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BP-489 BUILDING PERMITr FIELD INSPECTION i� Dartmouth Building Department Plat: 74 400 Slocum Road P.O. Box 9399 Lot(s) :5-2 Dartmouth, MA 02747 Lot Size: 40,001 Telephone (508) 999-0720 Zone Dist. : SRB Issued Date: 1 /10 /97 Permit No: 489 Project Location: 4 Knollwood Drive _ Number Street Subdivision Name: Nearest Cross Street: Applicant/Agent: Christopher O'Brien _ Contact Person Phone #: (508 ) 998-8082 Proposed Use: Residential _ Residential, Commercial,Industrial,etc. Permit Issued To: Alteration _ Type of Improvement,Add,Alter.New Coast.,Demo, Land/Move,etc. Alteration to existing garage (432 sq. ft. ) Indicate no. of bedrooms and bathrooms and other rooms Owner(s) of Record: James & Linda Silva Address: 4 Knollwood Drive, North Dartmouth, MA 02747 DATE TIME TYPE OF INSPECTION REMARKS INITIAL SRN 2 8 1997 /a< ; - n'%f-2 /C FEB 1 4 1997 //4'5 A-,. ( Li fr,e r`, r' t I"C, — flP 0 5 1997 '/s t- , . Cnz:, . �Z ,� � ti 0/ J LiX: — i' 7-- `7 // t;, .1n-e';" rc/c 7 `CCUPk En _ BUILDING PERMIT' Dartmouth Building Department Plat: 74 400 Slocum Road-P.O. Box .9399 Lot(s) : 5-2 Dartmouth, MA 02747 Lot Size: 40, 001 Telephone 508-999-0720 Zoning Dist. :SRB January 9, 1997 (typed) Permit No. : Issued Date: I I/O! 97 Clerk: BAS Project Location: 4 Knoliwood Drive _ Number Street Subdivision Name: _ Nearest Cross Street: Applicant/Agent: Christopher O'Brien Address: 33 Williams Way, Rochester, MA 02770 Contact Person Phone #: (508) 998-8082 Type of License: Owner: ( ) Const. Superv. License #: (003213 ) Architect: ( ) Engineer: ( ) Other: ( Proposed Use: Residential Residential, Commercial, Industrial,etc. Permit Issued To: Alteration Type of Improvement,Add,Alter, New Coast.,Demo,Land/Move,etc. Alteration to existing aaraae indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : 432 sq. ft. Cost of Const. $23 ,000 . 00 _ Cost-Other Const. : TOTAL FEE: $ 30.00 _ Owner(s) of Record: James & Linda Silva _ Address: 4 Knoliwood Drive, North Dartmouth, MA 02747 All work shall comply with 780 CMR 5th Ed. (MGL Chap. 142 ) and any other applicable Mass. Laws or codes and plans on file. 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 understan other agencies y/ have reason to STOP WORK if items under their jurisdictio re not met; o wi standi he issuance of this Building\Zoning Permit. Signature of Owner/Ag nt: Address: Signature: i✓V/ Approved/Issued B Joel S . Reed, Title Building Inspector COMMENTS: PLEASE OST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 COPY BUILDING � P- ERMIT Dartmouth Building Department Plat: 74 400 Slocum Road-P.O. Box 9399 Lot(s) : 5-2 Dartmouth, MA 02747 Lot Size: 40, 001 Telephone 508-999-0720 Zoning Dist. :SRB January 9, 1997 (typed) Permit No. : Issued Date: / //D/ 97 Clerk: BAS Project Location: 4 Knollwood Drive - Number Street Subdivision Name: - Nearest Cross Street: - Applicant/Agent: Christopher O'Brien - Address: 33 Williams Way, Rochester, MA 02770 - Contact Person Phone #: (508 ) 998-8082 Type of License: Owner: ( ) Const. Superv. License #: (003213 ) Architect: ( ) Engineer: ( ) Other: ( ) Proposed Use: Residential Residential,Commercial, Industrial,etc. Permit Issued To: Alteration _ Type of Improvement,Add,Alter.New Const.,Demo,Land/Move,etc. Alteration to existing garage - indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : 432 sq.ft. Cost of Const. $23 , 000. 00 _ Cost-Other Const. : TOTAL FEE: $ 30. 00 _ Owner(s) of Record: James & Linda Silva _ Address: 4 Knollwood Drive, North Dartmouth, MA 02747 _ All work shall comply with 780 CMR 5th Ed. (MGL Chap. 142) and any other applicable Mass. Laws or codes and plans on file. 