BP-21433RESIDENTIAh 2001
—I E3IDEMI1AL
-- - - - _ 2001
SECTION 2 - PROPERTY 6N NItRSHIP / AUTHORIZED AGENT
2.1 Owner,9f Record'
'Ok- ��- G 1l �,-� �z1�(�;��
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION -SERVICES
3A Licensed Construction Supervisor: C.5 : 0(a S-? 3� ;'
Not Applicable ❑
Licensed Construction Supervisor ;C. ja u , /
License Number
Address J 3 t2 1 1 _ 6
Expiration Date
C•5. P82
y�. a tv o -
Signature
Telephone ��—1 �d
12 Registered ® e Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ,,es ❑ no
If no, go to e next section!
Are you claiming exemption from the requirement? ❑ yes JZf no
If yes, submit the
required affidavit!
Company Name,` � S �r a
Registration Number (if none, state "none")
Address
Signature TelephoneS-09,, e6_7 76
Expiration Date
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c
3.3 For ResidentiaRemodel 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 02108, (617) 727-8598
Owners Name (print)
i
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
t
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 67ectly 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 ra 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:
Your signature carries certain responsibilities, including but not necessar,!\ limited to, general liability
C:\btde.forms\B1dt'anp..Tes.Ntod Paee 2 Rev. January 19, 2001
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructio_rn
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers 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)
❑ new construction* ❑ addition ❑ alteration ❑ repairs chimney/ ❑ woordstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door 0 other ❑ demtolition
(shed/garage) no. of windows doors_ (specify below): (specif-y`below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit I 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided -
❑ Hot Water: Gas Electric Fuel Oil Other
Brie Description o Proposed TVork: �!
f P f P +OC9til > U4 w
1 -
A 1 tt #'LQJ
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Phtmbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ L76D
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please pr��`
i, L 1 CcnGtiil�'�c� i i� , as Owner of the subject property hereby authorize
to act n�jmy b half, imall,matter5 relative to work authorized by this building permit application.
/lA
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DEC ARATT N
I as Owner/Authorized Agent hereby declare that the statements and information
on the f going application are true and accurate, to the best of my knowledge and belief.
-. and penalties of perjury.
Signe4fne
ii
SignaAuthorized Agent
V
(,\hId aSnnns\Rid..*ano-res.wod
Page 3— ---
ate
Rev:,?January 19, 2001.
SECTION - INSPECTOR'S REVIEW/COMMENTS
J _.'Date plan reviewed: -
2..,30 days to review period expires:
3_ 1 ;OIL to issue date:
«4.. OIK to issue subject to requested submittals(see project review worksheet): Date:
li
5. ' DENIED (see project review worksheet): Date:
6 ' HOLD reason: Date:
7 . HOLD subject to Zoning Board of Appeals action: Date:
S. Comments:
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9. Inspector's Signature: ate:
SECTION 9 - APPLICANT NOTIFICATION
Applicant inforTe f above `' Date: 71 Time Clerk:
I
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
? Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balanc$
FEE: V Gross Area - New Construction total sq. ft.
Gross Area- Alteration total sq. ft.
Permit Issued To.
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
�15
I
I
sF lee,
o OZ/NDA MN
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFEMABLE
: :� .Ll F. 'r, , DARTMOUTH BUILDING DEPARTMENT
o �l F. �, 400 Slocum Road, P.O. Box 79399
DATE RECEIVED
Z Dartmouth, MA 02747
lfifi3 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO VAMILY DVNELLINQ.
THIS SECTION
FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED•
OK TO ISSUE - SIGNATURE: DATE SEP 2 5 2001
i ding Commissioner/Inspe for of Buildings
Zoning District: Proposed thi Zone: ❑ B ❑ A ❑ V Outside Flood Zone ❑ Adrlgifer Zone
THE FOLLOWING AGENCIES SH' ULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. C] Energy Report
Appeals Health Affidavit Card Sent: Cut Off 1F?ollow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card , ❑ Zoning ® 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: Date:
Fire Chief: Signature: Date:
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: ❑ yes Ql no
` q
1.1 Property Address: � �Cd�GK` +�cfcf C�
1.2 Assessors Plat& of Number:
Plat Lot -
;_
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Commission?
❑ yes. ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal% Private Well
❑ Municipal XOn Silte Disposal System
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isposa
Rev. January 19, 2001