BP-57516 lifTh TOWN OF DARTMOUTH
j G BUILDING RECEIPTS / 5
J PHONE: 508-910-1820 FAX: 508-910-1838 ,yy �0 ?y3 16
Name: n
i _ // L//�. / .Property /t0u
.. \,/ DatUvner: (� - 7 /!�`- ! 0,
Job Location: " White Copy-Collector's Office
(//j ( - Yellow Copy-Customer's Receipt
`,r /� — Pink Copy-File Copy
Map: 7! Lot: !V/�/ / Green Copy-Building Department
Phone:
Description General Ledger#'s Ref. # /'y Amount )
License&Permits -Building 01000-44105 iii: tfE./r)i -7 1
License&Permits - Building Misc. 01000-44105 %
License & Permits -Electrical 01000-44106 r 2 ^`I T ''
License&Permits - Plumbing& Gas 01000-44107
License &Permits - Trench Safety 01000-44129
Other Department Revenue 01000-42420 -_>l't v .'
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS :.
Received By: •_ "9 �!.
RESIDENTIAL ❑ Approval in Part(Per 780 CM\2.5111.13)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE C k 1 k •3i ANSFEIIABLE
,M in I7 s'9' n%_; (J{� TC RECEIVED
p OUTttp. DARTMOUTH BUILDING DEPARTMENTr
/P
•
`0 cl 400 Slocum Road, P.O. Box 79399 —6At PM 2 03
�o ¢� y Dartmouth, MA 02747 ?fis r
;„ .j Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: �G/ C�' BUILDING PERMIT NUMBER: 5 7.
DATE SENT FOR REVIEW. /tv i` DATE ISSUED:
O.K.TO ISSUE-SIGNATURE: _ �_ �,� DATE: ->` d .
Zoning District: 3 2� Proposed Use: Zone: CSC 0 B 0 A O V Aquifer Zone: /LJjr
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑Board of 0 Board of ❑Cons. 3l Demo 0 DPW 0 Elec. O Energy Report
Appeals ' Health Commission Affidavit Card Sent: ' ' Cut Off. ' ' 'Follow`-up`
❑Fire ' B Gas ❑Planning 0 Sewer Card B Water Card a - O Zoning ❑Other
Chief Cut Off Board , i. .Cut Oft Cut Off .,,
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT..
• • -TMENTALAPP OVAL -
L��nj `
Zoning Review: Signature: LAG J ✓'?a Date: 0 �/ �_�
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date: cc.
Brief description of work being performed: Ct-Jillt 1- .j j�j
d_
e—
]J rStECTION 1 -SITE INFORMATION
m
1.1 Property Address: t I S V�� Y011I ICt y A . 1.2 Assessors Map& Lot Number:
Lot Area(sf.) Frontage Map 7/ Lot // / -
Required Provided
-
Front Yard 1.3 Historical District 0 Yes 0 No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard - 0 Yes 0 No Date:
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal 0 Private Well ❑ Municipal 0 On Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
■
i
RESIDENTIAL
SECTION 2-PROPE&TY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
ai+-3V\ Cr OcA //3 old 4fllri tr Lik 9-�9 .-�r�/�r ��,
Name (print) Contact Address Phone NNufhder
2.2 A ! prized JGiv, 6gent: P , ? uj4J?s1/Nn /lu4c, Dt IvI %q-7 ////
Name(print) (� i Contact Address Phone Number
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervis : Not Applicable 0
Licensed Construction Sup rvisor. q�/(n�/ r���1 T License Number: Q S-2i24
Ad• -ii a (, Abe it-tin 4227I S Expiration Date: z i
io
Signature: e- 'a-Telephone: eq ( - i 11
3.2 Registered Home Improvement C rector: 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 claming exemption from the requirements? 0 Yes 0 No
If Yes, submit the required affidavit!
Company Name: Care fim, . • 5 Registration Number(if none,state"none"):
•• � <�►�a `/dam' - I - 64-11Acyr-�P,u/oaWr
Signature: ��. Yr i�( � / Expiration Date: `. /h
3.3 For sidential 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
❑ I am a Homeowner performing all the work myself.
