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N 1q°5� 4�
LOT LINE INFORMATION TAKEN FROM PLAN ENf1TLID
r
"DAISY FARM" PREPARED FOR FLEMIMG ENGINEERING AND
w BUILDING BY B.R. McGEE & ASSOCIATES AND (RECORDED IN
PLAN BOOK_/35 _ PAGE_�� _<_� NEW B+EDFORD REGISTRY
OF
o
DEEDS.
�5 G PARCEL 5110\0 15 LOCATED 1N ZONING DI STRI CT "SINGLE
RE5IDEN CE A"
TIF
I CERY THAT TI115 LOCUS DOES NOT LIE \vAT} tIN THE FLOOD
LOT
- 13
PROPOSED
DWELLING
HAZARD ZONE AS DELINEATED ON
COMMUMITY MAPo`5�---
013 ft
#------0� Zo C ------
PANEL40
N 9
q
d—
a
00
,
i
Z
GRAPHIC SCALE
30 0 15 30 60
( IN FEET )
1 inch = 30 ft.
120
ELIZA
FROPOSED
FOUNDA ION F1 AN
Record Lot 13
"Daisy Farm Subdivision"
LANE DARTMOUTf1,
BRISTOL COUNTY MASSACIIUSETTS
Prepared For
ENGINEERS & SURVEYORS
N. A. S.R.
18 Quarry
Land Surve yo rrs
Street
Fall River
Massachusetts 027'Lr3.
508— 679—
6684
DATE: April
1gg7 SCALE: T = 30'
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TEST PIT LOG
DATE OF TEST: � 46 9L DATE OF SOIL E`MLUATION:
INSPECTOR GM l5 en' 4A' FtUr
PREFORMED BY: RA-6 a/ -7,, f/f u2 r Ifs
144.0 TEST PITH a " /yy, o T.:ST P1T12
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WATER TABLE S3 €-- WATER (A9V IL_S t f
BOTTOM OF PERC HOLE -II- BOTTOM 301` PERC HOLE: "
I PERC. RATE: & MIN/IN PERC. RA = oZ M1N/!N
CAST IRON OR CONCRETE � +
COVER BUILT TO WITHIN
6" OF GRADE WITH CONCRETE CAST IRON OR CONCRETE
RISERS. (310 CMR 15.228 (2)) COVIER BUILT TO WITHIN
I (OF GRADE WITH CONCRETE
• � ' I �RISfERS. (310 CMR 15.228 (2)�
THERE SHALL BE AN AIR SPACE iI
OF AT LEAST THREE (3) INCHES
BETWEEN THE TOPS OF THE I I I
I TEES AND THE INSIDE OF THE I l
5
3I� I
BACKFILL VARIES ESTANK COVER. Ii VARIES BACKFILL
FLOW LINE ! 1 ! 12" MINI ! 12" MIN.
4" INLET I L 10" MIN. 14" ( I I 4 OUTLET I
- 7 j8"- i j2" WAS IED PEASTONE
I
�1 i 1 j8--1jr WASHED FEASTONE� TOP OE PEASTONE-I Ib-2 C _§
tom— ,
tl ! 4'-0" MIN.
f LIQUID 9 ! i &�-
SET ON LEVEL LEVEL I i z 1 2' a !
STABLE BASE (6" ) �- i WASHED S 6NE W SHEDIS ONE�� W SHEDyS ONE
COMPACTED GRAVEL I
OR COMPARABLE)
ON SIDE I , _I
5 � J.1
�-
�' IN BETWEEN DISTRIBUTION LINES `L4v SIDE
l
SECTION A -A THROUGH LEACHING BED
PROFILE VIEW
i
I LEACHING BED
SEPTIC TANK t
NOT TO SCALE, I NOT TO SCALE -,
{
CENEIRAT
NOTES.
