BP-20656RESIDENTIAL
2001 RESIDENTIAL 2001 I
SECTION 2 - PROPERTY 0WNERSHIP AUTHORIZED AGENT
2.1 Owner of Record: $%
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'c�7 dot jv> ,,5-0r-b 7 -77� 7
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact 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
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? 0 yes ❑ 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, (617) 727-8598
Owners Name (print)_ ; ,/ y 0 , 2: ! , 1'1,
Signature
by signing t above, the home w r acknowledges that there will be no eligibilty to the Guaranty Fund
Date b
-44
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 I censing 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 dwelliniz, 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 no be considered a Homeowner.
If you are aMlying under this section sign below:
Signature:74
Your signature carries c ain responsibilif s, i hiding but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constfruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15J)
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 provicue 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)
new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ !]3`woodstove
(energy report required) (energy report required) fireplace
❑ deck Apool ❑ accessory bldg. ❑ replacement window/door ❑ other 131 demolition
(shed/garage) no. of windows- doors_ (specify below): (sppecify 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 l
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
11 Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
D tic i�% f31��r /.ltl�
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost {$) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
*Estimated Total $ I 0
SECTION 7A'- OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
1, "—e s - has , as Owner of the subject property hereby authorize
to act on my b alf, in all m t ers relative to work authorized by this building permit application,
// �'t'
Signature of Owne Date
SECTION 7B -OWNER/AUTHORIZED AGENT DECLARATION
1, iff , n.� , as Owner/Authorized Agent hereby declare that the statements and? -information
on the foregoing applications a true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/A orized Age t Date
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RESIDENTIAL
2001 RESIDENTIAL 2001
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
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):
5. DENIED (see project review worksheet):
6. HOLD reason:
Dater
"Dater
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
ate:
SECTION - AP LICANT NOTIFICATION
Applicant informed of above Date: Time:
Comments: r
Clerk:_
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: Gross Area -, New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To4
a
SECTION 11- ADDITIONAL COMMEN SKETCHES
❑ FOUNDAs UON ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRH NSFERADLE
�UTH DAJrE RECEIVED
DARTMOUTH BUILDING DEPARTMENT-
oP _ 400 Slocum Road, P.O. Box 79399 `R 3
o y Dartmouth, MA 02747 4
'fifi= 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO F&MILY DWELLING
SECTION FOR OFFICIAL USE ONLY-
s -b
Ic
RECEIVED BY BU21
ILDING PE1 MIT
DATE SENT FOR:REVIEW. NUMBER. ,
DATE I5SfIED
OK TO ISSUE - SIGNATURE777
.DATP;
ildin Commissioner/Ins ector o Buildin s ,
g P _' 9
Zoning District: .Proposed, se: .-=` Zones, (° ❑ B A ❑ V Outside Flood Zone; ❑ .Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED °
2NE
a
❑ Board of ,.� .. ❑ Board of ❑Con Com ❑Demo Y ❑DPW ❑ E, �
'Iec ❑ Enea 'Re ort
k gY P
Appeals a Health -` Affidavit Card Sent Cut -'Off Follw-u op*
❑ Fire ❑ Gas ; .': , ❑ Planning Board* _'"❑Sewer Card '❑ Water`Card ❑ Z�anmg ..W ❑Other
Chief Cut Off !Cut Off /Cut Off a. Revf�w*
x
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.,
:DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date)UL 1 6 2001
Energy Report: Signature: " Date: t
Fire Chief Signature: e:
Board of Health: Signature: ate:
v
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1 SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: yes ❑ no
1.2 Assessors Plat. &Lot Number:
1.1 Property Address: r ��v��� Plat Lot 45
Nearest Cross Street: /1), // ,04&
I
Subdivision Name: ` 1.3 Historical District ❑ yes g1f no
?� Has application been submitted tro the Historic Commission?
Total Land Area Sq. Ft.: /9GRe-
❑ yes ❑ no Dater
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal)( Private Well ❑ Municipal On Site Disposal System j
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