BP-28964RESIDENTIAL 2003
SECTION 2 - PROPERTY OWNERS JP / AUTHORIZED AGENT
2.1 Owner of Record:
NzIile (print) Contact Address Phone Number
2.2, Authorized Agent:
.-thmoun4 P06611 4.9&-9- wt PLE-ASAVLrf u, Ah/3 -
Name (print) Contact Address Phone Number
SECTION 3 CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor ES License Number A+-x�L8'
Address — PLC- f Expiration Date
fo ��4 VA-1
Signature " Telephoned d $' -R(t 9 -7/Q
3.2 Registered Home Impro merit Contractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? byes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Corzpany Name A,r Registration Number (if none, state "none")
Address - .-- �'-' ,,B ' /Oct 4?-. Q
Signature Telephone ,c�. 0Expiration /Date oi,q .• Q �•
3.3 For Residential Rem el Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS' call or write:
Hone 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 Hg)meowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109v1.. 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
buildh gs 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'provi�ions of this section; provides that if a
Homeowner engages a person(s) for hire to do such work, that such Homeowner act as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel oif land oq which he/she resides or intends to reside, on
which ilrere is, or is intended to be, a one or two family dwelline, 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:
Your signature carries certain responsibilities, including but not necessaril} limited to, general liability
RESIDENTIAL '`2003
NOTICE To LICENSED' CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR;15.2.15) -
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 2;5)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure,tto provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes,10 no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/' ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck Xpool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows_ doors_ (specify below): (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 l
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 (specify):
11 Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
.� - �• , Su) t ,�
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit aptplicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building' perm it)
(please
I, l 6 �1 as Owner of the subject roe hereby authorize
�./1 / � J property rh' Y
to act be 'n tters e t've to work authorized by this building permit application.
Signature of Ow r Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION - " _ -"
I, as Owner/Authorized Agent hereby declare that the statemrents and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
S i
� -
Signature of Own
thorized Agent bate
C:\bidg.f(orms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\blde.fonns\Bldgapp.res.wpd Page 3 Rev. January 19, 2001
RESIDENTIAL
2003 RESIDENTIAL 2003
El FOUNDATION ONLY
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 - PPLI ANT NOTIFICATION
Applicant inf me f bov Date Time:&�O/yj C
4j-
Comments: G'
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $��
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Grross Area -Alteration totals .'ft: r
q
' Permit Issued To• /rL,/z(5?_X
I
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
I
$25.00 APPLICATION FEE IS rON=REFUNDABLE NON -TRANSFERABLE
RTM TH BUILDING P A "_Rl CEIVEI
; �
y DA OU NG DEPARTMENT =
400 Slocum Road, P.O. Box 79399 -� k '2 I • r
l i I a i
- Dartmouth MA 02747
- 508-910-1820 FAX 508-910-1838
i
APPLICATION TO} C-ONSTRUt�T; REl AtR,'RENOVATE OR DEMOLISH A ONE OR TWO FAMXILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMUT
DATE SENT FOR REVIEW: - NUMBER.
ATE ISSUED:
OK TO ISSUE -SIGNATURE: DATE Q
Buildin C mtnissioner/Inspector of Buildings
Zoning Districts Proposed Use: Zone: C ❑ B ❑ A ❑ V Outside Flood Zone Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of oard of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elegy ❑ Energy Report
Appeals tealth Affidavit Card Sent. Cut OsTr' . 4_ Follow=up*
0 Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoniing ❑ 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: I) ate:
I
Fire Chief: Signature: Date:
Board of Health: Signature:__A, Date:
Conservation Commission: Signature: Date:
I
Other: Signature: DYate:
Descri tion o work bein er orvzed:
P .f � P .f 96 X 3
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: ( SITE PLAN SUBMITTED: yes ❑ no
p p 1.2 Assessors lat & Lot Number:
1.1 Property Address: 8 1� i- X ' at Lot % Nearest Cross Street: CE e 6 k
1.3 Historical District ❑ es
Subdivision Name: y mo Has application been submitted to tlhe Historic Commission?
Total Land Area Sq. Ft.: y �, ! a. s r
❑ yes Xno Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal Private Well ❑ Municipal lX'Cpn Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 19, 2001