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" • 3-��*` �. 6"4' x" �, .. � �.. ��`'-L�'��r'�L..�'-. •✓.',• ,.�: _ -t.• .•rxai � r �..�"��r�„ .r. ..-9:'� �,�T_.: ... i VO x FILE Ct' upy a Ic >k�� �• .;,,r �-x' �� � ,a Z: Z ,. _ m, ":; �:.,:n - ram. r '��'�• ,;,�.•_ y.: W �:Cj;!"1 (/1. a�z.'Z ;.cam�►� v, " ' (rl ''T * r , ( p:t- ..:ti : (fZ i :..,._. �•Z' � r '' 3 Y�. �` ' .. � *,;r. r ,••may, �.. r►-• `D•`.t:Uf O '9-riyy_✓16 ,z _ ` u.'Q-:. 1J C itr6 :r ���' -3: ,•fa7`.K Y;. •`�f:� m. n Z - � r i s i '' �` ' z�-t z O'3-�``•'�c'' ..'�;� '•A`'`�y, W%; �„x"� b � -�,.. THE BUILDING DURtNa TF?IS �T PROGRESS OF NIS WORK. BUILDING DEPARTMENTTown of Darttr►" 4j ��"� � ZJ,.J. J r � i� �� • fit. r � .,�,�. :� � V,V aa=-:� 1 re �w zrrrm To WN ®F Y� �fg�.�■!9/�p gq�i� Q=.` �*�,� k �' .r r'I •p; �y yt� �7 Q=`��:�y!�r;Z�. �7R�8$�76i�,$l RNRECO J✓�:. ± _ -L C '. Ay �. ,i � � < T' vt+ x���. .ySYz h - �C.l`�R r .�. �YQ.�I.i` Y:. W A �� � �•'tl • �i. V h.SY C�,IIt C��n r� +i. � J3 � a csG� id il Sig" :�jdy�,." Plan pyrjt�� c��.. p/'�j ' N Duri listIon 31 �7 Agwrxa)- ! tr . , pz_ -A • AWW So, -0 oy 4 F L m I -A m -`Q -D '0' � O .---Fs °Y,�.4��. ��2— r"S' S'' '� T` r r� 0"Z 0 M *n .0 z1v DRAWING MUST &E KEpT 0 �• r :`?'� a� ` � _' � r AT THE BUILDING URI DNG "'UUFiESS OF THIS WORK. THE ­;T7 IV -It BUILDING DEPARTMENT Town of Dartm" 14 CA 61 vim O Z rn M F 4r. C) PLAN A b!5 4 > plal ca sita Du ast, -tior, XY- gf -1 -4 z A 0 s?7 4 C _.gg 4XI-, IT- -- R-ESIDENTIAL 2003 RESIDENTIAL - SECTION 2 -PROPERTY OWNERSHIP / AUTHORIZED AGENT 2.1 Owner of Record: S�1 .� 1 S-L AANZ-lTln l p / �VA.z (c� 1Lt is .e V LA C1 ry✓ 66 j 79Y Name (print:) Contact Address Phone Number 2.2 Authorized Agent: �i3r1s � sP�s 5-9 33zb Name (print.) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: k&� ka - Not Applicable ❑ Licensed Construction Supervisor 6AP_W L.S pA S License Number 013 3AS Address j q 7 sr-t�-rc Expiration Date Signa e Telephone 29(, 3 3 Zo 3.2 Registered Home Improvem t 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 claiming exemption from the requirement? ❑ yes ❑ no If yes, submit the required affidavit! Company Name aAA0_,,,1 '7m t✓ S Registration Number (if none, state "none") 1(329-08 Address Sq? -M -£ 12�. Signatu Telephone 3 3 Z0 Expiration Date B A, of 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 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 family 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 ensed Conrtr.-action 2003 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any lic 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 15 , § 25) ,y} Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to providee 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/ ❑ voodstove (energy report required) (energy report required) fireplace Eldeck E rp- o—o1 ❑ accessory bldg. ❑ replacement window/door ❑ other 1-1 t'demolition (shed/garage) no. of windows doors (specify below): (spfacify 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 (specify): ❑ Air conditioning - (separate unit) _ ❑ None of the above to be provided ❑ Hot Water: Gas , -- Electric (�el'O'1,c� Other - 0 X!o Brief Description of Proposed Work: U(nt YL_ ti 2 S.v�mre) Lr-J ;,. SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ($) to be completed by permit applicant 1. Buildin 2. Electrical 3. Plumbing 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) * Estimated Total SECTION 7A -OWNER AUTHORIZATION r " (to be completed when owner's agent or contractor applies forbuilding permit) (please print) �? I, SW-a-h -1 Vi:' V—Y Ji . (}l Ct s 4A 4as Owner of the subject property hereby authorize rA AO ,,w 49ao L- , to act on my behalf, in all m tters relative to work authorized by this building permit application ,,. -��-.11 --),) W1,47 A /O?D Signature of Owner Date SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION ., I, 4A2,t,.r1 o-6 LE, , as Owner/Authorized Agent hereby declare that the statements and infformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Si ed u er the na of perjury. Signature of Owner/Authorized gent Date C:\bIdg.tonus\BIdgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.forms\Bldeann.res.��nd C:\bIdg.tonus\BIdgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.forms\Bldeann.res.��nd RESIDENTIAL ,7 2003 RESIDENTIAL 2003 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERA>'lc;LE SECTION 8 - INSPECTOR'S RE IEW/CONIMENTS 1. Date plan reviewed: X 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: S. Comments: Date: 9. Inspector's Signature:_ Date: SECTI N 9 - APPYfCANft NOTIFICATION Applicant inf r ed of ab ve Date: '/ rZ� Time: Clerk, Comments: ` r SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: ( Less Application Fee: $ 25.00 Remaining Balance: TOTAL FEE: ' . Gross Area - New Construction total sq. ft. Gross Area- Alteration totals%q. ft. Permit Issued To' SECTION 11 - ADDITIONAL CONIMENTS/SKETCHES Q DATE RECEIVEZ) . DARTMOUTH BUILDING DEPARTMENT r 4nE 400 Slocum Road, P.O. Box 79399 Dartmouth, MA 02747 - 508-910-1820 FAX 508-910-1838 " APPLICATION TO CO U T, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT DATE SENT FOR REVIEN : NUMBER: DATE ISSUED: , OK TO ISSUE - SIGNATURE: �_ DATE (.J B dinb Co issioner/ nspe r B 'Idings Zoning District: roposed Use: Zone: C ❑6 A ❑ V Outside Flood Zone ❑ Aquifer -'Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elee. ❑ Eneyrgy Report Appeals Health Affidavit Card Sent: Cut Off Follow✓ -up* ❑ Fire ❑ Gas ❑ Planninb Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ OtLier 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: ed­Signature: Date: Conservation Commission: /J ggii ature: Date: Other: Signature: Date: Description of work being performed: SECTION 1 - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: yes ❑ no 1.2 Assessors Plat & Lot Number: 1.1 Property Address: ILLIAm i�acc' Plat 1 L/ Lot 2-0 Nearest Cross Street: Lh,.1 Velxly Subdivision Name: 2TL04b k4-U-- 1.3 Historical District ❑ yes ❑ no Has application been submitted to the Historic -(Commission? Total Land Area Sq. Ft.: ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 j 54): 1.5 Sewage Disposal System: ❑ Municipal rivate Well ❑ Municipal ©Site Disposal System � ��� Rev. January 19, 2001 C:\blde.formsBIdgapp.res.�vpd Pa_c 4 Rcv. January 19, 2001 C:\bldc.forms 131dcapp.res.wpd Page