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800 MECHANICALS & PRIMARY FUEL
- Furnace (hot air) - Fuel gas (natural or propane), fuel ^oil, electricity, other (specify)
-tlBoiler (heating)- Fuel gas (natural or propane), fuel aiI electticity, 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 V
Other
900 SPRINKLERS FOR STRUCTURES OVER 7500 SQUARE
Q ARE 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
a•
Number of spaces - indoors'
outside oZ total provided
Handicap spaces -required YeS no. If yes, how many as a part of the total required
q 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 IDENTIh ICATION (print or type except as noted)
Current owner name To I1v � %�q ^a VO
/ uG�taK/
address7:�� /
phone F
If corporation• officer in charge
Architect/Engineer for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all lans, affidavits and other documents SHALL HALL BE originals and not
f
Architect/Engineer - project supervision and reports
I
Company name
Address ;
Phone number
I
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 nameZ.
Address S 4 20 e Q c /e -e
Phone number O 7
Construction Supervisors license number �� y
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes _ No If no go to next se.rction'.
Are you claiming exemption from the requirement? Yes _No _If yes, submit the required affidavit! "
I,
Remodel contractor name (please print)
Address
Registration number (if none state "none")
Phone number
i
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
I
"Owners name (print)
Signature
I
Date .
1300 OWNER SIGN - OFF
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 ini'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 issue, if no work is beguin or
six months after the last inspection if work has begun and that the permit may be extended for six months if no wotrk is
anticipated if I renuest curh nn PvtPncinn in writinn_ I understand that the permit may he Pvfan,4ari nnly three timeec hu
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
Name TO /J �cc V rJ
Signature -
The above signature is my voluntary act and is sig ed under the pains and penalties of perjury.
Date L3 (P
Who is authorized to is u )p, the permit at the Building Department'. (Please arintt o �t c
.Address & S 8 �� ��- a ! C? � v 2 Phone ' 1g 7 - 70 & i
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY 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 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 Home Owner performing work f6t- 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 only, a "Home owner" is -defined as follows: Person(s) who owns'a parcel of land
on which heishe 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
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, 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
2.1- ' of section `1
1500 COST
Cost of Improvement
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other
TOTAL $ t114,
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Dc--cltration required.
Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration rege�,ed.
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 exir;ting
I
Number of lavers when complete
i
A separate disposal declaration REQUIRED
= Replacement doors and windows - (for existing only) (only where doors and windows sexist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an exuding dwelling will be
considered as an Alteration, otherwise will he included in new construction. (see Code section 3401.10 for
residential and Article 8 for commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limrited periods of time.
Describe
500 CONSTRUCTION PLANS
_ None submitted. Why'
i
IZ Submitted, usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
❑ Not required, why?
Submitted When? - Previously, date TL With this application
700 UTILITIES
Water supply -required yes _ no, public ? yes _ no, on site well !/ yew 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 µrater supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal required e yes _ no, public sewer _ yes no
private septic - on -site Jyes no. Submit copy of permit as soon as availaiole,
I
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Instructions). Location(s) (list)
01 Fireplace(s) - (includes flue) List location(s)
El Game Court - describe (include overall dimensions)
Tent, Trailer (Mobile Home) or Other - describe
300 COMMERCIAL - PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
u TFIIS 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 overt years 9 months (see Code Section
304.0)
Factory / Industrial - (see Code Section 305.0)
= High Hazard - (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 number of dwelling units and bedrooms or occupant load as applicable,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
)/New Construction and/or Addition - total gross square feet / F 7,7 S T
(For commercial only total gross cubic feet) indicate
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
If project is an addition to existing structure Total gross square feet of existing
4 FOR 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 No (see Code Appendix 1)
APPLICANT TO PROVIDE
❑ DENIED see project review worksheet date
HOLD reason date_
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature Date
Applicant informed of above Date time staff (fax, phone, in I)erson)
J Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector Date
Advised applicant Date Time staff (by phone, fax or in person)
OFF MINSPECTORS NOTES
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
i
I
Permit is issued to
II
Comments/notes on permit
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-----------LUVI_ AND APPROVAL
I ,
Date of Application submission
E
Plat Lc Street (� Aquifer Zone
Owner
I
Owner mail address Ct
9 - k-J41U
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`( 3_
Owner phone # �
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT TEEM FOR REQUIRED SIIEMMMONS.
e,ns13
COLLECTOR
Approved BOLD By (1 !" ✓lt1�fJ 4 Dt
ervation Comm = Approved By Date
❑ D.P.W. water = Approved By Date
❑ D.P.W. sewer - Approved By Date
❑ D.P.W. crossconnection = Approved Date
❑ D.P.W. engineering Approved Date
1323 oard of Health well = Approved Date
oard (4 Health septic - Approved Date
❑ Board of Health food service = Approved Date
RE DISTRICT II - II - III) = Approved Date
❑ Plannin¢ Dept Approved Date
Othcr _Approved Date
I
Other — Approved Date
C.'Mmenu
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Project summary new constructioni alterationidemo sewage disposal - puhiiciprivate
[.-'klter:add interior walls] (add rooms] [add footprint] water supply - puhliciprivate well
(pool] fgaragershedl [game courtl (food sen•ice
Describe
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
yuesdons 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 Bp
i
O BUILDING, DEPARTMENT'
TOWN OF DARTNI FAX 908-999-0738
r[L" APPLICATION FOR TELEPHONE 508-999-0720
0 ZONING AND BUILDING ERMIT
5�e aQplicant sball complete this application to the best of their ability prior to submissi0gJCaviag no'tem•etmaoswered• The
Department staff will be available during regular business hours to assist as necessary• N/A should be inser'ad�d for those sections
ddays. im:w— not
which do not apply.. properly completed application wtII help avoid tmaeeessary
(for office use only) ed b Dote
Apphcatw n 1
n fee S received
Total Permit Fee $ Permit # 16,�..�
`T �)
100 LOCATION OF PROJECT
CURRENT ACCESSORS' PLAT
LOT ZONING DISTRICT
OTHER ZONING OVERLAY DISTRICTS, if applicable
�-
NUMBER & STREET o
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
3 S o r✓ , 'l2�0/�c�' �P
or BUSINESS NAME
PREVIOUS TENANT i OwNER
200 RESIDENTIAL - PROPOSED PROJECT' - one & two family residence only
= THIS SECTION NOT APPLICABLE
:' Single family number bedrooms number baths
Two famiIv _ .number bedrooms unit 1 number baths unit Inumber baths unit 2
number bedrooms unit Z
s Accessory apartment Total gross sq. ft.
YAccessory structure P e c %R X /
_ Garage detached - attached to dwelling, dimensions L
Carport detached - attached to dwelling, 'dimensions L
Shed - dimensions L w
Gazebo - dimensions L
w .Y
to
Swimming pool above around in -ground Size ® 3tal square feet
Chimnev - # of flues