BP-89047SECTION 11 - ESTIMATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
Sp p Oct O ,COD
1, Building
2. Electrical
3. Plumbing N �
o . o0
4. Mechanical (HVAC) N po0
5. Off -Street Parking Labor:000, Qo
6. Total = (1 + 2 + 3 + 4 + 5) Estimated Total Cost Including
$ Jt'
s
SECTION 12A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit) (Please Print} / M I C.� �-C ` C �-ey� �
I as Owner of the subject property hereby authorize
o act on my beha L II ers re lve ork authorized by this building permit application. v 23
Date
Signature of Owner
SECTION 12B - OWNERIAUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
1, �
Z
egoing application are true and accurate, to the best of my knowledge and belief.
nder the p ` s and penalties of perjury. I
Date
Signature of Owner/Authorized Agent
SECTION 13 - OFFICFJINS C R'S NOTES
Less Application Fee: 25.00 Remaining B lance; $
L-Aotal Permit Fee: $ v r Amount $ (J,�I Othe $ross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
COMMERCIAL
!$25.00 "pLICATION FIFE IS NON
NOiIN-TIkANSFIEBABLE
DATE RECEI E—
°" H ' DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 1
Dartmouth, MA 02747
iz -
��`:,h6� ..�' Phone: 508-910-1820 Fax: 508-910-1$38
- www.town.dartmouth.ma.us
APPLICATION TO CONSTR4qT# REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING Iinduding 3 ormmre ramify
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT/NU F2:
TE ISSUED: 1
SIGNATURE:
C mmissionedlnspector
Zoning District: __ Proposed Use:
FOLLOWING AGENCIES SHOULD BE NOTIFIED:
DATE:
ildings
❑ X ❑ BI ❑ A [IV Aquifer Zone:
O Board of E3 Board of ❑ Cons. ❑ Demo ❑ DPW ❑ Elec. 10 Energy Report
Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up"
❑ Fire ❑ Gas ❑ Planning ❑ Sewer Card ❑ Waler Card ❑ Zoning 10 Other
Chief Cut Off Board cut Off Cut Off
"REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health: Signature: Date: r
Date:
Conservation Commission: Signature: -
Other: r�
Date:
Signature: .
Date:
Signature:
Brief description of work being performed:
SECTION 1 - SITE INFORMATION
p ` 1.2 Assessors aLot Number: /-37
1.1 Property Address: 7�-L�"��'op - Map Lot �-
Nearest Cross Street: �� �° �a 1 MGL c40 s54
1.3 Water Supply ( ),
Business Name:
�Od-t L LL El Municipal ❑ Private Well
Business Phone #: Jr LY oZ� b 1.4 Sewage Disposal System: `
❑ Municipal ❑ On Site Dispersal System
Total Land -Area Sq. Feet:
2.1 Owner Record:
Name (print)
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
Contact Address Phone Number
2.2 Authorized Agent:�yy�#
Contact Address Phone Number
Name (print '
Page 1 Revised 10/11
---- - Page 4
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor t✓�L r1aTt D ifs / i r Tc�S
Not Applicable ❑ ", n*
`
Number
A-F+-So'i
License
Address: PD, G 5-9 --j { 1(,S{ are ►M 4 (
Expiration Date: %
'7�
Signatures e - — Telephone:77y og33_d
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(MGL c 152 § 25)
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
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable
New Construction o Addition ❑ Repairs ❑ Accessory Building (Shed/Garage/Other)
111�Z i-I-e �,vr� of F2V_p43 cLEAa s RmM
'Other (Specify Sec. 6) Demolition ❑ Sign ❑ Replacement window/door
No. of Windows Doors
Fire Protection
SECTION 6 - PROPOSED PROJECT USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
The following descriptions are based on the Massachusetts State Building 8th Edition, Code Article 3, as noted. See the Code.
0 Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0)
Describe:
❑ 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)
)<FactcTyllndustrial (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 -
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):
E Go i. t-T 14 ,1C1Z70J -
00Pa oov-'\
SECTION 7 - TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
❑ New construction andlor Additional (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. ) 3( 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.
u
IVA
Demolition* - describe structure: C o w m C.
❑ Trench Permit Required? ❑ Yes fgj No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq.
❑ Moving" - (provide copy of JDPW moving license)
*Type of structure, from where (map/lot or address):
to where (mapAot or address): number of dwelling units:
number of bedrooms per dwelling unit:
❑ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged)
EGRESS dimensions must be maintained.
❑ Temporary structure and uses - includes, when allowed, new tenants, trailers, tents and the like and only for limited periods (of time.
Describe:
SECTION 8 - MECHANICAL &, PRIMARY FUEL
❑ 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):
t9d IVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): IS Amt i G >l:5-
❑ Air conditioning - (separate unit) Roof Top Unit (RTU) New b Replacement
❑ None of the above to be provided Mechanical Ventilation ❑
❑ Hot Water. Gas Electric Fuel Oil Other
SECTION 9 - SPRINKLERS AND/OR FiRE PROTECTION 3 COPIES OF PLANS AND NARRATIVE REQUIRED
Required: plans provided 2S plans not provided, why?
❑ Not required, not to be installed, why? Narrative Submitted?Y�s O No
SECTION 10 - IDENTIFICATION
11.1 ArchitectlEngineer - for overall design
Company Name: � "' "� �� � rcL` c
Address: o Q L4 G
Phone#: SZ Ct - g 9Y
Certified by State of Massachusetts as: �EG+`� �2c N` T <
Certification Number: 52 9
Note: Signatures and seals on all plans affidavits & other documents SZBE originals and not reproductions.
11.2 ArchitectlEngineer - project supervision and reports
Company Name: _ S�2 CA
Address,
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Notes Signatures and seals on all plans affidavits & other documents SHALL BE originals and not reproductions.
11.3 General Contract6r r
5
Company Name:
Address: 1 3 .91 e y S C 9 G �,
Phone;#:
Const c'ion Supervisors License Number:l-
Note: ignatures and seals on aft plans at#davits & other documents SHAU BE originals and not reproductions.
raye 4