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BP-49875 permit No• ProjectBP-49875 Location: 26 GOLDFINCH DR , CommonTe9a3- a of Massachusetts TOWN ,...._ ,/,,.:.„, O..?.,......,, F D-i- A. R., T M. O U„„,„;_,„,, Tv,,, H m--+a----', ., 0 406Slou*,404d; 311n?nth „mA 02747- 10002 Phone: ( 0 )9404820:. !t(,668)911-1838 81bI9t:t 9077 Ii4IGPRIT Category: , ,INSTALL:-,',.,;,,...:.w lL ) troJeEtvW4Sik66046060,,, 0-,:,,- ,,,.... . ' C TIG FIEt 4billNsPE ''' ''' r ----- •e----- ' ----H.' coistichiiii;2;::.-,cAy/:„,,o,„:„;:t74,...„.... ,. Use Group: -„:::",.:„:,;1.:-.14:4 , ,:' -pflone#: ,Zoning: (sq..it,.? ,_ ' 1.14;O.,71, . „,.., ,_ Lot - - _ ,,- 'License. phone#: Contractor: New Const.: .?..z'..-„. - Alt.Con154.., Engineer: ........ - License: Applicant - ' - Phone#: TAMMY L SQAIR cc S71::'-''' - : ' 7 (508) 995-1369 Walls:Il''',',":"14,2a1;i1,74E,i );':::,,,*•,:- 1,4„: , g ff'- ' S:'TISDELLY OWNER:TISDELLE DANNY ,. '''`) "-;8;:71- m,;(1,,,L SO,AR, STISDELLE r :tlailifigICAMElip-0241,0:4R.... DATE ISSUED: w I ,c---- 7 TO PERFORM THE FOLLOWING WORK: Install above ground pool, 34'x 18' DATE TIME TYPE OF INSPECTION&REMARKS INITIAL Do , u )t 7//i ii d 1171 75-- de‘-tt fC" Y/16, - r_ ... ic a i 7 hasK er, ,0/<_ tied ..e.„„..,-,.. yrorA5-b x77 - a/ 9 a o_fr, ey,,,/e_ 4,3— a/ n en-, 7---Ate-Prz-C X deeru 1.cr_i) /0-,73--z2,P- 3 £7 es TOWN OF DARTMOUTH Y.% '37Q -c. U�` j BUILDING RECEIPTS A -4%; COLLECTOR'S OFFICE i Name: ,/ Property Date: 7 %-. i _, / Owner: V:1'.1}/_sw. 777/7r, _/'" Job Location. - -:f C cf , /7 f,,, A1, White Copy-Collector's Office Plot J/ Lot - - Yellow Copy-Customer's.Receipt _t, ,, 1L' . ->� 2 .2 Pink Copy-File Copy Green Copy-Building Department Phone: - - - - Description General Ledger#'s Ref.# / Amount License&Permits-Building 01000-44105 6/1-4, j /3 License&Permits-Building Misc 01000-44105 License&Permits-Electrical 01000-44106 TOWN OF UHR ofFi t COI I ECTOR'S pIFFI� License&Permits-Plumbing&Gas 01000-44107 JUL1 A 2fic a Other Department Revenue 01000-42420 Q 1 This is not a Permit or License for Building,Plumbing or Gas Received By: c— -—y-7j�e '2 c�I mAP 6'4 LOT l `2 TOWN OF DARTMOUTH INSPECTION CHECKLIST Date: 7-17,81-1 0 New Home ❑ Addition 0 Alteration D'beck or Shec Permit # `7'91j Address: a'6 `t/' [74 1 Inspector: j �?�� FO1 7NDATION/FOOTING/SONO-TUBES Pass Fail Description Code Section As-built&approved 110.10 Frost Depth 3604.3.1 A#1 Foundation walls braced 3604.4.1.3.1 .1 Footings on undisturbed soil - - - Spread footings 3604.3.1 A #3 Foundation wall grade clearance 3604.4.1.3 Pad location size and size per plan 3605.2.3.3B (table) Damp proofing/water proofing 3604.6 Anchor bolts/ties &straps 3604.3.IA #5 Thermal break/insulation in place 3604.3.1 All footings&pads fiee of foreign material 3604.9.3 Columns rust-inhibitive paint&structure 3604.8 Crawl space ventilation/ 1 sq. ft. = 150 sq. ft. 3604.9 Sono-tubes 3504.3.1 Comments: � 10 �� X Y /o LaJo --- x _ Permit No. BP-49875 BUILDING . BRMIT T .. xtslr5 �, 2910Q`.w s-;;+:� £ ,1 .16hi ` a Q2F.