BP-46592 Permit No. BP-46592 BUILDING-Pt RMIT
(.is#t. . a Eau( m.�:. Co ea W f Mach r�
ElitaaL
--, _ i0d� a=, "ma's',,,, c ,, f'flDF=DARTMOUTH
,�, d00 Slocum`RoadDart oath MA 2747
Lot. i OOO kPhone:(508)910-1820 . Fan (5p8)910 IS38
f tr
B J$
_ O. 8 `�'- PERMISSION IS ItERE,,inRANTED TO:
sC.,C&t i'` QOlN1 f0.,ah- ;
..,. - i it :C. Contractor: _ �.,.� "' ��
ins# ?I°e 3 Fhdr-eta? .11
WTwat— Engineer: _, tens r - Pba
� c c �r � '� #
twin =r d RB e 2
ew-�Con : -a 280 •
Applicant v "One#:
-ft. *.':ram. -'�`,-
MICHAEL R BA( 3ST-ESN
pCons`—a r- (SOS)9- 4062
(SW µQ BACHSTEIN MICHAEL R&,HEATHERcBACHSTEINT
DATE ISSUED -;71/i/� -
�
TO PERFORM THE FOLLOWING WORK:
Addition of barn/riding stable to property
roject Location: 89 REED RD
Approved/Issued By: / �L / 2Z�2
DAVID W MATTOS, OCAL BUILDING INSPECTOR&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 1tEGULAR 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 h aso ORK if items under their jurisdiction are not met; not
withstanding the issuance of this Building/Zoning Per
Signature of Owner/Agent:
Comments ttlit I> 155$ IL - 4 oil'.. t ` ® yt d
St:,F,iQRh%'n ra'4+5r?rrw n�'. +rnr Ei B �4. ` �kL a1Y1"aEat—
"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 46818
c BUILDING RECEIPTS �1
COLLECTOR'S OFFICE fat' ��` I
Name 1 `� - Property< Date , i
>< /( it-c.t , . Owner: - 7Lc rh�<�_ /, . f f�
Job Location: / j { i�FJ ✓
f�X r i �f "L i"f ` k '6 White Copy-Collector's Office
Plot: Lot: Yellow Copy-Customer's Receipt
%'j 1 Pink Copy-File Copy
�j a " J Green Copy-Building Department
Phone !e'l 0 _ -
Description General Ledger#'s Ref.# - Amount
License&Permits-Building 01000-44105 jj G c t
License&Permits-Building Misc. 01000-44105
( -.. .. _ _ _
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000- ;uv'': ',CC
Other
Other Department Revenue 010001 424 r--
/7
This is not a Permit or License for BuildingPlumbingGa rued By: ?'`" i'-: -a.Z% --
lin '1
-
TOWN OF DARTMOUTH
BUILDING: RECEIPTS
ram-
COLT tTOR'S OFFICE
Name: r Property Date: ,
- Owner: , _ .,
Job Location: / = /
TOWN OF DARTMOUTH
'' / 1 �' G , / ,-.�,- COI I FCTOR'S-OFFICE .
v_... ,
White Copy-Co[[ector's Office -
- OCT 2 4 2006 Yellow Copy-Customer's Receipt
Plot: - Lot: -
i,? - -;�; - - f )- Pink Copy-File Copy
B8�� gg �¢ ! ( I;..n./ Green Copy-Building Department'
Phone: M A J E � -
N0 TAX]S UES
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 N 7 , y
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 -
aJ ✓
This is not a Permit or License for Building,Plumbing or Gas Received By: _ /Li 7!7.�r r -
❑ SPECIAL PERMIT(Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE &NON-TRANSFERABLE
oirH •rt i%rr;DATE RECEIVED
M b�.
