BP-2005-42822 'ermit No. BP-2005-42822 Project Location: 70 SHANNON WY
Common eaCtFi of ffassacfiusetts
TOWN OF DART ..MOUTH R �• ooT4°°°
400'Slo�um Road,Dartmouth,MA,.02747 1=Lot e : " t: Y`0020 a r
Phone: (508) 910-1820 Fax (508)`91'0 1838
BUILDING PERMIT, elai
Pat e° o�OY
Project "JS 200q
BUSINLSS NAME:7�YLE1I STUDIOS t. �E
• . 50 oo " �E t
Fee'" -k, t $501,
FIELD INSPECTION �Otr - SS
Use-Group 4€w " "`tR,4 mlligi
pEM
Lu� (�4irt {27 �C €,d>
Contractor: License. Phone#: i rSEE
Engineer. License Phone#:
44141
Necnst • N/A
Alt tu:».M a ;N/A y '
Applicant. Phone#:
WILLIAM BENTON` - (508) 287-7412
OWNER:
BENTON BENJAMII . , SH LBY H BENTON PIi may.:y
t C� CLOSED
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK:
Home-occupation; 120square feet in cellar; TO-BE-IN AC£ORDANCE WITH THE TOWNOF
DARTMOUTH ZONING BY-LAWS
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
/ 1
3 a3�� _' �� StoArs io Cl ����E / �f� w�� C aE € v ���
�7�dG �.'/� L/j n�� SSA eta.: heA rsf /drz 'i �(y%�
/ / . t - .a .a .
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4.,• . /0 ;7. P
Permit No. BP-2005-42822
botat Q' c
CommonwraL icb / • addac etto
MZISATYSift, � Efin t Q TOWN. OF DARTMOUTH
8 i 400 Slocum Road,Dartmouth,MA102747
111 Phone (508),919 1820 tFax (508)910-1838
IntRSCA174,1,AriltittirsktaaPERMISSION ISHEREB GRANTED;7Th
Cons
$$y}s t $ Contractor License Phpn• e#:
Engineer tcert Phone#:
a £ f
-. Applicant Phbne#:
of ' i I I W WILLIAM BEN I ON P§08)287-7412
OWNER:
. .-
BENTON BENJAMIN G 4t S1ELBY 1-1 BENTON
DATE ISSUED: l I >r
TO PERFORM THE FOLLOWING WORK:
Home occupation, 120 square feet in cellar; TO BE IN ACCORDANCE WITH THE TOWN OF
DARTMOUTH ZONING BY-LAWS
BUILDING PERMIT
Business Name: XYLEM STUDIOS
Project Location: 70 SHANNON WY
Approved/Issued By: y�eg
DAVID BRUNETTE,LOCAL BUILDING INSPECTOR
All work shall comply with 780 CMR 6Tn Ed. (MGL Chap. 143) and any other applicable Mass.Laws or Codes and plans on
file.
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS
REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.8(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 to receive this permit, I further understand other
agencies may have reason to STOP WORK if items under their jurisdiction are not met; not
withstanding the issuance of thyl3ui1 ' Zoning Permit.
Signature of Owner/Agent:
Comments: PERIYIIT`NUM$ER IS REQUIRE E WHENRRQUESTTI�FCU iSPEC'LIONS
RE:If SPECTIO FOPS 1VII7STBE P3, B F REL- _ Al grniE SPECTI ) I
"Persons contracting with unregistered contractors do-not have access-to the guaranty fund(as set forth in MCI e.142A)"
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD
TO1NN. OF DARTMOUTH V:;�1413976
BUILDING RECEIPTS ‘TheJ'.i
COLLECTOR'S OFFICE t_
1 ) i/ /
7.4
1 a Date: r /%'
Name: ` ' f 1 .:t E Property, " �' _Ls.,
i ✓ 4 _ is t -.>L-'- 1(' �"'r Owner: 1 ,t„ry ` ' ,1
Job Location: li> // ��' Al ;i -i% 1/
.— j,; 'l ?r _ c- Whi Copy-Collector's Office
Plot: 3 . i L Lot _j �" f' '�` Yello Copy-Customer's Receipt
j f� t. t v'f t_Pink py-Tile Copy
- t Fp s$ _ ' Green opy\Building Department
Phone: - O 1/TAX ISSUES f,--„Hu
�
F _ � dy
Description General Ledger#'s i 1 f. Amount `:
License&Permits-Building 01000-44105 /� j v `c (CIt' . i ZTh '_ CV '
License&Permits-Building Misc. 01000-44105
\License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000 44107
Other Department Revenue 01000-42420 ,—� S
/
This is not a Permit or License for Building,Plumbing or Gas Received By:
