BP-223952001
-1 RESIDENTIAL 2001
RESIDENTIAL
E TI N 2 - PROPERTY OWNERSH1P AUTHORIZED AGENT
2.1 Owner of Record:
%r,z)®rtiP CrvX R % l oc-jeR ,aid' ` F- Z � e - Y 7
Name (print) Contact Address
� Phone Number
2.2 Authorized Agent:
Sr�TP RD S�Q S�- - 5',SZ
Name (print) :70 Contact Address Phone Number
SECTION3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
i Not Applicable
Licensed Construction Supervisor License Number'? 0
Address
Expiration Date
Signature Telephone
fk)
3.2 Registered Home Improvement Contractor: Not Applicable El to
Are you a Horne Improvement Contractor subject780 CMR-6
J( yes
❑ no
If no, go too theext section!
Are you claiming exemption from the requirement? ❑ Yes E24. o
If yes, submit the
required affidavit!
Company NamePEL a ` - Registration Number (if none, state "none")
Address ° a"p
Imo?
Signature Telephone; T r," n ? xpiration Date
3.3 For Resid ial emodel Work Only l
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
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 Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor: provides that if a
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 which there is, or is intended to be, a one or two family dwelling, attached or detached w o reside, is
g structures accessory to such use and/or farm structures. A person who constructs
more than one home in a two` -year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2
Rev. January 19, 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 78(b CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 1,2
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 buildingpermit. Signed Affidavit Attached: TO yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
�i h❑ woodstove
❑ new construction* ❑ addition ❑ alteration ❑ repairs �fir�epla
(energy report required) (energy report required)
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify,,'below): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit l 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
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:S`/�A
Of el�n/Gc:
ko
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildiruz
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ 00
SECTION 7A'- OWNER AUTHORIZATION s;
(to be completed when owner's agent or contractor applies for Xbuilding permit'
(please print)
L lnk Ny Se V G cv v , as Owner of the subject property hereby authorize /')Sy ✓;g y
to actor nly be lf, in l matters relative to work authorized by this building permit application.
Signature of nee 77 Date
SECTION 7B - OWNS AUTHORIZED A ENT D E LARATION =
I,�✓>tY� avv , as Owner/Authorized Agent hereby declare that the ttatements 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.
Signature of Owne Authorized nt ZI®Date
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RESIDENTIAL
2001
❑ FOUNDATION ONLY
$2S.00 APPLICATION FEE ES NON-REFUNDABLE & NON-TRA11iMERABLE
RESIDENTIAL 2001
SECTION 8 -INSPECTOR'S REVIEW/COMMENTS
1, Date plan reviewed: -- r7 7
2.
30 days to review period expires:
3.
OK to issue date:
4-
OK to issue subject to requested submittals(see project review worksheet):
Date:
5,.
DENIED (see project review worksheet):
Date:
Ea
HOLD reason:
Date:
7'.
HOLD subject to Zoning Board of Appeals action:
Date:
S-,
Comments:
9. Inspector's Signature: Date: 1--
ON 9 AP,gLIC NOTIFICATION�j
Applicant informeo ojabovle D te: (� Time: ( Clerk
Comments. �1..
,. 10- OFFICEVNSPE CTOR'
SNOTESSECTION
Total Permit Fe
e: $ Less A licati pp on Fee: $ 25.00 Remaining Balance: $
TOTAL FE • _
E. , ' Gross Area New Construction totals . ft.
q
Gross Area'- Alteration total sq ft.
fJ/////jj✓f/
M/. v
Permit Issued To• �(
SECTION 1 -ADDITIONAL COMMENTS/SKETCHES
j 9T=
zCit e
i
I
C:\b1dg.fbrrns\B1dgapp.res.wpd Page 4 Rev. January 19, 2001
V
�rnouTH: y,, DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT Y.
n
o 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
sy 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE ORDEMOLISH A ONE OR TWO FAMILY'
DWELLING
THIS SECTION FOR OFFICIAL' USE ONLY "
"
�
b
., ,, ;. .• - w .. 3 �.., . ;. _.
RECEIVED BY.
3y;��' � �, c ^r" a � d S tom' li
n r
BUILDING PERIVII
DATE SENT FOR REVIEW:NUMBER:..
= s
DATE ISSUED
s,
OK TO ISSUE SIGNATURE
Buildi Commission r/Inspector offt, dings.,* d, ,
Zoning x ;: __ _
ng District -.Proposed Use.
p :Zone :> B A ❑ V Outside Flood Zone �4ii1
,0 WZone .
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED N, u,4N}
P.:, .. ... t ..:.. .. u:'. +h .ram f:' .t S� '<L.' �d'^=" fi th'i'kti '� Y.,
_.. . -. ..,.. , .�Lf
+�,♦
oard of .. ❑Board of ;.,❑Con. Com r ❑Demo :. DPW ❑ Elec „h
_...."`M=::
4,❑ ❑ Eiaer' 12e
A eats ealth a . , .i r x.,
PP >.. , :. .. L .Affidant - Port
Card Sent -� Cut Off
-: 2
_ r.. P
❑ Fire ❑Gas ❑ Planning'Board ❑ Sewer Card Water
O Card : ❑ Zonmg ❑ Otlier `
n .:
Chief Cut ff
O :F /Cut Off "/Cut Offt Review h
j
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF
kPERMIT..:
DEPARTMENTAL APPROVAL`' ',- `' •
.�r t
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:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
1.1 Property Address:_ ,(��y'
,®'
Plate' Lot- �,
Nearest Cross Street: _ 17),•11&Ri5 PA
1.3 Historical District ❑ yes j4[no
Subdivision Name: 1,'�-�=,q�+
Total Land Area Sq. Ft.:
Has application been submitted to the Iistoric Commission?
yes ❑ no Dater
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:'
❑ Municipal Private Well
❑ Municipal Z On Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Pagel Rev. January19 J,�1