BP-44032RESIDENTIAL
SECTION 2 - PROPERTY-OW'ERSHIP/AUTHORIZED AGENT
2.1 Owner Record
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Name (print)
Nam
Contact Address Phone Number
2.2 Authorized gent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
ompany Name: x,�L S�Y�
Registration Number (if none, state "none"):
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Address: S, —j ; i s
Telephone: M 3 ?�
Signatur�2��
Expiration Date: ' b
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:
Hoare Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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 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
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Zonstrucfron
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
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Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failu;Fes
rovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ No
❑ Deck #001 ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace
❑ Woodstove/Pellet;:Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding
❑Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ Addition ❑ Replacement window/door
❑ Demolition
(Energy report required) No. of windows — Doors _
(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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work: I e �3 s�O , �- V4,1 IL
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Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = M + 2 + 3 + 4) r-%, n,a
(Please Print) (�
1, 1`L C C LL- Z as Owner of the subject property hereby authorize
to act on my be-tialf,_ip all matters r ative to work authorized by this building permit application.
Signature o Owner Date
❑ SPECIAL PERMIT (Per 780,CMR 111.13)
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Dater s 0
tTime: Clerk: (l�ly
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Less Application Fee: $9' Remaining Balance: $
Total Permit Fee: $ 0.00
Other $ Amount $
TOTAL FEE: (, Q . 0 = Gross Area New Construction total sq. ft. _,� Sez
Gross Area - Alteration total sq. ft.
Permit Issued to X .3 C /A/ � � 1 pGr L f' �° eC Cf ' !�° 1-7-
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DATE F�E� LDS �
DARTMOUTH BUILDING DEPARTMENT EJ
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14 400 Slocum Road, P.O. Box 79399 :
z i Dartmouth, MA 02747 00 I
Phone: 508-910-1820 Fax: 508-910-1838 `3
/664J/
wwwJown. dartmouth. ma. us
APPLICATION TO CQN$TRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Signature: /t j'
G" Date:
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/
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Dater
Conservation Commission:
Signature: 4A
Date:
Other.
Signature:
Date:
Brief description of work being performed. IR X-3 �,
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