BP-2004-36605 Permit No. BP 2004 36605
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TOWN OF DA TH
'" ' l°� .- E _ 400 Slocum Road,Dartmouth MA 027477 >'
Pro e k„ '2 m :a i i '"' T! Phone (508)910 1820 ?Fax: 508)�^,�910-1 � k
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PERMISSION IS HEREBY GRANTS' ` O v
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iUse u + Contractor , a teen i phone#:
-az "E ".a • $ 5 r
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r 43 i 9 f^` "-:, s.. Engineer .`, *o- LrtdCn.� 'k x ,4,Phone#:
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.�4."' Applicant. `; ' � �?, �� �u *; '�� ,>� , Phone#:
11,7�` 8d i i ALEXANDRE L FERNANDES . �,;�: , ,y(774)526-5327
OWNER: ` . J .
FERNANDES ALEXANDRE L
DATE ISSUED: I(/C/Ot-/ ya,
TO PERFORM THE FOLLOWING WORK:
Install wood burning insert in existing fireplace
BUILDING PERMIT
Project Location: 3 GOLDFINCH DR
Approved/Issued By: ale
aizet
LYNWOOD R.COMSTOCK,LOCAL BUILDING INSPECTOR
All work shall comply with 780 CMR 6TH Ed. (MGL Chap. 143)and any other applicable Mass. Laws or Codes and plans on
file.
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS
REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(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 this Building/Zoning Permit.
Signature of Owner/Agent: e e1,„Ars
Comments:
"Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)"
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
COPY
TOWN OF DARTMOUTH 3 873
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: r ' Property 1 Date / G
l am ti.A.__ FC ."..)r AS..C� _. Owner: ��i/_I�-t.,�_ /! i Sin /
Job Location: 2 / (
` i s f ,-JC EN-)l ti E'
White Copy-Collectors Office
Plot: r,- - Lot: 7 Yellow Copy-Customers Receipt
y L...." r Pink Copy-File Copy
Green Copy-Building Department
Phone: \ cji
Description General Ledger# Ref.#—SKS Amount
License&Permits-Building 01000-44105 ;- 1
License&Permits-Building Misc. 01000 44105
want \
License&Permits-Electrical 01000-44106 E
License&Permits Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 704
kr This is not a Permit or License for Building.Plumbing or Gas Received By: ' `� 3
( —
TOWN OF DARTMOUTH 36605
7k BUILDING RECEIPTS ; i
1 --iii % I COLLECTOR'S OFFICE "` /:
Name: _ _ - Property �•, Date / % . /1 V
1 .1 - :l l i lt`�C J Owner: . 1 ' --k -_—" l/ l �- f
Job Location:.C t /: f i .
-- white Copy-Collector's Office
` .../ - - Yellow Copy-Customer's Receipt
Plot: / / Lot:
Fink C File Ca
r-- Greer Copy-Building Department
Phone: - \ \ 5 1; z.. C ti
Description General Ledger#'s il of#"� r�sy ��" ' Amount
•
License&Permits-Building 01000-44105 / cJ A � j
'ir
License&Permits-Building Misc. 01000-44105 �- EJ /r
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: f,iv/ , l
✓RESIDENTIAL ❑ FOUNDATdON,ONLY 2004
$25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE
°°T"'?'M DATE RECEIVED
°�'ee :; DARTMOUTH BUILDING DEPARTMENT
o>r :e=' 400 Slocum Road, P.O. Box 79399 r
3° >v Dartmouth, MA 02747 I G
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFNPL iUUSE ONLY
REC D BY - • " 111 DI1tIG PERMI I N E+R.
rkan.'{F'4 :;. qF. �m � � 1,��.� •.a. s✓*a tttxv�r:':p a-�
OKaTO SIGg4WRS "• t � / DABE'
- +: eomroievioaer/Inspector ofBaildutgs .- _
Zoning District$ Proposed Use: F P2 ir-Zone: 'C B u A 0 V Outside Flood Zone ❑s Aquifer Zone
#:.t• ,ti s ;m:"-.THE F0LLfl1gINGAGENCIES.SW IULD BE NO1HriP,Il m
i»v '� �t st?w.x
.+ " �;4 �.
