BP-33317COMMERCIAL. 2003
$25.00 APPLICATION FEE IS NON-REFUNDABLE NON -TRANSFERABLE
COMMERCIAL.
03
13.1 Licensed Construction Supervisor: Not Applicable ❑
Name of Construction Supervisor License Number '
Address Expiration Date
I
Signature Telephone
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Oft
Workers 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
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• new constructionaddition ❑ alteration repairs accessory bldg.
P Y(shed/garage)
❑ other (specify Sec. 6): ❑ demolition ❑ sign ❑ replacement window/door no. of windows doors
The following descriptions are based on the Massachusetts State Building 6th Edition, 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 303.00)
❑ Education - 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- (see Code Section 306.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
o Mercantile - retail stores (see Code Section 308.0)
❑ Residential three or more family, hotel (see Code Section 309.0)
11 Storage - includes garage (see Code Section 309.0)
❑ Utjlity & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
D4ew Tenant - for any of the above, please indicate (see Code Section 119.0 and Zoning By -Law Section 35)
❑ Tent or Trailer - temporary
purpose?
❑ Other:
Describe the proposal briefly, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
condition (if extra space is needed, attach an additional sheet):P'' rn0,55ca 54e e rrx ,o
-Lei s
❑ New Construction and/or Addition (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required. '
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ yes ❑ no
If yes, see Code Section 116.0. Designer to submit Code Synopsis in addition to original plans.
Will this project require Peer Review (over 400,000 cu. ft.) ❑ yes ❑ no (see 110.1 Code & Appendix 1)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE.- SEE 780 CMR.
o Demolition* - describe
10 Moving* - (provide copy of DPW moving license)
Type of structure: from where (plattlot or address):
to where (plat/lot or address): number of dwelling units:
number of bedrooms per dwelling unit:
0 Re lacement doors and windows for existin onl onl whey e doors and windows exist and will not be enlar ed E
p ( g Y) ( Y g ) �REss dimensions must
be maintained. Enlarged or new windows in an existing dwelling will be considered as an alteration, otherwise will beiincluded in new
construction. (see Code Section 3603.21 for residential and Article 10 for commercial).
❑ Temporary structure - includes, when allowed, trailers, tents and the like and only for limited periods of time.
Describe:
µ
:
1-� Pill
❑ 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ -Hot Water: Gas Electric Fuel Oil Other
os�� _ ,
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ma
NO REM
.#- ROOM
-,
❑ Required'. plans provided plans not provided, why?
❑ Not required, not to be installed, why?
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❑ Parking plan submitted to: Building Dept. Planning Board date submitted
Number of spaces - indoors outside total provided#
Handicap spaces - required yes no 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? yew no
Submit copy of application and/or permit as soon as available.
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11.1 Architect/Engineer - for overall design
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits, & other documents SHALL BE originals and not reproductions.
11.2 Architect/Engineer project supervision and reports
Company. Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits, & other documents SHALL BE originals and not reproductions.
11.3 General Contractor
Company Name:
Address:
Phone #:
Construction Supervisors License Number
Note; Signatures and seals on all plans, affidavits, & other documents SHALL BE originals and not reprcoductions.
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Page 3
rev. January 1, 2003
COMMERCIAL
COMMERCIAL 3"
2003 $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFE,RA LE
AM
Item
Estimated Cost ($) to nearest dollar. To be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical HVAC
Total —-'� 5. ota - 1 + 2 + + 4
3
/
Estimated Total Cost Including Labor:
�.a:�
[: a
ONwpm.. ._� .�°:
�pleasWmt)
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, as Owner of the subject property hereby authorize s C� h e Ck 0..Y
J p P Y Y n� t!
to act on my behalf, in all matters relative to work authorized by this building permit application
Sign re of ner,_ Date
_ - _ _
asr E - .=
_01 : RE
sue.:..
air
/ statements and information f
I c: as Owner/Authorized A ent her eb declare that the
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on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains,aTO penalties rju
4A he I-(
Signatur of caner/Agent Date
SECTION 14 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: 5. DENIED (see project review worksheet):
2. 30 days to review period expires: Date:
3. OK to issue date: 6. HOLD reason:
4. OK to issue subject to requested submittals (see project Date:
review
ev ew worksheet): Date: 7. HOLD subject to Zoning Board of Appeals
J g action:.
8. Comments:
9. Inspector's Signature: DatPR 2 2 2004
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a.�-° mar _ __�'xI �, y,: -_ =s.:
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A Applicant informed of ab e Date: - e
pp Time: Clerk:
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Total Permit Fee: Aga Less Application Fee: Remaining Balance:
Gross Area - New Construction
Gross Area - Alteration
Permit Issued To:
`�°°`"� � DARTM TH B I
,Q��'"+ \ OU U LDING DEPARTMENT
°
DATE RECEIVED
400 Slocum Road, P.O. Box 79399,
' Dartmouth, MA 02747 :, ;'
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508-910-1820 FAX 508-910-1838
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APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING (includes 33cor more family dwellings)
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Zoning Review: Signature. /�' � DateATR 2 200
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
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Description of Work Being Performed:
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1.1 NkMBER OF PLANS SUBMITTED:
1.2 SITE PLAN SUBMITTED: ❑ yes ❑ no;
.3 Property Address: �i f� �?' �.- /��-.
1.4 Assessors Plat & Lot Number:
Nearest Cross Street:
us. Name: ) rYig_s5mgn -Cur- Phone#
hec leg
rea
Plat- Lot r�
S144,
Total-Larid Ft.:
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1.5 Water Supply (MGL c 40 § 54):
1.6 Sewage Disposal System:
❑ Municipal ❑ Private Well
❑ Municipal ❑ On Site Disposal System
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2.1 Owner of Record:
Name (print)
Contact Address Telephone
2. uthorized Agent:
Name (print)
Contact Address Telephone
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