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RESIDENTIAL, 2003
2003
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGEN,'T
2.1 Owner of Record:
ti
i
JLi A"
Name (print) _
`Contact Address PhoneNtmber_
2.2 Authorized Agent'
Name (print)
Cont ct Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable El
Are you a Home. Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section)
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
Signature Telephone TExpiration
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'
HomeInlnrovenlent Contractors Registration, One Ashburton Place - Room 1301, Boston; MA 02108, (617) 727-8598
{
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty 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 Licensingof Construction Supervisors: Except forthose 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 requiredshall 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 considered a Homeowner.
If you are applying udder this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
No,rICE 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)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affdavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
/
L� new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodsttove
(ener t1 report required)' _ (energy report required) fireplace
❑ deck ❑ pool ' ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolittion
(shed/garage) - no. of windows_ doors_ (specify below): (specify beilow):
* If new construction, please complete the following:
Single Familv: no. of bedrooms .3 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)
El None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
1 6G� Wll- IV1'57 1At&
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Building
2. Electrical
<
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total ` $ r
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
1,I, y/� PA U L"O as Owner of the subject property hereby authorize /161L10 5!Z-14
to act on my beha in all matters relative to work authorized by this building permit application.//y�y
Lam` t�6 L[
Sig ure of Owner -Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I - y� as Owner/Authorized Agent hereby declare that the statements and infornnation
ou he foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
4— /Yiy_40�
Owner%Autl Agent
Signature of rized
C:`,bldg.torms`,131deapp.res.wpd Page 2 Rev. January 19.. -001 C: bldg.forms`BId<aapp.res.wpd
Da e :
Page 3 Rev. Janualry 19, 2001
RESIDENTIAL
2003 RESIDENTIAL 2003
FO UNDA TION ONL Y
$25.00 APPLICATION 7 EE I5 NON-RErUNDAI3LE '_c'NON-TRANSFERABLE
SECTIONS - INSI' :CTOR' RENT! ENNICOMINIENTS
1. 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):
S. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
r 9. Inspector's Signature:
Date: -
SECTI N 9 - PPL 'T NOTIFICATION
._
Applicant infor=A of ,,bove Dater 1 ) - Time: 1 Clerk: p
. i r ®�
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: S ✓s47 •
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: /'iJ Gross Area - New Construction total sq. ft.
!� Gross Area - Alteration total sq. ft.,,
Permit Iss e o A
SF,tfION 1 - ADDITIONAL COMMENTS/SKETCHES
/��� • 00
0C)
� �00
rF, •.
DARTMOUTH BUILDING DEPARTMENT
DATE,IRECEIVED
\('\6JJ
400 Slocum Road, P.O. Box 79399
i
Dartmouth; MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAM3ILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIIT
DATE SENT FOR REVIEW:
NUMBER: % `5
DATE .ISSUED: ,
.A ...
OK TO ISSUE -SIGNATURE: - DATE
Building mmissioner/Inspector of uil ings
Zoning District r roposed Use: C� Zone: C ❑ B VA ❑ V Outside Flood Zone 01 Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo DPW ❑ Elec;.' ❑ Energy Report
Appeals Health Affidavit Card Sent Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoniing ❑ Other
Chief Cut Off / Cut Off ! Cut Off Reviews*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
EPRT ENTA�APPROALI !�
Zoning Review: Signature: � - )J DPate:
Energy Report: U 4 Signature: Drate:
Fire Chief: Signatur (r�'�'i's'••_s"... Dte:� ��
Board of Health; Signature:
g Date:
i
Conservation Conunission: Signature::::: Dute:
Other: Signature: Dune:
Description of work being performed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
6 ,
1.2 Assessors Plat & Lot Number:
1.1 Property Address: ��
6 o IVU
_
Plat--� Lot-45
Nearest Cross Street: t✓ C j�0 flo"
1.3 Historical District ❑ yes ❑ nco
Subdivision Name:
Has application been submitted to tthe Historic Commission?
Total Land Area Sq. Ft.:
yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipai Private Well
❑ Municipal Ey6n Site Disposal System _
0�7 53
Rev. January 19, 200__. '
C:`h1dz.1brms\B1dgapp.res.wnd Pagc 4
Rev. January 19,2001
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