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TOWN OF DARTMOUTH 52938
BUILDING RECEIPTS
COLLECTORS OFFICE
i /,C ) - -
Name: /' pr en "(� 4 's Date:. �"j '`�l i l�
i r Owner: `: .�'\..�- !� i. %
Job Location: 9 Jl y j, ) - _
✓ " / /AA - 0 -P: y C4 ! ' 11 �' tvt
J -I �-'" r _. ,/. White Copy-Collector'sOffice
Plot: tt1./'%j; Lot: % yE. :.�'��.{^C � TMo .rnic Copy-Customer's Receipt
y 1 ''S` .�kli■�OF DAR 'v1 (((J'K�'kdc Cop;-PIle Cory
COLLECTOR'S OFFICEreen Copy Building Department
Phone: :. r S 7s IF , K ,. 718SW*
Description General Ledger#'s WWI Athount
License&Permits-Building 01000-44105 /A' Tom"-/--:>" ✓Li ;,
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
f
This is not a Permit or License for Building,Plumbing or Gas Received By: ‘.
RESIDENTIAL o Approval in Part(Per 780 CMR.5111 13)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE S NON-fl 3NSFEIIAIILE
- -DATE-RECEIVED
/�`;,o 9s. DARTMOUTH BUILDING DEPARTMENT
i 0 -kra ' - f 11
400 Slocum Road, P.O. Box 79399 2-,n n + : 37
Z Dartmouth, MA 02747
3O<_=,` Phone: 508-910-1820 Fax: 508-910-1838
lfifi4
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
T IS ECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT NUMBERa� r
DATE SENT FOR REVIEW: DATE ISSUED:
j
)� DATE: YL l/G) o--
O.K.TO ISSUE-SIGNATURE: Tv }sip�_ ,/�--v
Ir-
'Il
Zoning District: ,�r Proposed Use: / `�. Zone: I B ❑A 0 V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑Board.of 0 Board of 0 Cons. 0 Demo ❑DPW ❑ Elec. 0 Energy Report
Appeals I Health Commission Affidavit Card Sent: Cut Off ' 4 Follow-up'
0 Fire Q.Gas El Planning ❑Sewer Card ❑Water Card ' ❑Zoning 0 Other
Chief Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A'PERMIT.
DEPARTMENTAL APPROVAL " '
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed:
/- SECTION 1 -SITE INFORMATION
1.1 Property Address: 9 A/C/a/tL (+'r3 ,t` "/ 1.2 Assessors Map& Lot Number:
Lot Area(sf.) Frontage Map tefiY/1 Lot
Required Provided
Front Yard 1.3 Historical District 0 Yes 0 No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard 0 Yes 0 No Date:
1.4 Water Supply(MGL c49454): 1.5 Sewage Disposal Syste
1 0 Municipal WePrivate Well 0 Municipal n Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
Name(p t) • ContactPddt s �: on fyp�ber
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
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 CMR.110.R6)? 0 Yes 0 No
If No, go to the next section! - -
Are you claming exemption from the requirements? 0 Yes 0 No
If Yes, submit the required affidavit!
Company Name: Registration Number(if none,state"none"):
Address:
Signature: Telephone: Expiration Date:
32, For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY,FUND:,
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place-Room 1301, Boston;MA 0210$,'-617-727-8598
0 I am a Homeowner performing all the work myself.
Owners Name(print): JC-2 1: t J G1//f�1.•
Signature:
By signing the above,the homeowner acknowledges that there will be no eligibility to the Guaranty Fund"
Date: V,30-- 0
3.4 Homeowner Exemption-One&Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR-OWN PRO9ECT- :1...
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,effective July,1,-19132_tio 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 ofthis 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"Homeownef is defined as follows Person(s)who owns a parcel of land on_which Ae/she_rQ;i4eg.gfinSBads..folpsisle,.M which
there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use-OW[0faml-sUMietureS776personwhofcon56ocTs inorethan
one home in a two-year period shall not be considered a Homeowner.
If you are applyin under this se n sign below:
Signature: /'"/ /71'n
' 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 this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑Yes ❑ No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑Deck of ❑ Repairs ❑Alteration ❑Chimney/Fireplace 0 Woodstove/Pellet Stove
❑New Construction* ❑Accessory Bldg. 0 Roofing/Siding ❑Other
(Energy report required) (Shed/Garage) (Specify below)
❑Addition ❑ Replacement window/door 0 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 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 Fuel Oil Other
Description of pro osed work:
7 r
SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) v
5. Total= (1 +2+3+4)
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
I, , 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 Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
I, g-iyce i G'r I,VG ,A,ii- , as Owner/Authorized Agent hereby declare that the statements and information
on the foreg6ing application are true and accurate,to the best of my knowledge and belief.
