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TOWN OF DARRAOLUTH
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13UILDING DEPARTMENT
Tara of Dartmouth
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RESIDENTIAL
2002 RESIDENTIAL
2002
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
�610 aj oGC--114
6 a,®rD
Name (print.)
Contact Address Phone Number
2.2 Authorized Agent:
z sc�P�iTU�� p
VW/17DA/ /Pi"V az790
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor fyjlC/�C �� �`j
License Number Q 3
Address /� lG,c S S� L✓/if IVAt A,&e
Expiration Date
Signature Telephone �V9479 ��Z3
3.2 Registered Home Improvement Contractor: '
Not Applicable ❑
Are you a Home Improvement Contractor subject to (7SO CMR-6)? des ❑ 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 'Hone")
Addres's
Signature '`�- Telephone 4-vS 4V 023
Expiration Date
3.3 For Reside ial 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, ILA 02108, (617) 727-8598
Owners Name (print) �E22,47G%�
Signature
y signing the above, the hone owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Hoineoxvner 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 I, 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 Licensin_
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 engkges 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 its 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 hoonie in a two-year period shall not be considered a Homeowner.
f you are apph'ing 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 Constriction
Supenvisor, 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 ,vith this application. Failure to proviAe this affidavit
wIII result in the denial of the issuance of the building permit. Signed Affidavit Attached: Ryes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
now construction* Q addition ❑ alteration ❑ repairs Elchimney/ Eliwoodstove
report required) (energy report required) fireplace
deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other Eldiemolition
(shed;'aarage) no. of windows doors (specify below): (sptecify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms ® no. of baths
TvN o Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
F:.rnace (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 r0`0' Other
Brief Description of Proposed I' ork:
2 Z Z f�DD/770i1 / G�� �oeMr f3 ?U CZ'�:Awl ate G'f�lLral''"
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
. Building
'. Electrical
ADO
'. Pl.u?llnitl?
3 000
\!echanlcal (HVAC)
. --
5. Tort) = ( i - 2 + 3 + 4)
x Estimated Total S 30
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 wt on my b h f 'i/ajll matt releiu to work authorized by this building permit application.
.� r-e
SI�ninnlre of Owner r Date
SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION
I. %1�ile�///✓ �"���- � 0 , as Owner/Authorized Agent hereby declare that the statements and in -.formation
on the foregoing application are true and accurate, to the best of my knowledge and belief
Si=ned under th 11 n penalties of perjury.
Signatte t caner/AuthorizedAgent Date
C'bldg.(bnms 131.i_.c;pp:res.wpd
Pazc 2
kcv. Januar, i9.
PnapI -- �_,�--
RESIDENTIAL
2002
RESIDENTIAi. 2UUZ
❑ FOUNDATION ONLY
$25.00 APPINZCATION rEE IS WON-REL'>i MDABLE NON -TRANSFERABLE
SECTION 8 - INSP CTO 'S REVIEW/CONIMENTS
1. Date plan reviewed: l
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(sce project review worksheet):
5. DENIED (see project revic% v,orkslieet):
6. HOLD`ieasocn:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
S. Continents:
Date:
9. Inspector's Signature:
Date: l�
SECTION 9 - AP I
aNT NOTIFICATION
:cant in -n o above Da : A,4 ()2 Time:�/W
Comment .
Clerk:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee; S
Less Application Fee: S 25.00
Remaining Balance: Sc� y
TOTAL FEE: (� ` D`�ross Area - New Construction total sq. ft. �p
Gross Area - Alteration total sq. ft.
Permit Issued To- >
L
��.. V
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
_ -
` yf... DARTMOUTH BUILDING DEPARTMENT
r
DATE RECEIVED
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
- a
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: v J
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE:
DATE
Building CdArnissionerilnspec
r Bu dings
C
Zoning District: roposed Use: Zone: C
95
A ❑ V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
Board of ❑ Board of ❑Con. Com. ❑ Demo
❑ DPW ❑ Mee. ❑ Energy RelDort
Appeals Health Affidavit
Card Sent: Cut Off Follow-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 '
Zonin« Review: (� k Signature:
Date:
I nergv Report: �� 4
a Signature:
Date:
Firc Chief- Signature: f
Board of Health: � Signature:
Date: �d�l op el' -,I,
Date:.
tom''
Conservation Connnissiou Signature:
Date:
Other: Signature:
Date:
Description of work being performed:
SECTION 1 - SITE INFORMATION
.\U,\IBER OF PLANS SUBMITTED: ITS
SITE PLAN SUBMITTED: yes ❑ no
1.2 Assessors Plat & Lot Number: If'
1.1 Property Address: tom%/UGG �lldVl�
Plat Lot _
Nearest Cross Street:
Subdivision Name: �—
1.3 Historical District ❑ yes 2- o
AA
Area Sq. Ft.: OCJ%
Has application been submitted to the Historic Comrmission?
Total Land �Y� �`�
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 S 54):
1.5 Sewage Disposal System:
❑ Municipal R On Site Disposall System
El Municipal Private Well
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Pace 1 Rev. Jamuary 19. 2001