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VOID Permit1999 1999 Residential Residet ltial 2.2 Authorized Agent: NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any llicensed responsible for code compliance. (see Appendix of 780 Address ress Construction Supervisor, whether or not they -have taken the permit are � � CMR R5.2.15) (print) Name notX. to hone Te P a c ..`.il�t?il:.. I��(; .:::..: ::. .>: >:: ;:::::..:::::.;: Tlf�.r.:11dSRk�C.11)..: ..:.. i4ER.: S. CQ1L2iiA .::. 1�T...... G4t11..... SCTI© .. ........... lure to ro e this affidavit submitted with this application. Failure p wid Insurance affidavit must be completed a p ers Com ensation I Work p _. .. ::........:...... ».: ::....:....:::.::.........::::::...::::::...... lea CRi3C . fR?xCJ; :() ".;. ; .......::::: :..... :.::.....:::::::.:. ........:.: ...::. Not Applicable ❑ will result in the denial of the issuance of the building permit. Signed Affidavit Attached ❑ y — Construction Supervisor: 3.1 Licensed C p el!:.:. ,......... 1�1.. �`.tfRE)lt4$�l)r'�tk1:.�..;:.:. ;.;.:>:.:.:;.>::<>:;. Supervisor License Number �' ..............::::.......................:..... ... ; .. ;:.;:::::.:.;::::FP:::.:;>:;: "' ` Licensed Construction Expiration Date new ❑addition ❑alteration ❑repairs ❑ chimney/fireplace ❑ woodstove Address �� L/✓ .— Cam=' CJ-Z� construction* ❑ Bldg. ❑replacement window/door ❑other [❑ demolition Signature Telephone— � Registered Home Improvement Contractor: 3.2 Re is P � - Not Applicable ❑ ❑ deck ❑ pool accessory (shed/garage) no. of windows doors (specify below): ((specify below): Are you a Home Improvement Contractor subject to (780 CMR-6)? -❑ yes ❑ no If no, go to the next section! * If new construction, please complete the following: Are you claiming exemption from the requirement? ❑ yes ❑ no Single Family: no. of bedrooms no. of baths If yes, submit the required affidavit! Two Family: no. of bedrooms unit 1 no. of baths unit 1 no. of bedrooms unit 2 no. of baths unit 2 Registration Number (if none, state "none") Company Name Brief Description of Proposed. Work:.. , Address Telephone Signature Expiration Date _ 1R em odel Work Onl _._ ., ntia _ esid e Y .,. .. . . _ _ ST ... ChITI€U l' lflN.:. :.:::::...........: ::..........:: � -TIMAT ht............:.. CTIt3N... ............ ....SE .... ...... . li PEP aCONS CONTRACTING WITH UNREGISTERED'CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY Item- Estimated Cost ($) to be completed by permit appliciant li FUND: QUESTIONS OR COMPLAINTS call or write'. Nome Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 1. Building 2. Electrical Owners Name (print) • 3. Plumbing Signature 4. Mechanical (HVAC) by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund S.—Total =(1+2+3+4) Date Estimated Total b �� n_ O rre &Two Family OnlY3.4 Hameow ner Exemption CIT. ... ...:::. I FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT x .. ..... ..... .. .. `' f Construction Su erviaors: Except for those structures governed by Construction Control in Section 116.0, 109.1.1 Licensing 6 P (please print) as Owner of the subject property hereby authorize G , effective Jul 1, 1982, no individual shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, Y unless he or she is licensed in accordance I'n behalf, in all matter ve to work authorized by this building permit application. c, to ton y sk ) `7 �l repair, removal or demolition involving the structural elements of buildings or structures, with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Date • i e exempt from the provisions of this which a Building Permit is required shall b p foimtrt work for g Homeowner er Exception: An Homeo g E�ce t P P Y ignature of Owner ;..:..:. .:;... :...:::.:.;:, .. :. GEN°#:DF+I ARATTQ .. .. .:. 'ptL f1QRY.. £) caner shall act as u ervisor. work, that such Homeo p a es a person(s) s for hire to do such wo , that if a Homeowner en p O section, provides engages of this only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which he/she " :::... ...................::.:..;..::.;::.:.:.,...::..:::... .. ! � Owner/Authorized Agent hereby declare that the statementts and information For the purposes section ' or is intended to be a one or two family dwelling, attached or detached structures resides or intends to reside, on which there is, - than one home in a two-year period shall not be considered as I, on the foregoing application are true and ccurate, to the best of my knowledge and belief. accessory to such use and/or farm structures. A person who constructs more I a Homeowner. Signed under the pains and penalties of perjury. If you are applying under this section sign below: Print a c Sigirature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability igra re Date f O er Au horized Agent 1 � a January 20, 1999 c:\w win\forms\bld a res Page 3 January 20, 1999 p g pP• Page 2 c:\wpwin\forms\bldgapp.res g _ _ j Residential 1999 Residential OONDATION ONLY 1999 1_ I. Date plan reviewed: 1 -,_ 2 Y — COY 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: 6. HOLD reason: Date* 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: 1,2 9. Inspector's Signature: Date: 5_ 12zz c Applicant informed of above Date- Time: Clerk• Comments: Total Permit Fee: $ 150- 00 I Less Application Fee: $ 25.00 I Remaining Balance: $ TOTAL FETE: Gross Area - New Construction total sq. ft. Gross Area -Alteration total sq. ft. Permit Issued To DARTMOUTH BUILDING DEPARTMENT DATE REEIVED K. 400 Slocum Road, P.O. Box 79399 Z = Dartmouth MA 02747 il,vi'l508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIING Zoning Review: Signature: A -Date:— Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date_` Conservation Commission: Signature: Date: 2:i-0Date:— Other: Signature: AT ff NUMBER OF PLANS SUBMITTED:SITE PLAN SUBMITTED O 1.1 Property Address: 1.2 Assessors Plat & Lot Number: Nearest Cross Street:,Plate Subdivision Name: - � % 1.3 Historical District ❑ yes opothe o Has application been submitted Historic Commmission? Total Land Area Sq. Ft.: ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal❑ Private Well ❑ Municipal ❑ On Site Dispoosal System Contact Address /� Name (print) �U C-. - G 41 ✓ 41,14Ti phone number c:\xvpwin\f6rrns\bldgapp.res Page 4 January 20, 1999 c:\wpwin\forms\bldgapp.res Page 1 J,hnuary 20, 1999