc✓ to a pi my bel if, It all matters relative to work authorized by this building permit application. V- Si`,nature of Owner Date SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION l.l4e'g✓ tar/-/r-('}` (/ as Owner,/Authorized Agent hereby declare that the statements and in 'ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under le pains t id penal ies of rjury. C C> � A,9.q j Signature of OwnerAuthorized Agent Date, r'', l foi ;,s.Bl 1 "p,p.res tilt d paize 2 cal Paze 3 Rev, J.ianuary 19, 2001 RF CTTIF.NTT A T , 2002 SECTION 8 - INSPECTOR' - (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, feet review worksheet): Date: HOLD reason',J Date: 7.HOB sus ect to Zor,�� f' 4 dof Appeals action: Date: 8. Comments:`:,_: - nspector's Signature: A. _ Date: ECTION 9 - APPLIC NT OTIFICA ON ,. Clerk: Applicant informed of ab v a� Date: '-pC ime: Comment SECTION 10- OFFICEVNSPECTOR'S NOTES / Total Permit Fee: $V ` Less Application Fee: S 25.00 Remaining Balance: $ v ° `_)TAL FEE,: , L'YDGross Area - New Construction total sq. ft. 1 ' Gross Area - Alteratio` total sq. ft. � r ' Permit Issued /61 ! ,S CTION 11 -ADDITIONAL COMMENTS/SKETCHES C:\bldg.fonns\Blehapp.res.wpd Page 4 Rev, January 19, 2001 RESIDENTIAL 2002 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE 3S NON-REFUNDABLE & NON-TRANSFERA. BLF :......--- --- DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 ; 2 Dartmouth, MA 02747 r y; 508-910-1820 FAX 508-910-1838 tha APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINfG THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: `- ' 1 BUILDING PERMIT DATE SENT FOR REVIEW: NUMBER: 27'� r DATE ISSUED: a OK TO ISSUE - SIGNATURE: DATE` 11 ui ding mmissioner nsp or of B i ings Zoning District: S oposed Use: J&4 Zone: i- ❑ B VA ❑ V Outside Flood Zone ❑ Aquifer Zmne THE FOLLOWING AG :'LIES SHOUL E NOTIFIED: [VBoard of Board of 3Con. Com. ❑ Demo ElDPW ❑ Elee. ❑ Energdy Report A peals Health Affidavit Card Sent: Cut Off Follow-ulp* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ' ❑Other - Chief Cut Off / Cut Off // Cut Off Review* 6 (../ f * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review:Signature: Date: 1v 0 Energy Report: (� �� Signature: . �� x h, Date: /- 6 Fire Chief: Date: Signature A Board of Health: Signature: Conservation Commission:-- Signature: Date: Other: Signature: Date: Description of work Lein; perfornzed: SECTION 1- SITE INFORMATION LUMBER OF PLANS SUBMITTED: SITE PLANSUBMITTED: ❑ yes no I 1.2 Assessors Plat&�L/ot Number: 1.1 Property Address: �i l nior Plat 7 Lot _ Nearest Cross Street: t? �' _LnJ_p S t �� 7 / 1.3 Historical District ❑ yes , 2/no Subdivision Name: �� n LCl lie 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: t 8Municipal(] Private Well 9/municipal ❑ Or, Site Disposal System r � C `.bid�.lorms\Bideapp.res.�pd Page Re:N, January 19, 2001 i