BP-2003-28967 TOWWOF DARTMOUTH 28067
BUILDING RECEIPTS
COLLECTOR'S OFFICE ,
j
` f
Name: �Date:
f �7„/, �i " :.r-r,-_�.s. lroperty \)�Jt� �-._� �i / /
T 6 . � / / ••L'�+r Owner: �-•/f/ /
Job Location: 1.15.-e-r / - _
White Copy-Collector's Office
Plot ` Lot f ,� ,, 7`t'� '.` Yellow Copy-Customer's Receipt
t t r. f Pink Copy-File Copy
- - Green Copy-Building Department
Phone: MAC 1 8 2003
Description General Ledger It's t,a 'Ke£l R'` Amount
License&Permits-Building 01000-44105
License it i ^01000-44105 ' ' C % i
License ettilts%Rlettr£t al 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: ° /
RESIDENTIAL 2003
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED
400 Slocum Rd, P.O. Box79399
Road, - - .
�� -
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: / BUILDING Pf tf✓f[� ?
DATE SENT FOR REVIEW: 3 r]'�'( ✓ NUMBER:Q'Sn(J!DIIY/I/I
DATE ISSUED:
OK TO ISSUE-SIGNATURE: ,�it; - DATE Cap % ] j
dding Coin ssioner/Inspector o uildings
Zoning District: to Proposed�Us/ : (( ,rZone: EtC ❑ B ❑A V Outside Flood Zone ❑ Aquifer Zone
TIIE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑Board of ❑Board of ❑Con.Com. ❑Demo ❑DPW ❑Elec. 0 Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑Fire 0 Gas 0 Planning Board* 0 Sewer Card ❑Water Card ❑Zo mg Other
Chief Cut Off /Cut Off /Cut Off Revidyv* ''"
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Dire Date:
Energy Report: Signature: 4/g Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being perforated:
SECTION 1-SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑yes 0 no
1.2 Assessors PI t of Number:y
I:1 Property Address: (l{
I rJ ���� Plat VLot f -
Nearest Cross Street:
Subdivision Name: _ 1.3 Historical District ❑yes 0 no
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
0 yes ❑ no Date:
1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System:
0 Municipal❑ Private Well ❑ Municipal ❑ On Site Disposal System
.s&p- # -- S
, .7/4 %/g/I7 7,
( :Id Bld_aup res.‘‘ ea 1/k/9 (lgi Rev.January 19.zoui
RESIDENTIAL 2003
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1'Owner,of Record: (1
.Nanie(inrint) -TROMA5 s FCyNAAJI(S ContadtAddress Phone,Nntnber
2.2 Authorized Agent:
•
•
•
1d5?' REED "RD SoS- 99c-')Oat)
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
Signature Telephone
3.2 Registered Home Improvement Contractor: Not Applicable 0
Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 yes 0 no
If no,go to the next section!
Are you claiming exemption from the requirement? 0 yes 0 no
If yes,submit the
required affidavit!
Company Name Registration Number(if none,state`none")
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, 1617) 727-8598
_Owners Name(print)
Signature
by signing the above,the home owner acknowledges that there will be no cligibilty 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 governed by Construction Control in Section 116.0,effective July I, 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 structure& .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:
Your signature carries certain responsibilities,including but not necessarily limited to,general liability
Cibldg!brmstaldgapp.res,wpd Page 2 Re:.January i9.2001
RESIDENTIAL 2003
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.I5)
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152 §25)
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: ❑ yes 0 no
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ 0 woodstove
(energy report required) (energy report required) fireplace
❑ deck 0 pool ❑ accessory bldg. 0 replacement window/door •c other ❑ demolition
(shed/garage) no. of windows doors (sP'eefgbelow): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit I 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):
❑ I-1 VAC (combined unit)-primary fuel, natural gas,propane, electricity,other(specify):
❑ Air conditioning- (separate unit)
❑ None of the above to be provided
O Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: j( F UCC I i pil.T/UD OM& QP{ F (V"\)UI
p4u0 STO G-E No Arat'IX ,- `v EEO te
SECTION-6 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(5)to be completed by permit applicant
I. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2 +3 +4) *Estimated Total 5 50 i t9 O
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
1, ,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
h TH'OM AS G A FIEA ,NF1top Li 5 ,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.
n
likinitta. :414 454 OW/g do03
Signature of Owner/Authorized Agent Date.
