BP-2046042'
6' 14' 22'
6' 8' QP 19,
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SCALE
6 14 22 24 JUNE 28, 2001
44'4
42'
6' 14' 22' , .
6' 8'3' � 19'
------ ------SASH------ ---SASH---------------------
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WITH 5/8" TYPE X FIRECODE a =
SHEETROCK 36"X36'Xl2" DEEP COLUMN PADS BEAM POCKET
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—SCALE 1/4" = 1' 17' �� 5,
E61 �� 14' �� 22' 2'4
JUNE 28, 2001
44'4
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RESIDENTIAL
2001 RESIDENTIAL
---------- ----
--ZUU1
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1'Owner of Record:
�5g `'E.S �,Cr'`�S Rj�.i�% ,
� - _
�l \tk �— �I o2t1
` 5 o Eyo
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
I a
V\N oan4s
(
Contact Address Phone Number
Name (print)
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor?
License Number C° !F,,
Address 1
Expiration Date
Signature Telephon _
3.2 Registered Home Improvement Co tor:
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")
Adliress
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:
Horne Improvement 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 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 familv dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs
more than one horn 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
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)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afffidavit
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)
newt structton f"� ❑ addition ❑alteration ❑ repairs ❑chimney/ ❑ woodsaove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demoliition
(shed/garage) no. of windows doors (specify below): (specify beelow):
* If new construction, please complete the following:
Single Family: no. of bedrooms 3 no. of baths Z
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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
Hot Water: Gas Electric FDuelOi Other
Brief Description of Proposed Work:
- SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildinizg
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ Q('�
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(pl se print)
I,^ � , as Owner of the subject property hereby authorizel��5�_�F
to ac on lf, in 11 matters relative to work authorized by this building permit application.
Mml�
— tea c" cnC -
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
a Owner uthorized Agent hereby declare that the statements and inf05rmation
on the foregoing application re true and accurate, too th�of my knowledge and belief.
SigneA under the pains and penalties of perjury.
Signature of Owner/Authorized Ag nt Date
-_ _-C:`bld-g.fbrms\Bld mapp.res.wpd Page 2 Rev. January 19, 2001
0
C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. Jarnuary 19, 2001
RESIDENTIAL 2001
2001
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date 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. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
Date:
SECTIO 9 - API ANT NOTIFI,C�A°TION
Applicant inform d of above Date: Time: Clerk:
Comments:.--
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ i
Less Application Fee: $ 25.00
Remaining Balance: $'
TOTAL FEE. Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Pe. nit Issued To
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
C:\bldg.forms\BIdeapp.res.wpd Page 4
Rev. January 19, 2001
Y
RESIDENTIAL
�FOUNDATI01V ONLY
$25.00 APPLICATION FE I NON-REFLiI�iIDAEL
:'&c NON -TRANSFERABLE;
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT;= -
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 01747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTJzrJCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING;
THIS` SECTION FOR OFFICIAL USEONLY
RECEIVED ..
BY: 'J.
BUILDING PER1V><IT
DATE SENT FOR REVIEW:
') :.
NUMBER:
�
ATE ISSUED:
OK TO ISSUE -'SIGNATURE:
DATEF a
Building
Comud , ioner/Inspec r of Buildings
Zoning District: roposed Use:
Zones C ❑ B ❑ A` ❑ utside Flood Zone O Aquifer 7,onie
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:1v
i
❑ Board of < ❑Board of -','[]Con. Com
❑Demo °"' : ❑DPW ❑ Elec. i� Energy Tl3eport "
Appeals U: .< Health .
Affidavit ,.; Card Sent Cut If ='Follow-up*,
❑ Fire ❑ Gas ❑ Planning Board*
❑ Sewer Card ❑ Water Card 3 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:
Fire Chief Signature:
_- Date:
Board of Health: Signature:
Date:
Conservation Commission: Signature:
_ Date:
Other: Signature:
Date: m
Description of work being performed:
SECTION I - SITE INFORMATION
i
NUMBER OF PLANS SUBMITTED:
Cam,
SITE PLAN SUBMITTED: es ❑ no
Svc 1-o-c ti� CA�ci-��v1S, �Q1�
1.2 Assessors Plat &Lot Number:
1.1 Property Address ] �� �
�
Plate Lot ez - 1g
Nearest Cross Street:
Subdivision Name: (°�y�"C� �'k�
1.3 Historical District ❑ yes i no
Total Land Area Sq. Ft.: �16�
Has application been submitted to the Historic Commission?
___ -
D t
yes Lno a e.
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
Municipal Private Well ❑ Municipal On Site Disposall System
c9f
(66
C:\bldg.forms\Bldgapp.res.wpd Page I Rev. Jamuary 19, 2001