BP-71487 Permit No. BP-71487 BUILDING PERMIT
G1stt , 346soo Commonwealth of Massachusetts
Map - 006ti _ TOWN OF DARTMOIJTH
:Lot ,'0045 :q00 Slocum Road„Dartmouth,MA 02747 _
v,
Suib-Lat - '0000 Phony (S'008)910181Q r Faa (508),910-1835
Category R ROOF
.'Project# 2614 o01000 -. PERMISSIONL HERE$YGRAea,NTED TO:
EekCost: $3500.00 Contractor: Li. _cif, license Phone#, x"
Pet $7S00 - iI.
-fe'
Ill n
Corot Chet: Engineer: < `� a Phone,#'
antik:
LotSTtt{eq. t.) Applicant r { s i *Ole 9,
3Gpair 8MB ANTONIO R )ARO$A '�4' p r (508)94 -9 0
Mtdkr Zone ZONE 3
fond one `ZONE3: • DARO. ;
AROSAANTOjYfOR& - ,fai ian
Alt(oust: NIA DATE ISSUED: /4 5:,%13
hate Typed:; 10 IS 2013 § `
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof dwelling
Project Location: 9 DARTMOUTH FARMS TR
APprovedllssued By: O J�9�/itite_/ ✓
DAVID BR ,LOCAL BUILDING INSPECTOR
All work shall comply with 780 CMR dm 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.
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/Zoning Permit.
�- t2
Signature of Owner/Agent: '✓ t i'lY/- T t `�� At,
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 Serviced: Rough Frame:
Insulation: Final:
Final: Final:
Cross Connection Final: Final:
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
i
TOWN OF DARTMOUTft" Bust It E . 3-,?
MU
PHONE: 5R-910.1820 FAX f��
Name; /Gl "' Property wner: 4 `J�� / , /Property
c/ _ J/ Da'te.. ���
Job Location: 9 /k= 'i�`� `4�' 4 / /}diJ7 'J: 4 (I Lot: Y
Description General Ledger#'s Ref. # /Amount
Building & Building Misc. 01000-44105 /U - drir 9j (0
Electrical 01000-44106 �pFDARTMpv,
hog INS
Plumbing & Gas 01000-44107
Trench Safety 01000-44129 Oa 15"
Other Department Revenue 01000-42420 8 A' ?
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received.By / Nit//- ./
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
RESIDENTIAL ❑ Phased Approval(R106.3.3)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE
�/ ,
`sr:r m. LCIYCUED
tte 9 _ DARTMOUTH BUILDING DEPARTMENT DARTMr,' i,' ^I DG.DEPT.
;o fl1tj t i 400 Slocum Road 2013 OCT I S PH It -
;3 Dartmouth, MA 0274715
,`°;: .r Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
/La..--
RECEIVED BY: 1/ BUILDING PERMIT NUMBER:
, „ c‘2. , DATE ISSUED:
SIGNATURE: 49d2- DATE: /015 �7
Building Commissioner/Inspector of Buildings
Zoning District: siza Proposed Use: /c. Zone: C4�C ❑ B t7 A ❑V Aquifer Zone:
-17
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: DPW
0 Board of ❑Board of 0 Cons: 0 Planning 0 Address " O Engineering ' ❑Cross
Appeals Health Commission "t Card ' 0 ' Connection
0 Are 0 Gas ❑Electric ❑Other 0 Water Card - 0 Sewer Card
Chief - Cut Off Cut Off - Cut Off Cut Off - -
DEPARTMENTAL APPROVAL(S)= w t
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: )rll7 V K —/Z1 1//�
" x 4 ' ,SE I�QN1 -SI M.2AsseNp1/PropeyAddress: q tz Assessors M/an/&Lot Number:
Contact Person: J,WtOA) I C 11. -it `0ca Map ( 290 Lot VI -
Phone Number: S()-2 /- 9 /A_CC
1.3 Historical District ❑Yes 0 No
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built
❑ Municipal ❑ Municipal 0 Altering more than 25% per side of building
❑ Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission?
❑Yes ❑ No Date:
Revised 5/13
0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
"' ' " SECTION,Z-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2 Owner Record:
tXt//(1(Ci C` Ct - Cidl l ,( tRphc �.
r��(print) t ct Address Phone Num r
/U i /L�Cr(i d� S� O l2'�-k �n_ ctiLk o GC' ,, cs ta r//7
2.2 Authorized Agent: oa7 7-
7
�o — 4/— ?/mac
Name(print) Contact Address Phone Number
C a . k . x K. SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
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 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: /./2.7T �t-6 R ` SST,` po_ -
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 provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes 0 No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Firepla 0 Woodstove/Pellet Stove
❑ New Construction* 0 Accessory Bldg. 0 Addition ofin Siding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No.of windows_ Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): 0 Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*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
I
:: SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) ta 5- �D --
5. Total = (1 +2 +3+4)
SECTION 7A-OWNER AUTHORIZATION '
(to be completed when owners agent or contractor applies for building permit)
(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
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
1n/4
47 A-cia- ---e as Owner/Authorized Agent hereby declare that the statements and information
the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
I? , � to (5/ 3
ig toe or owner Au�ized Agent Date
SECTION 8-OFFICE/INSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balance: $ `e
Total Permit Fee: $ 76
Other$Amount$
Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
L
Permit Issued to: gT re..vt r'�. ,/62A, Att4.,;-&in C_?. Jl
. ., i 3ECTicw9;-DESCRIPTION OFWORK BI ING PERRZOM D t, «.. .; `.
Permit No. BP-71487 Project Location: 9 DARTMOUTH FARMS TR
Commonwealth of Massachusetts
lmi
TOWN O DA MOUTH , ;1, k kL__; r 11
`,,, 3 ja °' '�°
400 ue
Slocum Road,Dartmouth, A 02747 1 ;,� � , "
Phone: (508)910-1820 • Fax: (508)910-I838 g
BUILDING PERMIT �MJ .E7 m, v €, # 3
'JELDNPETON ,a$ kk
Contractor: License: Phone#: -- yy4
L 47:777;Ali:,t4
CAI }i " S it � zik? fiiL"'I .'�3
Engineer. License.' Phone#: / Ix
A heant r:• "Fr,-b p..P l .!' m 7
PP Phone#:
ANTONIO R DAROSA (508)441-9120 ;" - -a ,-
OWNER: _ W f,
DAROSA ANTONIf)/R&
DATE ISSUED: / 0i ��
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof dwelling
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The Commonwealth of Massachusetts
Department of Industrial Accidents
I F ': �' Office of Investigations
;.( c w trx- 171 1 Congress Street, Suite 100
Hr
(Le f;
._ _ Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Lep-Plla
ame (Business/Organization/Individual):
" � n
�tldr s:_
ty/State/Zip: _-„ s:; ' ,e .1,A & Phone #: 'f-CF / — 7[Z O
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ElI am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
shipand have no employees These sub-contractors have
8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. Buildingaddition
[No workers' comp. insurance comp. insurance.: ❑
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions tti
myself. [No workers' comp. right of exemption per MGL
12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.0 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins.Lie. #: Expiration Date:
•
Site Address: _ �� /State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati dot ).'
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 certify under the pains and penalties o/perjury that the information provided above is true and correct
S ture: -•°e— 4dfe:6vi_/OJ/S://
Phse.lir tri'/7G//— 7/ ca o
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. 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
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 7-2010 Fax # 617-727-7749
www.mass.gov/dia