BP-59121S` The Building Code provides in the Rules and Regulations serction that any licensed Constructior
NOTICE TO LICENSED CONTRACTOR
of the have taken the permit are responsible for compliance. ,(see Appertfdix of 780 CMR R5 2 15)
vTIAL Supervisor, whether or n y
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AFFIDAVIT MGL"� 152 25
SECTION 21 PROPERTY OWNERSHIP/AUTHORIZED AGENT
1 Owner ecor : C a/l =(
�• 1► we umber
Name (print) Contact Addres Phone N
p
lZe
thor!zed Agent: ����►/� Phone Number
N(print) Contact Address
CTION;SERVICES
:..
-.CONSTRU. .._ ..._.M._.,.
3.1 -Licensed Construction Supervis r:
Not Applicable ❑
Licensed Construction Supervisor: License Number:
EAddress: �'j !'� Expiration Date:
L gnature:'
Telephone: �' ✓ " ` , `� j �/ ��
Z 3.2 Registered Home Improvement on-tractor:LU Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
I � If No, go to the next section!
LL Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
'- Company Name: Registration Number (if none, state "none"):>
i�
0 Address:
� c• Telephone: '�f � Expiration Dater
(�
Signature:
3.3 For Residential Remodel ork Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write: -
Place - Room 1301, Boston, MA 02108, 617-727 8598.
I Home Improvement Contractors Registration, One Ashburton
P
❑ I am a Homeowner performing alfthe work myself.
Owners Name (print):
Signature:
B signing the above, the homeowner acknowledges that there will. be no eligibility to the Guaranty Fund
Y 9 9
Date:
3.4 Homeowner Exemption One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 .Licensing of construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
engaged in directs supervising persons engaged in"construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
shall beY P
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors. if a Homeowner
Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section, provides that
Exception: Any Homeo p 9
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
only, a "Homeowner' is defined as follows: Person(s) who owns a parcel of land on which -he/she resides or intends to reside, on which
' For the purposes of this section o y,
there is or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are a Ing under this`sectio n elo
Signature: alliabilit
'r r si re car cert responsibilities, including but not necessarily limited to, genet y
S ECTION 4 ..WORKER'S:COMPENSATION INSURANCE:. �... -
Compensation Insurance Affidavit must be completed and submitted with this application. Fajilure to provide this
Worker's Comp ��
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached% P-?es ❑ No
,.
ED;WORK'.; Check:alL:appllcble
SECT[ON:S,.-DESCRIPTION::O.F=PROPOS ( ) - -
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
* Roofing/Siding ❑ Other ❑ Roofin
❑ New Construction ❑Accessory Bldg. 9
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
*If new construction, please complete the following:
Single Family: No. -of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit No. of Baths Unit 2'
❑ Fumace (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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed. work:
0
SECTION 6 = STIMATE D:C.QN.STRUCTLON::COST.-:u _
Item Estimated Cost ($) to be completed`"by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) 1 3 00
-
,. r.... _.
O.N
w... RIZATIOWNER AUTHOCTIOW7ASE
. � .�.w;, ,. ,.:.,_ .,.., .__ .:�:: or a [►es for.bulld►gg �`oerm►t _ . __._ :. _ .:.
(Please Print)
1. , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Daite
,
RATION ...
_. SEC.TION 7B;-;OWNERIAUTHORIZEDAGENTUECLA
as Owner/Authorized Agent hereby declare that the;sstatements and information
on the foregoing application areftrue and accurate, to the best of my knowledge and belief.
2ature
under the pains and pen es o er•ury._
of Owner/Authorized Agent De#%—
;.:SECTION 8 . INSPECTORS REVIE.WlCOMMENTS
_
1. Date plan reviewed: FEB 0 2 2010-
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Date: FEB
2 2010
..r, :.:- .... ,.; .,::SECTION`S /iF:PLICAN:TNOTIFICATLON
Applicant informed of above: Date: Time:
Comments:
Clerk:
�»
Total Permit Fee: $ t
Less Application Fee: $25.00 Remaining Balance: $P�
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total,sq. ft. Y
Permit Issued to:
,AD.DITIONALGORAMENTS/SKETCHES;:..,..:,.
ALI
ElSPECIAL PERMIT (Per 780 CMR 111.13)
$2 5.00 "PLICAXION FEE IS NOON hE-FUNDABLE a. N0jV-`; RATNSIFEHABLE
_ DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 RECENM
flarfmni ifh M! A n77d7 A � . ->
�� CONSTRUCTION PLANS SITE PLAN ENERGY REPORT