BP-84557 VOID TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8 4 5 cJ 7
PHONE: 508•910.1820 FAX: 508-910)1838
'��
Name: (11 i I K-- Property Owner: -5 41.- - Date: i IZ/1 L
Job Location: //6' S /2r/-. to(--- Map: C%'a Lot: A _
Description General Ledger#'s Ref.# Amount
Building & Building Misc. 01000-44105 ' 0fr
e 1 )-Mgt rElectrical 01000-44106
Plumbing & Gas 01000-44107 ° 5� N o r \�n
Trench Safety 01000-44129 ` $ rs U ` 1V r
e.,J
Other Department Revenue 01000-42420 2/N-
eke
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received '1 ),-ttsie,C,
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
' UTH M\ DATE RECEIVED
QA.t. % 4/ DARTMOUTH BUILDING DEPARTMENT
o fr 'R'I 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
�Y=. /` Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR LING
THIS SECTION FOR OFFICIAL E ONLY
RECEIVED BY: 1 BUILDING PERMIT NUMBERSV )7
0 \ 011'0 DATE ISSUED:
SIGNATURE: V I �� DATE:
t I rt ng CAMYni�sioner�i �Of Buildings ip rAj
c� 111 1 YY ^ J 111�1�1
Zoning District: fop d Use: S Zone: ❑X 0 B O A O V Aquifer Zone:
THE FALLOWING AGENCIES SHOULD BE NOTIFIED:
,Yf7 Board of 0 Board of 0 Cons. 0 Demo 0 DPW0 Elec. 0 Energy Re
port
Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up'
O Fire 0 Gas 0 Planning 0 Sewer Card 0 Water Card 0 Zoning 0 Other
Chief Cut Off Board Cut Off Cut Off
{ *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL _
i Board of Health: Signature: Date: _
Conservation Commission: Signature: Date: _
Other: Signature: Date: _
Signature: Date: r —�
Signature: efe:/Lf.) hAL*71<i 1 .5
Brief description of work being performed: (
7:
SECTION 1 -SITE INFORMATION
•
1.1 Property Address: // 6/'r i,�J"e'e og I CL 1.2 Assessors Map&Lot Number.Lot Area(sf.) I t .73 A c Frontage Map 6,f, Lot 76 -
Required Provided
Front Yard 1.3 Historical District 0 Yes KNo
Side Yard
Rear Yard Year Built
❑Altering more than 25%per side of building
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑Municipal,Private Well ❑ Municipal ,,On Site Disposal System 0 Yes 0 No Date:
• Revised 10/11
3 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
Lir( lit/l f a eft: //6c Reed &( 6-O8=96/ - 73s9
Name(print Contact Address Phone \lumber
2.2 Authorized Agents e+
Name(print) /Y Contact Address Phone Number
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 shalt 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':hen
one home in a two-year period shall not be considered a Homeowner.
•
If you are applying under this section sign below:
Signature:
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)
❑ Deck 0 Pool 0 Repairs XAlteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
❑ New Construction` 0 Accessory Bldg. ❑ Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) (Specify below)
❑Addition ,Replacement window/door ❑ Demolition
(Energy report required) No.of windows J Doors 2 (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(specify): _
❑Air conditioning-(separate unit)
❑None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
SECTION 6-ESTIMATED CONSTRUCTION COST
r Item Estimated Cost($)to be completed by permit applicant
1. Building S%30ra r O
2. Electrical / 3 D. 0 o•
3. Plumbing S�✓-7�, 00
4. Mechanical(HVAC)
5. Total=(1 +2+3+4) 2- et)
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owners agent or contractor applies for building permit)
(Please Print)
,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
//�1 //rr SECTION 78-OWNER/AUTHORIZED AGENT DECLARATION
I, 4/0 F H'e //0 Cc ,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.
3 —2/— 17
Signature of O er/Authorized Agent Date
SECTION S-OFFICE/INSPECTOR'S NOTES
Less Application Fee:$25.00 Remaining Balance: $
Total Permit Fee:$ / 3.fro
• Other$Amount$
Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
Permit Issued to:
11 �((1� SECTION 9-ADDITIONAL COMMENTS/SKETCHES� /
X Al/7/ ,t7C-/'�-rnr`S)//r9J. 4 1 V/Ot4 u rTI NI.C" e/ CkV/1e of
:J Qse wr €l� //'i(S' Jtie ea/r(' WI/,/ )1,0i7.(r(e hall-Covek'IHjs)CQw7W41i))1 -1'�%or-
C O V 2.r-I NjY Ce,A 4_1 q i-r�l /l jb f -}j�C1 , .2- lJ i l/ A€ wrp(ay/147
et 13 Iu-NJOCC `rihe hi cia./e rLo kn o-( heA_Wad‘P dgesc. hoaw,1 htt
/Ire ca_ e 'CC 1446dded /S � h�x/ � ae � /�I /II See
RT/ kCti•e / �t2i ra to
The Commonwealth of Massachusetts
Department of Industrial Accidents
---'0i=tl Office of Investigations
=an.= 5 600 Washington Street
it =;ti)= '• Boston,MA 02111
..• , www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ['�/ Please Print Legibly
Name (Business/Organization/lndividual): ZJoy-( t/ .11 b e I
Address: iur ta-el et)
City/State/Zip:��ct.t4rne4`i( , MA oz7y7 Phone#: .5r798--916/ — 73.
Are you an employer?Check the appropriate box: I I Type of project(required):
I.❑ 1 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.$ 7. M Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0Electrical repairs or additions
3.rt 1 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 19 ri Roof re_pnirs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.❑Other J
*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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
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.Lic.#�: 0Expiration Date:
Job Site Address: '`� / 6,S R e-e14 i( City/State/Zip: ,.kv7ii e&& /M'( D2797
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 hereby certify under the pains and penalti of perj ry that the information provided above is true and correct.
Signature: p�e1 � e�/ Date: 3 '17(
Phone#: CO 8' — 96 / ^ 73.5 _(
IIOfficial use only. Do not write in this area,to be completed by city or town official 1 ll
City or Town: Permit/License# I 1
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#:
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