BP 1998r .
BUILDING PERMIT ISSUANCE
i
DATE: / / /1// ?
ADDRESS: a ((At,-- -,e_ ..
IL® _ ,,Ki. it
After review of your application, the following items are needed before 1 \
application is approved: \
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2.3. / ` i,41\ '' ''
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Balance Due: $ /� -
Left message with: Time: \
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COMMENTS: ) i ' �-' Di? n I M
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TOWN OF DARTMOUTII BUILDING DEPARTMENT
TELEPHONE 508-999-0720 FAX 508-999-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Instruction The applicant shall complete this application to the best of their ability prior to submission,leaving no item unanswered.The
Department staff will be available during regular business hours to assist as necessary.WA should be inserted for those sections
which do not apply.A properly completed application will help avoid unnecessary delays. Netus Rig fees ant rdweiiie.
(for office use only) ❑FOUND TlQluj-ONLY
Total Cost $ Received By__ay)._ Date Rec'd, '
Less Application Fee$Total Permit Fee $ Permit# V Issued Date
et Er
100 LOCATION OF PROJECT TOTAL LAND FEET -I ao 0
CURRENT ACCESSORS' PLAT 66' LOT 2-i3 ZONING DISTRICT
OTHER ZONING OVERLAY DISTR'TS , if applicable
NUMBER & STREET 3 firer L. aY1-e
NEAREST CROSS STREET 5 C)11ath�+rcx D r v C
SUBDIVISION NAME & LOT# SO n -j, A f.r e) L of 7.5
or BUSINESS NAME •.'t
PREVIOUS TENANT / OWNER A soil ea l-AI
200 RESIDENTIAL-PROPOSED PROJECT- one & two family residence only
THIS SECTION NOT APPLICABLE
Single family - number bedroo AIL er baths
k
= Two family - number bedrooms um1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. ft. 'i I
Accessory structure: ...
Garage - detached - attached to dwelling, dimensions L W
E Carport- detached - attached to dwelling, dimensions L W
L. Shed - dimensions L W
r
check- dimensions L 1.� W t'v
= Gazebo - dimensions L W
= Swimming pool above ground in-ground Size
72 Chimney - number of flues
Woodstove - used (will require inspection prior to installation), new (provide manufacturers
instructions). Location(s) (list)
C Fireplace(s) - (includes flue) List location(s)
Game Court-.describe (include overall dimensions)
C Tent, Trailer(Mobile Home) or Other-describe
300 COMMERCIAL,-PROPOSED PROJECT/USE-INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
C THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3,AS NOTED) (See the
Code)
C 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 over 2 years 9 months(see Code Section
304.0)
- Factory/Industrial - (see Code Section 305.0)
- High Haza-d - (,ee Code Section 306.0)
- Institutional - hospital, nursing home, infant day care(see Code Section 307.0)
Mercantile - retail stores (see Code 308.0)
l.,
Residential - three or more family, hotel (see Code Section 309.0)
Storage• includes garages(see Code Section 309.0)
C Utility & Miscellaneous Structures -includes tents and _.gricrdtu al structures (see Code Section 311.0)
C New tenant for any of the above, indicate above(see Code Section 119.0 and Zoning By-law section 35)
C Tent or Trailer- temporary purpose?
C Other
Describe the proposal briefly,INCLUDE r+umber of
also existing condition dweIImgmitt and bedrooms or occupant load asapplicable,
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
C New Construction and/or( • total gross square feet
(For commercial only total gross cubic feet) -indicate
It will be considered new construction if there an increase m square footage in addition to any
alteration(s).
If project is an addition to existing structure- Total gross square feet of existing
C FOR COMMERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL(over 35,000 cult.)_Yes_ No. (If yes
see Code section 127.0). Designer to submit Cade Synopsis.
Will this project require Peer review(over 400,000 cult) Yes
APPLICANT TO PROVIDE _No (see Code Appendix I)
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
Demolition"- describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration required.
._ 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 existing
Number of layers when complete
A separate disposal declaration REQUIRED
Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be
enlarged)EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for
residential and Articb 8 fcr commercial)
Temporary structure-includes when allowed,trailers,tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
_ None submitted. Why?