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 understan other agencies dal have reason to STOP WORK if items under their jurisdictio re not met; o wi standi he issuance of this Building\Zoning Permit. Signature of Owner/Agent: �C — Address: — ******************** *** I *y*** *** * ************************et** Signature: ✓1f}/ — Approved/Issued B�Joel S. Reed, Title Building Inspector COMMENTS: PLEASE OST PERMIT CARD SO THAT IT IS VISIBLE FROM THE STREET 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 9 1040I1: y w? / /� fr,�/� :£g paniaaan ¢. se°:o Suegwn1j'Sunpling Do;asuaaq to}Iuuad a}ou sr spa vs OZtZt-00OI0 anuanag}uaunaedaQ zeq}p. 1 1 CO S V S ZOii Y 00010 set ag Sucguinid-s}tuuad ag asuaac7 1.66 0 t NYC 90IT't-O00i0 • jeatx}aaig-s}turaad 29 asuaac7 t f •psnAl 2urnSut m s uxlad asuaat7 Jai l os.�Ql��rlaaxvl H1101N1udo 10 NMOI 901ff-000io pimfl-s}iuuad 18 asuarj • }unouly ' #•;ag •s,#aaSpa11exauaD uogdnasaQ • • S :auogd auaugledaQ&twang-6dop uaasD Ado,ang-Adoj xu'd adiaDag s iauco}snj-Ado'mo11ax - :101 rm / :Iola aay}p vapanoj-%dop an-gm i ! `. v I (/• r J s Y! f l i :u0?rea0']gol_ � / 1 _ :a}eQ 494/..�. x;adold �r f•,j`'a - , I�-'D'�J�! ,1'5-1.� Y t/ e _�� :auieN 30Iddp S�a0103'1100 s nssi Xtl� o � S1d1303E1 JNIar1118 Hlnowlada dQJ4MO1` TOWN OF DARTMOUTH �, BUILDING RECEIPTS vn5..i2 NOTAX ISSUES COLLECTOR'S OFFICE Name: / , i 1'l.3,I �91 Property /9/n L=5 _)r /t/A Date: 7//// 27 .t' t ' Owner: J f �'. i dJ Job Location: (/( . - .. y' / White Copy-Collectors Office Plot: �„<-// Lot: C Yellow Copy-Customer's Receipt f J Pink Copy-File Copy Green Copy-Building Department Phone: Description General Ledger#'s., Ref.# Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 TOWN OF DARTMOUTH J;_ 0 ) TAX COLLECTOR'S OFFICE License&Permits-Electrical 01000-44106 99 License&Permits-Plumbing&Gas 01000-44107 `� 1 0 ' Other Department Revenue 01000-42420 S A S 03 J c_cin ii This is not a Permit or License for Building,Plumbing or Gas ) Received By: 6 � IVVVV/ ,- / TOWN. -OF DARTMOUTH 0040,E BUILDING RECEIPTS NO TAX ISSUESCOLLEC OR'S OFFICE Name` r :r�'- , _ f �> ., r.Property ;7 r `- % �.. Date .-.�- , f /="/ 1,. .� '! ...i ^ tier iLJ '� Owner: f' if7 f / .^ Job Location: / ;✓ l /'j A44' ej ), y c f) '1 L,I White Copy-Collector's Office Plot: r7 Lot. __ ,�{ Yellow Copy-`Customer's Receipt Pink Copy-File Copy Green Copy-Building Department Phone %.y' c.f TOWN OF DARTMOUTH TAX COI LECTOR'S OFFICE Description General Ledger#'s Ref.,d r 2 7 996 Amount iJJCC ' License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 NIBS ` 02 1<'--d License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building.Plumbing or Gas Received By: i�d ,t ?--i RECEIPT FOR PERMIT C� — 1 ci(oure.� TOWN OE ( i /(//(� _�PjERR)MIIT NO. o �l No iv=.ty ' Date /7/U/2 Received From . Owner V /6v a aL0 ) ic Location //�� ff�/'-'�,�;�,, � �\ Type l�•^c.f .4_942r/u- ,V stACJI 1{✓L,Q eilG/; G CI U Amount Paid Received By TOWN OF DARTMOUTH BUILDING DEPARTMENT TELEPHONE 508-999-0720 FAX 50S-999_0738 APPLICATION FOR ZONING AND BUILDING PERMIT (trnractiom wend.TheThe applicant shall complete this application to the bet of their ability prior to submispon.'leavm uu g no item aas Department staff will he available during regular business hours to assist as necessary WA;Mound be inserted for those sections which do not apply.A properly completed application will help avoid toinecessary delays. Nacre Fig[tars at rdemialie. (for oWm use only) /� ?/� Application tee S IJ �`/J received by C7•' Date1. 