BP-21734plLAW00,5i floorirq
2'' X 4" fur sub floor bay
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SONS
F/IMLY 1200M
L-iviriq Arca,
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New Partition
Water Pump
U
Oil rumace
rw"11
Ll
6 2
2
Wall
-4' H X 6 " W -b. & �roovo
Shoot P-,ock, to Coil in6l
Chair Dail @ -4,
Ali DPAINING, MU-ST E-33E, KEP-f
AT THE Bt. flL.D! iN G D URR 1 i,4 G THE
PP jS WOE ".
1101,"2RESS Or -1-m 7? 1
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of D-axammirdl
FILE CO?Y
OF MIRUI 01-f
Ccpy Of This End-qrsed
rv'�'ust Be Kept On Situ
xr
D u r i �,igy Icons s L I "u, C,17. i 0 n
2 ?n I —
RESIDENTIAL 2001 RESIDENTIAL
200-
SECTI N I— PR PERTY WNERSill
P / AUTHORIZED AGENT
2.1 Owner of Record:rr.�'�
m ►� r
Rob 014 F�(( 4`je.-44, d-6G91
Name (print)
Contact Address Phone Number
2.2 Authorized. Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number "
wss
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
address
Signature Telephone
Expiration Date
3.3 Fdr Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTION S OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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
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 Rules Regulations
entitled and 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 dwelliniz, 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 si .nkbelo,Signature:Your
signature ain responsibilities, including but not necessaril% limited to, general liability
Si
r•v,l;« t ,n„e Rldeann.:res.«nd __
_Page 2 Rev. January 19. 2001
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. 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):Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date: ,
8. Comments:
9. Inspector°s Signature: Date:
SECTION 9 - APPLICANT NOTIFICATION
Applicant info of Bove at : '� Time: Clerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $'`
Less Application Fee: $ 25.00
Remaining Balance. $
TOTAL FEE:� Gross Area - New Construction total sq. ft.
Gross Area —Alteration total sq. ft./
Permit Issued'To�
SECTION 11- ADDITIONAL COMMENTS/SKET HES
❑ FOUNDATION ONLY
$25.00 APPLICATION rEE IS NON-REFUNDABLE & NON-TRANSFERABIM
....... ......
DATE RECEIVED;
DARTMOUTH BUILDING DEPARTMENT
o l 400 Slocum Road, P.O. Box 79399
Z - Dartmouth, MA 02747
508-910-1820 - FAX 508-910-1838
r he
APPLICATION TP CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELL11k;
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW: `
NUMBER:
DATE ISSUED:
T Z 2001
OK TO ISSUE - SIGNATURE: DATE
B fiilding Comnussione nspector o uildings
Zoning District: ProposedUS. Zone: L!'C�� B ❑ A ❑ V Outside Flood Zone ❑ Aquifer done
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of 1 ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals c Health Affidavit Card Sent: Cut Off Follow&=up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Othesr
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/.o/
a
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: 5yes ❑ no
[�
��E? oW r'c Ri� -
1.2 Assessors Plat & Lo umber:
1.1 Property Address: w 4
Plat Lot
Nearest Cross Street: X'V t ('e
v
1.3 Historical District ❑ yes Idno
Subdivision Name:. 9.C?13'�
Has application been submitted to the Historic, (Commission?
Total Land Area Sq. Ft.:
❑ yes lit no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal( Private Well
j
❑ Municipal R On Site Disposal System
-751
C:\bidg.forms\Bldgapp.res.wpd Page 4
Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd Page I rev. January 19, 2001