BP-255732002
RESIDENTIAL
RESIDENTIAL
r 2 TY OWNERSHIP 1 IZED AGENT "'
SECTION - PROPER AUTHOR
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed (orstruction
(see Appendix of 780 CMR RS-2.15)
1
-
Supervisor. whether or not they have taken the permit are responsible for code compliance.
l
2.1 O\vner of Record."
11N�
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 25
77
Contact
Address Phone Number
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pirovide this affidavit
ni (print)
Na } l
(p �
idol ermit. Signed Affidavit Attached: ❑ yes ❑ no
St tance of the bui g
will result In the denia 1 of t he is g p
2.2 Authorized Agent:
check all applicable)
SECTION 5 -DESCRIPTION OF PROPOSED WORK ( AP
I
new construction ❑addition ❑alteration ❑ repairs Elchimney/ ❑ woodstove
T
Nance (print)
Contact Address Phone Number
_ fireplace
(euerg}• report required) (energy report required) p
SECTION 3 - CONSTRUCTION SERVICES
eck El pool ❑accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
_
Not Applicable ❑
(shed/garage) no. of windows— doors_ (specify below):: (specify below):
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
�
License Number
x If new construction, please complete the following:
Address
r
Expiration Date
Single Famil}•: no. of bedrooms no. of baths
Signature Telephone
TN� o Family: no. of bedrooms unit 1 no. of baths unit 1 _
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
no. of bedrooms unit 2 no. of baths unit 2
Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Are you a. Home Improvement Contractor subject to (780 CMR-6)'? ❑ y es ❑ no
- Boiler (heating) - fuel gas natural orpropane),fuel oil, electricity, other(specify):_
( `^ ( y pe cify):
fuel, natural gas, propane, electricity, other (specify):
If no, go to thenext section!
- HN'AC (combined unit) - primary
1 q v
Are you claiming exemption from the requirement'? ❑ yes ❑ no
If }'es, submit the
-- Air conditioning - (separate unit)
None of the above to be provided
required affidavit)
7-Hot Water:: Gas Electric Fuel Oil Other
Registration Number (if none, state "none")
Brief Description of Proposed (fork: - r
Company Name
Address
Telephone
Expiration Date
SECTION - b ESTIMATED CONSTRUCTION COSTS
S i «mature
Estimated Cost (S) to be completed by permit appilieant
3.3 For Residential Remodel Work Only
Item
PERSONS CONTRACTING tITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND:
1. Building
QUESTIONS OR COMPLAINTS call or write:
Hoare Improvement Contractors Re(,isti-ation. Oiic .4shburtort
Place - Room 1301. Boston, JI-I 02108, (617) 727-5?98
�. Electrical
_
3. Plumbing
Owners Nance (print)
�
!. \tcchanicil (HVAC)
* Total �° 'd (� (��
5. Total-= (i + 2 - 3 + 4)
Estimated :
nature
51by si<*i,iii the above, the home owner acknowledges that
there will be no eligibilty to the Guaranty Fund
SECTION 7A - OWNER AUTHORIZATION
D ate
(to be completed when owner's agent or contractor applies for building permit)
3.4 Homeowner. Exemption - One & Two Fami11 ly Only -
TO PERFORM A\'D
BE RESPONSIBLE FOR THEIR OWN PROJECT
(please print)
as Owner Of the subject property hereby authorize
1'
FOR HOMEOWNERS WHO INTEND
b Construction Control in Section It 6.0, effective July 1. 1982. no individual
109.1.1 Licensing of Construction Supervisors. Except for those structures governed y
demolition involving the structural elements of
thorized b this building permit application.
to act on my behalf. in all matters relative to work au y g
shall be engaged in directly supervising persons engaged in construction. reconstruction, alteration. repair, removal or
builldmgs or strictures, unless he or she is lice used in accordance with the and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing
Date
k
Siimature of O~s"ner
CQ striiction Supervisors.
Exception: Any homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section:` provides that if a
SECTION 7B -OWNER/AUTHORIZED AGENT DECLARATION
engages person(s) for hire to do such work, that such Homeowner 'shall act as supervisor. _ _ p
Homeowner a )
-� section only, a "Homeowner" is defined as follows: Pe son(s) who owns a parcel of land on �\ hich he/she resides or intends to reside. o''
this sect o
uthorlZed Agent perch declare that the Statert£teritS and information
as Owner/A g Y
For the Purposes of p
�- i intended to be, a en.c or two family dwelling, attached or detached structures accessory to such use and. or tam, structures. A person who constructs
Which there is, or s
I ,
accurate, to the best of my knowledge and belief.
,,,ore tliai, one i oii;e in a two year period shall not be considered a Homeowner:
on t to toreg ing app ication are true and
If Ou are applying underthis section sign bet w:
Signed udder the pains and penalties of penury. _
G1/Y'
Date-
S t&Mnatun.
Your signature' carries certain responsibilities, including but not necessarily limited to general liability
Signature of 0' ieriAutl orized Agent
Rev. January 1912001
Pave 3
Pa�gc
�.�. � Hama v 10, 1
rnm;.C3 d_., ..,<< td _
- __
RF�C3I�FNTTAT,
2002 RESIDE' TIAI, _-- - �()02
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFZERARLE
SECTION - INSPECTOR'S REVIEW/COMMENTS
I . Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4: OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
S: Comments.
Date:
j
r
Inspector's Signature: Date:
9. Y b
SECTION 9 - AP 9LIdANT NOTIFICATION
71
Applicant informed of ab ve Date: ( TTt' Clerk:
Con-imnts: Lt- fOV
14
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee:
Less Application Fee:
�;S 25.00 Remaining Balance: S
TOTAL FEE: Gross Area - New Construction total sq. ft. �
Gross Area - Alteration total sq. ft.
Permit Issued T -
SECTION 11 - ADDITIONAL''COMDIENTS/SKETCHES
e
t -
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k
r ; DARTMOUTH BUILDING DEPARTMENT
DATE RECEIVED
400 Slocum Road,P.O. Box 79399
Dartmouth; MA 02747
J
:...:=' S08-910-1820 FAX 508-910-1838
`.
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY'£DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: -
BUILDING' PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED:
Oh TO ISSUE -SIGNATURE:AKWA, DATE
B it ing rnissionerfln pector uildings
Zoning District:.50 roposed Use: Zone: C ❑ A ❑ V Outside Flood Zone 0 &quifer Zone
THE FOLLONVING AGENCIES SHOULD BE NOTIFIED:
❑ Board of Cl Board of ❑Con. Com. D Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date::
Fire Chief: Signature: Date::
r oard of Health: Signature: Date:_
Conservation Commission: Signature: Date::
Other: Signature: Date::
Deseription of work bein;; peifornzed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
1.1 Property Address: ?Vcc:- ej ;% r4 /
Plat Lot �(
Nearest Cross Street
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Has application been submitted to theJHistoric Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 5 54):
1.5 Sewage Disposal System:
❑ Municipal[] Private Well.
❑ Munici
C:\bMg—fois\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 C 61 i_.i rjns•C31d app:res.wp 1 Page I
to
m
pal ❑ On1`Site Disposal System
Rev. January 19, 2001