4 Total Permit Fee $ �J 19 Permit# / 8 100 LOCATION OF PROJECT 3a 1 2 6 CURRENT ACCESSORS' PLAT LOT Sai. ZONING DISTRICT S VC'6 OTHER ZONING OVERLAY DISTRICTS if applicable-I /) NUMBER 8 ,/� STREET , ' e//tdoCd or/ U _ NEAREST CROSS STREET SUBDIVISION NAME & LOT# or BUSINESS NAME PREVIOUS TENANT 1 OWNER 200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only = THIS SECTION NOT APPLICABLE Single family - number bedrooms number baths - Two family - number bedrooms unit 1 number baths unit 1 number bedrooms unit: number baths unit Z = Accessory apartment Total gross sq. ft. _ _ Accessory structure Garage - detached - attached to dwelling, dimensions L W = Carport - detached - attached to dwelling, dimensions L W Shed - dimensions L W = Gazebo - dimensions L W - Swimming pool above ground in-ground rod Size total square feet 7 Chimney -#of flues vvn•astove - used (will require inspection prior to installation), new (provide manufacturers instructions). Location(s) (list) = Fireplace(s) - (includes flue) List location(s) Game Court-describe(include overall dimensions) Tent, Trailer(Mobile Home) or Other- describe 300 COMMERCIAL-PROPOSED PROJECT/USE-INCLUDING THREE FAMILY OR MORE AND EXEMPT USES THIS SECTION NOT APPLICABLE (The following descriptions are based on the Massachusetts State Building Code Article 3,AS NOTED) (See the Code) Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code Section 303.0) Educational-structure for training including child day care for those over 2 years 9 months(see Code Section 304.0) - Factory / Industrial - (see Code Section 305.0) High Hazard - (see Code Section 3116.0) T. Institutional - hospital.'nursing home, infant day care (see Code Section 307.0) Mercantile - retail stores (see Code 308.0) — Residential - three or more family, hotel (see Code Section 309.0) — Storage - includes garages (see Code Section 309.0) • Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0) - Nen tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35) T. Tent or Trailer - temporary purpose? - O• ther Describe the proposal briefly,INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing condition -coo TYPE OF CONSTRUCTION OR WORT{TO BE PERFORMED New Construction and/or Addition - total gross square feet (For commercial only total gross cubic feet) - indicate It will he considered new construction if there an increase in square footage in addition to any alteration(s). If project is an addition to existing structure - Total gross square feet of existing FOR COMMERCIAL ONLY Will this project be subject to CONSTRUCTION CONTROL(over 35,000 cu.ft.) _Yes_ No. (If yes see Code section 127.0). Designer to submit Code Synopsis. Will this project require Peer review(over 400,000 cu.ft.) Yes _ No (see Code Appendix I) APPLICANT TO PROVIDE Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required. _ Demolition -describe structure — Number of dwelling units Number of bedrooms A separate Refuse Disposal Declaration required- : Moving- (Provide copy of D.P.W. moving license) Type of structure from where (plat/lot or address) to where (plat/ot or address) . , Number of dwelling units Number of bedrooms per dwelling unit . - Re-roofing - (for existing only, is included in new construction) Number of square feet Number of layers already existing Number of lavers when complete A separate disposal declaration REQUIRED - Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged) EGRESS dimensions must he maintained. Enlarged or new windows in an existing dwelling will be considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for residential and Article 8 for commercial) = Temporary structure-includes when allowed, trailers, tents and the like and only for limited periods of lime. Describe 500 CONSTRUCTION PLANS None submitted. Whv? _ _ Submitted, usually three sets required. Four sets for food serviceluses. Number of sets submitted __ 600 SITE PLAN 0 Not required, why? _ = Submitted When? = Previously, date = With this application 700 UTILITIES 1/7 Water supply - required_ yes _ no, public ? _ yes _ no, on site well? �' yes_ no. existing? _yes _ no If required and not existing have necessary permits been issued? _no_yes;.date (M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when required, is available. See Code 780 CMR section 114.1.2) Sewage disposal - required yes no, public sewer_yes_ no private septic - on-site yes _ no. Submit copy of permit as soon as available. ld a 800 MECHANICALS & PRIMARY FUEL I. 