BP-92215TIAL
E+Tl4nt>��ar crnlslfu
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2.1 Owner- Record:
J-_qJr2J`yD G�th�iq t^4
/0� n11k,�_ -Vr,
Name (print)
Contact Address Phone Number
2.2 uthorized Agent:
�a1" 1 ,N,14Yi_'i
15011 (% h S AZ.b ogy/ 6294:l'S% � v�
Name (print)
Contact Address Phone Number
1
License Number.®` 5ry !;;�,`7
3.1 Licensed Construction Supervisor/Specialty License:
b4ilde-,y l7��t7
Company Name/Contractor Name: t / - - ®
Address: Z� , AC at OA-7ty
Expiration Date: 'VIO/AO
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 11Q.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
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 pe.-son(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: Parson(s) who owns a parcel of land on which he/she resides or intends to reside, on which
constructs than
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures: A person who more
one home in atwo-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
SEGI�N. 1illElR.S CQnlAf(�FlEJJ�G�FF3►tT (MCa�._ 2 ..., ._ s s '-j
Worker% Compensation Insurance Affidavit must be _completed and submitted with this application. Failure toyrovide this
❑ No
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ®'Yes
g _-1�l43ni 5: T?BEl1Ttt QF t?6�k'DEDINOR ll>klf ppltcalEtte `_,_
❑ Deck ❑ Pool ❑ Repairs ` ❑ Alteration ❑ Chimney/Fireplace ❑ WoodstovelPellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition V Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows _ Doors
❑ DEMOLITION (specify):
o site - ❑ Dum stet On Street
Dum star n s t
Location of debris removal (per MGL C.40 .Sec 54): p
/pp
Facility Name: Ab e" 01-s � 0 5a Location: �(�i.�,. �e 0(4-J 1t%�
*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 /I/
No of Bedrooms Unit 2 No. of Baths Unit
❑ 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):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of tthe aboveve ,.- : d
❑ Hot Wate:.-: G= = Electric Fuel Oil Other
_ t
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical I
3. Plumbing
4. Mechanical (HVAC)
5 Total (1 +2+3+4) C S®
Y SteG1l?h1 �A Glnt1=R [lTJfil t
(Please Print) ,�-
Uurener
��M In , as Owner of the subject property hereby authorize QGN r g2�t '�
to all matt
rela e to work authorized by this building permit application. j7a l ��^ ti Ci Date
M_ ZEQ ►G l� r o�l=e loll
1 ��fiLG y/ Q �v�y�tidt
as Owner/Authorized Agent hereby declare that the statements and information
t
on the foregoing application are true and accurate, to the best of my knowledge and belief.
'11
Signed under the pains and pe alties of perjury. I
i nature of OwnerlAuthorized Agent Date
Signature
Total Permit Fee: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total s ft
Permit Issued to:
Less Application t!5Y
Other $ Amount $
X
Remaining Balan $
t
Poerfm , thew // »ew l c e, or 1,vq,4tv, � �/ e 6 ki I.67WC "
itiAll
RESIDENTIA1. ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & ICON TRA
Contact Person: ra u l_ V e oh z tf
0 CONSTRUCTION PLANS 0 SITE PLAN D ENERGY RF
RESIDENTIAL
2001 RESIDENTIAL 2001
SECTION 2 - RROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record: O
A
` 1
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? Dyes ❑ 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
PERSONAS 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'
Signa 're
i ing 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; provides that if a
Homeowner engages a person(s) for hire to do such work, that such Homeowner shallactas supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows:
Y o s. 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 dwelling, 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 not be considered a Homeowner.
ying under this section sig belo
If yoLtdre:
Sign
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
`V
C:\bldg.forme\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd Page 3
NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Con huction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.1,t, )
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 providde 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 / [!_] woodstove
(energy report required) (energy report required) lye ace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ED 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),'f iel 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:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. PlumbinLy
4. Mechanical HVAC
5. Total = (1 + 2 +3 + 4)
* Estimated Total $
SECTION 7A -OWNER AUTHORIZATION,- _4
�,.
to be con leted when owner's agent or contractor applies for building` permit) r
( p gtnm
(please print)
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
SECTION B - OWNS AUTH BRED AGENT DECLARATION - T -
I, , as Owner/Authorized Agent hereby declare that the statements aind information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
igned under the pains andVena's o
,erjury. 1-61
AIhA M0
.Signature o, Owner/Authorized Agent Drate
Rev. January 19, 2001
RESIDENTIAL
2001
RESIDENTIAL 2001
F
` 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): Dater
5. DENIED (see project review worksheet) Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature: Date:
"SECTION 9 - APPLICANT NOTIFICATION
Applicant informed of above ate: Time: Clerk:
p � _
omments:
SECTION 10- OFFICEVNSPECTOR S NOTES
/V4
1 • Remaining Balance: Total Permit Fee. $ Less Application Fee. $ 25.00 g $ (C!�
TOTAL FEE. � Gross Area -New Construction total sq. ft.
Gross Area Alteration total sq. ft.
e
Permit Issued To
SECTION 11- ADDITIONALCOMMENTS/SKETCHESqu
b-014-
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-RErUND$BLE & KON-TrtmsFERABLNh j
DATE RECEIVED
M 2�
`;"T" DARTMOUTH BUILDING DEPARTMENT
[ 400 Slocum Road, P.O. Box 79399
!o x;
Dartmouth, MA 02747
508-910-1820" FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINrC
THIS SECTION FOR OFFICIAL USE ONLYNb
2
RECEIVED BY. _
BUILDING PE b
DATE SENT FORYREVIEW-
NUMBER.
_ .. .
r MF
s=
DATE ISSUED
OK TO ISSUE -SIGNATURE...
�• - ilding Commissioner/Inspector f Buildings s
' ° ❑
Zone:.' �'C,.❑ B ❑ A ❑ V Outside Flood Zone ,
Zoning District. Proposed :." 4Aquifer ifte�'7777777
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: r ` F
,,, m M . i
i.^n. `sue 19,R-
~
- ~ s
❑ Board of ❑ Board of Co Com ❑Demo ❑DPW a ort
,
Appeals ' "Health Affidavit =� -Card Sent �`CutiOff Foll w * p
_
s _.
3 s.
❑ Fire ❑Gas -' ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning;❑Other w
Cut Off Off Review*
Chief Cut Off / /
"Cut
x. ..r x# Q
REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A -PERMIT: P'
DEPARTMENTAL -APPROVAL
_.. ._� _�.z._.
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date: y"
Conservation Commission: Signature: Dater a
Other: Signature: Date:
Description of work being performed:
SECTION 1-SITE INFORMATION h
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: 0 yes ❑ no
1.2 Assessors PlaattJ& Lot Number:
1.1 Property Address:} hli
Plat /� Lot/& - 2
Nearest Cross Street:Ave
f '
1.3 Historical District ❑yes ❑ no
Subdivision Name`. %t�e_Es a o
Has application been submitted to the Historic CSommission?
Total Land Area Sq. Ft.: �C���
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ On Site Disposal System
r
C:\b1dg.fbrms\B1dgapp.res.wpd Page 4 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd "Page 1 Rev..JJanuary 19, 2001