TOWN--OF DARTMOUTH ‘; . --�
NO TAX IS
' ct L OR'S OFFICE
r' i ,
Property ', Date: 1 �
Name: Owner: nT"- _ i - / % / : t i(n
Job Location: '
White Copy-Collectors Office
r �\ i f 1 ' Yellow Copy-Customers Receipt
Plot: j ,i Lot: `i C.: t P' ,C°Py Filg'Copy
' pJ N i • Copy-Building Department
Phone: )r x % a` t l,fi.,( _.. . C: ,. 9
General Led er#'s Ref.# _'"
Description g
License&Permits-Building 01000-44105 �-il , €. ,71 y j
License&Permits-Building Misc. 01000-44105
I License&Permits-Electrical 01000-44106 —_—
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
ici
This is not a Permit or License for Building,Plumbing or Gas Received By:
4 >
i
. 0 SPECIAL PERMIT(Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON REFUNDABLE& NO,�:I7IMSVSURABLE
'''" r DATE'Tt`EC'EIVED
*44 H�. DARTMOUTH BUILDING DEPARTMENT !',r zT� ''''t
e� _ 400 Slocum Road, P.O. Box 79399 l- =
\3� 4r Dartmouth, MA 02747 m`
j' Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
/ / THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: /I�=>j/P=(,-.6-5--- BUILDING PERMIT NUMBER:92 ./ t'2-
DATE SENT FOR REVIEW: ///`s' / . ( DATE ISSUED:
O.K.TO ISSUE-:SIGNATURE: __C DATE: `/-.2 S—D 6.
Zoning Distnct '9 - Proposed Use: ' Sys Zone: C 0 B ❑A 0 V AqufferZone:
THE FOLLOW! G AGENCIES SHOULD BE NOTIFIED: _ =
of ' CyBoard of 0 Cons. 0 Demo ❑DPW 0 Elec. 0 Energy Report '
Appeals Health (5,, Commission Affidavit Card Sent: Cut Off Follow-up*
0 Fire :• ❑Gas yi, tytiPlanning ' - 0 Sewer Card 0 Water Card 0 Zoning 0 Other
-- Chief -t ; Cut Off - �"''"���, Board -: Cut Off Cut Off
'REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
I:DEPARTMENTAL APPROVAL"-.
Zoning Review: Signature: ia,,,,,p , C,+,,.cne.ffe Date: /--;3- 0 -,
Energy Report: Signature: Date:
Fire Chief: Signature: y Date:
L„Board of Health: Signature: ( 1, ,('/L , ( .(_<_.k = 'LT' Date: i/I- ( 6
Conservation Commission: Signature: Date: •
_
Other: Signature: Date:
Brief description of work being performed '/I/n 1 I/ , ,. ;,;.n,/, �,,t
SECTION 1 -SITE INFORMATION
t 1.1 Property Address: -70 S�1ANtion/ wA
Y 1.2 Assessors Map& Lot Number:
Nearest Cross Street X f f —'� - Map 7 7 Lot .% - 7
Subdivision Name: Ur--\-1 Q-r--" //i /,)
5�iL . ' - 1.3/Historical District 0 Yes 0 No
Total Land Area Sq. Feet: � .A i l ��` j Has application been submitted to the Historic Commission?
--/ ❑Yes ❑ No Date:
' .4 Water Supply(MGL���ZZZ /c40 s54): 1 Sewage Disposal System:
/p,0 Municipal Urivate Well 0 Municipal On Site Disposal System
El CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2._PROPERTY OWNERSHIP/AUTHORIZED AGENT
2. Owner Record:
Si .e...I1c 29_,1,. 6V. L/ nvwa 5Ct-Ca73-9tea
Name(print) Contact Address Phone Number
2. Au horized Agent:
�i zedA el �j�ni7on/ 67X7o 5#47A0 9A1 lyAy fa8 Z87 74j7 "
Name(print) Contact Address Phone Number
SECTION 3-CONSTRUCTION SERVICES - `.,.
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: License Number:
U) Address: Expiration Date:
lig Signature: Telephone:
Z 3.2 Registered Home Improvement Contractor: Not Applicable❑
W
VAre you a Home Improvement Contractor subject to (780 CMR-6)? 0 Yes CI No
J - If No,go to the next section!
U. Are you darning exemption from the requirements? ❑Yes ❑ No
O If Yes, submit the required affidavit!
dCompany Name: Registration Number(if none, state"none"):
O Address:
U
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
' ❑ I am a Homeowner performing all the work myself.