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 U 900 SPRINKLERS - FOR STRUCTURES OVER 7500 S '-SQUARE FEET and certain multifamily residential : Required. :plans provided, _plans not provided, why? L. Not required, not to be installed. Why? 1000 REQUIRED OFF-STREET PARKING - for ZONING & .Architectural Access • NOT APPLICABLE _ Parking Plan submitted To = Building Department = Planning Board Date submitted Number of spaces - indoors outside total prov;.3ed Handicap spaces - required yes_no. If yes, how many as a part of the total required number. Is Route 6 (State Road) Entrance permit required? yes = no -. If yes has it been issued yes = no _- Submit copy of application and/or permit as soon as available. 1100 IDENTIFICATION (print or type except as noted) (S ,//"� •� � Current owner- name ���1 1—6 — address (i. 7 phone !/40, 2 If corporation, officer in charge O� Architect/Engineer- for overall design Company name Address Phone number Certified by State of Massachusetts as Certification number NOTE Signatures and seals on am, affidavits and other documents SHALL BE originals and not reproductions. Architect/Engineer- project supervision and reports Company name Address Phone number Certified by State of Massachusetts as Certification number NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not reproductions. General Contractor(if Homeowner. state.{ homeowner here then complete section 1300) Company name 0 ".A r/..5tO)the'r L'` / ///������" Address p3 (j."t/ic-�c-'c,r ,�iJ /4 / Phone number 9 /L' l r D 0c I — 7�® Construction Supervisors license number 3ca1c_3 NOTE Signatures and seals on all plans. affidavits and other documents SHALL BE originals and not reproductions. F*****;S;mamma* ; ;;i;i;lii;ii** i !f<ii;Y>f/#ti% 1200 FOR RESIDENTIAL REMODEL WORK ONLY Are you a Home Improvement Contractor subject to(780CMR -6) ? Yes_No_If no go to next section! Are you claiming exemption from the requirement? Yes _No If yes, submit the required affidavit! Remodel contractor name (please print) _ Address Registration number(if none state 'none") _ Phone number PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTEE 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 _ Date • 1300 OWNER SIGN - OFF I, the undersigned,am the owner of record or authorized lessee(provide documentation) and I have reviewed the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this application is true and correct and that the permit requested be issued. Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or six months after the last inspection if work has begun and that the permit may be extended for six months if no work is anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by • written request.I understand that once the permit expires a new application may be required,including fees and current other requirements (including Zoning). - Name Signature The above signature is my voluntary act and is signed under the pains and penalties of perjury. Date Who is authorized to pickup the permit at the Building Department? i➢lease onnu Address Phone 1400 HOMEOWNER EXEMPTION - ONE &TWO FAMILY ONLY FOR HOME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 I-i.