�ew Ete ~�p� „ 'u s' 's" �'�Q `DAR IMOU'fit N * n - '000 eats Goo Sloum Road,Dartmanth,,M4 02747 3.4147Atikia ' 0 0 _71p�i i t PERMISSION I'I LRE GRANTED TO. ";Z„- ='. , 3 t 414-41 - 09 '�'" "` Contractor �r *�� 4 ,� �,� Pah'8�te#� a- *4Atast,.74c _PC'_e=,e qua s Ym Engineer $ ," a Oa Phone'# nCng Applicant _ :� .iane4 C on * � TAMMY L S S T SDELLE 08)995-1369 Atoatale -tie--"1.7YRO-1 7 �i. TISDELLEDA "P ,TtM ,...r, Oz' . _ r - i5/,; DATE ISSUED: ?/ /d - TO PERFORM THE FOLLOWING WORK: r Install above ground pool, 34'x 18' 4,29 Pr 'ect Location: 26 GOLD CDR Approved/Issued By: /t DAVID W MATTO ,LOCAL BUILDING I ECTOR&ZONING ENFORCEMENT OFFICER All work shall comply with 780 CMR 6"H Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK,FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.8(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. 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/Zon' g Permit. //��j� Signature of Owner/Agent( ,(1- �( Comments PER'LYTI'C NLIMBE 1tY;Q � s,e � D A .PEG 4N ES 1Vl.11,4`"�.t_B_kll?� WW1'. :OW.* i�Rl "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Treasury: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET TOWN OF DARTMOUTH 49875 BUILDING RECEIPTS x COLLECTOR'S OFFICE Name: % . Property' - Date: Owner. ?G . ,,c 7J>t e Job Location: .. /if Dri " - White Copy-Collectoi s Office Plot: Lot TOWN OF DARTMOUTH Yellow Copy-Customer's Receipt ' 7 7 COLLECTOR'S OFFICE Pink Copy-File Copy r+ JULGreen Copy-.Building Department Phone: ! 5 £ si ''' -: S U 2 4 20Ui g ",z rF ?-'3 i® ram ?...skmc MAJ13 Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 �ii License&Permits-Building Misc. 01000-44105 t' License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building.Plumbing or Gas Received By: ❑ SPECIAL PERMIT(Per 780 CMR 111.13) $25.00 APPLICATION FEE IS NON IIE-FUNDAIILE a& NON•TIIANSFEIIABLE f._TH i�r ) DATE RECEIVED /� - � DARTMOUTH BUILDING DEPARTM Elah°I',` �'aa . "�, r) . �J 21 400 Slocum Road, P.O. Box 79399 ' Dartmouth, MA 02747 �t-.r,,7 JUG 24 AN jQ: 50 s /.5?/'Y Phone: 508-910-1820 Fax: 508 910 T83$ 664 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i. ,THIS-SECTION FOR OFFICIAL USE ONLY RECEIVED BY: - - BUILDING PERMIT NUMBER: tt;(`tbi DATE SENT FOR REVIEW: - '7/a- /c DATE ISSUED: V eil0? Zoning District: Proposed Use: , .0 Zone: C O B 0 A 0 V Aquifer Zone THE FOLLOWING CI AGENCI S SHOULD BE OTIFIED: Board of Board of j_ pions ❑Demo ❑DPW IJ Elec. O Energy Report Appeals . . Health Commission _ Affidavit Card Sent Cutoff :Follow up' El Fire ❑Gas D Planning ,CI Sewer Card- *„❑Water Card „El Zoning ❑,Other ' Chief Cutoff i Board ... .Cut Off - 'Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. -DEPARTMENTAL APPROVAL ' Zoning Review: Signature: A 'mil 1 Date: 0,?A ? Energy Report: Signature: Date: ire Chief: Signature: Date: ✓ 9r Board of Health: Signature: % 4L441CJ tC c _ Date: r / Conservation Commission: Signature: oZ --hil?