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RESIDENTIAL
RESIDENTIAL
SE TI 2 - PR PER R HIP AUTTFORIZED AGENT
2.1 Owner of Record: v
In
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3- CONSTRUCTION ERVI ES
3.1 Licensed Construction Supervisor: / G
Not Applicable ❑
Licensed Construction Supervisor
License Number C .5 03 �24 3%
Address
Expiration Date
Signature 3(/1V777i0 A/? Telephone �¢
3.2 Registere errt 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 %Ii/C/�/,����C,G�
Registration Number (if none, state "none")
AddressdKS ST"
Signature - : - Telephone C��Rcf773
Expiration Date
3.3 For Re den ' 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 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 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 dwellin¢, 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 applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructi
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5 2 15)
µ . SECTION 4 - WORS COMPENSATION INSURANCE KER'AFFIDAVIT
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide tthis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Oyes ❑ no
SECTION 5'- DESCRIPTION OF PROPOSED WORK (check all applicable) h
❑ new construction* 93 addition ❑ alteration ❑ repairs ❑ chimney/ ❑ w!oodstove F
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dYemolition
(shed/garage) no. of windows doors (specify below): (spe#cify 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 Electric Fuel Oil Other
Brief Description of Proposed Work: 00 X 20 -
SECTION -:6 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) *Estimated Total $®O®
SECTION 7A OWNER AUTHORIZATION ''a
(to be completed whenw `oner's agent or contractor applies for bwldmg permit)
(please pri
as Owner of the subject property hereby authorize
to a on my behalf,ia a l matters relative to work authorized by this building permit application.
Signature of Owner Date
' SECTION 7B - OWNS AUTHORIZED AGENTDECLARATION
as Owner/Authorized Agent hereby declare that the statements ancd information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the send penalties of perjury.
Signa ° Owner/Authorized Agent ate;
on
CAblda.forms�\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.fomms\Bldgapp.res.wpd Page 3 $Rev. January 19, 2001
on
CAblda.forms�\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.fomms\Bldgapp.res.wpd Page 3 $Rev. January 19, 2001
UND
_ SECTION 8 - SP TOR SREVIEW/COMMENTS �..
�,.,t;�•.... ,. -.,. �� _._.,E_:.. " $25.00 APPLICATION FEE IS NON-REFUNDABLE NON-TRAMSFERABLE
i
1. Date plan reviewed.
2. 30 days to review period expires:
3. OK to issue dater
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. Date:
8. Comments:
9. Inspector's Signature: Date:
SECTIO 9 - ICANT NOTIFICATION
Applicant informed of above Date: S DZ- Time: y Clerk:
Comments: 4_ W i lL o —wza
E - SECTION 1 T R S NOTES _- ON 0 OFFICE�INSPEC O
F V Total Permit ee.; $ Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE: CQ Gross Area - New Construction total sq. ft.'
Gross Area -
Alterationtotal sq. ft.
l �F
Permit Issued To ,
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
1
DATE: RECEIVED
DARTMOUTH BUILDING DEPARTMENT
V+.
400 Slocum Road, P.O. Box 79399
-
Dartmouth, MA 02747
G�.:•'fifi4
L
5'Y 508-910-1820 FAX 568-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO" AMIALY-DWELLING '
= THIS SECTION FOR OFFICIAL USE ONLY-
�. _n
RECEIVED BY ,.,
DATE SENT FOR REVIEW..
BUl<I,DING R1ViIIT WV
_NUMBER:y
DATE ISSUED..
OK TO ISSUE - SIGNATURE.-77
_.
= B ildin ,,itommikgionerfinspectorof ui ings ` _ ..
ZoningDistricsedUse: one:A ❑V'Outside.EioodZonetCl . Aqro ouiferZone : _ ::
THE FOLLOWING AGENCIES SHOUL BE NOTIFIED'= €� a
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_ . '�. 3...~ '#i+. +p$tR..-r`2g1°'✓ l?`='#-bs '_+ :3• ,.: �"aw3 T:-.§'.'p' T'._..a`�"
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;::. ,.... `.:Y: „�•- "'b. .Fr:ra:l-$ r'SN:.. , <.: "4''e... zK.. 4 S #�'..
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❑ Boa d o a o �Co Co x ❑..Demo- ..,,❑DPW. ��^ - �..:_.,� D,Eleg ,�. :DEner -Re ort --
..
.;;: ..a__._
. _ ,x_.._ �. '-:e= 'tin
:•
Appeals Health Affidavit Card Sent Cut Uyrf W up
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.x..,~.,. ...-,..: gi ..., - .:z?d, y-. .g.... . 5., �. 'i- w.. n.: :re .�
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❑ Fire ❑Gas .❑:Planning Board* ?_ ❑:Sewer `Card `Q Water Card er ❑ Zoniing i❑ Other z
, " .
Chief ` -`-'Cut Off }/ Cut Off Cuf Off Review*
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£ § n•".4 4
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REQUIRES INSPECTOR S REVIEW BEFORE THE ISSUANCE
DEPARTMENTAI:`APPROVAL`" `
,. Wi- -
Zoning Review: Signature: ate: C b
Energy Report: Signature: oe Date:tt '
Fire Chief- Signature: = Date: -
Board of Health: Signature: Date:
Conservation Commission: Signature:Z7ate:
Other: Signature: Plate:
® x
r' i n o work being Z Desc rpto f o g0 �/�.�/` ,00QA7 4Ai �er
SECTION 1- SITE INFORMATION `r §60
p
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat &)Lot Number:
1.1 Property Address: ,
Plat U Lot
NearestCross Street: /C�1 C�>i
1.3 Historical District ❑ yes ETino .
Subdivision Name:
Area Sq. Ft.: �.Tat;V
Has application been submitted to,`the Historic Commission?
Total Land —
❑ yes ❑ no Date: '
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal Private Well
❑ Municipal V On Site Disposal System
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