-easing of Construction Supervisors:Except for those structures governed by Construction Control in Section 127.0. 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 BRRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception:Any Home Owner performing work for which a Building Permit is required shall be exempt from the provisions of this section: provides that if a Home Owner engages a personis) for hire to do such work ,that such Home Owner shall act as supervisor. For the purposes of this section only,a"Home Owncr" is defced r, follows: Personjs)who owns a parcel of land on which he:she resides or intends to reside, on which there is. or is intended to he,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 two-year period shall not be considered a Home Owner. 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 Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see of section 51 1500 COST Cost of Improvement $ Items to he installed but not included in the above cost: Electrical S Plumbing HVAC Other TOTAL $ The following section for official use only. INSPECTORS' REVIEW Date plan reviewed 30 days to review period expires !! OK to issue date OK to issue subject to requested submittals (see project review worksheet) date DENIED see project review worksheet date HOLD reason date HOLD Subject to Zoning Board of Appeals action Comments Inspectors signature DaterAN 0 7 199g Applicant informed of above - Date time_staff (fax, phone, in person) YYiiYiii Y** YY Y YY******YYYY Yi Y i Y if******f YYYYifi f iff ►f fYf f*Yfif*YYf YYfY ff Yf Y Y Y YY f f i fY Over six months since approved for issue - DEEMED abandoned! Advise applicant. Hold 90 days for return then dispose if not picked up. Inspector Date Advised applicant Date Time staff_(by phone, fax or in person) iYYiYYYYiYYiY*YYYYY**Y*Y*Y YY*YYYY YY YYiiii YYYYYYif***Y** fi YffYY**YYY**YYf YY**YYY fii YY*****YY Yi OFFICEUNSPECTORS NOTES TOTAL FEE So B Gross area - new construction Total Sq. Ft. alteration Total Sq. Ft. Permit is issued to Comments/notes on permit II 1600 TO'[T1fL+APPLIG1ffi' " --------.--- L AND APPROVAL •^1 ) /�, Date .� 1 o/fApplication submission / 3 / // �" Plat /% Lot _ Street 2-/ k )0/AGO 00QA I In Aquifer Zone Owner Si I — -- Owner mail address S e rv\,_e___, Owner phone# - OTHER INVOLVED AGENCIES -The following agencies require separate jurisdictional permits or approval proposed ro'ect. Nfor your project. CONTACT FOR REQUIRED SQg�QS,�ONS. ® TAX COLLECTOR = Approved _ HOLD By Date ❑ Conservation Comm = Approved By Date ❑ D.P.W. water = Approved By Date ❑ D.P.W. sewer = Approved By —_— Date _ ❑ D.P.W. cross connection _ Approved — Date _ a D.P.SV. engineering = Approver! Date a. Board of Health well = Approved Date ❑ Board of Health septic = Approved Date _ ❑ Board of Health food service = Approved Date S FIRE DISTRICT (I - fI - III) _ Approved • Date ❑ Planning Dept = Approved Date Other _ Approved - Date _ other _ Approved Date t',•mments Project summary new construction/ alteration/demo sewage disposal - public/private Alter-add interior wails) [add rooms! [add footprint! water supply - public/private well !pool) [garage shed! [game court) �r � -7 [fo d sen�ijc�el/Describe ((/✓✓LiL[,"" �i`-'��* ^'" '�'v itia,g. 'o the various departments: This notice has been forwarded to you for your information and any appropriate action. Should you have any aesdons please advise. If any reason to withhold the requested permit is found. please advise. Your assistance and operation is appreciated. to Building Department //,�//, Date sent for review /.%� !,�— 7 'c"` 1' I - . . _ . - - . 