BP-221431 I ! Z
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c> (3) 2X6 HEADER v UP
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! I 4" PERIMETER DRAIN SD DBL 2X6 SILL 1 P.T. & 1 K.D. FORM 5'-5" BELOW
d'
! DROP 4'-2 10" - 3f4" STONE O O O T.O.F. TO INVERT ececTRic
! ! 4" CONCRETE SLAB I I
I- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,- - - - - - - - -
26' 10'
[NOT TO SCALE NOVEMBER 8, 2001
36'
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RESIDENTIAL
2001
2001
SECTION ., 2 - PROPERTY 0WNER HIP AUTHORIZED AGENT
2.1 Owner of Record:
��8 C° - Aq° coy zzl �•
1yF�y '5 zU1Mt, 0an4
C56a� 99 S - 8a ko
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
kgsa Cm���AC CZM� ��y4
'�11 �a F ot�l MPS a;?_T_ks
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor 6 --
License Number C '�, us L�l
Address n
Expiration Date
C55t La-Io
Signature Telepho c�
3.2 Registered Home Improvemen Co actor:
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 - Room 1301, Boston, MA 02108, (617) 727-8598
Owners dame (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 ther;, 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
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. ailure to proviide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ no)a
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable
ew"Ic'Oonstn1cchanPk_� ❑ addition ❑ alteration ❑ repairs ❑ chimney/ CJ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other r7 demolition
(shed/garage) no. of windows doors (specify below): (:specify below):
* If new construction, please complete the following:
/
Single Family: no. of bedrooms _2�) 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 lectricity, 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 c� Other
Brief Description of Proposed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS ,
Item
Estimated Cost ($) to be completed by permit applicanft
1. Building
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
trti
*Estimated Total $ �JQiJ,
SECTION 7A OWNER AUTHORIZATION art,
to be completed when owner's agent or contractor applies forbuilding permit) 4
(please rint)
I, O JZ.'� , as Owner of the subject property hereby authorize���
to a? my , ' all ma s relative to work authorized by this building permit application.
Signature of Owner Date
ECTTON B - WNE A TH RIZED AGENT DE LARATI' N �'
as Owner/Authorized Agent hereby declare that the statements aind information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
I
k��Z3 L_::iL
Signa re of Owner/Authorized Agent Datte
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C:\bldg.forms\Bldgapp.res.wpd
Page 3 'Rev. January 19, 2001
RISIDENTIAL
2001 RESIDENTIAL 2001
` SECTION $ -INSPECTOR'S REVIEW/COMMENTS
$25.00 APPLICATION FEE IS NON-REFUNDA13LE NON-TRANS7VERARLE
{u
c.
I. Date plan reviewed: l 1� Lo
2. 30 days to review period expires:
3- OK to issue date:
4.. OK to issue subject to requested submittals see project review worksheet Date:
J q ( P J ) I
5e ` DENIED (see project review worksheet): Date:
E. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
S. Comments:
9. Inspector's Signature: Date:(Q
_ I
SECTION 9 A P ANT TIFICAT ON ,-. , _ C NO
Applicant mfo�f d above Date: I Time �G2-1�% Clerk:
Comments: C/
SECTION10 F E R S NOTES
O FICE NSP CTO
• • � • • • • .. y ill
Total Permit Fee. $ Less Application Fee: $ 25.00 Remammg Balance. $
TOTAL FEE: Gross Area New Construction total sq. ft.
Gross Area - Iteration total sq. ft.
Permit Issued To
SECTION 11 ADDITIONAL COMMENTS/SKETCHES
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fi-7°E.�`
C:\wldg.forms\B1dgapp.res.wpd Page 4 Rev. January 19, 2001 C:\bldg.forms\B1dgapp.res.wpd Page 1 Rev. January 19, 2001
DATE RL�;CEIVED
r� �M°"T" •�'' DARTMOUTH BUILDING DEPARTMENT'
-
400 Slocum Road, P.O. Box 79399
.r'o
Dartmouth, MA 02747
•«�°�-' S08-910-1820, FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIL�y DWELLING
THIS SECTION FOR OFFICIAL USE ONLY y�
4�
. C•'.'. -.$ V xy _ 'K �:�yS. li 1
�' ..ems 4 ` k ' i k:..� "�2 2 3
RECEIVED BY:
PE
BUILDING RMIT
DATE SENT FOR REVIEW
NUMBER
r
DATE ISSUED
OK TO ISSUE -:-SIGNATURE:DATE
Buildin Co 'ssioner/Ins ec � of ui dins
Use
Zoning District. - ro osed ...w,Zone:'r ,. [7 B, A'�❑ V .Outside Flood'Zone= ❑ ,, <A infer:Zone :
g � >P _ q
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED��*
x
❑Board of � ❑Board of ❑Con Com ❑Demo ❑DPW � z ` � QElecj ❑ Energy"72eport
�
Appeals HealthAffidavit Card Sent`=Followup*
i
4 �
❑ Fire ❑Gas❑Planning Board* ❑Sewer Card ` Water Card; r ❑Zoning; ;=❑ Other
a
Chief � Cut Off'Cut Off �/ Cut Off Review* E '`
T S s a
m- *REQUIRES
INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT ����x
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Dater:
Energy Report: Signature: Dates:
Fire Chief: Signature: Data:
Board of Health: Signature: Dati�:
Conservation Commission: Signature: Datce:
Other: Signature: Datte:
r
Description of work being performed:
'.SECTION 1-SITE INFORMATION
NUMBER OF PLANS SUBMITTED: CJJ
SITE PLAN SUBMITTED: yes ❑ no
1.2 Assessors Plat &Lot Number:
1.1 Property Address��� ���N,pt� �Ay�
Plat_ Lot
Nearest Cross Street:
1.3 Historical District ❑yes �no
Subdivision Name:1°py'�
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
❑yes )(no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal Private Well
❑Municipal �Oln Site Disposal System