--- _
Y p g 12.) Some manhole locations sl'nown on the precast concrete GWEERS AS -BUILT
v� \ 1 I his system shod be Ins ected when the leaching area is
�Lk" I. rte p p g structures may not be standard, locations ond must be specially CONSTRUCTION OF THIS SEPTIC SYSTEM CERTIFICATION
.� ,,.Iv excovat d, when all components are In lace and a al after y p y MUST BE COMPLETED WITH THREE (3) ` ATI® 3, __ w L� �� o ode scam fete. The contractor shall notifythe ordered as such from the suppl!ler.
ar \Ll �iY;� '~�` o•, -' final covert Y
1 ocol Board of Health and the Engineer a minimum of 24 hours in SWEVENT RE
r T - 1 13.) The contractor shall excavrate all unsuitable material in the SEARS OF THE DATE OF APPROVAL �U���a
«dvance of any required inspections
rj 9 leaching oreo shown on the plot and bockfill with clean gravel or
lJ o 00 S Q , f �, \ a coarse sand 310 CMR 15.255 BOARD OF HEALTH STAMPS:
v 1 \ 2 i All base aggregate for leaching structures shall consist of ( (3))
_• double washed stone 3/4 to 1 112 inches in diameter and shall be Dd
4,
free of iron, fires and dust in place (310 CMR 15.247 (1) (2). 14.) A Certificate of Compliancy as required by Title V. 310 CMR T1 his S stem Is c eSiine
15.021, must be obtained by the contractor upon completion of the
y, p
`ievoUons for the system are based on an assumed datum. work. If on "As -Built" plan as required due to the contractor For Garbage Grinclar, Whirlpool
deviating from these plans, the cost of said "As -Built" plan
I,- The contractor shall not allow any heavy equipment to be shall be paid for by the contra rctor Or Other High Water Use Devices.
Ai
opercted over the limits of the sewage disposal system during `
construction of the s stem. 15.) The contractor shall be responsible for verifying. the actual
_ � �_,--T-�'"�` �- � "�i,��• y location of any existing utaitles shown on this pion. �
I, m a ttot
i ✓_ _. ._ ` '^� 3 lc �V ttield modifications shall be made to the ystem without 1 &. This septic s ste s designed for the use of a garb BOARD OF �-• AMPS BOARD �F HEALTH INSPECTION
r; wrl en approval from the Engineer and the Town Board of ) Y QED
Health disposal unit. O
o� Hry s REQUIRED WHEN EXCAVATED
,. 6 j Unless otherwise noted, all system components shall be 17')4 It is recommended that thte septic tank be pumped out at
THE APPROVAL �. ���� �F�€cE ELEVA aI0 S MUSTNOT
i 4 { ataiieu Ir accordance with ,he current edition of Title V of once every three years. % V
_ - - stalled r eas,
�y V• = ;,- the State Environmental Code and applicable Town of r _ ®*� DOES NOT GUARANTEE THE
re ulations. ®+ �� EFFECTIVENESS AD WITHOUT
- _ grit ��. cT�vEEss of �� 0
�-
L�i - ► Z �- - IN
yam.. �l ;,- 3y.J { , .- 3 . ;,' - — — = _ _ �'' p ow F o sTI��LaT�o� HEALTH APPROVAL
\ •y + .___ __R _ 7 At all oinks of intersection of water lines and sewer N DARTMOUTH BOARD OF HEALTH ��
•�' ( lanes, mechanical joint cast iron pipe shall be installed for _
r ' " bath lines for 10' On either side Of the intersection point. TI1!C cFPTN' CYCTFAI nFQI'Al /C 11,4/ In null Y STAMP OF P.E.
