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BP-5360 BUILDING PERMIT FIELD INSPECTION Dartmouth Building Department Plat: 66 400 Slocum Road P.O. Box 793N/999 COPIED If���� �r���np Lot(s) : 2-79 0, 951 TelephonDartmouthe (508 ) 999-MA 0720 COc f��U t`. ZoneLot Dist. : SRB Issued Date: 2/ 9t/ Q8 Permit No: ,�3&O Project Location: 21 Goldfinch Drive Number Street Subdivision Name: Nearest Cross Street: Applicant/Agent: Douglas E. & Deborah Jones Contact Person Phone #: (508) 998-6220 Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To: New Construction Type of Improvement,Add,Alter,New Coast.,Demo,Land/Move,etc. 16 ' x 16 ' deck -- 256 sq.ft. Indicate no. of bedrooms and bathrooms and other rooms Owner(s) of Record: Douglas E. & Deborah Jones Address: 21 Goldfinch Drive, Dartmouth, MA 02747 DATE TIME TYPE OF INSPECTION REMARKS INITIAL 11)- --//— fi? //� Z> 4> /tit �cc- ‘Z-e-cJ4-. (z S- CORPET 13 CMP EYED BUILDING PERMIT Dartmouth Building Department Rlat: 66 400 Slocum Road-P.O. Box 79399 Lot(s) :2-79 Dartmouth, MA 02747 Lot Size: 40, 951 Telephone 508-999-0720 Zoning Dist. :SRB February 5, 1998 (typed) Permit No. : 5.36,d Issued Date: a /W/°I Clerk: BAS Project Location: 21 Goldfinch Drive Number Street Subdivision Name: Nearest Cross Street: Applicant/Agent: Douglas E. & Deborah Jones Address: 21 Goldfinch Drive, Dartmouth, MA 02747 Contact Person Phone #: (508) 998-6220 Type of License: Owner: (x) Const. Superv. License #: ( Architect: ( ) Engineer: ( ) Other: ( Proposed Use: Residential Irox.inai. etc.. Permit Issued To: New Construction Type of Improvement,Add,Alter,New Coast.,Demo,Land/Move,etc. 16 ' x 16 ' deck indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : 256 sq.ft. Cost of Const. $1, 250 .00 Cost-Other Const. : TOTAL FEE: $ 40 .00 Owner(s) of Record: Douglas E. & Deborah Jones Address: 21 Goldfinch Drive, Dartmouth, MA 02747 All work shall comply with 780 CMR 5th Ed. (MGL Chap. 142) and any other applicable Mass. Laws or codesand plans on file. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building\Zoning Permit. Signature of Owner/Agent: 4 , ( Address: ******************** ** *** ** ********************************** Signature: Approved/Issued BK- oel S. Re d, T tle: Local Building Inspector COMMENTS: PLEASE4 OST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 BUILDING ,, Its Dartmouth Building Department Plat: 66 400 Slocum Road-P.O. Box 79399 Lot(s) :2-79 Dartmouth, MA 02747 Lot Size: 40, 951 Telephone 508-999-0720 Zoning Dist. :SRB February 5, 1998 (typed) Permit No. : 433.3(o0 Issued Date: 02 /,Diss Clerk: BAS Project Location: 21 Goldfinch Drive Number Street Subdivision Name: Nearest Cross Street: Applicant/Agent: Douglas E. & Deborah Jones Address: 21 Goldfinch Drive, Dartmouth, MA 02747 Contact Person Phone #: (508 ) 998-6220 Type of License: Owner: (x) Const. Superv. License #: ( ) Architect: ( ) Engineer: ( ) Other: ( ) Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To: New Construction Type of Improvement,Add,Alter,New Coast.,Demo,Land/Move,etc. 16 ' x 16 ' deck indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : 256 sq. ft. Cost of Const. $1,250.00 Cost-Other Const. : TOTAL FEE: $ 40.00 Owner(s) of Record: Douglas E. & Deborah Jones Address: 21 Goldfinch Drive, Dartmouth, MA 02747 All work shall comply with 780 CMR 5th Ed. (MGL Chap. 142) and any other applicable Mass. Laws or codes and plans on file. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Builoing\Zoning Permit. f 4ey.�Signature of Owner/Agent: �l ��Y 0 -e-C , Address: ******************** ** *** *** ********************************** Signature: Approved/Issued By/� del S. Re d, T tle: Local Building Inspector COMMENTS: PLEASE ` OST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 C a TOWN OF DARTMOUTH 05360 BUILDING RECEIPTS COLLECTOR'S OFFICE Name:-?