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RESIDENTIAL
2002 RESIDENTIAL
2002
SECTION 2 -PROPERTY OR'NFRSHiP / AUTHORiZED AGENT
2.1 Owner of Record:
�L)N\�\R(C- Mo�P-i nJ5
(4tim-L�uudvb bpa so 9 -
Name (print)
Contact Address j or���v� �v I }� Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Horne 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
Registration Number (if none, state "none")
Address
Signat-Ire 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 Lnprovenielrt 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 strucrures, 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 famt 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 b
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 Constructiorh
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
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 thi* affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑alteration ❑ repairs ❑ chimney/ ❑ wmdstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify below): (specifyy below):
x If netiv construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit l
' no. of bedrooms unit 2 no, of baths unit 2
u 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):
Ei 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: ork: D p t (, a- t R 0 U�J L_�, 1 O V O G fU 6 f�
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. BuildinR
'. Electrical
�. Plumbing
4. Mechanical (HVAC)
5. Total = (I + 2 + 3 + 4)
,ric?
* Estimated Total $ , o 0o —
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 Oxvner Date
SECTION 7B - OWNER/AUTHORIZED AGENT -r DECLARATION
I. . as Owner/Authorized Agent hereby declare that the statements and iinformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pai and penalties of perjury.
Signature of Owner/Authorized Agent Date
J L
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RESIDENTIAL
2002
SECTION 8 -ANSYECTORS REVIEW/COMMENTS
I. Date plan. reviewed:
i
2. 30 days to review period expires:
3. Oh to issue date:
4. OK to issue subject to requested subrnittals(see project review worksheet):
5. DENIED (see project review Nvorksheet);
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
S. Cori meilts:
Date:
9. Inspector's Signature:
Date:
SECTION 9- A P C T NOTIFIC�yAT�ION
j
Applicant infourivd ofiabove / f ate: Time- Clerk:
Conlnwilts:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: S 25.00 -F
Remaining Balance:
—�
TOTAL FEE: Gross Area -New Construction total sq. ft.
Gross Area - Alteration total sq. ft
Permit Issu,-A To �.��� �°t✓
SECTIO7 11 - ADDIT NAL COMM T /SKETCHES
e
RESIDENTIAL - 2002
❑ FOUNDATION ONLY
$25.00 APLmLHCATION FEE IS ICON-111EFUNDABLE & NON -TRANSFERABLE
DATE RECEDED
... DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
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:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED• ,
OK TO ISSUE - SIGNATURE: DATE
iidmg Co issioner/Inspector uildi gs
- `
Zoning District: oposed Use: Zone: n'C C7 B ❑ V Outside Flood Zone ❑ Aquiifer Zone
TIIE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elee. ❑' Energy Report
Appeals Health Affidavit Card Sent: Cut Off Foillow-up*
❑ 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:
I Fire Chief- Signature: Date:"
'Signature:
B -d of Health: Date:
jConservation Commission: Signature: Date:
I
Other: Signature: Date:
Description of work bein peffornted:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ Ino
i
_
1.1 Property Address: 01111A �L Q�� (1%I=
1.2 Assessors Plat of Number:
Plat Lot -LL_
I Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
LJ q
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.: 1 ()DO
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 5 54): -
1.5 Sewage Disposal System:
❑ Municipal Private Well
❑ Municipal ❑ On sposays SiIte, 1D'l1 System
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