-�bmitted, usually three sets required. Four sets for food sexvice(uses. Number of sets submitted
600 SITE PLAN
❑ Not required,why?
:P ubmitted When? Previously, date C With this application
700 U'IT ITIES
Water supply - required_ yes_ no, public ? _yes_no, on site well? _ yes_ 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 water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required_ yes _ no, public sewer_yes_ no
private septic - on-site _yes _no. Submit copy of permit as soon as available.
1
800 MECHANICALS & PRIMARY FUEL
= 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
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE 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
I NOT APPLH'ABLE
- Parking Plan submitted To = Building Department C Planning Board Date submitted
Number of spaces - indoors outside total provided
H9ndicap spaces - required_ yes_no. If yes, how many as a pert of the total required 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 IDENTIFICA'7ON(print or type except as noted)�
i
Current owner- name I!1 Gr'e✓1 L rr
7 Cu :�70•7, Nungcs
A
address °Y Livl e'�7 k !1
phone# Ylv. ?96'-2.706
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 plans, affidavits and other documents SHALL BE originals and not
reproductions.
Architect/Engineer-project supervision and reports •
Company name
Address
Phone number
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 name in[7 (e Yl G�y l-. u 4 O i'Yi
Address 4 (A Jca' I/61 )9 ,
Phone number (5-nR) Y9 51700
Construction Supervisors license number G/ln -4
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
ZZZZZZZZZZZZZiZZZZZZZZZZZZZZZZZ ZZZZZ*muss Ziit ZZZZZZ ZZZZZZ ZZZZ*****
1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (7S0CMR-6) ? Yes_No_If no go to next section!
Are you claiming exemption from the requirement? Yes No If yes, submit the required affidavit!
Ren_odel contractor name(please print)
Address
Registration number(it none state"none")
Phone number
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
Owners name (print)
Signature
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 in 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 begun or
six months after the last inspection if work has begun and that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request.I understand that once the permit expires a new application may be required,including fees and current
other requirements (including Zoning). y�/�
Name ZC/ALI Inv 'revicy
Signature (3iilt �, vrn®/it.n./.4--c)The above signature is my vooltary act and is signed under the pains and penalties of perjury.
Date 9-2-y45-
Who is authorized to ickup the permit at the Building Department? fpleaseprintl " , 4Oft jueipA
Address Wei '"Z,(J,7
Phone ('S(if%) r/Y.f-57GQ /
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 individua
l 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 rt<ies and regulations promulgated by the BBRS entit'ed
Rides and Regulations for Licensing Construction Supervisors.
Exception:Any Home Owner performing work for 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 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
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,Y:fffffff.YYfYffffffffffffffffffffYf******:***********ffffff*****fffffffffffffffff*Yg general ffffliabtlityffffffs
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
2.15.2 of section 5)
YY Y Y YY f Y Y f fY fYfY Y Yi Y fY f f ffYffYf ffYYf Y f f f ifYfifi
1500 COST C��
Cost of Improvement S ,,UU
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other �'� /'/�
TOTAL $ !)� 0 4+
6
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
L OK to issue date
OK to issue subject to requested submittals (see project review worksheet) date
7. DENIED see project review worksheet date
I - HOLD reason
date
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature / 2,
- ` Date 4 57
- Applicant informed of above- Date time staff
(fax, phone, in person)
YYYYYYYY___YYYYYYYYYYY Y YYYYYi Y YYYYYYYYYYYYYYYYiitiYYYYYYYYYYY YY YYYYYYY Y i Yt Y
Over six months since approved for issue- DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector
DateLi
Advised applicant Date Time_ staff
(by phone, fax or in person)
YYYYYYYYYYYYYYYYYYYYYYYYYY YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY YYYYYYYYYYYYYYYYYYYYYYYYYYYYYY
OFFICEUNSPECTORS Nr�
TOTAL FEE f O
Gross area - new construction /v'O Total Sq. Ft.
alterations�-- � Total Sq. Ft.
