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TECHNICAL IMAGE PRODUCTS
Residential
1999
Residential
1999
v
2.2 Authorized Agent: Y
-
Contact Address
Lo►�s�,� S.�,�s T*-VC_
Name (print)
Telephone
��........
:.. ::.
........:
.. ..............::..
3 License Construction Supervisor
Not Applicable ❑
ai- _. A S=
Unnsed-Construction Supervisor
S 4 v A.
License Number
Address lb
Expiration Date
Signature Telephone0+C,Z` ♦(� 2
t
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? J yes 0 no
If no,p�o to the next section!
Are you claiming exemption from the requirement? ❑ yes EYno
If yes, submit the required
affidavit!
Company Name
Registration Number (if none, state "none")
SC> C_
Address
l
SigraturL N Telephone
Expiration Date
3.5 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY
f;UND: QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print) !J �l�} {� � C— 1la 1. 1 C— M_P�
Signature
by signing the above, the home owner acknowledg&,th t there will -be nT eligibilty to the Guaranty Fund
Date
3.4IHomeowner 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 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
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. (seep,ZAppendix of 780
CMR R5.2.15)
IWorkers Compensation Insurance affidavit must be completed and submitted wit
h this aPp licatio:n1�F 'lure to
rovide this affidavit
will result in the denial of the issuance of the buildingpermit. Signed Affidavit Attached achedes no I
❑ new ®'addition ❑ alteration ❑ repairs ❑ chimney/fireplace ❑ woodstove
construction*
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ 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 1—no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
Brief Description of Proposed Work: .N V n
SQmGt &Q-5-.ire_
Item Estimated Cost ($) to be completed by permit appllicant
1. Building L` e' , "% �1 " 2- '�'
2. Electrical +
to
3. Plumbing
4;
4. Mechanical (HVAC)
S.Total =(1+2+3+4)
Estimated Total $ 4-A "'XI
(please print) (� r
I,y3„,P. tz ti V P6-nZ -Ci3 S , as Owner of the subject property hereby authorize y L� �1� S,P_y
to act y behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ;I jV1_ A &!L,_ / , 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 pains and penalties of perjury.
�A� c A. Lq SSC_-1/
Signature of Owner/Afuthorized Agent
,-, �� lam: j
Date
c:\wpwin\forms\bldgapp.res
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January 20, 1999
c:\wpwi n\forms\bldgapp.res
Page 3
January 20, 1999
Residential
1999
Residential ❑ FOUNDATION ONLY 1999
"i5T DATE RECEIVEb
"T� DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 L�"'
y Dartmouth, MA 02747 I;`_:'t '' 0
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature:_
Energy Report: Signature:
Fire Chief- Signature
Board of Health: Signature:_
Conservation Commission: Signature:_
r D.
D.
Date:
Date:
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ER'Yres ❑ no
1.1 Property Address: _ '4Zg 1.2 Assessors Plat & Lot Numbcer:
Nearest Cross Street: OC -11i OL ' i` c iZ O Plat >✓%t
l
Subdivision Name: (' �`� ,, A$ �a c S 1.3 Historical District El -yres o
Has application been submiltted to the Historic Commission?
Total Land Area Sq. Ft.: ('0 -- C IT) d 2 1; ❑ yes - P'no"o Datte:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal( private Well ❑ Munici pal elOn Site Disposal System
2.1 Owner of Record:
Contact Address
Name (print)
phone number
c:\wpwin\forms\bldgapp.res Page 4 January 20, 1999
c:\wpwin\forms\bldgapp.res Page 1
January 20, 109