-i };(''1 11. V j Property Owner. -lef ti Date : 4 r k Job Location:--! Xfit� _, i r c <<i - 5 Awhite Copy-Collector's Office Plot: Lot: - Yellow Copy-Customer's Receipt V ;,1' !f Pink Copy-File Copy Green Copy-Building Department Phone: c ri.. Description General.Ledger#'s Ref.# Amount License&Permits-Building j 01000-44105 l L J License&Permits='Building'Misc. 01000-44105 License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 - Other Department Revenue 01000-42420 / i - This is not a Permit or License for Building.Plumbing or Gas Received By: _ /$}1. - TOWN OF DARTMOUTH BUILDING RECEIPTS ,, ... COLLECTOR'S OFFICE • Name: i I I (i Property �.6 r Date: v, / L _c F-: , /••t c. f "- _, Owner 'J- L,-;— c� 1 , ` f Job Location: / ! ' ' White Copy-Collector's Office Plot / 7,- 1'Lot: ,. --- /- Yellow Copy-Customer's Receipt r ( 'S` . Pink Copy-File Copy Green Copy-Building Department Phone: Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 /Y i Z - C'—I- License&Permits-Electrical 01000-44106 / d y" - -ey License&Permits-Plumbing&Gas 01000-44107 `7,/ Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By: 2 •Ct-a. t /- 4 y7 TOWN OF DARTMOUTH BUILDING DEPARTMENT TELEPHONE 508-999-0720 FAX:508-999-0738 APPLICATION FOR ZONING AND BUILDING PERMIT Instructions The applicant shall complete this application to the best of their ability prior to submission,leaving no item unanswered.The Department staff will be available during regular business hours to assist as necessary.N/A should be inserted for those sections which do not apply.A properly completed application will help avoid unnecessary delays. fins Big Gill S aefJaiit= (fa oast®e only) - -.. [7 FOUNDATION ONLY Total Cost $ V.GO Received By 8 Date Ree'd_4 Lem Application Fee$ 7J o G J Tca!Pm.-.:.;Fee $ 5:Gti Permit# 1/43 J3 lP imam ima Date , / ''`Cr0 100 LOCATION OF P CF . TOTAL LAND AREA SQUARE FEET CURRENT ACCESSORS' PLAT Ea E' LOT i--71 ZONING DISTRICT OTHER ZONING OVERLAY DIST3RI7CTS', if applicable NUMBER & STREET -I GO 1 C lS�> /C/k ('Or)v21 l (� ) _ NEAREST CROSS STREET SOrJgbu d Df,l - tkzrJ ` 1 L � d SUBDIVISION NAME & LOT ft Lb r'4CLk > y ,� Li or BUSINESS NAME �J PREVIOUS TENANT / OWNER 200 RESIDENTIAL -PROPOSED PROJECT- one & two family residence only THIS SECTION NOT APPLICABLE - Single family - number bedrooms number baths Two family - number bedrooms unit 1 number baths unit I number bedrooms unit 2 number baths unit 2 Accessory apartment Total gross sq. ft. Accessory structure: f - Garage - detached - attached to dwelling, Limensions L W !,/�,1/ �Cn(/I UUU (x� _ Carport- detached - attached to dwelling, dimensions L W 1 4 (/) = Shed - dimensions L W 614 v i NZ Deck- dimensions. L 1 6 W It ' 0 / -2 Gazebo- dimensions L W 11 �1' _ Swimming pool above ground in-ground Size Chimney - number of flues 2 I - Woodstove - used (will require inspection prior to installation), new (provide manufacturers instructions). Location(s) (list) := Firepiace(s) - (includes flue) List?aci.tioifs) Game Court- describe(include overall dimensions) - - Tent, Trailer(Mobile Home) or Other-describe CNV300 COMMERCIAL-PROPOSED PROJECT/USE INCLUDING THREE FAMILY OR MORE AND EXEMPT USES THIS SECTION NOT APPLICABLE (The following descriptions are based on the Massachusetts State Building Code Article 3,AS NOTED) (See the Code) Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe - Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code Section 303.0) - Educational-structure for training including child day care for those over 2 years 9 months 304.0) (s ee ee Code Section - Factory / Industrial - (see Code Section 305.0) — High Hr:ard - (see Code Section 306.0) - Institutional - hospital, nursing home, infant day care(see Code Section 307.0) - Mercantile - retail stores (see