C. SId_.Gn:m 13ldsapp.r s.. pd Puuc 3 Rev.January 19,2001
RESIDENTIAL 2003
SECTION S-INSPECTOR'S REVIEW/COMMENTS
I. 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:
S. Comments:
IVAR
9. Inspector's Signature: � Date: 2 1 /003
SECTION 9-APPLICANT NOTIFICATION 7
Applicant infort e of a ove Date: Time: Clerk: /
Comments: (/ � /(j r
SECTION 10-OFFICE\INSPECTOR'S NOTES 1
( �.
Total Permit Fee: $ Less Application Fee: S 25.00 Remaining Balance ,_
enf)
TOTAL FEE: 6) Gross Area-New Construction total sq. ft.
Gross Area-Alteration total sq. ft.
Permit Issued To•
mar— 144 :3-US
SECTION 11-ADDITIONAL COMMENTS/SKETCHES
ie - IS fi -71 _
How\E Co pv1Ek Iic&E
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bldg.lhrmsVBldgapp.res.wpd Page 1 fri
Rev.January 19.2001
1
Permit No. BP-2003-28967 Project Location: 1257 L
Commonwealth ofWassachusetts
GIs#: 3462.00
TOWN OF, DARTMOUTH Map: 0066
400 Slocum Road,Dartmouth,MA 02747. Lot: 0042
Phone: (508)910-1820 Fax: (508)910-1838 Sublot: 0000
BUILDING PERMIT Project#: TO J-003-0787
BUSINESS NAME:HANDYMAN TOOLS Est.Cost: $50.00
FIELD INSPECTION Fee: $50.00
coast.class:
Use Group: R4
Lot Size(sq.ft.) 40679
Contractor: License: Phone#:
Zoning: $RB
Engineer: License: Phone#: New Const.: N/A
Applicant: Phone#:
Alt.Const.: N/A
THOMAS S A FERNANDES (508) 995-7724
OWNER:
FERNANDES THERESA E LIFE EST ry
/ c P4
DATE ISSUED: d$L�
TO PERFORM THE FOLLOWING WORK:
Home occupation PER PLAN to meet the requirements of Dartmouth Zoning By-Law, Section 4B.205
DATE
TIME TYPE OF INSPECTION&REMARKS INITIAL
m/°
V?> s �3 /6 fi'v/smg we r IQ it f'd'rz mr✓ F',r`.>r' ',c -
A
Permit No. BP-2003-28967 -
�GIS# .3 110 y Q �`
IY.I'a h i�., �'` ,' �. .'� ' „'' 3 Com mom uea' 'O f ,f aditieka4etfd
S4 . t • TO. F D�� ° "TI
�4:zDtL � 0 : �r N ,� � LTTH
Cut goryr�; St)1 ct n... 4 400 SloeuglRoad,Dartmouth,MA 0274�7
Project-*Wier I 1003 07873W Phone,(50S)9(0 1820 ,Fax: (500,910-1838
Est Cyst: 50AI( ;i,
Fee 50 00 PERMISSION IS HERE!?Y GRANTED TO '
(mist„C assx _ M
i serGroup: R4 a Contractor License Plume
Lot tE*Sft,) a 4k7,9a Engineer ieenseaw } 'Phone#:
y n
Nery,Cotlst �N/ � Applicant: Pfiape#:
Alf,l onst N/A THOMAS S A>FERNANDES (508) 995-7724
;Date Typed 04-11-2003,. OWNER:
FERNANDES
TH ERESA E LIFE'
EST
DATE ISSUED: ..
