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RESIDE1iTIAL
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:'
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERN'TCES
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 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 rCONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONYS OR COMPLAINTS call or write:
Home Intprovenzent Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
1 Owners Name (print)
( sm�
C
•J ignature e�
by signing the abo e, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
/
ate
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 supers isor.
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 Linnder this section sign elow:
Signature: /jr�i(..-t�
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
2003
NOTICE To LICENSED CONTRACTORS: The Buildin; Code provides in the Rules and Regulations section that any licensed Cojnstruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2115)
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 prolvide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ rio
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ [❑ woodstove
(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 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 Fuel Oil Other
Brief Description of Proposed Work: L 1
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (8) to be completed by permit applicants
1. Buildinu 600
2. Electrical
3. Plumbing 60�
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)
(please print)
I, , 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
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION `-
I C'1>01 1> 5i r_p h+ VW V , as Owner/Authorized Agent hereby declare that the statements andliinformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
J 1163
Signature of Owner/Authorized Aent Date
C:`,bldg.ti>mis\Bldgapp.res.wPd Page g 2 Rev. January 19. 2001 pd
RESIDENTIAL 2003
SECTION 8 - INSPECTOR'S REVIENV%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' reviewworksheet):
5. DENIED (see project review worksheet): `
6. HOLD reaso AR 14 7003
Date:
Da e: -
7. HOLD subject to Zoning Board of Appeals action: 4;4-
S. Comments:
Date:
9. Inspector's Signature:
Date:
SECTION 9 APPL ANT NOTIFICATIION
,17
Applicant inforryXdof ab ve Da e: Time: �! Clerk:
Cornnents: 1 ��w
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $ L)
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area= Alteration total sq. ft. /C
Permit Issued To
SECTION.11 - ADDITIONAL COMMENTS/SKETCHES
RESIDENTIAL � 2003
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
DATE RECEEIVED
E ov DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
3 :1 Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY BjWELLING ,
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING P �r
DATE SENT FOR REVIEW:
NUMBER: L
DATE ISSUED:
OK TO ISSUE - SIGNATURE:Ll DATE MAR 2 1 200-.
Buie',- Commissioner/Inspector of Bui ings
Zoning District: Proposed Use:� one: C4�nB ❑ A ❑ V Outside Flood Zone ❑ Anquifer Zon
THE FOLLOWING AGENCIES SHOD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. 0 Demo ❑ DPW ❑ Elee. t❑Energy Report
Appeals Health Affidavit Card Sent: Cut Off ...,Follow-up
❑ Fire ❑ Gas ❑ Planning Board* q Sewer Card ❑ Water Card ❑ 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: h
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
V
It
Board of Health: Signature: Date:
Zz
Conservation Commission: Signature: Dater
Other: Signature: Date:
Description of work being performed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes Cp no
/
1.1 Property Address: 0<10 Sb(i mgem It)-q q
1.2 Assessors Plat & bot Number: -
Plat Lo -
Nearest Cross Street: )y4rV./
Subdivision Name: (�2y7 �i4R��
1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: 12
%a
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ On S ite Disposal System
C:\bId,—%Jorms\Bldgapp.res. wpd Page a Rey-. January 19, 2001
C:;bldg.iurms+.Bldgapp.res. pd Page I
Rev. January 19, 2001