Qa:�«r�,N,, DARTMOUTH BUILDING DEPARTMENT 1 .
pz germ*,it, l 400 Slocum Road, P.O. Box 79399
vi- H' Dartmouth, MA 02747 imr cIT 7il i i II: 27
�R6 / 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
RECEIVED BY: BUILDING PERMIT NUMBER: y_s�Z
DATE SENT FOR REVIEW: DATE ISSUED:...' �/%
O.K.TO ISSUE-SIGNATURE: et..." DATE: /7 6
Zoning District: J i Proposed Use: Zone: ® C ❑ B ❑A 0 V Aquifer Zone:
THE FOLLOWING AGENCIESIE SHOULD BE NOTIFIED:
❑Board of C3'Hoard •of - �O Cons. 0 Demo 0 DPW 0 Elec. 0 Energy Report
Appeals Health Commission r Affidavit.' . Card Sent: - '.Cut Off Follow-up*
IOYfire # 0 Gas 0 Planning 0 Sewer Card 0 Water Card 0 Zoning . 0 Other
Chief 3 Cut Off Board Cut Off Cut Off
/Vgf/a 6
xj)ii *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
(//DEPARTMENT'AL'APPR�OVAAL�'
Zoning Review: Signature: � NT
y °t/ �'�" " Date: /74/ S
Energy Report: Signature: Date:
Fire Chief: Signature: �7� Date:
/Board of Health: Signature: /LIZ -&&Lc(.&ASt L /J Date: / v� Or
Conservation Commission: Signature: V� �t D.,/, .m),c Date:
Other: Signature: Date:
Brief description of work being performed: (-7?r-1 e I .t <IT A k4 t '`
SECTION 1 -SITE INFORMATION
1.1 Property Address: /2. ,640-2., _e! - 1.2 Assessors Map&Lot Number:
Nearest Cross Street: Map 4:v40 Lot _-
Subdivision Name:
/2',i'J Tapplication
1.3 Historical District 0 Yes No
Total Land Area Sq. Feet: ✓ Has been submitted to the Historic Commission?
0 Yes 0 No Date:
1.4 Water Supply(MGL c40 : 1.5 Sewage Disposal System
❑ Municipal rivate Well 0 Municipal On Site Disposal System
0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION-2-PROPERTY OWNERSHIP/AUTHORIZED AGENT !}/ZQ
2.1 Owner Record: 5W- 97�f -Z77b
i �!fr t ti /2/ /4v®yl4 ? 3AS'`Z94 bz
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 0
Licensed Construction Supervisor: License Number:
/ Address: Expiration Date:
LLI Signature: Telephone:
Z 3.2 Registered Home Improvement Contractor Not Applicable 0
W
() Are you a Home Improvement Contractor subject to (780 CMR-6)? 0 Yes 0 No
If No, go to the next section!
IL Are you darning exemption from the requirements? 0 Yes 0 No
Q If Yes, submit the required affidavit!
dCompany Name: Registration Number(if none, state"none"):
Q 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:
Horn provement Contractors Registration, One Ashburton Place-Room 1301, Boston, MA 02108, 617-727-8598
I ar•a Homeowner performing all the work myself.
Owners Nam' (print):
Signature:
By signing the above,the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date: /— 9l�
GGG
3.4 Hdmeowner 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 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 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 thi se 'on sign below:
Signature:
our 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 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 provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes ❑ No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑ Deck 0 Pool ❑Repairs ❑Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
0 New Construction' Accessory Bldg. 0❑ Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) p/r Vl/1�. (Specify below)
❑Addition 0 Replacement window/door ✓SY 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):
❑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:
emu-) f—.ft 1e4,4 I el lit
SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical(HVAC) /
5. Total=(1 +2+3+4) Fea
SECTION 7A-O ER AUTHORIZATION
(to be completed when owner's 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
// S N 7B-OWNER/AUTHORIZED AGENT DECLARATION
` as Owner/Authorized Agent hereby declare that the statements and information
on the fo egoing a plication are true and accurate,to the best of my knowledge and belief.
Sig under th ains and penalties of perjury.
Ignature of Owner/Authorized Agent Date �/
SECTION 8 INSPECTOR'S 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:
Inspector's Signature: Ay `+� Date: l`/ �` C
SECTION 9-APPLICANT NOTIFICATION
Applicant infor d of above: Date: /i( 9/4 Time: 02 Clerk: <--1,71
Commen
SECTION 10.OFFICE/INSPECTOR'S NOTES f
C, G. Less Application Fee:$25.00 Remaining Balance: $ �� / - Ce
Total Permit Fee: $
Other$Amount$
TOTAL FEE: // / /, a G Gross Area-New Construction total sq.ft. , a 8-® S �.j /e
Gross Area-Alteration total sq.ft.
