BP-2001-20680 Permit No. BP 2001 20680
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waif x� c. '00741 ` 1- Co elz o • addacn({Qam
4 Act.Nv. j z a se'
Lot _� , !MO xH
Sul Lot ifill TOWNLOF D: a 0�`
Category 1EW. , 400 Slocum Road,Dartmouth,MIA,0 47 ;
Project# r 52002 0120 Phone:(508)910.1820 I n 508 910-
Est.Cost 7000 00 , ...„), ` , ,- -
Fee:' * .1$5100 ^ PERMISSION ISHEREBYG TEI TO'* ' �_ 1is a
Const.Class —e 2 } 3
Use Group 'ITC RIetc Contractor-4 =a cw ytcense t mope'#:
t 1 vit a, xn n ♦i :t
Lo Size q ft) 40001 t Engineer k * `imicense Phi'1 4#:
Zoning x"'tl iSRB ; :4S-;-
1 � F je."- y x• ., � 1 ' oNew Const !iA 4512 sqft t$ Applicant '.t. -ha �-t i > i „, Phone
#:
Alt.;Const �NA -- x: SILVA JAMES V �, = .'S )32446 37
-, ; , ,
Date Typed 08-02-2001 =«z. OWNER: r ">,-
r
SILVA JAMES V&LIlVDA " ' "� , �" �:"- "
DATE ISSUED: �a' D`1 -.,
TO PERFORM THE FOLLOWING WORK: ' -
16' x 32'deck
BUILDING PERMIT
Project Location: 4 KNOLLWOOD DR
I ,
Approved/Issued By: r/,, ,�
RAL(. SOUZA,LOCAL BUIL I SPECTOR
All work shall comply with 780 CMR 6111 Ed. (MGL Chap. 143)and any othe•licable Mass. Laws or Codes and plans on
file.
POST THIS CARD SO/T/S VISIBLE FROM THE STREET
SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS
REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(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 receive this permit, I further understand other
agencies may have reason to STOP WO • ' em under their jurisdiction are not met; not
withstanding the issuance oft ' uilding/ P m
~Signature of Owner/Agent: miff r c /lt
Comments:
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
COPY
TOWN OF DARTMOUTH 20899
1 BUILDING RECEIPTS
COLLECTOR'S OFFICE
rry
Name Property ;l i 1 1.- —` _ ., Date: f
Owner -
Job Location / 1/ Y'_ ,f /./ J,If-) - C. F j t,, t; �t ,
f- 'r F - (a y�
~- White Copy-Collectoi s Office
Plot: t f—/ Lot d-, - — `Zvi, -Yellow Copy-Customers Receipt
i .`x'' N\\C. k Pink Copy-File Copy
' Green Copy-Building Department
Phone: - _ n,
Description General Ledger#'s itef.# Amount
License&Permits-Building � •I.01 4 105`' S.' 7 ,, -�; z: 2 6 21
.. A� Ff
i
License&Permits-Buildiii'g , a� 01?00-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
/7t--�,I
This is not a Permit or License for Building,Plumbing or Gas Received By: ,• J)
TOWN OF -DARTMOUTH
fuss'$
BUILDING RECEIPTS
COLLECTOR'S OFFICE {
Name: � -d �`` } : � .. Property- ��n t i`� Date '1 µ f,d % "-%
Owner;
Job Location Ii f { t
White Copy-Collector's Office
Plot: a_ le Lot: """ ec _ Yellow Copy-Customer's Receipt
0 - .75. _ Pink Copy-File Copy
. - . Green Copy Building Department
Phone
A- A fC
Description General Ledger#'s Towiu OnpuTH Amount
COLLECTOr s OrrICL
License&Permits-Building 01000-44105 —�
License&Permits-Building Misc. 01000-44105 JUL 1 7 2001 j
License&Permits-Electrical 01000-44105 I
License&Permits-Plumbing&Gas 01000-44107 S0 0"
Other Department Revenue 01000-42420
+ ° f This is not a Permit or License for Building,Plumbing or Gas Received By:
RESIDENTIAL 2001
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE&NON-TRANSFERABLE
o�TH DATE RECEIVED
M :;;�9, DARTMOUTH BUILDING DEPARTMENT
/o f - Al 400 Slocum Road, P.O. Box 79399
z. ' Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY - -
RECEIVED BY: r 'rtp` "' BUILDING PERMIT
DATE SENT FOR REVIEW: -- NUMBER. :•
7- ^ i DATE ISSUED
OK TO ISSUE-SIGNATURE: ( ' // DATE / :'
Build' g Comm' ioaerIIp or of Buildings• '�`r a: __,
Zoning District: Seoroposed Use: Zone: " t B A Q� Outside Flood Zone ❑ "Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED
•
❑Board of ❑Board of ❑Con Coma :. . []Demo '_ ❑ � � � ❑Elec. f7_Energylteport
Appeals " `=Health Affidavit - -.Card Sent. ". '�"' ` rCut Off
❑Fire ❑Gas '❑Planning Board* ❑Sewer Card -❑Water Card -❑Zoning ❑Other
Chief Cut Off /Cut Off /Cut Off .`'Review*
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
;.-•DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: '..1[/� /& / iS i Date: 7 /6. c)/
Conservation Commission: Signature: Date:
Other: Signature: 11 rr Date:
Description of work being performed: ( .o I � n-n _ ^ C c 1 n k 0(
SECTION 1-SITE INFORMATION -
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 0 yes 0 no
�� 1.2 Assessors Plat&Lot Number:
1.1 Property Address: Lt kit 0Lt u�p$ ��..�`j Plat 7 y Lot S - 2.
Nearest Cross Street:
Subdivision Name: 1.3 Historical District 0 yes 0 no
Has application been submitted to the Historic Commission?