C$oard f,4 ❑Board'1 t o;Con Comp Y ❑"Demo C DPW 3 ❑Elec. Energy Rep i ,
Appeals ;�. Health. Affidavit m ry Card Sent. Cut Oft 1'+rFollow-up*
Fire„ - ❑Gas ❑Planning Boarfl°, ,C Sewer Card°-- ' o Water Card z r ❑ Zoning U Other
Chtef« Cut ofl+aaft fw.`: 4 I /Cut Oft t t" :14 I Cut Oft' t R evie+ 't # Wt
ro ``". tP 'r4w4:4 SSUAN +EonaiskiviTT:REQUIRES fN ET3$SREVIESBEEURET
• DEPA$3iVEiTAAPFR53
'
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:
sBl TIN1 SITEIi1FORMATIQN
NUMBER OF PLANS SUBMI El ED: SITE PLAN SUBMIFl ED: 0 yes no
1.2 Assessors Plat Lot Number:
1.1 Property Address: a 6OLL re ttlet4- 1.) .
Plat Lot d
Nearest Cross Street: ReD
Subdivision Name: ft./6 662G1 1.3 Historical District ❑ yes 0 no
Total Land Area Sq.Ft.: red !7Q P Has application been submitted to the Historic Commission?
0 yes ❑ no Date:
1.4 Water Supply(MGL c 40§54): 1.5 Sewage Disposal System:
Municipal 0 Private Well ❑Municipal ❑ On Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev.January 1,2003
RESIDENTIAL 2004
ON 2 ROPERTYOWNERS.II•Y AUTHORIZED AGENT'". " > i��
/f/��
'�
2.1 Owner of Record: COCA Lait feet '"7 /0 77v 4
62--FAliveitiw L - re7LR/nx,ve s 6c - ntvctd DR- ,moo&-g9.S-3 Fola
Name(print) Contact Address Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name(print)
-, SELPION 3-CONSTRUCTION SERVICES -
3.1 Licensed Construction Supervisor: Not Applicable
Licensed Construction Supervisor License Number
Address Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor: Not Applicable El
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!
Company Name Registration Number(if none, state❑ noneo)
Address
Signature Telephone Expiration Date
3.3 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 02108,(617)727-8598
Owners Name(print)
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
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures go%emed by Construction Control in Section 116.0.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 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 a person(s)for hire to do such work,that such Homeowner shall act as super.isor.
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 dwellino,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:�� /-✓ - -/ Qsp sc
Your signature carries certain responsibilities,including but not necessarily to.general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January 1,2003
RESIDENTIAL 2004
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 Appendix of 780 CMR R5.2.15)
xxx SECTION SECTION 4 kai WORTW s coWgNsAt{0 INSURANCE AFFIDAVIT(MGL,} 52 § 2$'}' : x lit
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: 0 yes 0 no
a x .::'s' a M-SECTION 5-DEScRIPTi I4 OF P4 O;1'OSEI}W;ORK'l �Ieck all pplicalile ff 74 1"k -
❑ new construction* 0 addition 0 alteration 0 repairs 0 chimney/ &<oodstove
(energy report required) (energy report required) fireplace
❑ deck 0 pool 0 accessory bldg. 0 replacement window/door ❑ other 0 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: ii/j de j4iz 1 , �fly/ '
....'. }'t , _•' * ,. SECTION- 6 E$TIMATEID CONS' OCTION‘COSTS a *6' g" ' .*A, .tz..
Item Estimated Cost($)to be completed by permit applicant
1 Rnildina
2 Flertriral
4 Plnmhinv
4 Mechanical (HVACl
5.Total=(1 +2+3+4) *Estimated Total $ 4 / 1/
SECTION 7A- ,r W NER AUTHORIZATION - n r n
(to completed when own ' agent or contractor applies for building permit)
(please rint) �-,,n
I, ' Allp as:�t ,IIIARiffig , as Owner of the s ject property hereby authorize
to act on my behalf,in all matters relative to work authorized b t is py}nding permit application.
Signature of Owner Date
*A. . SECTION 7B :OWNER/AIJTHORCT�ED AGENT DECLARATION ' `...: a ` ., I.. '...
��
IS,as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate,to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
/ak-Q. ,.. e.-_ r /a-a - o yV
Signature of Owner/Authorized Agent Date
C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev.January 1,2003
RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERABLE
SECTION S-jNSPEctoR'S'REvww/GO 1ST
•
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK 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: UA�9/J7 • Date:j74i14
xx ........
