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3.1 Licensed Construction Supervisor. C..+O Cep ���� ' 10
Not Applicable ❑
License Number:
' Expiration D te:
Address: `t W,
Telephone 1 �� t
g�x �a
Si nature:
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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
srioi�.��t11�tt�toa�.N..:,: .,:
s_
a New Construction ❑Addition Repairs a Accessory (Shed/Gars e/Other)
o Other (Specify Sec. 6) cilRdmolition ❑ Sign ❑ Replacement window/door
No. of Windows Doors
❑ Fire Protection
si✓T1t}N1sPRQPOEIR€?JE ..:.:. ......:.. __..:_... _
The following descriptions are based on the Massachusetts State Building &th Edition, Code Article 3, as noted See the Code.
- lounge, theater, school, etc. (see Code Section 303.0)
❑ Assembly restaurant, I g ,
Describe:
A usiness - 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)
❑ Factorylindustrial (see Code Section 306.0)
❑ High Hazard (see Code Section 307.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 308.0)
❑ Mercantile - retail stores (see Code Section 309.0)
❑ Residential - three or more family, hotel (see Code Section 310.0)
❑ Storage - including garage (see Code 311.0)
❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
• New Tenant - for any of the above, please indicate (see Code Section 105.1)
❑ Trailer -temporary
Purpose?
❑ Other.
D cribe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
ndition (if extra space is needed, attach an additional sheet):
G IPa� `P1fi UtJMTIi (Od (4 TO BL FrfRFGJI�t1EQ '. `. s.. ,.,.J'AR,c _ IN
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❑ New construction and/or Additional (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
01 iteration 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 107.6.2 Designer to submit Code Synopsis in additional to original plans and if existing building Chapter 34.
Page 2
a'Demolitron describe structure:
in Trench Permit Required? ❑ Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CIVAR 7.00 et seq.
❑ Moving* -(provide copy of DPW moving license)
*Type of structure; � l ., from where (map/lot or a6dress):
to where (map/lot or address): number of dwelling unitfs:
number of bedrooms per dwelling unit:
eplacement doors and windows - (for existing only) (only where doors and windows exist and will nfot be enlarged)
EGRESS dimensions must be maintained.
❑ Temporary structure and uses includes, when allowed new tenants, trailers, tents and the like and°ronly for limited periods of time.
Describe:
t:A1 CAL: pF�iIARY Fl1El ` b y
t r ;. , �rSE�GTION 8 611iE �
urnace (hot air) -fuel gas (natural or propane); fuel oil, electricity, other (specify):
❑ BoilerIfieating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
9 AC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
rr conditioning - (separate unit) Roof Top Unit (RTU) New ❑ iReplacement ❑
❑ None of the above to be pr ed Mechanitcal Ventilation ❑
lot Water: Gas Electric Fuel Oil Other
<..'LA�S Age w. fil�aE RE I�lREi3
AD(ROR PIti�...e�IP3EF, :._ .:.... _�®ARt:......,:
9 equired: plans provided plans not provided, why? V ) G 6AL, - el t.&IU47 MS°'1 L7-
❑ Not required, not to be installed, why? Narrrative'Submitted? ❑ Yes. ❑ No
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3ECTlcfdQ, I?EP�9TtICATtt3A1
11.1 ArchitectlEngineer - for overall design
Company Name: 1, F
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number.
Note Signatures and seals on all plans affidavits & other documents SHALL BE originals and nrot reproductions.
�.2chitectlEngineer - project supervision and reports
Company Name: -
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number.
Note: Signatures and seats on all plans affidavits &other documents SHALL_ BE originals and niot reproductions.
11.3 Ge ral Contractor
mpany Name: C/+P C fL f�'1 6 1
Address: 14 k r v s � 1 5 6 n'1/`j
Phone #: !S9 1 ` )
Construction Supervisors License Number,
Note: Signatures and seals on all plans affidavits & other documents SHALL BE originals and mot reproductions.
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'f4 ESTtMATFD GOPtS,iRt3CT(ohI�O:ST
Item
Estimated Cost ($) to be completed by permit applicant
$25-04 APPLICATION FEE IS NON BE -FUNDABLE
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Off -Street Parking -
8 Total (1 + 2 + 3 + 4 + 5) Estimated Total Cost Including Labor: $ "
lease Print
I, TMs Owner o the subject a r f . 1 property hereby authorize _ C�'x_.P
to act o ehalf i II n a tiers relative to work authorized by this building permit application. _
6)
Signature of caner Date
S,E�H DATE RECEIVED
z , DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road,
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
t.
www.town,dartmouth.ma.us
APPLICATION TO CONST CT, REPA R, RENOVATE OR -DEMOLISH A COMMERCIAL BUII,�DING(including 3or more family dwelr-gs)
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DEPART(>nENTAI- APPROVAL
Board of Health: Signature: Deate:
Conservation Commission: Signature: Q: te:
Other: Signature:' Date:
Signature:' Date:
Signature.- Date:
Brief description of work being performed. IA17-6eivC_ P,). ice`/ 776kj
/.PropertyAddress: cif V 1/�6? f'� (�Q �J,i� 1.2 Assessors Map& Lott Number.
Map Lot
Street:1.3
ZNearCross
Water� Supply (MGL_z40 s54):
s Name: CL �'d..17b �✓ /' [R'Municipal 1= t Private Well
siness Phone #: G I% "�'7 1 s "SLf %
1.4 Se Disposal Disposal Syrstem:
Total Land Area Sq. Feet: ty t Z°1 Lilunicipal IM On Site Disposal System
2.1 wrier Record:
Name (print) Contact Address Phone Number
2.2�thorized Agent:
PZ Cft9,� 5,T7t
'Name rint) Contact Address Phone Number
t f Page 4 C-CS.W, o
Debris Removal Page 1 Revised 10/11
Per 114113L C,40 See. 54