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AGENT i`, c TF—"-
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N (PrInQ Canted Atltl "I"..
rN „-' 44 SECTION 3 OONSTRUCTIONSERNCES eFFtb1PAa,
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3t LicensetlCounterpane Supervisor N tandicable 0 '
?ao Q ��Uk Lices_Number,
Lwsetl Connotation Sr
Atltlress: Expilaticn Date
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Stinnett Telephone:
3.2 Registered Home Improvement ConGasl.r Net Asp[ iwble0
1 Are you a Home Improvement Contactor subject to p811 Chip, 110 Rb]] k es 0 NO
' HN 9 tot, hJlextension'
. Areyoudamingazemp4onfiomfhe g emenfe. OYes 6F
If Yes, submit Us required afitlamt.
`\\.4. vN'�as Or
Reglsbetion Nu b (fnone,&Wfe'noney:
Compan Name
UO-CU
Addreea: *gBO
G gneNre: Telephone Expiration Date
3.3-For Resltlential Remotlel Work Only
PERSONS CONTRACTING MATH UNREGISTERED CONTRACTORS DO NOT HAVEACOESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or while: -
ffon, Ong Activated Feace-Room 1301. Boston, MA 0210, 517-727-6598.
HonelmpmvemenfConhnc(arsRegi
0 Jam a H.meownerpel 'n9dithevmrkmyselC
Owned Name
harr
Structure:
Byst9ning ibe abo a ibe bomea BnowlaCgezibe.PerexAll be nc eltgDlllyto Ae Guaranty Fond
- ..
Date
34 tralwarromer Em pg n One & Test Family Oly
FOR HOMEOWNERS WHOINTEND TO PERFORMAND ERESPONSIBLE FOR THEIR OWN PROJECT
users meaning cmn AOBF RangeHorse, ores noBiad S cwswWe H
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non by He eers orki RIIB aau aowaam br
freeness ,.H p
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ry .mo () eeDoor as Idea en .,In nor, end ... r ound, he agurn 11 lardi
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If you are applying under Is seat onsgn robot
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$'+ SECTION 4[. WORKERS -
anchare, asomponsation InsuranceAffidavit mustb plted and submitted wth this ppl ( Failure W pq tle the
atldevt will result in the tlenal of the issuance of the building permit Signed Affidavit Attached 0Ye3 EdNo
OESCRIPTIONAFPROPOSED WORKjOheON allapplcatiley_ ,[
a "+y BEC'(JOIlb
O Best 0Awl 0Repairs 0nambern �O//hlmnay/Flreplaw 1 WbooderavellSlave
0 New CogranG.a` It Parreamy BlEg P1 RaOfinq/SCng 0Other
(Bpaoty, below)
(Energy m on own red) (Shed/Carags)
MA tl:icn 0 Replacement lonedeventrem aconston
- (3gacRybelow)
(Energy repot repulmo Nod Indwrs_Om
'If newconstmction please complete the Sitewn9
Sngle Family: laborseadrearni No.pf Baffa
Than, Family No of Fatleoms Unit No. of Baths Unit
No M Bedrooms Unit No. of Baths Unit
D France) (hot As heel gas(naWrel orproposed. ! il, destroy, other (Notatio)
O Ban Sending)Bad Saw Ai or paper )iul obb eflenrcurs,b (pafy)
O LOAD (Combined unb artery ba. ni re194 Progans Ile4ldly other(
O Air wntltllonng (sensors unit) -
lb None of the so... lobapronded
eaHbotioNatem Gai EeWc FusONer
Description of proposed work:
aS F obvi..L SECTION 6;EBTIMATEEstimated
c
Ifem East Gp N he do pleted tyo t arifificant
1. Bullamg
3a aoo
2. Elec
3u. Plumbesing
4. Meal-(112+AC
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Pl aulhIsI
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t b half II tle relatvet k uthotlzetl by tbsbu ltl ng permit appl qt on
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sgnewre at Date owner
nc. rp:YSELTION ]B:OWNERo, "Unrest, GENFAECLARATION
�j \Ci ,as Owner/Autncenzed Agent hereby declare that the stator nets and inormaflon
P�`Ki
on fine forego ng fabrication are true and accurate to the best of my knowledge And belief.
Sign ntlar[he m�pe iss egury; ,/ 1// p
Bgaature of Owner/AUNonzotl Agent Date I
.1"' .. ,X- %`SECTIONO-;IN[S7PECTgO¢R�S R/�EV�IEWICOMMENT3'.L
z.
1. Data all real f�—(
2'DENIED (see purred ramewworksheme
a HOLD J
Reason. /✓
4L HOLD a led W Zoning Spent of Appeals smom
Cam emar
Dale: -
Date
Diane
Inspectors Signal
�a
Data: 5'18 b�E
CTIO 9.APPLIOANTNO N
v. pt
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Applicant informed of aboveDto G Time JJ
Commentia
ones
>r,ti ..>t. _ t5ECDON
107 CLECIVINSPEGTORS NOTES
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5 emiC Fee $ Total
P�
Less Application Fee $6P
Over $ Amount $�
Remaining Baltimore
-_TDTAL FEE: Gross Area -New ConsWcbonIII sm ft.
Gross Area - Alt`eart ontotal sq.ft -
Pool Issued
q Qyty, i,L's t,T z`SECTICN,11 ADDITIONAL COMMEKSSISKETCHES^
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RESIBENNAE ❑ Approval In Pan (Per 760 CMR511113)
ECEIVED DATE RECEIVED
- DARTMOUTIABUILDING DEPARTMEieTP�RTf
RLC6 D'cPT.
400 Slocum RoEx]8999
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D 1, MAA 2m9
EP I S AM ID 55
Phone 508-g1010-1821820 Fax: 508-91a 1838
www rown aartmoum ma us
' APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR OEMOLI3HAONE ORTWO FAMILY DWE LING
g 4, Y THIS SECTION FOR CFF1CIAL USE ONLY -' .P 2 °
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R,.:q s. rC�=r@5 a„kr.. . «M1 4'y,'DEPARTNIENTALAPPR VALe'�.'eo.".+S. T3v:.r�&"Fii y.ry yp.M;�HsnS
Zoning Renew: Sgnature Dater
Energy Repoli Signrm Date:
Fire Chief. Signature Bate:
Bi of Hearin Signaroo DdP
Conservation Comm .. slgna er Date:
Ol Signature: Date:
9rieFde dPbon ofworkbeingPa6ormetl' �60 NCr
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1,-SITE INFORMATION E _r h": T
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1.1 Propehy Addroae /6� S t N&GM A��
12 Asaessom Map &Lot Number.
Lot Area (of.) l! F�� .. Fmntage
Map I6Z Lai
Reoured Provided
Fruni
13 Hineural Dtot yes
Side Yard
Xasappl nteenjatni ed itX ,Qmn eon]
R myonl
> For 9Mo _ D to
14 Write Supply(MGL pi shn:
1.5 Sovarge Disposal System
, MAurnicipal OPmars Well "
(a'FAunit O On Site Dsposal System
® CONSTRUCTION PLANS SITE. PLAN ENERGY IREPo T
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