Total Land Area Sq.Ft.: `{D K
0 yes 0 no Date:
1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System:
0 Municipal9lPrivate Well 0 Municipal ❑bin Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev.January 19,2001
RESIDENTIAL 2001
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
-
2.1 Owner of Record:
/tnnPS )NbF! VtLI/n- N i<Z04,,1-woon 57211-N637
Name(print) Contact Address Phone Number
2.2 Authorized Agent:
/ 1,Pil b" SIG. f Li d<N17ci-L O 2 3ze1-ye57
Na Trim) Contact Address Phone Number
SECTION 3-CONSTRUCTION SERVICES
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-6)? 0 yes 0 no
If no,go to the next section!
Are you claiming exemption from the requirement? 0 yes 0 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
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 elie•:biitg 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 govemed by Construction Carol hi Section 116.0.effective July I,1982,no it dividual
shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,myth.ream?!or demolition involving the structural elements of
buildings or structures,unless he or she is licensed in accordance with the rules and regulations promuigated 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 tercel 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:o salt, ardor 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 der this sect g e .
Signature:
Your signature carries certain responsibilities,including but not nececodly a:nzt c geaerai liability
C:'bldg.forns\Bldgapp.res.wpd Page 2
g Rev.January 19.2001
RESIDENTIAL 2001
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.I5)
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 provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑yes 0 no
• SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
❑ new construction* 0 addition ❑alteration 0 repairs ❑chimney/ 0 we odstove
(energy report required) (energy report required) fireplace
deck 0 pool ❑accessory bldg. 0 replacement window/door 0 other 0 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 I no. of baths unit I
no. of bedrooms unit 2 no. of baths unit 2
El Furnace(hot air)-fuel gas(natural or propane), fuel oil,electricity, other(specify):
In Boiler(heating)- fuel gas(natural or propane),fuel oil,electricity,other(specify):
HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify):
El 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
I. Building /(ot It 3 2 t'eci.c
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5. Total=(I +2+3+4) *Estimated Total $ `J43 0
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 relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
I, , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate,to the best of my knowledge and belief.
Signed under the p s and penalties of erj ry.
n 14
Signature of ner hori ed Agen
tF Date
C:\bldg.forms\Bldgapp.res.w d
P Page 3 Rev.January 19,2001 ■
RESIDENTIAL 2001
SECTION S-INSPECTOR'S REVIEW/COMMENTS - -
1. Date plan reviewed: ?'/7-b/
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 Board of Appeals action: Date:
8. Comments:
7-7
9. Inspector's Signature: Date: -7-/7—Ol
SECTION ' -APPLICANT NOTIFICATION
Applicant informed of above Date: Time: Clerk:
Comments:
SECTION 10-OFFICE\INSPECTOR'S NOTES
Total Permit Fee: $ S) 'cep() Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE: 751,0 6 Gross Area-New Construction total sq. ft. C7 _
Gross Area-Alteration total sq. ft.
Permit Issued To. ' x1c, /� • J�
SECTION 11-ADDITIONAL COMMENTS/SKETCHES
/�
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev.January 19,2001
Permit No. BP-2001-20680 Project Location: 4 KNOLLWOOI) DR
Commonwealth ofMassachusetts
TOWN OF DARTMOUTH M P# 0074 0°
400 Slocum Road,Dartmouth,MA 02747 Lot: 0005
Phone: (508)910-1820 Fax:(508)910-1838
Sublot: 0002
BUILDING PERMIT Project Js 002-0120
FIELD INSPECTION Est. $5°00 0
Const.Class:
Contractor: License: Phone# Use Group: R4
Engineer: License: Phone#:
Lot Size(sq.ft.) 40001
Zoning: SRg
New Const.: 512'sq.ft.
Applicant Phone#: Alt.Const.: N/A
SILVA JAMES V
OWNER:
SILVA JAMES V INDA
DATE ISSUED: ` �
TO PERFORM THE FOLLOWING WORK: C
16' x32' deck
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
/6 a of /c*5-5- P e<W � a
/90 ' eem._ Rid
L
a' The Commonwealth of Massachusetts
�� •
V-P _�( Department of Industrial Accidents
gad `= , ==_ Office of li vesligations
kr
600 Washington Street
Boston Mass. 02111
Workers' Compensation Insurance Affidavit
r Dhca c f s .matort �a T ""PIeaS R a t *'"
name: CA/1/le Si I.
location: —1' Y\!t•/oLLA_Joc1 f?
city t1Vt2O.-Ti N( _phone# 4-6Af -3c9t/-zt6 i
0-I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: phone#:
insurance co. policy#
0 I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone#:
insurance co. policy#
comna y name: - - -
address:
city: - - phone#:
insurance co. policy#
Failure�to secure coverage as required under Section 25%of NIEL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit/license# manacling Department
❑Licensing Board
check if immediate response is required - Selectmen's Office
Health Department
contact person: phone#; ❑Other
(revised 3/95 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
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