Code 308.0) - Residential - three or more family, hotel (see Code Section 309.0) — Storage - includes garages (see Code Section 309.0) = Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0) _ New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35) - Tent or Trailer- temporary purpose? - Other Describe the proposal briefly INCLUDE- -- afro exiting condition -amber dwel�g units and bedrooms or occupant load as applicable, 400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED Z56 New Con struction and/or Addition - total gross square feet i 6 'X 1 1dec k 7 (For commercial only total gross cubic feet) It will be considered new construction if there Increase In square footage in addition to any alteration's). If project is an addition to existingstructure '""� c� - FOR If cture- Total gross square feet of existing.j`)XZ6--)IFS",:;- see) r1 COMMERCIAL ONLY Will this project be subject to CONSTRUCTION CONTROL(over 35,000 cu.ft.) _Yes No. (If yes see Code section 127.0): Designer to submit Code Synopsis. Will this project require Peer,review(over 400,000 cu.ft.) Yes 2 APPLICANT TO PROVIDE _ No (see Code Appendix I) Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required. - Demolition - describe structure Number of dwelling units Number of bedrooms A separate Refuse Disposal Declaration required. - Moving - (Provide copy of D.P.W. moving license) Type of structure from where (plat/lot or address) to where (plat/lot or address) Number of dwelling units Number of bedrooms per dwelling unit . Re-roofing- (for existing only, is included in new construction) Number of square feet Number of layers already existing Number of layers when complete A separate disposal declaration REQUIRED Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered as an Alteration. otherwise will be included in new construction. (see Code section 3401.10 for residential and Article S for cnn.nerciai) Temporary structure- includes when allowed, trailers,tents and the like and only for limited periods of time. Describe 500 CONSTRUCTION PLANS None submitted. Why? Submitted. usually three sets required. Four sets for food service\uses. Number of sets submitted 600 SITE PLAN El Not required, why? Submitted When? - Previously, date C2 With this application 700 UTILITIES Water supply- required_yes _ no, public ^. _yes_ no, on site well? _ yes _ no, existing? _yes_ no If required and not existing have necessary permits been issued? _no _yes, date (M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when required, is available. See Code 780 CMR section 114.1.2) Sewage disposal- required_ yes_ no, public sewer_yes_no private septic - on-site _yes _no. Submit copy of permit as soon as available. j 800 MECHANICALS & PRIMARY FUEL -C 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) Air conditioning - (separate unit) = None of the above to be provided - Hot Water Gas Electric Fuel Oil Other 900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential Required, :plans provided, _ plans not provided, why? Not required. not to be installed. Why? 1000 REQUIRED OFF-STREET PARKING - for ZONING & Architectural Access NOT APPLICABLE Parking.Plan submitted To = Building Department = Planning Board Date submitted Number of spaces - indoors outside total provided Handicap -paces - required_yes _no. If yes, how many as a part of the total required number. Is Route 6 (State Road) Entrance permit required? yes = no =. If yes has it been issued yes = no -. Submit copy of application and/or permit as soon as available. 1100 IDENTIFICATION (print or type except as noted) Current owner- name i.ACA�.({T j C & 1r4) ,IoNP,s address L I GC14;N CK, OQII� phone rf ! 9 6220 If corporation. officer in charge AtchitectfEngineer- for overall design Company name Address Phone number Certified by State of Massachusetts as Certification number NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not reproductions. 