Permit Issued to: / /7 / T/a /4✓ O F 4 /4 n .-v C /0/ 9 S%/7 eir G, re
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
i
/ e_ Ad /2 / lc/ / s' ' O C
/ t do
foram //-S
Michael R. Bachstein Architect
Architecture - Construction Management,- Planning-, 7,_
October 24, 2005
Dartmouth Building Department
400 Slocum Rd.
North Dartmouth, MA 02747
RE: 1289 Reed Rd.
The existing land area is 129,163. The new lot coverage with new structure is 12,736 sq.
ft. or 9.86%
Any questions feel free to call.
pF
Profes ' n ' -�
—•' z No 10684 "
NEW BEDFORD�
MASSACHUSETTS h
µPSS,d•
Michael R. Bachstein, AlA rirrvvi
MA#10684
DIE COPY
1289 REED ROAD, NORTH DARTMOUTH, MA 02747 508-989-2176
- 0 SPECIAL PERMIT(Per 780 CMR 111.13)
05.09 APPL11;_AT1ON FEE IS NON 11,E.FUNDNELE.44c NON-TSANSFE11POILE
T.
k.T;DATE RECEIVED
^;:•« , DARTMOUTH BUILDING DEPARTMENT „ . ......, t ,7 .
• rr:,t -i,ik.' 400 Slocum Road, P.O. Box 79399
(• Dartmouth, MA 02747 Vim,` ;; T ',;C_ I ' f i
, Phone: 508-910-1820 Fax: 508-910-1838
"69— www.town,dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
' > t ,ciT:HIS',SECTION(FOR'OFFICIAL'OSEONLY,,, `
'''BUILDING PERMIT NUMBER. -'
ti
DATESENTFORkEVI-.lc': ..... ;7Q/ f DATEISSUED:-�„_if, '
O.IC TO ISSUE SIGNATURE: DATE:_
Zoning District ,Proposed Use done a C 7:tY • V Aquifer Zone:
THE FOLLOWING AGENCIES HOULD 1 E N231FIED . - ". t8�
D Board of Surd or-} n5 ?1,". a Den10 ' O OPW 17 Elec- CI Ener y Repert
Appeals '` Heslth.. Corr rtlisstun -.i Af'idavd Cerrl Sent' ,Cut Off Follow-up"
P ann' wer Ca Water Card CI Zoning 0 Other'
❑Fire :a Gas - R la �n9 Cl4 S .rd, 57.... .;
.Olaf Out Qtr •
::. Board Gut Off Gut off
"REQUIRES INeRECitORSREVIEW BEFORE THE78SUANCE OF PERMIT.
rDEPARTMENTALAPPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:— - --
�Ff Chief: Signature: q A / Date:
ard of Health: Signature: /�d 1-J ( 1 Date:- p V • S -16b(o '
Conservation Commission: Signature: I Date:
Other: Signature: ]] Date:—
Brief description of work being performed: 1 1 Ct
SECTION 1 -SITE:INFORMATION. 1
1.1 Property Address: 12.-J" 1' 1.2 Assessors Map&Lot Number:
Nearest Cross Street: Map �� Lot_!�l/ -
Subdivision Name:
1.3 HistoricalDistrict ❑Yes fl No
Total Land Area Sq.Feet: / V/i��.cJ� Has application
be6n submitted to the Historic Commission?