f
LEGEND
I
p 0 SEPTIC TANK
DISTRIBUTION BOX
7 0Q— — EXISTING CONTOUR j
i
C� PROPOSED CONTOUR
1
TEST PIT
� I
17T/� RESERVE AREA
I t1G
i
iiA/ WATER LINE
- - - - - LIMIT OF EXCAVATION
FINISH GRADE
�11!�!hil�!I=1ii=Ili-i! Ti�Il�ll�ll=ill-!! ,!I=,f.l�
' 4" INLET
;
C � o
-I-II i
O0
I SET ON LEVEL
COMPACTED GRAVEL
OR COMPARABLE)
I
PROFILE VIEW
I
' DISTRIBUTION BOX
I
NOT TO SCALE
FVVISH_GRA OVER
TANK THREE (3) 20-INCH MANHOLES WITH REMOVABLE
I FINISH G 1D T",� CAST
IRONORCON CONCRETE COVERS
VERS OF DURABLE MATERI
AL
DWELLING HOUSE BUILT UP WITH CONCRETE RISERS FINISH GRRADE ELEVATIO
TO WITHIN 6" OF GRADE 4" SOLID WALL
\ (310 CMR 15.228 (2)) PVC PIPE
\ FIRST TWO FEET TO BE A
TOP OF FOUNDATION +G y LAID LEVEL
ELEVATION =
MI
i
SLOPE 2% SLOPE"M) )% I TOPSOIL AND SUBSC)IL BACKFIL�l 5 , MIN
'-1 " WASHED PEASTONE
o %010 I! ! u I -
CAP ALL ENDS
GAL 5 2 WASHED H .� OF PERF PIPES
REINFORCED � q S, q . , , 9 ' BOTTOM OF BED � I
SEPTIC TANK 2 BOTTOM Of` LEACHING FACILITY
1 < `qs. ✓ L LENGTH OF BEG) 0'-8' FEET
CLEAN
CLEAN Ll A COARSE
LEVEL STABLE BASE COARSE
SAND ,
SAND BOTTOM OF EXCAVATION [ELEVATION = I r� i
..................
LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY WATER TABLE ELEVATION �39•�8 i
COMPACTED ANO ONTO WHICH SIX (6) INCHES OF
CRUSHED STONE HAS BEEN PLACED TO MINIMIZE
UNEVEN SETTUNt" (310 CMR 15.228 (1))
SEPTIC SYSTEM PROFILE
NOT TO SCALE
I
ya.4V
Sq.✓o�/L.c>y� I
/oyR s/4-4.
/7,
SRiJ/��.L.oA�I
�.sy �! j
i
I
I
%0
Gs," 5+"'nyL >q.4
i /o yR s/3
!
/°/V/z a
I
8.) The precast concrete septic system components shall be F ACCOMPANIED t4'1TH THE ORIGINAL SIGNATURE rAn il
\ g == manufactured by M & S Cement Block Corp., Fall River, MA or AND SEAL OF P.E. OF
J & R Precast, Inc., Berkley, MA or use an approved comparable Fes• � c
17
z o, ALA=N J.
substitute- �`� � 1�
HEUREUX
N� 9 j Grout shall be used at all points where pipes enter or exit o civil. � r
a!i concrete structures to provide a watertight seal. t� p No. 33811
10..I Ali shlplop joints in the septic tank shall be sealed with {,
neoprene gaskets or asphalt cement. 3 t D.A
Y \IL
1.) All PVC pipe used shall meet ASTM D 3034-73 SDR 35 and
i10 ra R 15,251 5) I l
\ / schedule 40 PVC (V' except inlet and outlet tees ees which shall beIDAR
^" SUBSURFACE'
SEWAGE DISPOSAL SY, T ET
_�x VIEWEDRF
S i R� T nrIO.N':
A"-' � manes OWNER. <1
1�� j
SEE REPO �.�
We Of Rw'01" n T a' PLA T: 98 i3
_ - - - REVISION ; L T .
SYSTEM DESIGN DATA � i CATS' <-, //3/9�
I I
I i I
l7ESGN _A PA I Ty gE!)RnQhAS a110 GALIDAY= a GAL iDAY ! I I
SEPTIC SYSTEM COMPONENTS
APHIC SCALE ' ' f ' ` LEACH1N." BEr' DEC/C' Ab WIDE IONC, / � DEEP ;1 MAUK, BOUCHER HEUREUXa INC.