Owurs Name (print):
Signature:
By signing the above,the homeowner acknowledges that there will be no eligibility 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 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.
xxception: 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
onngages 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 arnansory to such use and/or farm structures. A person who constructs more than
e home in a two-year period shall not be considered a Homeowner.
If you are applying under this sedi sign b .
Signature: /
Y ur signal car 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 Appendix of 780 CMR R5.2.15)
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25)
Worker's 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: 0 Yes 0 No
SECTION 5-;DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
❑New Construction* 0 Accessory Bldg. 0 Roofing/Siding Other
(Energy report required) (Shed/Garage) (Specify below)
❑Addition 0 Replacement window/door 0 Demolition
(Energy report required) No.of windows_ Doors_ (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
❑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
❑Air conditioning-(separate unit)
❑None of the above to be provided
❑Hot Water: Gas Electric Fuel Oil Other
D sription of proposed work:
s SECTION 6-ESTIMATED CONSTRUCTION COST v
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5. Total (1 +2+3+4)
- - SECTION 7A-OWNER,AUTHORIZATION . '
(to be completed when owner's agent or contractor applies for building permit)
lease Print)
�y n /� 2/
7✓fLG2-l6 U�-(/�. w, ,a caner�he subject property hereby authorize wl'l((yyv.y�et't�
to act on my behal ' all ma relati to work authorized by this building permit application.
Signature of Owner Date
, ;SECTION-7B-OWNER/AUTHORIZED AGENT DECLARATION
t/l,/Wi w/a.n BF/vron/ , as Owner/A orized Agent here declare that the statements and information
on the foregoing application are true and accurate,to the best of my nd belief.
Signed under the pains and penalties of perjury.
f /3 vn 6
Signature of Owner/A thorized Agent Date
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED(see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Aaii.J 0,au91r144- Date: 7 cv3"Ph
SECTION 9-APPLICANT NOTIFICATION
Applicant informed of a ove: Date::: //45 4t Time: /2f Rif Clerk:
Comments: a F) v
SECTION 10-OFFICE/INSPECTOR'S NOTES
Less Application Fee:$25.00 Remaining Balance: $ —. C —
Total Permit Fee: $ CO
Other$Amount$ --
TOTAL FEE: Co Gross Area-New Construction total sq.ft. 4/-4
Gross Area-Alteration total sq.ft.
Permit Issued to: t D c .
7� p
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
I01
fAnn,t_j rem. - -
12.'
.2znzM4
fl4 t/s
■
1) A R T M ® U T H 4 ` °U""�e MASSACHUSETTS
OFFICE OF THE TOWN CLERK ao -yam ` : I ;' TowN CLERK
400 SLOCUM ROAD•P.O.Box 79399 . — ELEANOR J.WHITE
DARTMOUTH,MA 02747-0985 'saa TEL: (508)910-1800 •FAX: (508)910-1894
v ,2006
TO: BUSINESS CERTIFICATE APPLICANT,
IT IS THE APPLICANT'S RESPONSIBILITY TO INQUIRE WITH THE BUILDING
DEPARTMENT IF THEY ARE IN COMPLIANCE WITH THE ZONING LAW REGULATIONS OR
WHETHER AN OCCUPANCY PERMIT IS REQUIRED REGARDING THE ISSUANCE OF THIS
BUSINESS CERTIFICATE.
THE TOWN CLERK'S OFFICE WILL RECORD THE NAME OF THE BUSINESS ONLY.
GETTING A BUSINESS LICENCE FROM THIS OFFICE DOES NOT EXEMPT THE APPLICA T (G
FROM ANY VIOLATION OF THE ZONING LAWS. l 13
PLEASE SIGN: SIGNATURE:
S
ry\-
BUSINESS NAME: X y t,Sri >7 2 DtvS P7fi-i/UlL)
•
BUSINESS ADDRESS: 70 ,S1-44i✓A.c4✓ 'WA`/ !1 J � 1 'n kt) 'v
n lti
TYPE OF BUSINESS: Lows-v�4_77 o.1./ j
TEL#: ?79 5 7 74 17 0 LVITII
lb Pr
TOWN CLERK ONLY: // / �`
- NUMBER_OF CERTIFICATE: v�W- 6 3l
DATE: L.C./Q-! i . /5 c1`-o0k
BUILDIN DEPARTMENT SIGNATURE: d117Z� G2
BUILDING DEPARTMENT COMMENT:
- ys, Dartmouth Building Department
AT N
Jr;4 ,
iq` _ 2; 400 Slocum Road
,Z a' P.O. Box 79399 508-910-1820
'.IC :�% Dartmouth, MA 02747 FAX 508-910-1838
REQUIRED INSPECTIONS
FORM #115
READ ME: The applicant is responsible for
calling this office when scheduling
inspections. Please refer to the list
below for required inspections.
i AA II -1 l h
Address 70 ._i iditia,D td4 t/ Date_ - 3 --D-6
n *FOUNDATION (as-built needed): 0
Notice
*BEFORE INSPECTION,FOUNDATION BRACING MUST BE INSTALLED.