( Q,C�',s-e/-1._ Date: -7 ML / Other: Signature: Date: Brief description of work being performed: /t X,3y aLi i,.fi p top-, 7 SECTION 1 -SITE INFORMATIOPF, ` ' ^�/ J / L 1.1 Property Address: r-)(o C old 4 r h v ✓i ` 1.2 Assessors Map& ot Number: Nearest Cross Street: ,�L:1 ,I I F.I, - ��} I v l_ Map AE 62 Cor Lot - 7 7 Subdivision Name: Sn3bI2C ac eR 1.3 Historical District ❑ Yes o Total Land Area Sq. Feet: Has application been submitted to the istoric Commission ❑Yes ❑ No Date: 1.4 Water Supply(MGL�c40 s54): 1.5 Sewage Disposal S�m: ❑ Municipal 60rivate Well - 0 Municipal n Site Disposal System 0 CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY RFr t RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record` au,n�! 1 laminy 1iS�IP_? �e GCI 1C�� ivy Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES ` 3.1 Licensed Construction Supervisor: Not Applicable M Licensed Construction Supervisor. License Number: co Address: Expiration Date: al Signature: Telephone: Z 3.2 Registered Home Improvement Contractor: or: Not Applicable _V Are you a Home Improvement Contractor subject to (780 CMR-6)? 0 Yes 0 No J If No,go to the next section! Are you claming exemption from the requirements? ❑Yes 0 No 0 If Yes, submit the required affidavit! iCompany Name: e� A _ as Address: 9�j Registration Number(if none, state"none"): 3.3 For Residential Remodel Work Only Expiration Date: PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE Af:r'sSS 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 ❑ I am a Homeowner performing all the work myself Owne _ Name(print) 4 t� gnature. By signing e, e homeowner acknowledg es ges that there���eyto the Guaranty Fund ! Date: //1771Q .. 1 3.4 Homeowner Exemption-One&Two Family Only 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 shall be engaged in directly supervising persons engaged in construction,reconstruction, Conte in Section 178A, Sr structures,unless he or she is licensed in accordance with the rules and regulation alteration,repair,remora'a deflation_ -may 1,1982,no individual Supervisors. sery lures promulgated by the BBRS entitled Ries and morel elementsineo of uct ongs Exception: Any Homeowner performing work for which a Building Permit isfcrz nit atLi ifa Homeowner o Construction engages a person(s)for hire to do such work,that such Homeowner shall act as requiredbe horn the Prov�ats t'as For purposes of this section only,a"Homeowner is defined as follows: Person(s) fiat Homonw hi the is,or is intended to be,a one or two familystructures vita owns a Parcel of land c which stun riles er o•e home in a two-year period shall not be considered a Homeowner-ed or detached