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BP-20030sTIAL 2001 - SECTION 2 - PROPERTY OWNFR1`HiP AUTHORIZED AGENT a 2.1 Owner of Record:'ztc- t :7�,-Ccs, ool�cla ame (print) Contact Address r Phone Number 2.2 Authorized Agent: c✓ y iarne (print) Contact Address 4o Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number tiaaress - Expiration bate 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! Company Name Registration Number (if none, state "none") Address Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERS©NS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: zUES`I'IONS OfOAINTS call or write: entent Contracttors Registration, One Ashburton Place Room 1301, Boston, MA 02108, (617) 727-8598 )wners Na`. e Y S1F�1 iignattt/�Y �--R ., signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund )ate .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 ,all be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of iddings; ur structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing onstruc2ion 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 )meower enrages on(s) for hire to do such work, that such Homeowner shall act as supervisor. For t>he purpo e section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intend s to reside, on rich there is, dot`is e .d d to be, a one or two familydwelline, attached or detached structures accessory to such use and/or farm structures. A person who constructs )re than one. o i in vo-year period shall not be considered a Homeowner. e you are a a �i - this section sign belo ®"' ,nature Your signature carries certain responsibilities, including but not necessarily limited to, general liability r `- dg.forrns\BldRapp.res.wpd Page 2 Rev. January 19, 2001 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 R,2.15) 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 PP 1provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes 01 no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove (energy report required) (energy report required) fireplace ❑ deck p 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 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): ❑ Air conditioning - (separate unit) j ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: , z SECTION - 6 ESTIMATED CONSTRUCTION COSTS -`Item Estimated Cost ($) to be completed by permit applicfant 1. Buildin% 2. Electrical A0DD 3. Plumbing 4. Mechanical HVAC o 5. Total = (1 + 2 + 3 + 4) *Estimated Total $ SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) Alre 'as Owner of the subject property hereby authorize, y half, in all matters relative to work authorized by this building permit applicon.�of Owner Date G r SECTION 713 - OWNE AUTHORIZED AGENT DE LARATI N a Owne Authorized Agent hereby declare that the statements %nd information on the f regqung a plication are true and accurate, to 4 est of my knowledge and belief. Signeollu�l derlthe pains and penalties of perjury. t� 1 F Signature o Owner/Authorized Agent Datte C:\bldg.foims\Bldgapp:res.wpd Page 3 rn_- 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: Date: Date: Date: 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: Date: 9. Inspector's Signature: AN Me: 20oI `> SECTION N 9 - P LIC NT NOTIFICATION Applicant informed eabovej Date: Ti Clerk: Comments: �- SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balanc : $ TOTAL FEE: / Gross Area -'New Construction total s . f . / % - - q t Z Gross Area - Alteration total sq. ft. - . �. Permit issued ssued To - ` SECTION 11 -ADDITIONAL COMMENTS/SKETCHES RESIDENTIAL 2001 RESIDENTIAL ❑ FOI /NDATION ONLY - SECTION 8 - INSPECTORS REVIEW/COMMENTS _ n t� $25.00 APPLICATION FEE IS NON-REFUNDABLE &. N®iN-TRANSFERABk 4 DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT - N 400 Slocum Road, P.O. Box 79399 ;v n; G y c Dartmouth, MA 02747 `:..'.fi ...... =' 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE Old; TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: ., . DATE SENT FOR REV IRSs3 , SIGNATUREr_K TO ISSUE y._:DATE;-d uilding Commissioner/Insli&ior of Bu s Ma} Zoning District:" Zone CSC❑ B ❑ A Otatside 4� V Fler�odZone O A`quifer Zornf THE FOLLOWING AGENCIES SHOULD BE NOTIFIED. =y , .._ .m ❑ Board of ' ❑Board of ❑Con Com T ❑Demo A `❑ DPW _ ❑ Elec ❑Energy R R Appeals "Heath Affidavit Card -Sent pP Follow up YF'i„ s �4s.::� '�S' .+.+P�..S t-.nm,'_dYY' '°'-`7 S. �x-hf.,. {.33, .,STa,-v WA ❑ Fire ❑Gas ❑ Planning Board* ❑`Sewer Card ❑ Water Card ❑ Zomn - ❑Other g Chief =Cut Off Cut Off 'yt 0 ` :'/ / Cu ff yReview* r E."may q'44 . :-.,—, 3i` "4' i•r 'd,'S' '.'.i' E t-,O, .. ?` REQUIRES INSPECTOR S REVIEW BEFORE THE ISSUANCE OF A :PERMIT „_ _ APPROVAL .. :DEPARTMENTAL Zoning Review: Signature: e r Date: Energy Report: Signature: L74'_ JUN 2 7ZQ® Date: Fire Chief. Signature: /-, Dater Boo of Health: , Signature Dater / f Conserva on Commission: Signature: Dater e Other: Signature: Date: Description of work bein er ormed: SECTION 1- SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: yes ❑ no 1.2 Assessors Plat &�LLot Number: 1.1 Property Address: i Plat ,---7 Lot- _ Nearest Cross Street: 1.3 Historical District ® yes E o ® Subdivision Name: c �,.� `�..� a%•=✓'°� Has application been suk)mitted to the Historic Comrr Total Land Area Sq. Ft.: ❑ yes ❑ no IDate: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipalo Private Well ❑ Murhicipal On Site Disposal v C:\bIdL. forms\B Id,app.res.wpd Paoe 4 Rev. January 19. 2001 C•\h1da fnrmc\R1dannn — w•nd P 1