BP-32586�_saso FVUINUA I IVIN /A7--CJUILI I�LI-HIV
co
SCALE J_ 60APPROVED BY DRAWN BY
o �O. - -
DATE 6-H-99 REVISED
MILLERS DRIVE NUbLHT URY, MAIP 70, LOT I3-3I.
Z
MILLERS FARM DARTMOUTH MA..
DRAWING INUMBER
KENNETH R. FERREIRA ENGINEERING, INC.
D
S
`6514.-.31A
46 FOSTER STREET. NEW BEDFORD, MA. 02740 E
STOCKDRAFTING FORM NO. 101.61
RESIDENTIAL
2.1 Owner of Record:
Name (print) Contact Address
2..2 Authorized Agent:
Name (print) Contact Address
Phone Number
Phone Number
3.1 Licensed Construction Supervisor: Not Applicable El
Construction Supervisor License Number
Address Expiration Date
Signature Telephone
32 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
r 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)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeown
er 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 Sectiion116.0, 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
Horeowner engages a persons) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of this section only,a "H
omeowner" i s defined as follows: Person(s) who owns a parcel of land on which he s or intends to reside, on
whia there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structuresd A more than one home in a two-year period shall not be considered a Homeowner. person who constructs
If you are applyin nder this section sign below:
Signature: I`
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2
Rev. January 1, 2003
RESIDENTIAL 2004
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Cnonstruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R53;2.15)'
.P.�'P.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to Iprovide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes q; rno
❑ new construction* ❑ addition
(energy report required) (energy report required)
❑ alteration ❑ repairs ❑ chimney/
fireplace
❑ deck ❑ pool q. accessory bldg.
❑ replacement window/door ❑ other
(shed/garage)
no. of windows_ doors_ (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)
❑ None of the above to be provided
❑ Hot Water: Gas Ele is Fuel Oil Other
Brief Description of Proposed Work: s)i cfru Ac►!q
�0� n
�► read., ; n �IG..�
A Tic ✓1
Item I Estimated Cost ($) to be completed by permit applicant
❑ woodstove
❑ demolition
(specify below):
5 Total (1 + 2 + 3 + 4) *Estimated Total $
� A 'r' d,l�r a d,� @ ro f�r� a a ��dlr rir! ad.`•'7 � � �°rJ r �a a � ,
d� A � � Ear P r� � as �a "�Pp"i?a .l §� ,�t�p,. r=i � wrJw w: r✓�d �, ids dm�.�
�d.
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:�r'g, ry - i a s d '� r �.w `� r✓r ,' ��„° . � ;r i .; d gy -.,a° F i ��u@„,�� � a rft rr'
ri. rlawd�. , a;w"I` J`.rr�°iw � ��a �::a= rp J' e:° :":'"' ,a Y�iv, d -�Ir �?, , J �.� 1'a&��1; �1�.. �(��% rr✓.� .:,. a ,:" ip � r .:.:u �i �� �u�.� a , �"2 �.
(please print)
I, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
wr.
1C&
rAA
as Owner/Authorized Agent hereby declare that the statements atnd information
on the for in application are true and accurate, to the best of my knowledge and belief.
Signed and the pains and penalties of perjury.
Signatu f ner/Authorized Agent D
M to
C:\bldg.forms\Bldgapp.res.wpd Page 3 _
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): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning PP Board of Appeals action: Date:
8. Comments:
A
9. Inspector's Signature: Date: (/
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m e®a m�a � �.b.. m m. � " m.m.� �
Applicant informed f bo e Date: Time: Clerk:
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.�_®...:m..m..�...ra..�._..--. , ,.",.�....,`�a..F,.m. �,.m �.:
Total hermit Fee. �
$ � �
Less Application Fee. 25.00
pp $ Remaining Balance. $
TOTAL FEE: Gross Area - New Construction total sq. ft. 1�
/ Gross Area -Alteration total sq. ft.
Permit Issued To:
N05
�..
a .x �..m.� �, �. _ems . am� t
C:\bldg.forms\B1dgapp.res.wpd Page 4 Rev. January 1, 2003
RESIDENTIAL 2004 RESIDENTIAL 2004
❑ FOUNDATION ONLY ❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE $25.00 APPLICATION FEE IS - EFU DA LE & NON-T ANSFE AM'ME
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DARTMOU�II BUILDING DEPARTIVIENT
_
� "
� -
E DATE RECEIVED
f+o _' 400 Slocum Road, P.O. Box 7939Z
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Zoning Review: 0 �� Signature:
te:
Energy Report: I,/A/ Signature:
Date: cS7 t�
c
Fire Chief: Signature:.
DD te• �'3
Board of Health: Signature:
Conservation Commission: Signature: _.�-
9� �J
f
Other: Sign Lure:
Date:
Description of work being perform d �ifcrcnS�r,Ac art - TiSGltYlt fl ,'� �` ev?i r
$ER
SITE ❑
NU OF PLANS SUBMITTED:
PLAN
SUBMITTED: ❑ yes no
1.2 Ass sors Plat & Lot Number:
1.1 Property Address: w-7 MR )k rs JD r ; �'P
Plat 7G� Loth
t
Nearest Cross Street: CIA &1) R�r A
Subdivision Name: j k(3 F+r`w)
1.3 Historical District ❑ yes ❑ no
e\•
�, DOCK
Has
application been submitted to the Historic "Commission?
Total Land Area Sq. Ft.:
❑
yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1. ° Sewage Disposal System:
//
❑ Municipal Private Well
El Municipal �n Site Disposal System
K)
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