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I. . , . . . . . . . . . . . .. . . . . . . . . , ..... . . : . . .. . = � The Commonwealth of Massachusetts Department of Industrial Accidents rif OfficeOfficeollnesestIoils s = 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit l , l- it It ..i a , . t i^1 .:. dl'-f n'dt.8 i\$E,.(� i .xl.. .:xE't''' name: (� !Iln6"/`'GI e / _ /r� hel le location: ,r G( i-i f > /2 '< e ,/ city �- . F r � 'F 7t 1 fAJ.7 /t/IGr r phone# /� / c;" r� ❑ 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 1 y providing workers' compensation forrmy employees working on this job. comoanv name; 6'4 /^ )& f / -re 175 - - address: / 'Y Q• {A Y � ' :. / city: a- t F,)" 'L'`r' c7GV// 474/ op,7/ 7 phone#: 74 3 ' I77 A insurance co. 71 ''J4Vs ❑ t am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below wha haue the following workers' compensation polices: comnanv name: address: .. city: phone* insurance co. . _- •_ c —. ram. ..�_.aaR^.34Y`.v�'y� i.3n �._Yn company name: - - address: city: phone* insurance co. tiohev# -- kttichidditio iiii1e titaeewa •-- '_" Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500 00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 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 cenify der the pains and penal ies ofpe�that the . orntation provided above is true and correct Sienamre`/ � �ilt `�S�lvG2� Date � 7 Print name(c--14Vyope ! , kmie/ \ Phone# 74 7 / b official use only do not write in this area to be completed by city or town official - city or town: permit/feense# (Building Department ❑Licensing Board 0 check if immediate response is required °Selectmen's Office r- QHealth Department . contact person: phone#; °Other__ 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 even'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 requ:ired. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract fcr 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 .M ., 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 Off e of Investigations would like to thank you in advance for you cooperation and should you have any questions. please io 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 Qsto c 9 — a PERMIT NO. /14 LTx �;s TOWN OF DARTMOUTH DATE ISSUED TOTAL COST • h APPLICATION FOR 3 v' LESS APPLICATION FEE g'e• ,ee4 Sy BUILDING PERMIT FINAL PERMIT FEE ray 1 LOCATION OF BUILDING • ( 01 Number & Street h 14 , " , / to L+Ab 9t'iyf '' 01.1 Zoning District_ • 02 Cross Streets(between) and 03 Lot Plat 04 Subdivision Lot OWNERSHIP COST 05 Private (individual, corporation, 36 Cost of Improvement 203 d©O, a 0 non-profit institution, etc.) 36.1 To be installed but not 06 ❑ Public (Federal, State, or local government) included in the above cost TYPE OF CONSTRUCTION 36.2 Electrical 07 New Construction 36.3 Plumbing 08 ❑ Addition -Type of Room(s) 36.4 HVAC 09 gAlteration 36.5 Other - Specify 10 ❑ Foundation Only 37 TOTAL example: elevator 2, 11 ❑ Demolition (#of units if residential) l Co 6 ,0e 12 ❑ Moving (relocation) STRUCTURE STATISTICS 38 az Wood Frame 13 Number of Bedrooms 39 ❑ Masonry (wall bearing) 14 Number of Bathrooms (Total) S. 40 ❑ Structural Steel Full-Tub 1 41 ❑ Reinforced concrete 3/4 - Shower / 42 ❑ Other- Specify 1/2 - Toilet Only RESIDENTIAL-PROPOSED USE ,DIMENSIONS 15 1;ti One-Family 43 Number of stories 16 ❑ Two or more families 44 Total square feet of floor area, all floors, Number of units based on exterior dimensions .5 76. '—s. 18 ❑ hedge 45 Total land area, square feet 19 ❑ Carport 20 ❑ Swimming Pool SEWAGE DISPOSAL In-Ground_Above-Ground 21 ❑ Woodstove 46 ❑ Public or private company . 