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BP-224592001 SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT 2.1 Owner of Record: t✓F� C°aM�sV� , ^C t�F,t�t�F�FoP� 1 o2.�T�45C "19 4 F = p F 5e81 Name (print) Contact Address Phone Number 2.2 Authorized Agent: IE2) �° 4J�S MC Q0MRR1 QJ-yl, NEvJ FoR4,MR oP-riLks Contact Address Phone Number Name. (print) SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor �6QF��L License Number C e: ©51_L� Address TTeIephoiie Expiration Date Signutur _gam O 3.2 Registered Home Improvement Contr o Not Applicable Are you a Home 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 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 - Roan 1301, Boston, MA 02108, (617) 727-8598 Owt�ers 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 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 RESIDENTIAL 2001 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Q7onstruction 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 prrovide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: )Kyes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) �pUction 1, CJtJ ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove new construction (energy report required) (energy report required) fireplace ❑ 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 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), 1 of 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 X Hot Water: Gas Electric Fuel Oil '�p�}�FSS Other Brief Description of Proposed Work: SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item - Estimated Cost ($) to be completed by permit applies ant 1. Building 2. Electrical 3. Plumbing 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) Q'0 *Estimated Total $ , SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) as Owner of the subject property hereby authorizeVv�C�_11' `�FS to y beha 1 matters rqfative to work authorized by this building permit application. - Signature of Owner - Date SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION 1, \Zcsa�� a Owne Authorized Agent hereby declare that the statementt's and information on the foregoing application are true and accurate, to the best of my knowledge and belief. S' under the pains and penalties of perjury. Signature of Owner/Authorized Agent IDate C:\bldg.forms\Bldeapp.res.wpd Pace 2 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 19, 2001 RESIDENTIAL 2001 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: 2. 30 dayfs 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: 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: Date: Date: Date: Date: 9. Inspector's Signature: Date:. 001 SECTION 9 - APPLICANT NOTIFICATION l Applicant informed ab ate: ' Tim : Comments: j .. Clerk:_ SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balanc : S TOTAL FEE: Gross Area - New Construction total sq. ft. ,Gross Area - Alteration total sq. ft. , Permit Issued To SECTION 11-ADDITIONAL COMMENTS/SKETCHES C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 RESIDENTIAL 2001 FOUNDATION ONLY $25 00 APPLICATION FEE I NON-REFUNDABLE & NON-TRANSFERAEiZLE DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 !O Sr T + Dartmouth MA 02747 , 508-910-1820 FAX 508-910-1838 Zoning Review: Energy Report: Fire Chief: Board of Health: Conservation Commission: Other: Signature: Signature: Signature: Signature: Signature: Signature: Description of work being performed: SECTION 1- SITE INFORMATION Date: Date: Date: Date: Date: Date: I NUMBER OF PLANS SUBMITTED: (' 2,\ I SITE PLAN SUBMITTED: %,Yes ❑ nra 1.1 Property Address:* �-:n 5;1�NQi1 �,jg� Nearest Cross Street: u6 Subdivision Name: Total Land Area Sq. Ft.: 1.4 Water Supply (MGL c 40 § 54): C:\b1dg.forms\B1dgapp.res.wpd ❑ Municipal Private Well 1.2 Assessors Plat & Lot Number: Plat_ Lot eC) .t. J E 1.3 Historical District ❑ yes )�Ino Has application been submitted to the Histor,is Commission? ❑ yes Y�no Date: 1.5 Sewage Disposal System: Page 1 ❑ Municipal AOn Site Disposal System (gcg-o �q Rev. January 19, 2001