Il
i 2O' U /vZ p >E h � ANC <, : USE 1,500 GAL TANK AS MANUFACTURED BY M&S I ! I
� -
O �.E ,T CORP. APP , I �FPTIr, �Y4T F• /0
M N, BLOCK OR, OR POVED COMPARABLE _ EM DE r;,T PFRrniAT/ON RAT M/N�IN I I II ter+✓I�jFI V,1R0iVMENTAL ENGINEERS, SCIENTiST� Tit-
, I I Ii L+�'-t- �' i ' J TITUTE I"tJ85 ll BY. %ZE �7. E ! L?iy� SJlKVt ' AlV ?L 1�IVEDRAWN !DATE I
JEFF rQ S A R�
LEACHING BE JL �1� CALCULATIONS: i 1 ; I i _
___ __-_ _ _ __ __._s___-. _ .___- _ 648A AMERICAN LEGION HIGHWAY WESTPORT MASSACHUSETTS 027t''O
\ IN FEEPT ) _. ------ - ^;h FT AV 'BAFFLE AS MANUFACTURED cZ8 ^i,'i x � x . 6,0 GPD SF = '�3� CP11 7 7
'i;Ji\' vS£ r SU. / L+J.1J
BY M&S CEMENT BLOCK_ CORP. OR APPROVED +. / , { DESIGNED 8Y.• �F FR c 1_ d7`I-,_1 E i DPAw7NG NO. 1 I Et: 508-636-5905 FAX 508-635-24, 7
tCArACII;) I !
V.D c,E ISUBSr,a�'Tc_ 1 I
I ! C.y"C,(ED BY.•
Architect/Engmeer - project supervision and reports
800 A IECHANICALS &PRIMARY FUEL
Furnace (hot air) - Fuel gas (natural orpropane),fuel oil electricity,
ty� other (specify)
i
Company name ---
f�Z A �
Boiler (heating)- uel gas natural or propane), fuel oil, electricity, other (specify)
` I
Address I
= HVAC (combined unit) - Primary fuel, natural gas, propane, electricity, other (specify)
Phone number --
_ Air conditioning -(separate unit)
Certified by State of Massachusetts as
None of the above to be provided
Certification number
Hot Water Gas Electric Fuel Oil Other
NOTE Signatures and seals on all plans affidavits and other documents SHALL BE originals and not
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
reproductions.
- Required, plans provided, plans not provided, why'?
General Contractor (if Homeowner, state homeowner here then complete section 1300)
/
Company name 4 5 f CC) A It fig Otte e S O "� X/� 64,6 /Ax d -7-rt <. .
Not required, not to be installed, Why? . /_,, o ► V up r /%0$w0
—
Address
1000 REQUIRED OFF-FrREEI' PARKING - for ZONING & Architectural Access
Phone number s'd _ 6 o
NOT APPLICABLE
/ ) J p
Construction Supervisors license number �iCt w41 � l� _ �/t �r' � S 0.57 � [ j
Parking Plan submitted To Building Department Planning Board Date submitted •
NOTE Signatures and seals on ail plans, affidavits and other documents SHALL BE originals and not:;
Number of s aces - indoors outside
P ,�. total provided Z..
reproductions.
Handicapspaces required es no.
P q _ y 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 J.
1200 FOR RESIDENTIAL REMODEL WORK ONLY
Submit copy of application and/or permit as soon as available.
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes - No _ If no go to next s*ction!
Are you claiming exemption from the requirement? Yes No _If yes, submit the required affida-lvit!
1100 IDENTIFICATION (print or type except as noted)
Current owner - name �/,�} eft► S , �.Q yt C V to I
Remodel contractor name (please print)
/ .. _
address �? SD 7),4C/0 Sf . � � /�Ill2/` O 2 /%Zp �(rt'h ff //Z�
Address
phone # - 3 3 ®0j
Registration number (if none state "none")
If corporation, officer in charge
Phone number
Architect/Engineer -for overall design
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
t'yt P R 5 fa-s, @ S l /
Company name Co ��Z /etc /c.fL 9g9rt/t e e S 714 C...
