BP-52829 Pdih i o""BP 2822g z'4'k a a"t41: t" „ , `_BUILDING N V IT I' '' x;{.{e;, . .n..� �.ul'InOr:-sm. any,y
Map .. t; P _ 'n TOWN.5 an ART O-U rn 0
01 Y 0' ,4400 uliniRgacT,Dartmoluth D 747
i 7 •1 ` .} '.rS: c- ' 'alo :> 508 710-11,82b, • „Faxr„ 8 9`10-1838 ass. ,
a *, dR
wee� 6l - PEi2MlSSION�ISEJE GRAM r e � It
,Co - - - s$ -I e es ', ss g. i aa- ,
� � , z," .1 Contractor '` a 't".` �.sg Pint#pi
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s,: a 1
,P + l j Engineer s S n Peen et
i)n 7<. e _ ,wa4Pa r € f
i {» ~ ` Applicant : T r . illaine
#'m
ia : er, i_ 's 1: ... .. STEPHANIENIB' (508)y -5999
. _ . . .. `ae
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OWNER oc At ''
ffi
BAKER STEPHAI*(IPt- �. `" C. e°__3" _
DATE ISSUED: s f_r 11l I °: �t„�3'
ava '.
s.
TO PERFORM THE FOLLOWING WORK: _ -- .. -
10' x 16' shed; TO MEET THE TOWN OF DARTMOUTH ZO LA REQUIREMENTS
(SETBACKS)
Approved/Issued By: '�
Project Location:on 90 MILLERS DR
I
DAVID W MATTOS,LOCAL BUILDING INSPECTOR&ZONING ENFORCEMENT OFFICER
All work shall comply with 780 CMR 7w"Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file.
SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK,FINAL INSPECTION IS REQUIRED. THIS PERMIT
WILL EXPIRE PER 780 CMR 5110.9(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY
PERMIT.
I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent.
and to receive this permit, I further understa d other age 'es may have reason to STOP WORK if items under their jurisdiction are not met not
withstanding the issuance of this Building/Zoni Permit
Signature of Owner/Agent: ; r
Comments: PERMIT NUllMBER iS* QTm(EJ WHE (QUE rtbintrirdatkgrikat`rWststirRA
BUl?O REQE,IVH. noThER SPE ?TI,O
"Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)"
Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department
Plumbing Wiring
Water Service#: Footings: Underground: Oil:
Underground: Service:
Foundation:
Rough: Smoke:
Rough: Rough: Sewer Service#: Rough Frame:
Insulation: Final:
Final: Final:
Cross Connection Final: Final:
Treasury:
Board of Health E-911
Additional Comments:
Planning Board
Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary
inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of
the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET
TOWN OF DARTMOUTH
BUILDING RECEIPTS
COLLECT,OR'S OFFICE
Name: ' 'l'. f Property f. e--,:. "--1,- . Date: ,.i f r
Owner:/ t , .'
Job Location: r i 1 2 ' i''-
i 1 I P' t��/. .� ' i` - r&) N OF DARTMO
_ ®e 1 ECTUR OF ' �opy-Collectors Office
Plot: f /, tot: �A? ,� F.Pe6 Pntpp 1'- �''Copy-Customer's Receipt
t i.- ..-1 ,,I— , wii ��. 0 iQOBPink opy-FileCopy
Green Copy-Building Department
Phone: - - -
y7 r 1
Descnpti&i *1 I*a r**beneIal Ledger#'s Ref.# - Amount
License&Permits-Building 01000 44105 _ w / l tom'
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue. 01000-42420
f
This is not a Permit or License for Building,Plumbing or Gas Received St/
TOWN OF DARTMOUTH i.
nwki
i 52829
BUILDING RECEIPTS 1 �
\ \ \i COLLECTOR'S OFFICE ,r,
� �
Name 3,1 i, . Property Tr,/ / z Date: -`.d`is ! r�G<=,{
Owner: f� •t '` r _?Job Location: I -� ' ' i
'7 t _ 3, tr
White Copy-Collectors Office.