Permit is issued to l,[y.(•e•r��(�r 4` f a X /a dte
Comments/notes on permit /
7
1600 TO THE APPLICANT/REFERRAI,AND APPROVAL
Date of Application submission 9-�-9g.,
Plat&IC Lot 4-13lmSb.eet (S (I I,L-R. __
/� t p /� Aquifer Zone_
Owner � /�r' tint f a( /� g6--ncC/_
Owner mail address � /))I ��-7+ !/ M , kit"
P 1111 esla / /t-7 _I ,V
Owner hone# V u
xYYYixxxxYSY**neennvvYYxYx ene:ss Y tY YxYxYxxxYxsYsxxxYYxY YxsYSYY YY Y sY ssYxYlxssYxYxs**vs
OTHER INVOLVED AGENCIES-The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REQUIRED SUBMISSIONS.
® AX COLLECTOR C Approved C HOLD By
(7
Date
❑ Board of Appeals C Approved By -
Date
❑ Conservation Commission C Approved By
Date
❑ D.P.W. Water C Approved By a D.P.W. Sewer C Approved By Date
❑ D.P.W. Cross Connection C Approved By
Date
❑ Treasurer(Bond) ❑Approved By
Date
❑ D.P.N. Engineering C Approved By
Date
oard of Health (well) C Approved By Oi,...._._....
J Date /^� �/'y❑,/Board of Health (septic) C Approved By7 /Date W CCC li
❑ Board of Health (food service) C Approved By
Date
❑ Planning Board (parking) C Approved By
Date
® FIRE DISTRICT (I - II - III) C Approved By
Date
tat tam litittiettaltalti
BUILDING DEPARTMENT APPROVAL_
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMIIIISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
PROJECT' SUMMARY:
new construction/ alteration/demo sewage disp
osal posal - publicyrisate
[Alter/add interior w rooms] [add footprint]tP ] water supply - public/private well
[pool] [garage/she /deck{gamme court] [food senice]
Describe /_ 1 ) /0 f
xxxssssssssssxssxsssxxssssssssssssssssGs7sYassssss`sxs[s*sssassxsssssxasaazx::�.+��Y�ixsssssssssxsxxsssssssY
To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated. �5
The Building Department- Date sent for review �'3 /� v X,� 3
By C..C<�
1
S
NE 7
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The Commonwealth of Massachusetts
- (fir Department of Industrial Accidents
Office oflalirestlgatleas
600 Washington Street
kra-a-k-07Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name: 2 ;AJO Ma R e).1 •
Cy
location: '' /- uu e!67 `TS ,
city 7rrJ el x \ 1 ek-ccvc {U a , nhone# 7a�n(cCik\99t —9700
• I am a homeowner performing all work myself.
0—Yam a sole proprietor and have no one working in any capacity
• I am an employer providing workers' compensation for my employees working on this job.
comnanv name:
address:'
city: nhone#:
•
insurance co. oolicv#
• I a'n a s-'e proprietor,general contractor,or homeowner(circle one)and ha•. -Mired the contractors listed below who have
the following workers'compensation polices:
company name:,
address:
city: phnneft
insurance co. policy#,
•
comnanv-name:
address:
city: ohone#:
insuranceto
Failure to secure coverage as required under Section 25A of DIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains laanndd ena/ties of perjury that the information provided above is true and correct
Signature ! ✓�I�(1� ._ ( y�y�.¢n�� Date �/—c�-9B'
Print name RIAki I f I()r.en 07 Phone# (s v?) %4 -970C)
official use only do not write in this area to be completed by city or town official
city or town: permit/license# °Building Department
°Licensing Board
0 check if immediate response is required °Selectmen's Office
°Health Department
contact person: phone#: nOther
f rrnsrd 3/95 PJA1
•
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.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers 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.
y
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.
y;
The Department's address, telenhcr._ and fax nu-t:i. — ----- — _
The Cottt15.::a,..._ith
Department ol 7adustrial Ae :51-2aw
dfficc of tnuesfiylaticus
600 Washington Street
Boston.Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406. 409 or 375