BP-93615,z
S 2
3.1 Licensed Construction Supervisor: ey
Not Applicable Q
License Number:
Address: T -
Expiration Date:
Signature: �. / -tf Q Telephone:
�tSiiFt�T
Worker's Compensation insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit (MGL 152 Section 25A).
Signed Affidavit Attached: ® Yes ® No
_-
New Gonstru tion - Addition o Repairs o Accessory Building (Shed/Garage/Other)
O�
pfn, a ybA1/uj
o Other (Specify Sec. 6) td Demolition o Sign o Replacement window/door
No. of Windows Doors
c Fire Protection
The following descriptions are based on the Massachusetts State Building &th Edition, Code article 3, as noted, See the Code.
o Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303,0)
Describe:
Ei Business - office, assembly with less then 50 occupants -indicate Medical or other professional (see Code Section 304.00)
❑ Education - struction for training including child day care for those over 2 year 9 months (see Code Section 305.0)'
❑ Factoryllndustrial (see Code Section 306.0)
o High Hazard (see Code Section 307.0)
El Instit-)itionai - hospital, nursing home, infant day care (see Code Section 308.0)
o Mercantile -retail stores (see Code Section 309.0)
o Residential - three or more family, hotel (see Code Section 310.0)
❑Storage - including garage (see Code 311.0)
o Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
o New Tenant - for any of the above, please indicate (see Code Section 105.1)
11 Trailer - temporary
Purpose?
Describe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
condition (if extra space is needed, attach an additional sheet):
C?IC1 7 T1t': �R CNT:tC3 ORtE t'EtF�RD _
11 N'ew construction and/or Additional (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure- total gross square feet of existin�9 :�5� /
❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to ONSTRUCTION CONTROL (over 35,000 cu. ft. } Yes --= o No
If Yes, see Code Section 107.6.2 Designer to submit Code Synopsis in additional to original plans and if existing building Chapter 34.
❑ Demolition - describe structure:
❑ Trench Permit Required? ❑ Yes o No . See Trench Requirements GL.C. 82A and 520 CMR 7.00 et seq.
❑ Moving* - (provide copy of DPW moving license)
x r
Typo of structure:
, from where (map.l
lot or address):
to where (map/lot or address): number of dwelling units: V
number of bedrooms per dwelling unit:
a a .
El Replacement doors and windows (for existing only) (only where doors and windows exist and will not be enlarged)
EGRESS dimensions must be maintained.
P
_ - periods
Temporary a s e allowed, new tenants, trailers tents an he i limited eno of f p r ry structure and uses includes, when I d t Ike and only for lim p Irma.
Descr�i e:
Furnace (hot air) - fuel gas (natural or propane); fuel oil, electricity; other (specify);'j�?�Ia�
o Boiler jrieating) - fuel gas, (natural or propane), fuel oil, electricity, other (specify)
aeeec"it HVAC combined unit primary fuel natural as propane, electricity, other (specify):
( ) p rY gas, p p y� (p f`I)
o Air conditioning - (separate unit) Roof Top Unit (RTU) New o Replacement o
o None of the above to be/provided Mechanical Ventilation o
' ,Hot Water: Gas t/ Electric Fuel Oil Other
o Required: plans provided plans not provided, why?
Not required, not to be installed, why? .ASS Ate,UiY_� Narrative'Submitted? ❑ Yes. No
11-1 Arch itectlEnglneer - for overall design
v !,
Company Name: ��Ol�� •I"C �%/ `L
Address: `YIO
Phone
Certified by State of Massachusetts as:L°�'_
Certification Number:
Note: Signatures and seals on all plans. affidavits & other documents SHALL BE originals and not reproductions.
11.2 Arch'iteetlEngineer project supervision and reports
//
Company Name: `���0� L. 0'"/r;=%�
Address. �'�yyl�ijl�l
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Not.,. Signatures and seals on all plans, affidavits &other documents SHALL BE originals and not reproductions,
11.3 General Contractor
Company ;dame: � C.D,�?G�6 +✓
Address:
Phone #: _r -
Construction Supervisors License Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
Page 2
Page 3
SECTliSt f E5[1lAd;ED CtSTRt3GTtOt QST
Item Estimated Cost ($) to be completed by permit applicant
1. Building 000
2. Electrical b b
3. Plumbing 3 Z'x &0d
4. Mechanical (HVAC) 3P
5. Off -Street Parking
6 Total (1 + 2 + 3 + 4 + 5) Estimated Total Cost Including Labor $ QQ
-
_
37_...-�
g a
(Please Print)
I, � S , as Owner of the subject property hereby authorize
to act on my be in all matters relative to work authorized by this building permit application.
deSign ure of e
SEC ...
R.TItIi 2 -'t � . � , . EiiTORi��D R1A
I Aa .
� 6 �'�►," ��. , as OwnerlAufhon_ed Agent hereby declare that she statements and information.
on the foregoing
g g pplacafion are true and accurate, to the best of my knowledge and belief.
Sign�unhe pains and penalties of perjury.
Sr atur of ent Dam 7
p _ _.: .:. Y...::_
SEC.
... -.:. - ._:.. _ .. 11!`3 --3 a7 '.: L.3=l5599'yL9'p•-.,..'(L`j'`/'..[.�', fj ::
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. _ .. ... _. .x ....- ._v_. _. .. .. ._ ...ems. T�
Less Application Fee: $25,00 Remaining Balance. -
Total Permit Fee: $
Other$ Amount $
Gross Area - New Construction total sq. ft: „-
Gross Area - Alteration total sq. ft.
Permit Issued to:
I
Cod
$25e00 APPLICATIOTI T FE1 IS NON ME-FUNDAME & N®I-THAMWTIt� ,A-ncir
h DART>I OUTH BUILDING DEPARTMENT
:- 400 Slocum Road,
DATE: RECEIVED
,..�
Dartmouth, MA 02747
�
Phone: 508-910-1820 Fax: 508-910-1838
si l 7
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING(incltudin9Iormore family dwellings)
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Bffi��7�ttL1L.{� Y f DATE S
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`� Appe 1eah - Commis t = �4tiidav >✓ar1#Setf Glli,Ctf 1liau� U
E3taterCar#1-CF�nang
�Cetverard C?Fier
DEPARTMENTAL APPROVAL
Board of Health: Signature: Date:
Conservation Commission: Signature: ^ Date:
Other: Signature:' Date:
Signature: Date:
Signature;.— Date:
Bader dascrfption of works being perfori-ned.
- = r - _ : SCit04 •, SITE iNtiIAAT.It, _= , _ -
1.1 Property Address: / `l V&n.����fle,
12 Assessors Map &Lot Number;;
Map 43 Lot -A
Nearest Cross Street:
-
1.3 Water Supply (MGL c4O s54):;
Business Name: / Q� C �
,Municipal ❑ Private `,Well
Business Phone l 1 6
1.4 Sewage Disposal System:
Total Land Area Sq. Feet:
X Municipal ❑ On Sitr%.@isposal System
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2.1 Owner Record:
.
Contact Address Phone Number
Name (print)
2.2 Authorized Age
Name (print)
Contact Address Phone Number
Page 4 ; 0-Caaflr3 Ns C eMs Removal ��a j s Page 1 Revised 10/11
1� l ear s
!Der I_,40 Sep. 54 %- h 1.