Plot: - -n it Lot: / ✓-- ✓ Yellow Copy-Customer's Receipt
Pink Copy-File Copy
Green Copy-Building Department
Phone: -
Description General Ledger#'s Ref.# ;' Amount
License&Permits-Building 01000-44105 /• .i, j` 1`
License&Permits-Building Misc. 01000-44105 ` ' /
License&Permits-Electrical 01000-44106 -
License&Permits-Plumbing&Gas 01000 44107 �j-,j
Other Department Revenue 01000-42420
i
This is not a Permit or License for Building.Plumbing or Gas Received By: "le , t' >/t 4--a% ,--
RESIDENTIAL ❑ Approval in Part(Per 780 CMR.5111.13)
S25.00 APPLICATION FEE IS NON RE-FUNDABLE &NON-TRANSFERABLE
• 'DATE RECEIVED
o-rH DARTMOUTH BUILDING DEPARTMENT
1[8 t: ><'; 400 Slocum Road, P.O. Box 79399
z - h Dartmouth, MA 02747
`-7° �YY: Phone: 508-910-1820 Fax: 508-910-1838
IR6G�i�
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
T HI SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: it t."9 f BUILDING PERMIT NUMBER:SSU
DATE SENT FOR REVIEW: (tr V DATE ISSUED:
O.K.TO ISSUE-SIGNATURE. �'� r2 <<v>`/L DATE: ' '
Zoning District. S !�-YS Proposed Use: 1S' Zone: C ❑ B 0 A 0 V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑Board of ❑ and of 0 Cons.` 0 Demo 0 DPW ❑Elec. 0 Energy Report
Appeals Health Commission -Affidavit Card Sent: Cut Off Followup`
❑Fire 0 Gas 0 Planning 0 Sewer Card 0 Water Card 0 Zoning 0 Other
Chief -. Cut Off Board .Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. >I
Dr ARTMENTAL APPROVAL
7,6 Zoning Review: Signature: - °'v� s/Z Date: / rr/ )
Energy Report: Signature: Date:
/Fife Chief: Signature: �I a Date: /j
(/Board of Health: Signature: efje t4 r F�CX G Date: Li '-c�t
Conservation Commission: Signature: Date:
Other: Signature: y— ,.(Date/:
Brief description of work being performed:/0 r 1(01 (Q c Le `
90
,SECTION 1 -SITE INFORMATION
1.1 Property Address: /r/I /�S L{'f(�� 1.2 Assessors Map& Lot Number: l
ii 0 r 1 T
Lot Area(sf.) . �� ' Frontage /50 Map Lot (
Required Provided
Front Yard /50 1.3 Historical District ❑Yes 0 No
Side Yard 60 6 Has appripation been submitted to the Historic Commission?
Rear Yard 37 00 ❑yes 0 No Date:
1.4 Water Supply(MGL/90 s54): Sewage Disposal System:/
0 Municipal ea Private Well 0 Municipal .d On Sjle Di posal System
I CONhSoTRUC ION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION_.-PROPERTY OWNER HIP/AUTHORIZED AGENT
2.(,1r-Owner Record::
1 hGA iC_ ,BaKe r 70 rfilers .3r 57467V59 t
\ Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SECTION -CONSTRUCTION SERVICES r
3.1 Licensed Construction Supervisor: Not Applicable 0
Licensed Construction Supervisor: License Number:
Address: Expiration Date:
Signature: Telephone:
3.2 Registered Home Improvement Contractor: Not Applicable 0
Are you a Home Improvement Contractor subject to(780 CMR.110.R6)? 0 Yes ❑ No
If No, go to the next section!
Are you darning exemption from the requirements? 0 Yes 0 No
If Yes, submit the required affidavit!
Company Name: Registration Number(if none, state"none"):
Address:
i 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
/
!3 I am a Homeowner performing all the work myself. /� v
Owners Name (print): c +Z 0hit n I e / / r r a/t Q -
Signature:S
[� B/y�e above,the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:' //c D8
3.4 Homeowner Exemption-One&Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 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 shall act as supervisor.
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 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.