Signed under th pains a d penalties of perjury.
Sii ture of Owner/Authorized Agent . Date
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
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:
SECTI 9-/ o '
LICANTNOTIFICATIONApplint infoed of above: Date: Time:"' Clerk.
Comments:
aSECTION 10 F NSPECTOR'S NOTES
Less Application Fee:$25. 6) Remaining Balance:
Total Permit Fee: $
Other$Amount$
TOTAL FEE: Gross Area-New Construction total sq.ft.
..,[ Gross Area-Alteration total sq.ft. `
a.
Permit Issued to: ,K..,(1 (�ci�- ! fT ( 7 9—A-c�c.U�.-2.., �'''e. f.0''✓C�i✓
./f-r1,9). ✓.d .J cot a c_ , /� J / EfCY7.-.7cm-' ay. C. 3..X i
C�/`i/2 7 F 2) /1S-. S,4.--ta-, (i cam/2-..A.-27 14,-7s1 - 7// a- .`'3?
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
1/- /1t // J
The Commonwealth of Massachusetts
'*__ - 1
Department of Industrial Accidents
_it'Ne� Office ofInvestigations
Y- 600 Washington Street
.4:= c`
Boston, MA 02111
s- "-- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
ame (Business/Organization/Individual): Jt95rI ,/'j .Cy_7
4ress: 7 Ark'
%.if n5 Lam/
_ Qity/State/Zip: thlicc/� /*J £417C// Phone #: �S-99foci 'k
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
I?
"myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp..insurance required.]
*Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: r r I r5- fl f i ,
r a ._ ,
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: 14.c..124, G0/4/ City/State/Zip:
Attach a copy of the worlfers' compensation policy declaratge(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce fly un r t e ns an penalties of perjury that the information rovided above is true and correct.
irtgn re: � -, l fY a CJ
Date:
one#: f//- ,.,Socl-: —9 roa n3
Official use only. Do not write in this area,to be completed by city or,town official
City or Town: Permit/License#
Issuing Authority(circle one): •
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street .
Boston,MP,02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
wwwmass.govldia
May 02 2008 9: 03 DARTMOUTH BOARD OF HEALTH 15089101893 p. 1
Permit# 2008FP10 rt
$90.00
A
' -TELE COMMONWEALTH OF MASSACHOSETTf •
Town of Dartmouth Board of Resit('
T peofPo l ; Above-Ground Pool
Locattca�: Plat 66/2/41 - 7 Purple Wing Lane, Daftrnouttl, !VIA
owner: . e.h'Pimental a
Coy tracto , Se
Date . .ril 0 K008
T re, MU JO ' i D AS DESCRIBED IN THE APPLICATION FOR THE SWIMMING P001
Inspeotor '�
rgnahtre of Applicant a ,._
r ,
4
1 . Oa[1.4, !.'i' Da'i 1
RECO,c ) ?LAO
- , A Copy En' T,',-, s Endorsed
Plan Murst E; Kept On Site
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TOWN OF D RTM UTH
RED RD PLAN
A Copy CT This Endorsed
r Plan Must Be Kept On Site
Duringr� b,
�> Date
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ut',v•-, 0 4It/e-`^1 is //1,75
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SCALE: k '= 30 �^PPROVED BY DRAWN BY LFJO
DATE: 0/21I 99
jj�) • 20 /�-tlip G6
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+�}'� P DRAWING NUMBER
1 .
permit No. BP-52938 Project Location: 7 PURPLE WING LN
Commonwealth°' of. .:Massachusetts
T0066
OWN bF DARTMOUTH p#: 3257.00
400 Slocum Road,Dartmouth,MA 02747 Tot:' 0002
Phone: (508)910-1820 •, Fax: (508)910-1$38 Sabot: Qp�1T
BUIT ;T)ING PERMIT Category.
ro �t# TO INSTALL
7
Est.Cost: $2004.00
FIET 4D No iv
Fee:!
Const.Class:
Use Group: R
Contractor: License: Phone#: Lot Size(sq.It) 3.1QA
Zoning: SRB
Engineer: License: Phone#: New Const.: NIA
Alt.Const.: N/A
Applicant: _ Phone#: Ceiling
JOSEPH R PIMENTEL (508)998-0098
Walls:
OWNER: - ..
PIMENTEL JosU'H R ,REN E PIMENTEL ' Floor:
f Glazing:
DATE ISSUED (�
77
TO PERFORM THE FOLLOWING WORK: �`�U �� �,d ;' ,' !1=
Install 27 foot above ground pool with appropriate barriers and gates TO BE IN ACCORDANCE WITH THE
780 CMR OF THE MASS STATE BUILDING CODE 7th EDITION
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
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