accessory to sum use arhtlror;arrm�'--�� "> b reside,on which A pes-he who constructs more than If you are applying under this section sign below: r / Signature; b 4 lift,St•//j/' / our signature carries certain responsi.Fles,including .ri - ly limited to,general liabeay NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructic 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) Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provi e t affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑Yes o SECTION 5-DESCRIPTION OF PROPOSED,WORK(Check all applicable) ❑Deck ool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove c" ❑New Construction* ❑Accessory Bldg. ❑ Roofing/Siding ❑Other (Energy report required) - (Shed/Garage) (Specify below) ❑Addition 0 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): 0 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 proposed work: Ckju-e r-roxYtd -pan / /1iL 3y 6-ESTIMUATED CONSTRUCTION COST r, �; _, Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 4. ean Mechanical Plumbing 4. Mechchanical(HVAC) 5. Total=(1 +2+3+4) SECTION 7A-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) s (Please Print) �'p /_ I, �C ,SYa tt7 Q vet zCT{� , 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, li/ 1t'ny l) ( , as Owner/Authorized Agent hereby declare that the statements and information on the foregoi g application are true and accurate,to the best of my knowledge and belief. Signed nder the pains and nalti s dy- 07(/ (971? 7 Signature of Ow r Authorized Agent ate SECTION 8-INSPECTORS 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: Inspectors Signature: 4 P - " ! 25f— Date: 7/ `r� / :'_.` '; va SECTION;9 ` PPLIEANT NOTIFICATION Applicant informed of above: Date: Mo2 Time: / 11PM Clerk: Comments: e • SECTION 10-OFFCCEIINSP.ECTO/R�'S NOTES 0' d d Less Application Fee: $25.00 6-0,00 Remaining Balance: $ —'t-' Total Permit Fee: $ /y Other$Amount$ / TOTAL FEE: t tam' f e Gross Area-New Construction total sq.ft. (O / .S P/. Gross Area-Alteration total sq.ft. Permit Issued to: /noST/lc/ /9/SUVt JCA76 v ✓ o / 70o L- 3 %X / SECTION 11 -ADDITIONAL COMMENTS/SKETCHES C (ee c ,,G s ff fit( ._.0 / 9 ' k /e7 iLi 3 c'e5 ? 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Q r®. ® *91 ,l , t 1 00 z ku — A i= t. o W Vv... . 3 • Page 0 of 0 ESR-1481 at COLONIAL 6EBTION U4560 4280 1100 I11111I1I!I111111111I1i11 . 3972 IFI�I-;16110111111111 70111111 1 - FIGURE S Typical Note: The uee of the post cleave Installedover Insert other than thou describedln this report Is outside the scope ankle report. GL COLaOALSECTION PAM 71 SpEt 4280 CO 26 GoLpF7NCH DRIVE' : �A 11 00 11IIII�LIILIl11 ,. * par_ SocFinem IF488 tetttttttttttere TRADE flM K 7873 � Tb TOP of coM POS ITf w /(ANDR.kIL 34Ida RAILING-S FIGURE /` an.vwrDF1UN5ECFiON a 3.•.`lfc_".