BP-19034RESIDENTIAL 2001
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record: -
J Pv {' 11 5 l 1 C?Gd� �.. J 4/!
Name (print) Contact Address Phone Number
2.2 Authorized Agent: -
Name (print) Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVI ES
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 ❑
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)
Companyam «
Name Registration Number (if none, state "none")
Address
Signature Telephone Expiration Date
3.3 For Residential Remodel Work Only
i
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, (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_a
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 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 twTyear period shall not be considered a Homeowner.
If you are applying under this section sign below: ,
Signature: 1f
j/ our signature carries Bert n responsibilities, including but not necessarily limited to, general liability
C.`bid,,.3onns�Bld.app.res.NNpd Pace 2 Rev. January 19. '001
RESIDENTIAL
2001
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,15.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 2.3)
pp >ti
_I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure �orovide this affidavit
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) 1(
❑ new construction* ❑addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ther ❑demolition
(shed/garage) no. of windows_ doors ( pecify below,?): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths m
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):
13 ` Air conditioning - (separate unit)
❑: None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Pr posed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost ($) to be completed by permit applicant
1. Buildin
5. Total = (1 + 2 + 3 + 4) * Estimated Total
SECTION 7A - OWNER
(to be completed when owner's agent or cc
(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- OWNERAUTHORIZED A ENT DECLARATION
as Owner/Authorized Agent hereby declare that the statemenits and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed undler the pains an penalties of perjury.
Z 12
Signature of Owner/Authorized Agent 'Date
C:ibldg.forms\Bldgapp.res.wpd Page 3 Rev. January 19, 2001 -
RESIDENTIAL
2001 RESIDENTIAL 2001
ION S - INSPECTOR S REVIEW/COMMENTS
❑` FOUNDATION ONLY
$25.00 APPLICATION FEE IS NOW -REFUNDABLE NON-TRAN'`®;FERABLE
SECT
1. Date plan reviewed: .� " 7— 0
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review worksheet):
6. .HOLD reason:
Dater
Date:
Date:
7. ' HOLD subject to Zoning Board of Appeals action:
S. Comments:
Date:
9. Inspector's Signature: LaAlzDate:
SEC ION - AP L CANT NOTIFICATION
c
,Applicant infor ed of above Da �Time: �,� -Clerk:
Comments:
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: S 25.00
Remaining Balanc
TOTAL FEE: 0 G) Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To
71,
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
J
DATE,:RI;CENED
DARTMOUTH BUILDING DEPARTMENT
^, 400 Slocum Road, P.O. Box 79399
;
Dartmouth MA 02747
'6fi4 '=' 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING'
THIS SECTION FOR OFFICIAL USE ONLY '
RECEIVED BY: /
BUILDING PERMIT
DATE SENT FOR REVIEW: r _�
NUMBER:
DATE ISSUED:
OK TO ISSUE- SIGNATURE: DATE
Buildin ommissioner/Insp ' o of uildings
Zoning District: roposed Use: Zone: C ❑ B ❑ A ❑ V Outside Flood Zone EL, Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: -
Board
❑ Board of 13 of ❑Con. Com. ❑ Demo ❑DPW ❑ Elec., ❑ Energy Report
Appeals HealdAffidavit Card Sent: Cut Off_' Follow-up*
F
1 e ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zonirng ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*`
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Datte:
Energy Report: Signature: Daite:
Fire Chief.' Signature: Datte:
Board of Health: Signature: - Datte:
Conservation Commission: Signature: Datte:
Other: Signature:. r Dane:
Description being
of work performed:
SECTION 1 -SITE NFORMATION ��� ��
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: D�s ❑ no
°��
1.1 Property Address:.5-3 t -erS 1 .3r1 G/ C__.
1.2 Assessors Plat & Lot Number:
6
Plat �� Lot
rr
Nearest Cross Street:f7oX
f�'l
Subdivision Name: l' �PdS �{��1�?�
%" /
.storcastric
t ❑ yes ❑ nol Di i 3 Hi 1
_
Has application been submitted to thpv Historic Commission?
Total Land Area Sq. Ft.:
11 yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ Grn Site Disposal System
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Rev. Janusn 19„2001 C:'bldg:forms'\Bidgapp.res.x�pd Page 7 Rev. January 19, 2001