TO PERFORM THE FOLLOWING WORK:
Home occupation PER PLAN to meet the requirements of Dartmouth Zoning By-Law, Section 4B.205
BUILDING PERMIT
Business Name: HANDYMAN TOOLS
Project Location: 1257 ED RD
Approved/Issued By:
S.REED,LOC���lll���,,,BUILDING INSPECTO &ASSISTANT ZONING ENFORCEMENT OFFICER
All work shall comply with 780 CMR 6111 Ed. (MGL Chap. 143)and any other applicable Mass.Laws or Codes and plans on
file.
POST TH/S CARD SO/T/S 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 of this Building/Zoning Permit.
Signature of Owner/Agent:
Comments:
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
Commonwealth of flassachusetts
TOWN OF DARTMOUTH
BUILDING PERMIT
Project Location: 1257 REED RD Map 0066 Lot 0042 Sublot 0000
Issued To: THOMAS S A FERNANDES Contact Phone No.: (508) 995-7724
Date Issued. Permit No.: BP-2003-28967
To Perform.the Following Work
Home occupation PER PLAN to meet the requirements of Dartmouth Zoning By-Law, Section 4B.205
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector Building Inspector
Underground: Service Water Service#: Footings:
Rough: Rough. Sewer Service#: Foundation:
final: • Final: (. q§ Connection Final: Rough Frame:
Comment: Comment Comment: - Fireplace/Chimney:
Insulation:
Final:
Treasury:
Comment:
Inspector of Gas Fire Department , Board of Health E-911
Rough: Oil:
Final: Smoke:
Comment: Comment ,Comment: Comment:
Additional Comments:
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 green "Town Agencies" document
provided with the building permit application.
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
The Commonwealth of Massaschusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Applicant information: Please PRINT Legibly
name: THOMAS S.ra, FIERA) fi4IODES
location: (SS7 &EEr7 k
-`city 100Rm 3c cr MOV-ili j MI'a C7d-')�F7 Phone# CiOA -`Tg5- 77�y
❑ I am a homeowner performing all work myself.
❑ I am 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.
company name:
address:
city phone#
insurance co. phone#
❑ I am a sole proprietor,general contract*or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation policies:
company name:
address:
city phone#
insurance co. phone#
company name:
address:
city phone#
insurance co. phone#
Attach additional sheet if necessary •
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S I,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certifi,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: \ Date 1 ca063
PmtName: TF}oMHS Sep li FERNANDES Phone# CO2-W5-9IJ 2/
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
❑ check if immediate response is required ❑ Selectmen's Office
❑ Health Department
contact person: phone#: 0 Other
tnturm:wan aria tnstrucuuub
•
\iassaci;usetts General Laws chanter :52 section 25 requires all employers to provide workers' compensation for their
empio\ees. As quoted from the -late an employee is defined as even, person in the service of another under any
contract of hire. express or implied. oral or written.
An cnrnloreris defined as an individual. partnership, association. corporation or other legal entity, or any two or more
the .'ore ping engaged in a joint enterprise. and includir; 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, orthe occupant of the
dtv cllins house of another who employs persons to do maintenance , construction or repair work on such dwelling hour
r on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
\IGL chapter 15: section :5 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.
thethe
neithermveald norinto anycontact for
Additionally. commo t any of its political subdivisions shall enter
performance of public work until acceptable evidence of compliance with the insurance requirement of this chapter ha
been presented to the contracting authority.
• . .-..i • a i..
Applicants
Please HI in :he workers' compensation affidavit completely, by checking the box that applies to your situation and
smpi'ine ompanv names. address and phone numbers as all affT :e its 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 Depat wient 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 theriumber listed below.
City or Towns .
Please be sure that the affidavit is complete and printed legibly. The Department has provided aspace at the bottom of
the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Plea
be sure to till in the permit/license number which will be used as a reference number. the affidavits may be returned t
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 question
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 _
fax m: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375