4- Architect/Engineer- project supervision and reports • . Company name Address Phone number Certified by State of Massachusetts as Certification number NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not reproductions. General Contractor(if Homeowner, state homeowner here then complete section 1300) Company name. Address -- Phone number Construction Supervisors license number NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not reproductions. YYY#Y#sts##YYYYYYY# ! Y Y Y Y ifa#YYY f Y Yi#fY li YYff i YY > f # # Y 1200 FOR RESIDENTIAL REMODEL WORK ONLY Are you a Home Improvement Contractor subject to (780CMR-6) ? Yes_No S If no go to next section! Are you claiming exemption from the requirement? Yes_No If yes, submit the required affidavit! Ren.idel contractor name (please print) Address Registration number(if none state"none') Phone number PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration One Ashburton Place - Room 1301 Boston, MA 02108 (617) 727-8598 Owners name (print) _ Signature Date 5 I. the undersigned,am the owner of record or authorized lessee(provide documentation, and I have reviewed the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this application is true and correct and that the permit requested be issued. Further I understand that the permit will expire in six months, from the date of is sue, if work no six months after the last inspection if work has begun and that theors is begun or f no work is anticipated if I request such an extension in writing. I understand that the permit may be extended only thx months tree times by written request.I understand that once the permit expires a new application may be required,including fees and current other requirements (including Zoning). Name 4. O"«-O' ,..ram On C4-rd V Signature iC 0•"7: �. r,j0 ,��R� j The/ 'aboovve sign re is my volunta ct and is signed under the pains and penalties of perjury. Date i / 30 • • Who is authorized to ckup the,�permit at the Building Department? I omit otl t c F Address 7 i @Oct/biCh Y)W Phone —3110 1400 HOMEOWNER EXEMPTION - ONE &TWO k7A1VHLY ONLY FOR HOME OWNERS 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 127.0, 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 element of buildings or structures. unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Riles and Regulations for Licensing Co^structica Suorvisors, Exception:.Any Home Owner performing work for which a Building Permit is required shall be exempt from the provisions of this section: provides that if a Home Owner engages a person's) for hire to do such work .that such Home Owner shall act as supervisor. For the purposes of this section unly, a"Home Owner" is defined as follows: Persons)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 dwellin , attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in two-year period shall not be considered a Home Owner. If you are applying under this section sign below: Signature i,� ,�J,,`.yf/+ / Your signatur carries certain tl�sponsibilities, including but not necessarily limited to, general liability 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 2.15.2 of section 51 1500 COST Cost of Improvement Ptrt7C, s •, 2,570 Items to be installed but not included in the above cost: Electrical S Plumbing H\AC Other TOTAL I 2,50 6 The following section for official use only. - INSPECTORS' REVIEW Date plan reviewed 30 days to review period expires - OK to issue date • OK to issue subject to requested submittals (see project review worksheet) date • DENIED see project review worksheet date - HOLD reason date HOLD Subject to Zoning Board of Appeals action Comments • p Inspectors signature _---- DateFEB 04q9 8 _ Applicant informed of above- Date time__staff (fax, phone, in person) — Over six months since approved for issue- DEEMED abandoned! Advise applicant. Hold 90 days for return then dispose if not picked up. -- - Inspector Y Date Advised applicant Date Time staff_ (by phone, fax or in person) OFFICEWVSPECTORS NOTES TOTAL FEE --7-0�v Gross area - new construction c2-56..0 Total Sq. Ft. alteration Total Sq. Ft. Permit is issued to Comments/notes on permit x 1600 TO THE APPLICANT/REFERRAL AND APPROV t I� Date of Application submission .