BP-724672004 RESIDENTIAL
04
RESIDENTIAL% 20
�� CTORS: The Buildin Code provides in the Rules and Regulations section that any licensed Construction
NOTICE TO LICENSED CONTRA g CMR RS.21
�. s v �� ave taken the ermit are responsible for code compliance. (see Appendix of 780 5)
TIN8 w Supervisor, whether or not they h
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2.1 Owner of Record:%
II _ Contact Address Phone Number
Name (print)
2.2, Authorized Agent:
I Phone Number
Contact Address
Nanne (print) l , G ? 1/C<"!i�
_ ....FIRM 7.� � _-ate. ,� . �a
3.1 Licensed Construction Supervisor: Not Applicable ❑
ILicensed Construction Supervisor`s � License Number
Expiration Date
Address `J
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!
Registration Number (if none, state ❑ none❑)
Company Name
Address
Signature Telephone Expiration Date
i
i
33 For Residential Remodel Work Only
VHRSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
e QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (printl_/�
Signature
by signing t ove, e home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3A Homeowner Exemption One & Two Family Only
j
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
nstruction, alteration, repair, removal or demolition involving the structural elements of
shall be engaged in directly supervising persons engaged in construction, reco
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 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 dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs
._ __ -- _ ..,.-- o 4,,A a-11 nit I- nnnaidered a Homeowner.
,_...—
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
❑ new construction* ❑ addition
❑ alteration 9 repairs ❑ chimney/ Z❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ 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 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
Brief Description of Proposed Work: �!(I�yri�. St% C� ,- ' y i
4 co c, tl bods �� 0✓1 o�td s
n
Item
5.Total=(1+2+3+4)
Estimated Cost ($) to be completed by permit applr~ant
c'
Estimated Total $c'
(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
I, as Owner/Authorized Agent hereby declare that the statemenits and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
V.---A ,..,AI 14- inc and ne.nnities of Deriurv. -
RESIDENTIAL 204 RESIDENTIAL 200
❑ FOUNDATION ONLY ❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NOW -TRANSFERABLE $25.00 APPLICATION IS NON-REFUNDABLE NO -TRM S LE
OR
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1. Date plan reviewed: 2014 ,-
2. 30 days to review period expires:
3. OK to issue date:
4. OIL 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: D 5
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Applicant informed of bove Date. 7 Time: Clerk,
Comments:
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ff 9 ® ���a��`�N�a�r��ha.�we¢�s�d �tl- cisa. ��H� si.ros�.a-,�3 i_�y������i C
Total Permit Fee: � Less Application Fee. $ 25
.00 Remaining Balancer $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. y�
Permit Issued To: C;��U16lea:
MIA
fit A ONA CO E �MEMN
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C:\b1dg.fonns\B1dgapp.res.wpd Page 4
Rev. January 1; 2003 C:\b1dg.f6rms\B1dgapp.res.wpd
a�TH.�ry
EIVED
DARTMOUTH BUILDING DEPARTMET t,;a
DATE RECEIVED
i,1, jg
o 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 2014 J
i 14 PH 3: 16
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIILy DWELLING
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Zoning Review: Signature: Date: 1®� 5
Energy Report: Signature: Date:
Fire Chief- Signature: Date: E,
Board of Health: Signature:' �tJ j-� _Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed: t
ffiq
®m MEW r� B ks .
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yet ❑ no
1.2 Assessors Plat & Lot Numbltr:
1.1 Property Address:__ & '6 nd <A
Plat Loy°t Z -
Nearest Cross Street: Sp jq bi Cd PC.
Subdivision Name: LJ
1.3 Historical District ❑ ye,s phi no
Has application been submittfed to the Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal ❑ Private Well
❑ Municipaal ❑ On Site Disposal System
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Rev. January 003
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