If you are applyi under this section sign below:
Signature:
Your signature carries certain responsibilities,including but not necessarily limited to,general liability
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25)
Worker's 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 building permit. Signed Affidavit Attached: ❑Yes ❑ No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑Deck 0 Pool 0 irs teration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
❑New Construction* ccessory Bldg. 0 Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) - (Specify below)
❑Addition ❑Replacement window/door 0 Demolition
(Energy report required) 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
0 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): 1
❑HVAC(combined unit)-primary fuel, natural gas, propane,electricity,other
❑Air conditioning-(separate unit)
❑None of the above to be provided
0 Hot Water Gas Electric Fuel Oil Other
Descr'p ion ro os d vpork: y ,
dy /6 ' Ji o o'L--
t _ SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building -
2. Electrical
3. PMechanical
/
4. (HVAC) CY
5. Total =(1 +2+3+4) 3, OW j
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
I, ; ,as Owner of the subject property hereby authorize
to act on my behalf, in all matters r latij to work authorized by this building permit application.
Signature of 0 r
/ IiL}{ Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
I, 4A//.y112 /YI' f-e( , as Owner/Authorized Agent hereby declare that the statements and information
o the foregoing application are true and accurate,to the best of my knowledge and belief.jSig d under the pains and penalties of perjury.
/War
Signat a of Owner/ u horized Agent D e
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED(see project review worksheet):
Q A �i/ ..C/Vp 6— Date:
3. HOLD //
Reason: Ali fi3O Fir/1n/suf CxoSC S,fG i ion Date: / 0 II.
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date:
SECTIO G�9 APPLICANT NOTIFICATION
Applicant informed of above: �/Da e: / G',/ Time: 02 Al Clera
Comments: / //c- / v
64-7r)
SECTION 10-OFFICE/INSPECTOR'S NOTES
W Less Application Fee: $25.00 Remaining Balance: 5 G `o
Total Permit Fee: $ 7S.U U
Other$Amount$
TOTAL FEE: `7 S, c 6 Gross Area-New Construction total sq.ft. /(n S 6 / T"
Gross Area-Alteration total sq.ft.
Permit Issued to: A 0D /0 / / / 6 5 li n Td /feu /6-4 / /
SECTION:11 -ADDITIONAL:COMMENTS/SKETCHES
v ,1h7 / S
permit No. BP-52829 Project Location: 90 MILLERS DR
Commonwealth of Massachusetts
GTS#: 365¢,00
TOWN OF DARTMOUTH Map; OU70
400 Slocum Road,Dartmouth,'MA 02747 ;t)013
Lot.
Phone: (508)910'-1820• Fad:(508)'910-1838, Sublet: 0036
BUILDING PF,RMIT category:
008_002305
FIELD INSPECTION Fee•cest: $7s0 0
Const.Class:
Contractor: License. Phone#: Use Group: .; _ B
Lot Size(sq.It) 174A
Zoning: SRB
Engineer: Ltcerse: Phone#: NewConst.:
Alt,Coast.:
Applicant: Phone#: Ceiling:
STEPHANIE M BAKER (508) 674-5999 Walls:
OWNER: - Floor:
BAKER STEPHANI Ii'iO '
( . Glazing:
tI �{ f )J�r -�
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK:
10' x 16' shed; TO MEET THE TOWN OF DARTMOUTH ZONING BY-LAW REQUIREMENTS
(SETBACKS)
DATE TIME TYPE OF INSPECTION&REMARKS I INITIAL
���� /� �/ / °iC - L LY 0-1/1/trY Zj/� //l .
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FILE COPY
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The Commonwealth of Massachusetts
w= Department of Industrial Accidents
►p_ 1-1t Office of Investigations
5k _ifir ; 600 Washington Street
f Boston, MA 02111
dr
wwitzmassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
plicant Information D Please Print Legibly
Name (Business/organization/Individual): i'�.SPi rn t. `e r
L ess: qv m l delis Jr✓-e-
ti /State/Zi : �l\ , O(C Dad 7 Phoneo ,, // q
ry p � JG�f" Ts7'C �i�- y #: Jl 00�7`fS�/9
Are you an employer? Check the appropriate box:I
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
w king for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
o workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical rep
airs or additions
required] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required] 13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: ` )ej 1( ,,/,, City/state/Zip / ,-71
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I hereby ce under ihe s and pen ' s of perjury that the information ovided abov is tr and correct
i e: Co // ` Date: c2-Y o
ne#: �� Co ''7s 9
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License# F 1 L� r it l
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Numbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would hie to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26 os Fax#617-727-7749
www.mass.gov/dia
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