22 ❑ Fireplace 47 g Private (septic tank, etc.) 23 ❑ Other - Specify WATER SUPPLY 48 ❑ Public or private company NON-RESIDENTIAL - PROPOSED USE 49 N1--Private, (well, cistern) 24 ❑ Amusement, recreational 25 ❑ Church, other religious PRINCIPAL TYPE OF HEATING FUEL 26 ❑ Industrial 50 ❑ Gas 27 ❑ Parking Garage 51 MI Oil 28 ❑ Service station, Repair garage 52 ❑ Electricity 29 ❑ Hospital, institutional 53 ❑ Coal 30 ❑ Office, bank, professional 54 ❑ Other - Specify 31 ❑ Public utility 32 ❑ School, library, other educational TYPE OF MECHANICAL 33 ❑ Stores, mercantile 55 Will there be central air conditioning? ❑ Yes N No 34 ❑ Tanks, towers 56 Will there bean elevator? ❑Yes (No 35 ❑ Other - Specify PARKING PER ZONING BY-LAWS 57 M Enclosed 58 ❑ Outside R 59 Does this building contain asbestos? ❑ YES ❑ NO If yes complete the-following: Name & Address of Asbestos Removal Firm: IDENTIFICATION - To be completed by all applicants PLEASE PRINT 60 Owner (print) 'Mt t'l its./Li 1 5;Jv4. yIca oILL;coo d PJ',�P ..;t.�J— 416737 MAILING ADDRESS TELEPHONE NO. p 61)Signature s=�t1LL, /+�, DATE i�2 2 ' 7 4' p��9, 8-57 B-b^tr8Lg u i lder's 62 Contractor ( '• 01hr.5-11,eher 0 (jrtet 33 ..Ilt� l t` aACo- wvl- License No.003 3 MAILING ADDRESS TELEPHONE NO.02.)70 63 Signature CS) r --ice DATE 12/4 19l 7 64 Architect or Engineer (print {trtg'f'U AL." 0 15.rt-<— 5-4."4 oy �� �`1CR1 MAILING ADDRESS TELEPHONE NO. 65 Signature j DATE CERTIFICATION TO PERFORM WORK appointchit 'a 66 I/We hereby S7U��� � r t u" 3 3 U``r rl' i~-q-y, IC0 Gh'eij7`t' Y"--1- °4-n NAME ADDRESS as my/our agent r the pur ose of plying for and obtaining a building permit for the work to be done described in this application. at Signature .4 n L DATE /2 2) ADDITI 1N/ 71_ INFORMATION 67 Has A- or Determination been issued by Conservation Commission? ❑ YES ❑ NO Submit copy of notification sent to DEQE and the State Dept. of Labor Industries and result of air sample analysis after asbestos removal is complete. 68 Owner or Agent - I certify under peril of the penalties of perjury that the information herein is accurate to the best of my knowledge. Signature DATE Owner or Agent 69 BOARD OF HEALTH REVIEW DATE Inspector or Authorized Person COMMENTS: 70 DPW - WATER Service No. SEWER Service No. To be completed upon issuance of permit - (if applicable) 71 I will post permit and address so as to be visible from street. Signature DATE Owner or Agent 72 I have received list of required inspections Signature DATE Owner or Agent 73 FOR RESIDENTIAL PROJECTS OTHER THAN NEW DWELLINGS: Are you a Home Improvement Contractor subject to the registration law(780 CMR-6)? YES NO Are you claiming an exemption from the law by homeowner sign-off? YES NO (if yes,submit required signed affidavit) Contractor's Signature: Date PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (780 CMR-6) QUESTIONS or COMPLAINTS? Call or write: Home Improvement Contractor Registration One Ashburton Place-Room 1301 Boston,MA 02108 617-727-8598 Owner's Signature: Date: r r ft k I S f i i f � { I I ! 1 { { f i ; HOSE DES'I GNS YOUR DRAtVING MIUS i BCE AT THE BUILDING DURING PROGRESS OF T! IIS WORK. T � T.j w" yrJT H Fj F I-P, fl, Go pv Of T li is Ei do. sed Pf i c1tl ust Be, 1,e p t 0rl Sit 0 7 `* v R FD (D" rvt IV SCALE : i /4" 13447f � c . &% 2-4 3 N LE W K N E'WA K I r-I A I r\ f-\ k I r--r /-\ r-N % & it k i rN e-% i x ) F,' R 0 (".1 SE D FAMiLY IIR 0 0 MEW DOMETOP WINUC)w TIvi � i, \,-) M E D ESIGNS SEW SKYLIGHP.S. YOUR DRAWING MUST BE Kf- AT THE BUILDING DURING T, JE PROGRESS OF THIS S WORK. �flc__W KNEE-VALL T"-"n Dartmouth F11 oll� W_ It —his E ril d o -s I F!" C.-3 1 r) 0 ti-I S it e 1997 tol: __ VA F rR, WR R s 0 SCALE-: 1/4 NSTRUC � jr�i\ N`W KNEIEWA! TM HOME DESIGNS YOUR DRAWING MUST 6I� f%EP'i AT THE BUILDING DURINQ THE PROGRESS OF THIS WORT c--ee-�ecs•e-.err..ro*e^. i� �J `� i \-),R 'V R M R S. S VA SCAL`: 1 /4i' _ ;'-0 d