BP-32803RESIDENTIAL
2004
RESIDENTIAL .�
fl2004
d:
—PA
0(print)
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Cons uctlon
Supervisor, whether or not they have taken the
—
. �-tj�C 1
permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15,))
cL _ W)1 !� P� �> CC`FcI�AT[Ot
6��
CTIO �yQRI ER' (1 It' II'�U1G.#1IIJ!A.: .?
;:::.:..:.:. . ....:.::.: .. YI'E` (MIL
Contact Address Phone Number
2.2 Authorized Agent:
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to rovi& thts
affidavit will result in the denial of the issuance
/no
of the building permit. Signed Affidavit Attach d:❑ n0
.:. SECT iOTr F1�RpQSE1? h ta12K;>cecl>:ali>a
(. j3jille#e)
Name (print)
Contact Address Phone Number
:... .
`
❑ new construction* ❑ addition alteration ❑repairs ❑chimney/ woodst
❑ ove
(e er repo e u' ed) energy re o
(energy report required) it report required)
( P
F N.�;+>COi\. UCTI01 SFRV3 F3
3.1 Licensed Construction Supervisor. Not Applicable ❑
_fireplace
Q deck ❑ pool 2 accessory bldg. ❑ replacement window/door ❑ other ❑ d1'emolition
Licensed Construction Supervisor License Number
(shed/garage) no. of windows_ doors (specify below): (specify below):
—
Address
* If new construction, please complete the following:
- Expiration Date
Signature
Telephone
Single Family: no. of bedrooms no, of baths
3.2 Registered Home Improvement Contractor: Not Applicable ❑
Two Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
Are you a Home Improvement Contractor subject to 780 Ct - 7
'��
( 6) . ❑ es ❑ no
Y
❑ Furnace (hot air) - fuel gas (natural or propane),
p p e fuel oil elect r
)> . t I 1
c , other (specify):
tY (p fY)
If no, go to the next section!
❑ Boiler (heating) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
Are you Maiming exemption from the requirement? ❑ yes Ono
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
If yes, submit the:'
❑ Air conditioning - (separate unit)
required affidavit!
❑ None of the above to be provided I
Company Name
❑ Hot Water: Gas Electric Fuel Oil Other
Registration Number (if none, state `'none'')
Brief Description of Proposed Work: # ,
Address
_
_
S1r Itr;� Telephone Expiration Date
pI4JSTL�#A:T1�
p
car r 'orfti Only
�
..Ct3bST
L3.
CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY
ItemEstimated Cost ($) to be coin leted bSONS
P y permit applicant
STIONS OR COMPLAINTS call or write: FUND:
1. Buildin
Home Improvement Contractors Registration, One Ashburton Place -Room 7301, Boston, MA 02108, (617) 727-8J98
2. Electrical
Owners Name (print) °F }l
3. Plumbin ——
Signature �•
i
4. Mechanical HVAC
by si g the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date e ,
5. Total (1 + 2 + 3 + 4) * Estimated Total
_,: _ l w
i
3.4 Homeowner Exemption -One &
P Two Family Onl
Y Y
SECT ON.> ... . ............ .
- .. . ........... .
( .... atn. lefet#:wh .. :::..:.:.....
P en a3Yne.ra .r ent. arzco ,..,
�
;: .;:.: ;:.:..... . ntractvr
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,
shalt be engagedin directly
(pleas'p�]�-int)
I LOB / � 1�i � � ,
\ ! l 11 as Owner of the subject
effective July 1, 1982, no individual
supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural of buildings
or structures, unless he or she is licensed in accordance with the rules and regulations
to act y behalf, in all matt S
propertyherebyauthorize
3C
to work authorized by this building permit application.
Supervisors. promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Exception; Any Homeowner
l�
performing work for which a Building Perniit is required shall be exempt from the provisions of this section
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. provides that if a Homeowner
Signature of Owne
Date i
For the purposes of this section only, a "Homeowner" is d
defined as follows: Per
. O lofla �
Person(s) who owns a parcel
there is or Isdwelling,land on w .'
intended be, a one or P which he/she resides or intends to reside, on which
attached or detached structures accessory to such use and/or farm structures. A
one home in a two-year
c>. :....... .. -4.:
::
FCT >.�:.. <•;>;;::>:»;>;;;<;::;
_ O .... Olt l ,
no be considered person who constructs more than
period shall not be considered a Homeowner.
I, � �� �% `� �l �(� �:�—. , as Owner/Authorized Agent hereby declare I
If you are apply-' r this section sign below:
,
that the statements and lnfgrmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
isn ��
S� ature:
Signed under the pains and penalties of perjury.
Your sign carries certain responsibilities, inc u mg but not necessarily limited to, general liability
Signature of Owner/ uthorized Agent
Date
C:lbldg.fonns\Bldg-app.res.wpd Page 2
Rev. June 26, 2003
CAbldg.for-ms\13ldgapp.res.wpd
Page 3 Rev. Ju
lne 26, 2003
Tl T7 L� TTI T IL TTT ♦ T '1 11A .1
a�a��aa�a.l� a ar-ai. ♦.vv-r
.........::.. ........
........ .
.....
....:... .. ..:. �:: :...... ?>:� �i> i.TP l�TTI'\AT�.Q�: TAt�i^T)T`FeF't1TY �.C6.fY_E�LTTG�iV:�l2FlAA1dThT'�'C�::�: ��::i:::::>. ?. Q: ?;�.�.. �::.: ?:: 2::.?!:::•.
RESIDENTIAL' ���12>= 2004
❑ FOUNDATION ONLY
_ NON -TRANSFERABLE
D LE&N N TRANS FE
FEE I N REF N AB O $25.00 APPLICATION S NO U
1. Date plan reviewed:
2. 30 days to review period expires:
3. OIL to issue date:
4. Oh 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: Dater
8. Comments:
9.Inspector's Signature: Date:
Applicant informed of ve Date: r r�
Time: U Clerk:
Comments: ;
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT .
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747`�311 t ' 37
o y�ki
508-910-1820 FAX 508-910�838
APPLICAT7N TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FRAMILY
DWELLING n
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: J_ SITE PLAN SUBMITTED: es ❑' no
1.2 Assessors Plat & Lot Number:
i i ti l ��� �c Vi�-
f— Plat �'� Lot_-
Nearest Cross Street:_ �.l�lZ�
1.1 Property Address: (GL
Subdivision Name: :`VXVU-s m 1.3 Historical District ❑ yes no
Total Land Area Sq. Ft.: Has application been submitted to the Historic C)ommission?
TO -.�.
❑eyes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ MunicpalC-Vrivate Well ❑ Municipal /nSite Dispeosal.System
i
C:\b1dg.forms\131dgapp.res.wpd Page I Wev. June 26, 2003
C:\b1dg.formshB1dgapp.res.wpd Page 4 Rev. June 26, 2003