-:.SPA.41cNla 104560 Q r tto.... , a 4280 • Lao QAw s E/t pp S . S IIIII I I II I!I I LI'I I lilil I III��_II L 3238 pass I111.Jin 4.L eW� FIGURE 8 61.VICTORiAM gCIIDN i1.56O 42ED Te.000 IREFI 4200D IiIiIIIIti1iIIIIIHIk 44000 8 393: I' 1.111441111 �8i u. a FIGURE 9 __ _� �. n ... o.eror+onr CT'QT PPP]/PTUP 1,11 lig _ z itili z o X o a ! xbl h � 2 \. \ A i-• o - - • Y.-- --'"••••,) •••1) e_ ol o C _ 14) CZ 4. 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Q 004 1 'a tuR • ; i ' N;F- F> sc K Lu co ,� s� 11).4 . , y , �c.-, ' CIe - + ' TtL � - ' I ; k 4'1 ^" r)i Pore 4/1-Le 2/0 r Ciatiej . 020i \ „ �^ i 1 /.5bFe.GE 26 Go/b wr h 4, -dove l5<du.� r // DRAINAGE — - 2101'S2" W _ 281.16 - 100.00' aJ o 1 .03',., EXISTINCz / l IN WELL(, fi pROPDSED DECK T Nx (MOULT vpo0 ExtS'. DRAINAGE EASEMENT / 41 O �,� . QEZk KEM t_ovh c/ `, o A 4-) //2EXISNGI DWELLING N' �� o_ T O.E:=1 17.1 7 // / ,,..,....-TANK �R7 /` °0 FILE CO - yr cc) - I PLAT #66 LOT #2-77rn PLAT #66 SUBDIVISION LOT #20 0.. 40001 SQ. FT. 0.92 ACRES o co / 'e a /f' .w---W DI; �°. INSPECTION �' t 1 PORT 127 / \ / t N 01212 109.73' `\ N 14'57'10" E / / I CERTIFY THAT THIS SYSTEM HAS BEEN BUILT IN COMPLIANCE WITH THE APPROVED DESIGN PLAN MEETING STATE AND LOCAL REGULATIONS WITH RESPECT TO ELEVATIONS. = INVERT SCHEDULE LOCATION DESIGN AS— �x» AT HOUSE 114.95 114.95 BUILT INTO TANK 114.62 114.62 ASEMENI OUT TANK 114.49 114.49 IN O D-BOX 113.93 114.01 OUT D-BOX 113.76 113.85 B� �N� END OF F�ID 113.50 113.57 El r : E ' m af4f .©I / 1 N' �asek .fiTM +.-G a - 1 O� eN9iI ° ...„... \ C e,„ O 1 cico 1 TRIBUTION -0 -2 c) BOX I O� Ci/STE�� t�Q� SEPTIC SYSTEM AS BUILT PLAN OWNER: TO SION LOT #20 NY SOARE(SONGB S GOLDFINCH DRIVE IRD ACRES) PLAT #66 LOT2-77 SUBDM kli DARTMOUTH, MA / \ \ / ENGINEERING FIRM: i SITEC, Inc. « 5 W FAX<` )O9&7554 / ' DATE: AUGUST 01. 2006 Sf(F• 1' = 30' CONTACT PERSON: STEVE GOIOSA ACAD NO. k7LE NO. 08-3702 2-3m.tlir 2d Cf 0Z L)?7iWz ' �� �GLiL L! i/D� 'I/<2Ld'I The Commonwealth of Massachusetts w— Department of Industrial Accidents 1 -:riii=(I Office of Investigations .17 1.ii,=r ii1=y 600 Washington Street =TiI_ , Boston, MA 02111 ter, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indii/viddual)):: n �/�f}2�` // Alt e Address: 0262 GO/CC Cif? /'J Ze v`C l p City/State/Zip: ( Phone #: cs51'917 5 —/ cooUT` c3 6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition o workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12,0 Roof repaip „ insurance required.] t employees. [No workers' 13ther u�/v t"�fJ� comp. insurance required.] l *Any applicant that checks box RI must also fill out the section below showing their workers'compensation policy information. t 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 it the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(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 certif under the pa' s and enalties ofpe ry that the information provide above is true and correct. Si natur Date: 0?