Home Improvement Contractors Registration
,
One Ashburton Place - Room 1301
/
Addressr2t�t e,it /t Al w'4 Gl 5 %lAl 5�-',P i'jtl�-, 02i%�
Boston, :MA 02108
(617) 727-8598
Phone number
S d fora-", d L .e-U p ! 2.
Owners name (print) -S
Certified by State of Massachusetts as A,'1 ,
41
Signature
Certification number __
7
Date
NOTE Signatures and seals on all Plans, affidavits and other documents SHALL BE originals and not
1300 OWNER SIGN - OFF
reproductions.
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have ret�viewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided iin this
application is true and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is be%un or
six months after the last inspection if work has begun and that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three tames by
I _ I
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning). j
Name 7 le. C v-2, 4 ra.cc
Signature "'
Thjb, signature is my voluntary act and is signed under the pains and penalties of perjury.
Date q, l e 92
Who is authorized to pickup the ermit at the Building De artment? lease print)
Address Phone o� ?8'
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR HON4E OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
1il9.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control
in Section 127.0, 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 Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Homc: Owns. r" is defined as follows: Person(s) who owns a parcel of land
on which heishe resides or intends to reside, on which there is, or is intended to be, a one or two familv dwelling, attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner.
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 Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see
2.15.2 of section 5)
1500 COST
Cost of Improvement $ 0 000 d d
Iterzms to be installed but not included in the above cost: Electrical $ Z ! d D
Plumbing �j O OV vd
HVAC
Other p
TOTAL S 6 a , �U 0 tj
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
❑ Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Ref use Disposal
c2/ Declaration required.
El Moving - (Provide copy of D.P.W. moving license) 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
E Re -roofing - (for existing only, is included in new construction)
Number of square feet
Number of layers when complete
A separate disposal declaration REQUIRED
Number of layers already existing
C Replacement doors and windows (for existing only) (only where doors and windows exist and will not be;
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will he included in new construction. (see Code section 3401.10 for
residential and Article 8 for commercial)
-- Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
J None submitted. Why'?
�ubmitted, usually three sets required. Four sets for food service\uses. Number of sets submitted
600 SITE PLAN
`Submitted
required, why?
���,? Submitted When? : Previously, date With this application
700 UTILITIES
Water supply - required yes ® no, public ? _ yes no, on site well?es _ no,
existing? yes_ no
If required and not existing have necessary permits been issued? - no — yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required,.is available. See C�odee7780 CMR section 114.1.2)
Sewage disposal - required yes _ no, public sewer ® yes ® no
private septic - on -site eyves ® no. Submit copy of permit as soon as available.
11
Woodstove - used (will require inspection prior to installation), new (provide manufacturers
instructions). Location(s) (list)
U Fireplace(s) (includes flue) List location(s)
❑ Game Court - describe (include overall dimensions)
*Tent, Trailer (Mobile Home) or Otte describe J) ' S'�0kjll . C-Vk- /"' / ?�
300 COMMERCIAL = PROPOSED PROJECT IUSE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
Y.THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Section 303.0)
Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
Factory / Industrial - (see Code Section 305.0)
High Hazard - (s,-e Code Section 306.0)
- Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Mercantile retail stores (see Code 308.0)
Residential -three or more family, hotel (see Code Section 309.0)
Storage - includes garages (see Code Section 309.0)
Utility k Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0) `
New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
Tent or Trailer temporary 'purpose?
Other
Describe the proposal briefly, INCLUDE number of dweirmg units and bedrooms or occupant load as applicable,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
KNew Construction and/or Addition - total gross square feet 1 ty
(For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
If project is an addition to existing structure - Total gross square feet of existing
FOR COMMERCIAL, ONLY
Will this project be subject to CONSTRUCTION CONTROL. (over 35,000 cu.ft.) Yes No. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400,000 cu.ft.) . Yes No (see Code Appendix I)
APPLICANT TO PROVIDE
2
OK to issue subject to requested submittals (see project review worksheet) date
DENIED see project review worksheet date
I
u HOLD reason date
❑ HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature Dat e 2 9 1997
Applicant informed of above - Date time staff (fax, phone, im person)
Over six months since approved for issue DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector Date
` Advised applicant Date Time staff (by phone, fax or in person)
OFFICEXINSPECTORS NOTES
TOTAL FEE
j
i
Gross area - new construction O G Total Sq. Ft.
alteration Total Sq. Ft.
i
Permit is issued to
Comments/notes on permit�-
1600 TO 7= APPLICANT AND APPROVAL
_ ... .