❑Yes ❑ No Date:
1,4 Water Supply(MG_040 : F r copy1.5 Sewage Disposal Syste '
❑Municipal nvate Well £ ❑Municipal O�n Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
TO 39tld H11t73H AO (MMOS IHVQ £681-016-805 Z£:ZT 9003/£0/TT
❑ SPECIAL PERMIT(Per 780 CMR 111.13)
S25.00 APPLICATION FEE IS NON RE-FUNDABLE.&NON TRANSFE LE
-iv,_;DAT EIVED
pUTg? A
r��=r.�Nt DARTMOUTH BUILDING DEPARTMENT , ev
I t �_,1l' 400 Slocum Road, P.O. Box 79399
r t t. 6
. _ c, Dartmouth, MA 02747 nit :y7 'i L', F. ,• 27
*3O,= ` - Phone: 508-910-1820 Fax: 508-910-1838
dr
nsa�
www.town.dartmouth.ma.us
' APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
�ti 'THIS.SEG (ON FOR OFFICIAL;USE ONLY`
RECEIVED BY: *' BUILDING PERMIT NUMBER
DATE SENT FOR REVIEW. - /� DATE ISSUED: Id �U/
O.K.TO ISSUE SIGNATURE: DATE
Zoning District. -" Proposed Use: . - Zone%❑C O B ❑A O V Aquifer Zone: ,;
THE FALLOWING AGENCIES OULD BE N9TIFIED t" a - r -
❑Board of bard of ` r C.ns . 'U Demo ❑DPW .❑Efec 0 Energy Report
Appeals Health -Commission . r Affidavit ,Card Sent: , - Cut Off Follow up
❑Fire :::0-des. ❑Planning .- Sewer Card ❑Water Card ❑-Zoning ❑Other
.Chief ,ti Gat O(f _ Board Cut Off - , Cut Off ;:*REQUIRES INSPECTORSREVIEW BEFORETHE ISSUANCE OFA PERMIT.
' DEPARTMENTAL APPROVAL _ -‘•
'-
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
IJ
N:
bard of Health: Signature: Date: /
/COnservation/ 0 Commission: Signature: .>/ Date: 1 (- -"C�
iii///
Other: Signature: Date:
) t .
Brief description of work being performed: (AY Le /L(rl'k14 j 4, 4
SECTION 1 -SITE INFORMATION
1.1 Property Address: /2.-e, /620-j7 _eye ' 1.2 Assessors Map&Lot Number:
Nearest Cross Street: Map Kt:,eel Lot-4_-
Subdivision Name: ,/
/� /-3./f 1.3 Historical District ❑Yes t5 No
Total Land Area Sq. Feet: , L� Has application been submitted to the Historic Commission?
❑Yes 0 No Date:
1.4 Water Supply(MGL cA0 1.5 Sewage Disposal System'
❑ Municipal ovate Well 0 Municipal On Site Disposal System
0 CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
MAP b C LOT Y'6
M U H M
TOWN OF DARTMOUTH
INSPECTION CHECKLIST
Date: //t' o 0 New Home ❑ Addition ❑ Alteration ❑ Deck or Shed
Permit # y& < %2 Address: /X 9 AF g k'a
Inspector:,{0 2u mil /tads i £ 'c N /✓ /9%?f'.f./A7
FOUNDATION/FOOTING/SONO-TUB S
Pass Fail Description Code Section
As-built&approved 110.10
Frost Depth 3604.3.1A #1
NA Foundation walls braced 3604.4.1.3.1
Footings on undisturbed soil 3604.3.1A #4
Spread footings 3604.3.1A #3
AvA Foundation wall grade clearance 3604.4.1.3
Pad location size and size per plan 3605.2.3.3B (table)
A/� Damp proofing/water proofing 3604.6
Anchor bolts/ties & straps 3604.3.1 A #5
r/A Thermal break/insulation in place 3604.3.1
All footings&pads free 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:
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 ;,ail_El Office of Investigations
i511f_ 600 Washington Street
ID '•�il= v Boston,MA 02111
Vaawtsr, www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applic Information Please Print Legibly
N e (Business/Organization/Individual): „ tO
Address: /2-" q ,a sr
City/State/Zip: Mg/fderyj�lf-//7/ Phone #: LD8' —0� >a—
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. '' El Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[N orkers' comp. insurance 5. ❑ We are a corporation and its
quired.] officers have exercised their 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] employees. [No workers'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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.
l 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. 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 reby certify and p 'us and penalties of perjury that the information provided above is true and
correct.
'gnature: Date: /1/Zl/�
Phone#: J q3 ` 2i a-
Official use only. Do not write in this area,to be completed by city or town official
713 ` cc — €p
City or Town: Permit/License# U §-7a+ ao >y j 6
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 ajoint 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 apai tments 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 pennit/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.mass.gov/dia
'ermit No. BP-46592 Project Location: 1289 REED RD
. . . commonwo4akbf/lassachusetts
_ ,
TOWN OF DARTMOUTH
- , 4002SI6Cathiop4,RaHn'tata:-IVIA 027417 'Lotr -.7`1:11": '"'''j',„00407-
----.