(/ • - n� Phone#: (5(XJ - 73/ 9 Official use only. Do not write in this area,to be completed by city or town official E pyCity or Town: Permit/License# TEL ` ' u Issuing Authority(circle one): I. 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 number(s)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, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.rnass.gov/dia l 1 .wl 3;3. // DRAINAGE — S 21.01'52" W 281.16 100.00' -- — 161 .03' k ,// EXISTING / \WELL DRAINAGE EASEMENT / o 00 ln���� Mp I EXISTING o rU/h�. f DWELLING N- qa� o- I.7.F.=117.1 / K N.-1-/ V - - SEPTIC TANK N / I u' ! / - r atM Ocb• cn C m PLAT #66 LOT #2-77 ul ss Q ^ PLAT #66 SUBDIVISION LOT #20 Lo- 40001 SQ. FT. 0.92 ACRES ---1 0 on c r- DI: o t° INSPECTION Nv_.... 1 I PORT —�21- \ i 69 226 1 ---- N 01 Z1 1 ' \ I 109.73' \ N 14 57'10" E / / I CERTIFY THAT THIS SYSTEM HAS BEEN BUILT IN COMPLIANCE WITH THE APPROVED DESIGN PLAN MEETING STATE AND LOCAL REGULATIONS WITH RESPECT TO ELEVATIONS. I I INVERT SCHEDULE LOCATION DESIGN AS-BUILT AT HOUSE 114.95 114.95 INTO TANK 114.62 114.62 EASEMENT OUT TANK 114.49 114.49 -'j 20.13 - INTO D-BOX 113.93 114.01 `.I i \ OUT D-BOX 113.76 113.85 N � � _� ° END OF FIELD 113.50 113.57 M!O z N n J co J J V} (P Qi ,o I DRAINAGE i , EASEMENT \ / 1 / ' i i - `iA=40. 29 . (\\ I \ t 1 ��(. 1, 'n TRIBUTION �' eox q I 9 9,c o Q O,( 9/8 it?` t1/ ' ass/0 NC\\ SEPTIC SYSTEM AS-BUILT PLAN / owNER: TONY SOARES GOLDFINCH DRIVE (SONGBIRD ACRES) q / PLAT #66 LOT #2-77 SUBDMSION LOT #20 DARTMOUTH, MA \ O / ENGINEERING FIRM: SITEC, Inc. « VA�46 / a 1~IN N FAX(506)999-7554 / DATE AUGUST 01. 2006 SCALE: I" a 30' CONTACT PERSON: SIEVE GIOIOSA ACID NO. IFILE NO. 06-3702 77,3 L=CCj 2G COLdFiweH 61 AoZ. L, -c/ovT 1/23/61 % / /5D..feeE 26 Go/bt bit rvc Al it b,e «th.cs r / DRAINAGE - S 21'01 '52" W 281 .16 - 100.00' - - 161 .03' ` // EXISTING / , \WELL DRAINAGE EASEMENT / o A. 0 1,1��� �A EXISTING o `il\/^cv/ /' pv DWELLING (-7 q° o- T.O.F.=117.1 / SEPTIC CD / V/I o cn 1 / rn ih 0o. U, SS' 4- m PLAT #66 LOT #2-77 ki PLAT #66 SUBDIVISION LOT #20 �- 40001 SQ. FT. ZO 0.92 ACRES 0 L oP 0 DI c _i I" DI I 1 �= INSPECTIONS PORT �21� ' / 69 42 5 14 \ C 1 N 1212 109.73' \ N 14'57'10" E / I CERTIFY THAT THIS SYSTEM HAS BEEN BUILT IN COMPLIANCE WITH THE APPROVED DESIGN PLAN MEETING STATE AND LOCAL REGULATIONS WITH RESPECT TO ELEVATIONS. ' I, ?kit/0/7 INVERT SCHEDULE i LOCATION DESIGN AS—BUILT AT HOUSE 114.95 114.95 — INTO TANK 114.62 114.62 EASEMENT OUT TANK 114.49 114.49 — --- IC20.13 'i INTO D—BOX 113.93 114.01 'v 1 > \ OUT D—BOX 113.76 113.85 ^c) Z END OF FIELD 113.50 113.57 1 N ^ J :el . (oI (JP a DRAINAGE I I EASEMENT \ Ir >/ / \� - A=40. 