*SONO-TUBE INSPECTION:
*INSPECTION IS NEEDED BEFORE THE CONCRETE IS POURED.
*ROUGH/FRAME (with approved plans).
*AFTER ALL ELECTRICAL&PLUMBING HAS BEEN INSTALLED&INSPECTED
n FIREPLACE: 0 Footing(If separate) ❑ Throat ❑ Before cap is installed
nINSULATION (with approved energy report):
NOTE: N.F.R.C.LABELS MUST BE ON ALL WINDOWS AND DOORS OR USE DEFAULT CHART
VALUES.
X FINAL (with approved plans and energy report):
n
c:lwpdocslformslinspreq.wpd Revised February 1,2001
0 SPECIAL PERMIT(Per 780 CMR 111.13) '
S25.00 APPLICATION FEE IS NON RE-FUNDABLE & NOE.'DIM RARLE
`�Mo�rN" DARTMOUTH BUILDING DEPARTMENT A‘T ''�LL�-, ,,, pATEFfEIVED
rV� r'*0 N
o r al 400 Slocum Road, P.O. Box 79399 / q , ptq 1: 13
\;30 y»` Dartmouth, MA 02747
Q?u ,;nr 3
\"fi ./� Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
//// r THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: -/ /t.:•24-7_�/ 7 {.' .'"--- BUILDING PERMIT NUMBER 4?-2-,12
DATE SENT FOR REVIEW: / //` /( (---- DATE ISSUED:
O1C.TO ISSUE-SIGNATURE: DATE: 2;
. "i,l
Zoning District Proposed Use: Zone: O C ❑ B CIA £1 V Aquifer Zone: ` t 0
t '\
THE FOLLOW! G AGENCIES SHOO'D SE,NOTIFIED:
,`-�
1Brd'of card of 1 {.20 Cons. 0 Demo CI DPW
Appeals Health 1 I '; Commission Affidavit Card Sent Cut Off Follow-up•
0 Fire 0 Gas - D Planning -
i in�V ❑Sewer Card ❑Water Card - ❑Zoning ❑Other
Chief Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
i ,W.oard of Health: Signature: A) 5 p3. I Date: / /3�Zeo(p
Conservation Commission: Signature: Date: //
Other: Signature: Date:
Brief description of work being performed: ,y77 4 " .G_((-t roll'3'c. eX, rii.; rd;2., ce-
^-7 SECTION 1 -SITE INFORMATION
I 1.1 Property Address: /O 5#41Ntiei✓ ma
bit'
/ / Y 1.2 Assessors Map& Lot Number:
Nearest Cross Street/N N. H t' vt Ito IC..(( ,_ \ . Map 7 4;/ Lot .2- - J
Subdivision Name: ( r)Urc-1-6rt(� P C 'xr/fP/f/ \
1
��i•`�` 1-3 Historical District ❑Yes ❑ No
Total Land Area Sq. Feet: I acre Has application been submitted to the Historic Commission?
0 Yes ❑ No Date:
.4 Water Supply(MGLL�c440 s54): 1 ewage Disposal System:
❑Municipal $.Erivate Well 0 Municipal 9 'On Site Disposal System
ElCONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
,\ The Commonwealth of Massachusetts
a l Department of Industrial Accidents
ays _ Office of Investigations
600 Washington Street
•
Boston, Mel 02111
�i www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
App ' ant Information Please Print Legibly
are (Business/Organization/Individual): kt 4.1 571,ptof
/Qrfldress: 70 5,l4,v#t/ent/ wA/
/State/Zip: , paerivi ovrh, 52-717 Phone #: _Co 8 Z , 74/2
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
/ employees (full and/or part-time).* have hired the sub-contractors
2.Y)(�`I am a sole proprietor or partner- listed on the attached sheet t 2 ' , Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: a , a Expiration Date:
e� g
Job Site Address: ��' ®fm City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I doh eby certij,under the pains and penalties of perjury that the information provided above is true and correct
gnatitre: / _ ate: )a /3 Zpo 6
'le• • • #: Sob as? 7417.----
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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, §25C(6)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,MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to cany workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit/that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your 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
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
I •
t• :.204 Accessory Apartments
Is a separate living area within a residential dwelling which is clearly subordinate to the
principal residential unit and meets standards defined below.
