BP-23841- 2001
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
t, F-11t'
58 -S h 4A)1U vAv t / �&7S
Na�
Contact Address fr/ . ��Z f 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 Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you clahning exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
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: '
Dome Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
r
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 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 dwelliniz, 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 undeVhis section sign below:
Signature:
" Your signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
- 2001
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construcction
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 152i§ 25)
Workers 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: ❑ yes ❑ no
SECTION 5 -DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ wfoodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dc,molition
(shed/garage) no. of windows doors (specify below): (spe6ify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit I 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS =' s
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (I + 2 + 3 + 4)
* Estimated Total / 3; O t1 r d 0 $
SECTION 7A - OWNER AUTHORIZATION f
.L
(to be completed when owner's agent or contractor applies for building perwt)
(please print)
1, , 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 Owner - Date
ECTION 713 - OWNER/AUTHORIZED AGENT DECLARATI N
as Owner/Authorized Agent hereby declare that the statements and infcormation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
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RESIDENTIAL 2001
SECTION 8 -I PECTOR'S REVIEW/COMMENTS
1. Dote plan reviewed:
2. 30 days to review period expires:
3. ' OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason: ,
Date:'
Date:
Date:'
7. FOLD subject to Zoning Board of Appeals action:
8. C mments:
Date: '
Inspector's Signature:
9. g
Date:
SECTIO - AP LI ANT NOTIFICATION
Applicant inf0ea Date: Tim . Clerk:
Comments:
`SECTION 10- OFFICEAINSPECTOR S NOTES
.:
JJ��
Total Permit Fee: $LIUV
L 2 0
Less Application Fee. $ 5 0
L 7�
Remaining Balance: lJ
g $
TOTAL FEE: Gross Area - New Construction totals . ft. r
Gross Area - Alteration total sq. ft.
f
Permit Issued To -
SECTION I1-ADDITIONAL COMMENTS/SKETCHES
j
e
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RESIDENTIAL `2001
o FOL L'DAHON ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFEILABLE
5 DATE RECEIVVED
DARTMOUTH BUILDING DEPARTMENT - ° -
400 Slocum Road, P.O. Box 79399
:O
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
MA
RECEIVED BY. BUILDING PERMIT{ n t rz
,
DATE ISSUED x > .t
DATE SENT FOR REVIEW: NUMBER
�..
a :
OK TO ISSUE - SIGNATURE:
Bnildin ommissioner/Inspe r f ±ildings�.w
i
Zoning District: Prposed Use: Zone: C.: ❑ B ❑ A ❑ V Outside Blood Zone 0AquNer zone K,'
THE FOLLOWINGAG CIES SHOULD BE NOTIFIED: ' ,.,
t
❑Board of . • oard,of ❑Con. Coin ❑Demo ❑DPW , _.. ;:.. ❑:Elec D;t�nerQ{(Renort , a;
...... _- 'V' i* t..: 3.f:- _ '..i:.
A eals ealth Affidavit and nt ""=Cut'Off _.=.Fellow u
PP �.
❑ Fire ❑ t? Planning Board* ❑Sewer ❑Otlier
Gas Card 0 Water Cards ❑Zoning
�.. /Cut O
Chief = 'Cut Off A %Cut Off off Review*:
r 3
.'
�F
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT'
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Dater
i
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1- SITE INFORMATION
_.
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes 11.1no`
Number:
1.1 Property Address: J' �11.(��C2�✓ t %Cr' �%
1.2 Assessors PI t j
Plat_ Lot _ I
Nearest Cross Street: A), ti / vi /,,r
Subdivision Name: ( o L T T Lf 1, Cc r
1.3 Historical District ❑ yes ❑ no
/
Has application been submitted to the Histroric Commission?
Total Land Area Sq. Ft.:
❑yes ❑ no Date:
1:4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
/
❑ Municipal[�J/Private Well
❑ Municipal L3'On Site -,Disposal System
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