Date of Application submission
• D r�� � T T T� TAT
TOWN OF DAR MO V B V ILDIff G DE.PARTMENT.
Plat Lot Street
4
TELEPHONE 508-999-0720 • FAX 508-99�?_0738
Aquifer Zone
_
Owner 02
SO / g
APPLICATION FOR ZONING AND BUILDING PERMIT
Owner mail address '_~% 7l� t� / ��zfd.¢i1 GG�2r . f
112 f .y /% �tt� .� a U2 �?�
Owner phone # 5-69- 6129 - 33 c)
#f#f#«!«# f:xssssssss##s#s######s###;ss*ss#s«alas#!ss##ass#sssssss#s#s##sssssssssssssss##ass##ss#####:f!
OTHER INVOLVED AGENCIES -The following agencies require separate jurisdictional permits or approval for
The applicant shall complete this application to the best of their ability prior to submisseon.'leavmg ii item munswerc $. The
N/A should be inserted for those sections
business hours to
Proposed project. CONTACT THEM FOR REOUMM
your
SUBMISSIONS.
Department staff will be available during regular assist as necessary.
which do not apply. A properly completed application will help avoid unnecessary delays. f aid
® TAX COLLECTOR - Approved _ HOLD By
Date01
i
17 Conservation Comm _ Approved By
Date
(for ice use only) f � � cc��"�
Application fee 0� received by Date % / b�
�
D.P.W. water _ Approved By
Date
�s
Total Permit Fee $ Perffiiit#
_
I [3' D.P.W.sewer —Approved By
Date
}
17 D.P.W. cross connection _ Approved
Date
✓
100 LOCATION OF PROJECT V
0 D.P.W. engineering =Approved
Date
CURRENT ACCESSORS' PLAT LOT �_ ZONING DISTRICT
D Board of Health well -- Approved
Date
OTHER ZONING OVERLAY DISTRICTS, if applicable --
17 Board of Health septic = A roved
PP
Date
NUMBER_ STREET ._1 C�I Q
.
13 Board of Health food service =Approved
_
Date
NEAREST CROSS STREET G% le►
9 FIRE DISTRICT (I - II - III) — Approved
Date
SUBDIVISION NAME & LOT #
C3 Planning Dept _ Approved
Date
or BUSINESS NAME
Other — Approved
Date
PREVIOUS TENANT; O«'NER D A} / 5 tt F /4 2 44 L.
Other _Approved
Date
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
C-,mments
= THIS SECTION NOT APPLICABLE
A"Single famih• - number bedrooms number baths Z'
_.._.=====
PrQject summary new constructioni alterationidemo
sewage disposal - publiciprivate
- Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 1 number baths unit Z
[Alter:add interior walls] [add rooms] [add footprint)
water supply - publiciprivate well
Total sq. ft.
- Accessory apartment gross
[pool] [garagershed] (game court] [food service]
»
Accessory structure
Describe
* = Garage - detached - attached to dwelling, dimensions L W
1
r = Carport - detached - attached to dwelling, dimensions L W
..
To the various departments:
,
Shed - dimensions L W
This notice has been forwarded to you for your information and any appropriate action. Should you have any
W
questions please advise. If any reason to withhold the requested permit is found,
please advise. Your assistance and
a Gazebo -dimensions L
cooperation is appreciated.
Swimming pool above ground in -ground Size total square fleet
The Building :Department
y
= Chimney - # of flues
Date sent for review
Iiv
-