Owners Name(print):
Signature:
By signing the above,the homeowner acknowledges that there will be no eligibility 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
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 applying 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_pitecide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Mt es 0 No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) ,
0 Deck 0 Pool 0 Repairs ❑Alteration ❑Chimney/Fireplace 0 Woodstove/Pellet Stove
0 New Construction` 0 Accessory Bldg. 0 Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) (Specify below)
❑Addition 'Replacement windy/door 0 Demolition
(Energy report required) No.of windows b 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):
❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity, other
❑Air conditioning-(separate unit)
❑None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work: ‘ Alt 4) Ajijc'1^S
SECTION 6,ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2+3+4) 30-0
/ SECTION 7A-OWNER AUTHORIZATION '
(to be completed when owner's agent or contractor applies for building permit)
(Please P,(int)i�
I, ( fa t. 6(-46/'
,v--- ) , as Owner of the subject property hereby authorize lE/ji.Vte-,
to act on myy��behalf, in all matters relative to work authorized by this building permit application.
`Lehr✓ /9, i , e `�'t
Signature of Owner Date
sit - SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION,
I, re- l/LA, I kv ,as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing applicatio are true and accurate,to the best of my knowledge and belief.
Sign nder the pains an It s of perjury.
- purl-7
Si ature of thkfer/ lied t > Date g/4/ 7
SECTION 8-INSPECTOR'S� REVIEW/COMMENTS
1. Date plan reviewed: 3 -[J/
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: _ Date: V 7. v,
-:SECTION S-APPLICANT NOTIFICATION
Applicant informed of above: Date: Time: Clerk:
Comments:
• SECTION:10-OFFICE/INSPECTOR'S NOTES '
Less Application Fee: $25.00 Remaining Balance: $-V —
Total Permit Fee: $ 7 J
Other$Amount$
TOTAL FEE: S Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
Permit Issued to:
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
•
Fes«, lls
'ermit No. BP-57516 Project Location: 613 OLD FALL RIVER RD
Commonwealth of ssachusetts
TOWN OF D TMOUTH lit
M p# 3741.00
400 Slocum Road,D y mouth,MA 02747 Lot: 0061
Phone: (508)910 1820 • Fax: (508)910-1838 Sublot: 0000r.
BUILDING PERMIT Category: J-2REPLACE
100 02 2
FIELD INSPECTION Est Cost: $750000
Const.Class:
Use Group: R4
Contractor. License: Phone#: Lot Size(sq. ft.) 5.27A
DANA PICKUP JR CS-95228 (508) 997-1111 Zoning: SRB
5.27
HI-100503 New Const.: N/A
Engineer.• License: Phone#: Alt.Const.: N/A
Aquifer Dist.: N/A
Applicant: Phone#: Flood Zone: ZONE C
CARE FREE HOMES INC (508)997-1111 Ceiling:
OWNER: Walls:
GIFFORD ALTON 74%
Floor:
COMG)11„ETED Gzg:
(DATE ISSUED: a
TO PERFORM THE FOLLOWING WORK:
Install six replacement windows
DATE TIME I' TYPE OF INSPECTION&REMARKS INITIAL
J 2 . cl,c.
i ,.
a \ i
'� ✓/e �avino�u e�Il/ o�✓�aasacc%uaetta
i c,517 �F`Board of Building Regulations and Standards
1, 4`d Construction Supervisor License
wt; License CS 95228
{' Birthdate 3/22/1982
1 i •+3 Exprtation._3/22l2010 Tr# 95228
I Restriction "00
I DANA PICKUP
19NAML p 3. '�/1�^ ��
A A N ik • «Commissioner
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`.-_(- Registration.
eg stra io OVEMENT COWT�CTORs and "ds
EXP1ration: '.100503
•
TYpe: �19i2010
!-- CARE
FREE HOMES INC - PplementCard
PICKUP --::-1 _
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CJ v) 0enOW W 2 2 S = ° E S S Q F F FFFmg F -CIP_+. —___.__._ _ _- Z1wD
The Commonwealth ofMassachusetts
Department of Industrial Accidents
AQfticeofIrz:'est.g ions
600 Washington Street
x .-stir Boston, MA 02111
-"'^' ` www.mass.govAlla
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leuibiv
Name (Bncincss/Organization,2ndividuali: ,e. Fete, RoYVrQjs
Address: 23et__ ` :�-s _l .