29 ' 1� 2 P09 � N 00 \ IN ao ' ffRIBUTION �' � v `'� .CL) Sia BOX (a I 19 94 G/STEP` <(Q I ASS/0 N�� ytc / SEPTIC SYSTEM AS-BUILT PLAN OWNER: TONY SOARES GOLDFINCH DRIVE (SONGBIRD ACRES) A / PLAT #66 LOT #2-77 SUBDMSION LOT #20 DARTMOUTH, MA \\ steel O / ENGINEERING ARM: SITEC, Inc. «"� �� I / 0.6 M .I1se..IN kS...b. FAX(506)YB8-7ssI 14 Ms Pg / DATE: AUGUST O1, 2006 SCALE: 1' = 30' CONTACT PERSON: SIEVE GIOIOSA ACAD NO. !LE NO. 06-3702 713Pi Ct 2o C ozbFiweg IooZ. L,?(/ocr' 1/2sA7 0 SPECIAL PERMIT(Per 780 CMR 111.13) _ $95.00 APPLICATION FEE IS NON HE•FUNDADLE & NON-TD:ANSFEIIAIILE e �pVTN N DARTMOUTH BUILDING DEPARTM1�1,'I'�; f '�1 �'`� DATE RECEIVED /o-�M- yam` !t'�.i�r-i; - O� -o.= \t. l t ;o 400 Slocum Road, P.O. Box 79399' ' t i V Dartmouth, MA 02747 �, < JUL . ap �_� - 77 .iUa_ 2LrNl �U' k1 < sY Phone: 508-910-1820 Fax: 508-910-It$ $ �bd� www.town.dartmouth.m a.u s APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING '.THIS SECTION FOR OFFICIAL USE:ONLY - tr RECEIVED BYtr- �`'1 w"`s-,' s BUILDINGPERMITNU,M9ER /.., s' sit Y a z fr" t- °°, Y `"4'+. S� Y �� � Y ,C. 3 av DATE SENT FOR REVIEW 2 Ott DATE,ISSUED O I< TO ISSUE SIGNATURE " , fi' ` `+ '. a1,, DATE 4. Zoning District Proposed Use Zone- ❑C U B ❑A ❑V' Aquifer Zone > a3 J THEF,OLL':OWINGAGENCI S.SHOULDB_E_ ,,:- , D: _ _ - _ 5 X ❑Board of Board of��yt�� ' j4 �,- ' O Derpo , s❑DPW Elec - i ❑.Energy Report r Appeals Health t.�YJ}jr ;Ca �sion s Affidavit CardSent uRt CutOff . FofloW up ff O Water Card ❑Zoning O'Fre = ❑Gas 17�Plammn ❑Sewer Card g. I70ther Chief Cut Off Board -,, ,ry Gut Off Cut Off w 47. `REQUIRES CAISPEC�t'OR'S REII ENTAG BEFORES I HE ISSUANCE O A PERMIT - - - ,;. :DEPARTML APPROVAL _ .. _ . - `�. . Ming RSVAIew: Signature: Date: Vergy Rprt: Signature: F Date: .�__ ILA K, e Ghief:_ Signature: Date: J : iEmmission: Signature: ,l/ Date: —�� Other: Signature: e. Date: r q" ) Brief description of work being performed: 71/3y &Ln,,.2 q/iGL /a em,-I .'_SECTIONN I -=SITE INFORMATION,u.: _, / 1.1 Property Address: c (0 G old --6r r kj --by i W{' 1.2 Assessors Map&Lot Number: Nearest Cross Street: •;/l( k�i8�(.l I Map 4 6 G Lot P. - 7 �7 Subdivision Name: c �,Y"1(tY I r le e S 1.3 Historical District 0 Yes r}���n'o Total Land Area Sq. Feet: Has application been submitted to the 'stone Commission 0 Yes ❑ No Date: 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal Syst m: ❑ Municipal [Private Well ❑ Municipal n Site Disposal System El CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPOR1 . # 17 RI�HTVO,, u a $I,' 90.00 i. -1 i d T -:Yir 9 hf THE COMMONWEALTH OF MASSACHUS lc:'1"!S :Town of Dartmouth=Board of Health Type of Pool Above ground Pool U� Lorafion: Plat 66, Lot 2-77,26 Goldfinch Drive, Dartmouth, MA kG� °"� Danny &`'Tammy Tisdelle contractor' George VPools :vc 190 GAR Highway, Swansea, MA 02777, A . . , ii r _,,,, i. Date iul, 24, ai ell !do &uscl- it *fAh 7c,. a,� r�f� , THIS O or ,3`.o.Fc- s-/ we to be v99--iia�/re B I ' TRUCIED AS DESCRIBED IN'THE APP TION FOR THE SWIMMING POOL fit. . Inspec or, ! Signature o pplicant U r ✓ • •