- purpose of accessory apartments is to provide affordable housing typically for young
coup -s, singles or elderly individuals who wish to live in Dartmouth but do not have the
financi: resources or desire to own a single-family home. Accessory apartments are also
• meant to .rovide housing for younger or older family members of persons residing in the
p principal r- idence who wish to live in separate living quarters.
In addition to ' ' above purpose,an accessory apartment shall meet the following standards:
A. Only one . cessory apartment is allowed per lot.
B. No other renta or leased accommodations may be provided on a lot for which an
accessory apartm: t is allowed.
C. Is located within a s' !le-family residence in such a manner so as to maintain the
appearance of a single- ily residence.
D. Is designed as separate li ' ; quarters from the primary residential unit, but is
located within the same buildin_
E. Contains not more than 530 square et.
F. Is occupied by no more than two .ted persons or three persons related by
blood,adoption or marriage.
G. Is an addition or renovation to a residence whi had its original occupancy permit
issued at least 3 years prior.
H. The property owner must occupy either the accesso apartment or the primary
single-family residence,and may not sub-let either unit.
I. The Board of Health confirms that the accessory apartment r. be accommodated
with respect to onsite water, onsite septic disposal and any of -r standards of the
Board of Health.
J. Two off-street parking spaces are provided for the accessory apartm-'t in addition
to other required parking spaces for the primary single-family residence.
K. The primary single-family residence is not being used as a lodging house o ooms
rented.
•
L. The single-family residence/accessory apartment is located on a lot of at leas
15,000 square feet.
4B.205 Home Occupations
An occupation, trade, profession, activity or use which is conducted for financial gain and
such use is clearly incidental and subordinate to the use of the residential dwelling. The
purpose of these standards is to strongly limit the size and intensity of a proposed home
occupation so that the residential premises do not become retail or commercial in appearance
or character.
The home occupation shall be of a type that does not affect the residential character of the
neighborhood nor produce nuisances such as but not limited to, hazards from fire, fumes,
gas, smoke, odors, obnoxious dust, vapors, offensive noise or vibration, flashes, glare,
objectionable effluent or electrical interference which may impair the normal use and
peaceful enjoyment of any property,structure or dwelling in the neighborhood.
t 4
Any home occupation is allowed if the activities of the home occupation do not appear PM
different than the normal use of the property by the owner for his residence, appropriate
measures are taken to prevent any nuisances listed above,and the conditions listed below are
met.
The purpose of home occupations is to allow individuals to supplement their income or to
encourage the development of small businesses in an environment with minimal overhead
and financial risk. If the home occupation becomes successful and no longer fits within the
constraints of the residential district, the business will then have the resources, experience
and clientele to move into the commercial or industrial districts, thereby improving the
economy of the Town and region.
Home occupations are allowed under the following conditions:
A. The home occupation does not alter the residential appearance of the dwelling or 11.
accessory buildings.
B. Such occupation shall be carried on by the person who owns the property or his
immediate family who reside on the premises.
C. Not more than one non-family member is on the premises at one time who assists
or engages in the home occupation.
D. The home occupation shall not utilize more than 600 square feet of space on the
premises, including all areas for storage, office, work areas, or any activity
associated with the home occupation. 111
E. Off-street parking spaces are provided at the ratio of I space for each increment of
0 to 200 square feet of home occupation area and one for each additional employee.
F. Home occupation space outside a building shall be screened from the street or
abutting properties. Except that agricultural products, such as but not limited to
vegetables,flowers, fruits, eggs, etc.,produced on the premises, do not need to be
screened.
G. There shall be no exterior advertising regarding the home occupation exhibited on
the premises except for one wooden identification sign not to exceed two square
feet on each of two sides. Each side of the sign can be used for identification. The
sign shall not be illuminated either internally or directly. lig
H. Where products are offered for sale from the premises,at least 80%of the products
for sale shall be produced on the premises. This requirement does not apply to
products which are sold from the premises by mail.
I. Traffic or congestion in the street will not be objectionably increased above that
associated with a residential home. If more than two vehicles are regularly parked
in the street (total of four hours in a 24-hour period) as a result of the home
occupation,this will be considered an objectionable increase.
J. Traffic/parking/pedestrian regulation signs are allowed if required by the Town. N
K. The Board of Health confirms that the home occupation can be accommodated with
respect to onsite water, onsite septic disposal and any other standards of the Board
of Health.
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4B-4
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