City State.,%ilea- ,AN-- Phone #: � .] ILL V 1
Are/you an employer? Check the appropriate box:
� Type of project (required):
1. I am a employer with 4. ' 1 am a generalcontractor and t i
employees (full and/or part-time).*
. New construction
have hired Incthe sub-contractors
listed on the attached sheet. 7. Rtiemodeling
2.ri l am a sole proprietor or partner-
These sub-contractors have 1
ship and have no employees 8 Demolition
working for me in any capacity. employees and have Workers' . .lading addition
comp. insurance.1 r,:` d `
[No workers' comp. insurance F
required.] 5. n We are a corporation and its 10.i' a. ec • al repairs or additions
officers have exercised their ( 71,LJ
3.11 I am a homeowner doing all work PI airs or additions ,
myself. [No workers' comp. right of exemption per MGL I !
C. 152, s i(4), 12.E Roof i
insurance required.] ` s and We have no
employees. [No workers'
t3.(— Other 1
comp. insurance required.] I
*An) applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicang such.
1C oniractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the suh contractom have employees,they must provide their workers'comp.policy number.
I{an an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.sacC / d. -
Insurance Company Name: ,.L �'1' �`
Policy #or Self-ins. Lic.#:_�A 9 /7 in 7 7 Expiration Date: a/
job Site Address:19 /3 Oil 6('rrtv tr. 141 - City/Stale/Zip:_S
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
h:vestigations of the DIA for insurance coverage verification.
I do hereby ce nder pair an ties ofperjury that the information provided above i tra nd correct
S>unature: Date: /I fir
Phone a: 9974!`/
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
information _ instructions
Massachusetts General Laws chapter 152requires all employers to provide vYorkers compensation liar their ethployeds.
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 ajoult enterprise, and including the regal representatives of 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 d aeliinn house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an cinployer.'
NULL 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 a ay
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, 625C(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 till out the workers compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, sapplj ubion.t.acto 's),ainets), address(es) and phone numbers) along with their certificate(s) of
insurance imtted-Liability Companies (LTC)or I mated liability Partnerships (LIT)with no employees Other than the
members orartnets, are not required to carry workers' compensation insurance. If an ITC 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 pemidt 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 till 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 necessan) 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 like 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
Fax # 617-727-7749
Revised 4 4-07 ww-w.mass.gov:dia
Client#:33723 CAREF
ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(i(8mDY")
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Herlihy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Pullman Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
1 a 1 Pull
Str et 606 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
508 756-5159 INSURERS AFFORDING COVERAGE NAIL#
INSURED • INSURERA Acadia Insurance Company
Care Free Homes Inc INSURERS: Interguard Insurance Company
239 Huttleston Avenue INSURER C:
Fairhaven, MA 02719 INSURER D:
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER I nnUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ALKYL POLICY EFFECTIVE POLICY EXPIRATION
LTR NSRE TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/W) DATE IMM/DD/W) LIMITS
A GENERALLIABIUTY CPA0265674 09/01/08 09/01/09 EACH OCCURRENCE $1,000 000
X COMMERCIAL GENERAL LIABILITY PREMISES(Eaoccu RENTED
$300,0110
CLAIMS MADE X OCCUR MED EXP(Any one person) $15,000
PERSONAL&ADV INJURY 51,000,000
GENERAL AGGREGATE $2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000
7 POLICY n!MDT- UDC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSRIMBRELLA LIABILITY EACH OCCURRENCE
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND CAWC917429 09/01/08 09/01/09 WC STATU- H-
TORY LIMITS ER
EMPLOYERS'LIABILITY
PAR E.L.EACH ACCIDE $1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? EL.DISEASE- EMPLOYEE $1,000,000
If yea describe under
SPECIAL PROVISIONS below E.L.DIS E-POLICY LIMIT $1,000,000
OTHER
•
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PRO
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town of Dartmouth DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 n DAYS WRITTEN
Building Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
•
400 Slocum Road IMPOSE NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER,ITS AGENTS OR
North Dartmouth,MA 02747 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ..�
ACORD 25(2001/08)1 of 2 #M35563 }�� A���M/MSS O ACORD CORPORATION 1988