Phone: (508)910-1820-1• Fax: (508)910-1838; Stiblot: 4 . 4--„0000„: ,
. _
BUILDING PERMIT... .
,
Category: NEW
Prtiliet#- '' - '44' -.18-2007-lin-
. , _, sccost• ,-; - 4:-1$00000 00' 4,..,-,.. .
FIELD INSPECTION -E------- •------'44:- 1 ..--..t,t. - 444,47. 4,44,4-, . ,
Fear 44-11:14: --4tn511-219l00 7-444i. --
Coli#t.Class:
,,.
contra&or: . , , ',-....1'.. ...,.:!:License: I. . :Phone#: , T101'"irollpt!:::::- 414T,,, ,,,,r,,,h1:,
Lot Slie(44.-?it.) 1"'l\2.88A'''',
:- ) : i ,-..., - ' Zoning: -itit- 1.4 SRB
Engineer:
License: Phone#: genositl-p, ''-:ill:f 3,281ti-illift:-.1,0*/'c4i;
Alt. Coast.: :....N/A, _ •
- - ' Phone#: -
Cel11118:4444,.44,
Applicant: ''MICHAEL -,;-: , ,:-- ,,, , I," (508) 995-4062
OWNER: ' r.
BACHSTEIN MICHAEL 1 44,ri!EATYER4-13t,RACHSTEIN - Glazing:•IFS:4 4444 4 4-4-. 444- ,-•
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK: 'PRP:1,1r011, [CT i.i
Addition of barn/riding stable to property CV ...iiii.,_eliii t: ,_; [11, l‘,„
,
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
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MICHEAL R. BACHSTEIN ARCHITECT
1279 REED RD.
NORTH DARTMOUTH,MA 02747
a
Final Affidavit
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RE: 1289 Reed Rd L w
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Pole Barn v' -°
All work is complete per plans and specifications and in accordance with MASSACHUSETTS
STATE BUILDING CODE 6th Edition.
Professionally,
?yet7A11
�
Michael R. Bachstein
' Oft'`
MA Reg#10684 � •.1 i684 z
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d°� WITHIN BOTH A PRIORITY HABITAT
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BACHSTE►N BOOK 5406 PAGE 229. _
OF STATE PROTECTED RA RE SPECIES AND AN ESTIMATED
ED
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HABITAT OF RAREWILDLIFE
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THE PROPERTY IS SHOWN AS LOT 40 ON ASSESSORS MAP 6 HABITAT &ESTIMATED HABIT
AT MAP AS SHOWN ON
�'' THE MA
SUITE 2S 46 FOSTER
R STREET
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GiS WEBSITE ON MARCH 2 9, 2006.
THE PROPERTY IS ZONED SINGLE RESIDENCE B WITH A
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NEW BEDFC?RD
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MINIMUM MUM FRONT SETBACK OF 60 FEET AND SIDE AND REAR THE PROPERTY IS NOT LOCATED WITHIN SPECIAL F
FLOOD
TEL. 508 992-00 ?0
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FAX. 508 992-3 7
( ) 3 4
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SETBACKS OF 20 FEET l
REQUIRED. H AZARD ZONEAS DELINEATED ON THE F.E.M.A. FLO D
INSURANCE RAT M E A
I
RQ N P OF COMMUNITY NO.250051, PANEL No.
1 B 00 5 DATED JUNE 9, 9983.
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GREGORY L. and ALYCE A. PIRES
� BOOK 2015 PAGE 211
99, MAP 66-LOT 38
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CAROL A. BRENNAN - � X °�
w N o 22Bq • s2,�, DAVID U'�� and SUSAN P. VIERA
b� NOMINEE TRUST _ o � -- — "�' � BOOK 5569, PAGE 70
z 4 CAROL A. BRENNAN, TRUSTEE X��._ 4_____
BOOK 5760, PAGE 16'0�, i ohX�fAP 66 LOT 50
MAP 66 -� LOT 39 ;�1
S MICHAEL R. and HEATHER A. BACHSTEIN
MAP 66 - LOT 40 100 -
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TEL: (508) 992.4 D020
FAX: (508) 992 3374
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