- ill G (; 7) Plat (! Lot / Street O I _}. j 1 �'A (�'. �/ n- '� p �^ Aquifer Zone_ Owner T h UCk jt c t The C� )"f-� 1 r\ C) Owner mail address Sfl V3/41 Owner phone t OTHER INVOLVED AGENCIES-The following agencies require separate jurisdictional permits or approval for your proposed project. CONTACT THEM FOR REQUIRED SUBMISSIONS. ® TAX COLLECTOR = Approved HOLD By Date ❑ Board of Appeals Approved By Date a Conservation Commission C Approved By _ Dan. ❑ D.P.W. Water = Approved By a D.P.W. Sewer L Approved By Date --- ❑ D.P.W. Cross Connection u Approved By Date a Treasurer(Bond) ❑Approved By Date ❑ D.P.W. Engineering Approved By P Date J t r 0d of Health (well) Approved By //`/']I^ C — a f ate (\EL.Bdard of Health (septic) 0 Approved By Date a Board of Health (food service) = Approved By Date a Planning Board (parking) - Approved By Date ® FIRE DISTRICT (I - II - III) = Approved By Date BUILDING DEPARTMENT APPROVAL: ❑ ZONING ❑ BUILDING INSPECTORBUILDING COMMISSIONER ❑ CONTROL CONSTRUCTION AFFIDAVIT PROJECT SUMMARY: new constructions alteration/demo sewage disposal - public/private [Alter/add interior walls] [add rooms] [add footprint] water supply- public/private well [pool] [garage:shed/deck] [game court] [food service] Describe / l(J ,4,1 (0 6 ea '� To the various departments: This notice has been forwarded to you for your information and any appropriate action. Should you have any questions please advise. If any reason to withhold the requested permit is found. please advise. Your assistance and cooperation is appreciated. I The Building Department- Date sent for review /'( I By S. IMMIlmr- Cc pl , PLOT PLAN n C2'4 ati' n° CQ14,;" / vv,og p(A`j Tor_ Deck by jf r7om20wN2 / 0o 0(. 1AS E Tor) )ES i 2! Go I d 'i•)Ch DRIve o M TOWN OF DARTMOUTH RECORD PLAN A Copy Of This Endorsed Plan Must Be Kept On Site N During Construction -ate FEB 0 41998 • �,. czi ouS THE BU LD>NG DURING ,I El GRESS OF THI..1 WORK \O BUILDING D.9A.;tr:iE%vt t • Town of Dn_stmouth OE°'S .\ SSE ii! :O IS 01;in �`° I . 1CONDRE T E IS P Lt k U. • OR�VEWA '• BUILDING DEPARTMENT �,.. . Town of Dartmouth ?, is , 4, visa ----- a GOLDFINCH ORvc t-11 i `lip:'' tflei< , f , , 4 x- -1 (-. -fit r -I i • L 1- { -.l • i f 1 - T 1 - FL-- . _} .. � r - r • • • ) J r • • ' j - r < PO ?- 1 . • —C X L! - - 0 . _. . . 2 0 .. -_I[. _ - iii - J ® w 3 Ob Q d o S L. I- Q.) .e D O •Ir \ N . X X V • :3 oC] 1 - iil z co u Q s id TO 0 Q N Qz ->: v. .r r --. 1. — O C - r I . 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Boston,Mass. 02111 �z Workers' Compensation Insurance Affidavit 11P`iil III .. .".,_:._._.�.c....1.. 4 _. .c::.: ........ t a dYa:�F-`58t le`u 43t6�1 i7 f`:.____. .. .. „_ W . name: DO(A TrRS IF oi\iss location: t I GO 14111C1l 1 J�R ive city 0ART 1o(A -1-t VIA Atoned q7"l/� 31)03 Ea I am a homeowner performing ail work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name: address: city: phone#:' insurance co. oolicv# p I am a sole proprietor,general contractor or homeowner(circle one)and have hired the contractors listed below who have_ the following workers'compensation polices: companyname•' address:. city _phone#i insurance co: - ooliev# romnany name' addrer: city: phone#: insurantxcos ooliev# Failure to secure coverage as required under Section 25A of NMGL 