SEC N 9-: k?MACAWNOTIIuI � i t •
Applicant info of above Date: 0 Ti e: ,-0/TI,"1/I Cl rk
Comments:
SECTION 1Q QFFJCE�INSPEC 'S' e d
Total Permit Fee: $ 00 Less Application Fee: $25.00 Remaining Balance: $v�7.00
TOTAL FEE: cj, 00 Gross Area-New Construction total sq.ft.
/ Grossos Area-Alteration_ io total sq.ft.
Permit Issued To- 5 Val/� IIJOOC 1-te/&O 'i j✓/:5^F/j/ i✓J `,c 91 YCt >p,%cP
SECTION;7f 1 -ADDITIONAL CQN'CS/SIcSPO ` „ . .
L itiA/b Wofzu,\ `4 b\'nJ\ nl& Kg-vw�
',fin
it
00-,Y)� �peAcaa, / wee c% 91 c�/
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev.January 1,2003
The Commonwealth of Massachusetts
uze. Department of Industrial Accidents
Miro alivrestigavaes
/ Washington on Street
:_4aF:r.9n�:v
> 1 Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin lumbinWElectical Contractors
nnli� na:� t r a arr/ OS,�//% " ' 6 %//%/ %%%O//D//////////%%%//O�//////////////O/%%/%//O/O////%%/O%////4
name: AMP FeN A-NoG TTS -•
address: 31 b& 11
city �ta_A-tiv.00rtr l &
state: Yin t1 _ zip: O 2114.7 phone# 50 -G'g55-2O12d'
work site location(full address):
al/1 am a homeowner performing all work myself. Project Type: 0 New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
❑ I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: phone#:
insurance co. olicy#
%%/%///ii/%///%%/%%/%%%//r%%i%//%//%%%%%/%/%%% %/ %//////%//O%/%%%///%//%%%///l//%
❑ 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:
company name:
address:
city: phone#:
insurance en. policy#
7:7//i%�Aii%%/.%D%//O/%/���/%%%�O�%%/%00%///.%%%///%/%%%%% /O//////O.1///O//O//O.d/.��/O/%%/i%G�/////�/////////O/////O///1/,u
company name:
address:
city: phone it:
insurance co. olicv#
if's-n }A'dT3'Y.Hi Ili � � ��� r �.e.ZerS./�reSa
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine op to$1,50Q.00 and/or
one years'imprisonment as well as civil penalties io the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the°Mee of Investigations of the DIA for coverage verification
I do hereby/c�ertify under the pains and penalties ofpperj(uryy that the information provided above is true and correct.
�J
Sicnaturc i2 �.�,�ti ^^ '� e 7( /5 /v
°Print name "v A- L r�t?nithUD Phone fl 5O f l/L
392e
official use only do not write in this area to be completed by city or town official --
city or town: permit/license# ❑Bsldln tg pud Department
❑
❑:check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; DOther
:_.ixd S:pt.]CO3)
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 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, 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.
..... r.. s n.,. .SiMt.,... 'r ,.:.`.'-,�'x.. . ...t, gi':R`.S «t'- �3 an
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance 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.
-a.nt' a^t.s Y:+.Y(lt Y tVea'._ e 3 Yt.'{�W'1�"1xx xabT t4x r�,�'?C•fin�i ..N:1{i li'N.tri'1t" hi"7'uxe» x,..8'S
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.
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office at favestigatiias
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406
) Project No. BP-20 04-36605 Project Location: 3 GOLDFINCH DR
Commonwealths of flassackusetts
TOWN Off.DRTMOUTH � Y = ff
e a0 ti
400 Slocunl Road;Dartmouth,) A 0274)., , ..s s h 1
Pho¢e (508)410'-1820 Fax (5U8)910 1838 " ""4
BTIILDII G PERMIT casego - =
-s � os l„
FIE D INSPECTION
� � h
c a
u 3s �.t+n- arrr,-
' r ,- 'h'ta`s` _ _.--ally r`' "" :,
7 d
Contractor: License: phone#: Use" *CC rou
' a tea i i1s x.5124 �'� �
Engzneez ` License phone# �!
AIt.: to s: _t+ 4.
f
Applicant: Phone#: r 0
ALEXANDRE I.FERNANDES .. . (774) 526-5327 eilr ` £ ,,`
OWNER: Floor : . - ,
FERNANDES ALXA NDRE L : r la.,m
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK: O�i�������-li ' '=
Install wood burning insert in existing fireplace
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
4-4 f � ��