BP-548480
RFIRIUNTIAL
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record
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Nathe (print)
Contact Address Phone Number
2.2
Mtrized&j�ac-�
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES -
3.1 Licensed Construction Supervisor.
Not Applicable ❑
Licensed Construction Supervisor.
License Number:
Address:
Expiration Date:
Signature: Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone: Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUES IONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
I am a Homeowner performing all the work myself.
wners Narv�e (print): tl-4 —1^
Signature:
°� BY signing si nin the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
�
Date: i6y
3.4 Homeovner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
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.
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 Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of this section 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
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 applying under this section sign below:
Signature: J
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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 thiis
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ Nco
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstovei/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify bellow)
• Addition ❑ Replacement window/door ❑ Demolition
(Energy'report required) No. of windows _ Doors _ (Specify be;low)
*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 2 No. of Baths Unit 2
❑ 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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric F el Oil Other
Description of proposed work:
( cower l�+r-� v�d� ve_� e V✓i�
SECTION 6=ESTIMA ED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2, Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4)
". EE� SECTION 7A - OWNER AUT O IZATION
(to be'completed when owner's agent or contractor 'applies for'building permit)
(Please Print)
6C r= j b as Owner of the subject property hereby authorize
to Wony behalf, in all matters relative to work authorized by this building permit application.
\.
Signat e; of Owner Date
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SECTION 713 - OWNERIAUTHORIZED AGENT DECLARATION "• "
LT{ ( Ljf�C _ as Owner/Authorized Agent hereby declare that the statements amd information
a and belief.
on the foregoing application are true and accurate, to the best of my knowledge
Sign Winder the pains and pena ties of perjury.
AA Date r
Signa ure of Owner/Authorized Agent
>SECTION 8 - INSPECTOR'S REVIEWICOMMENTS
1. Date plan reviewed: L
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: ter' .._ Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's SignatureDate:
0
L
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13) -
$25.00 PLICATION FEE IS NON RE -FUNDABLE 4&;NON=IRANSFEltAI
. flATE RE
ARTMOUTH BUILDING DEPARTMENT` ;
. r� ��` E OVA ,.9� -• _ -s, a
.o 400 Slocum Road, P.O. Box 79399 b- E 17
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY C
-:THIS SECTION FOR OFFICIAL USE ONLY
.E
=1VED
ELLING
Zoning Review: Signature %'� Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other. Signature:
Date: I
Brief description of work being performed ��C- / C✓ �'v�
SECTION 1 - SITE INFORMATION
, .
1 Property Address:/
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1.2 Assessors Map & Lot Number:
r-� 1 ,•e Frontage �a
Map Lot -
Lot Area (sf.)
Required Provided
Front Yard
1.3 Historical District ❑ Yes ❑ No
,Side Yard 1
Has application been submitted to thra Historic Commission?
Rear Yard
❑ Yes ❑ No Date::-
.4 Water Supply (MGL,c40 s54):
.5 Sewage Disposal System:
Municipal�� ❑
❑
ffi Private Well
Private Well
ti.
I u Municipal qp v�i a��e ��ap�>a� oy��e���
❑Municipal On Site Disposal System
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❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY 4�10T