152 can lead to the imposition of criminal penalties of a fine up to S1 500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of erjury that the information provided above is true and correct Signature o G"'� /( __ E -e,�" Date /��//� (� Print name �(7tAl 1/]9 ----jr- es Phone# q7/ 3 LD S official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department °Licensing Board El check if immediate response is required °Selectmen's Office °Health Department contact person: phone#: °Other (revised 3/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 also states that every state or focal licensing agency shall wit/:hold 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names,address and phone numbers as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ft .As na-'t :i �`v it... .4.. S The Department's address, tclephc and Cr,: ^ r. •The .41th . ✓13=_..c Lus `_`:. Departmrn adL:;ir__'_ ,r_:: c c•is Silica fit investillatiaiis 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 1600 TO THE APPLICANT/REFERRAL.AND APPROVAL • Date of Application submission 1I4 l/' Plat Ok Lot / 9Street a l 0 id 1 1� �� b r. Aquifer Zone OwnerNibeunk-S Ie b 7 041-1 (\E, Owner mail address ` i ill ce._ -- Owner phone ft ' OTHER INVOLVED AGENCIES-The following agencies require separate jurisdictional permits or approval for your proposed project. CONTACT THEM FOR REQUIRED SUBNI SSIONS. ® TAX COLLECTOR C. Approved = HOLD By Date ❑ Board of Appeals = Approved By ' Date ❑ Conservation Commission C Approved By Darr. ❑ D.P.W. Water C. Approved By a D.P.N. Sewer = Date By ❑ D.P.W. Cross Connection a Approved By Date ❑ Treasurer(Bond) ❑Approved By Date ❑ D.P.N. Engineering a Approval By Date Bo rri of Health (well) =Approved By. / Al ' :: Y (/ ❑ Board of Health (food service) C Approval By Date ❑ Planning Board (parking) = Approved By Date sr FIRE DISTRICT (I - II - III) _ Approved By Date BUILDING DEPARTMENT APPROVAL: O ZONING ❑ BUILDING INSPECTORBUILDING COMMJSSIONER ❑ CONTROL CONSTRUCTION AFFIDAVIT PROJECT SUMMARY: new construction, alteration/demo sewage disposal - public/private [Abe fadd interior walls] [add rooms] [add footprint] water supply - public/private well [pool] [garage shed/deck] [g me court] [food service] Describe / b / C\ u lc To the various departments: This notice has been forwarded to you for your information and any appropriate action. Should you have any questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and cooperation is appreciated. The Building Department - Date sent for review / "((/ ! f ,-. By r2--rs 2. Dartmouth Building Department 400 Slocum Road P.O. Box 79399 508-999-0720 Dartmouth, MA 02747 FAX 508-999-0738 VIOLATION • January 26, 1998 Douglas and Deb Jones 21 Goldfinch Drive Dartmouth, MA 02747 Re: Deck constructed, no permit issued - Plat 66 Lot 2-79 Dear Mr. & Mrs. Jones: It has come to the attention of this office that you have constructed a deck at the above mentioned premises. After review of the department files, no permits or permission was found. Therefore, please fill the necessary application for this work. Enclosed is an application form for your convenience. Also, you will need to submit a site plan showing the existing location of the deck as well as two sets of plans. Your application and plans will be reviewed and you will be advised of any further action required. Your cooperation and prompt response will be appreciated and will preclude the necessity of more formal action. Your response is anticipated not later that February 2, 1998 . Should the facts stated herein be not correct please advise so the record may be further reviewed. ' ncerely, oel S. Reed JAN 1 3 1998 Local Building nspector JSR: sgh )4 Enclosure Ace,, CURRENT MESSAGES / DATE I MESSAGE BY .- � 1 tr---ruz-s. __hi:7 ii..... ., __2....n....er?.? s