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CTION IS REQUIRED BEFORE
THE COidORETE IS POURED. �.
BUILDING DEPARTMENT r' �
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of Dartmouth st.,X',�}mi€Ted to d e l'ttildin
Town of
Dept. prior to calling for
a foundation inspection or
24' any farther coa%tructi-on. l
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2003 RESIDENTIAL
UIIIN
RESIDENTIAL
_ SECTION 2 = I'Ittll'�RTY O TtSHII' 14012Ii&� AGENT =_
2.1 Owner of Record-
t
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
�
Contact Address Phone Number
Name (print)
r SECTION 3 COSTI2UCTIOIERVIC`ES
, -
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 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)
ignature
b signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
t 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
I 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 on are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
�r
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed,rConstruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR k_5.2.15)
g�® SECT C N �- ORI � 'EN` ' ONO%X URANGg ti�
vq u .5. �8i�u::imbia� �.s. .t�f fi pce`'� ..a _.duti t ILL ayfi _"J..s.� ,.':°9u. <1 Y i��i i, fl vide ... Er_ A i11
,xr `.. ;. v.. ..._.....a'S. arm ..,w.. _,d'_. .... msr. �.,. _ -_- , e,.,.r ,.a,., .:flit..
Workers Compensation Insurance affidavit must be completed and submitted with this application Failure tWprovide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑1 no
TIOI DES]!TON O�]k20POSL `b1tick"'albillcab , w,
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
INIAdeck El pool ❑accessory bldg. replacement windo 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 �
— - SECTION a= 6' EST, TED CONSTRUCTION COSTS
r = v
Item
Estimated Cost ($) to be completed by permit applicant
1 Rnilrlino
� R1Pctrical
q Phimhino
A Mechnnical (I-IVA( )
5. Total = (1 + 2 + 3 + 4)
* Estimated Total01
SECTION iA 0WNERIJTHORIZA1 IIiN
} F {to becrtpleted whin wner'sgent or contractor apples for bwldrrtg permt
(plea rint)
Owner of the subject property hereby authoriz
4-c—
to act on my b ha , all matters r .lativ to o au rized by this building permit application.`�
."7—(Ls j
Signature of wner Date
-=SECTI93N- OWN]WAUTHOM&D AGE\THECLARATIt3N =
- — ,- , .±'h '3'�' ,u" _ = 'h - �' - tIUIOr;�y �{, �h.,, 4t` T
, as Owner/Authorized A� T, \ ` gent hereby declare that the statemets and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed e pains and pen lties p
03
ignature of Owner/Authorized 4gent Date
Cr:\bldg.forms\Bldgapp.res.wpd
Page 2
Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd
Page 3 Rev. January 1, 2003
RESIDENTIAL ❑ FOUNDATION ONLY
442 %-AA APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
2002
_ mE ON$ — INSPE TOR'SI2YIEW/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 pr ject revie wor het) Date:
5. e ect review worksheet):IP/ Date:
�DENI
6. LD reason: Date:
I
7. sect to Zoning Board of Appeals action Date:
8. Comments:
9. Inspector's Signature: Date:
,.e''ie , +`. _ 7 - t. _
— : " _:sc ": = i 9 4_!.[r.
a umcns+ µ .rytha ii`+Y`
,_t x.: ., T 1. I A'- , .,,:,,:x.,::, ., _. .._ ; ,
'tiT 9 P N (? + m m .._.::,...,.
WANT,��m::mc:u
�e. �..__L_�i
.._.1. �$.. mam:. P .
�t� ��a .�t'ta«$....eli�+:ym
e
Applicant in ed f abov Da Time: �� d Clerk:
Comments
Jd w fl
i h
rr C 0 OFFI E R TES O 1 C 11
s � t
--a" � I, �„ Sant m.� •?L "a,@. a!G! ,ui>r ae+}�:tw 5 fiui`%+'mar .''}i n e a _ ._3t>t'as x,.
-
s Less Application Fee. $25.00 Remaining
g Balance.Total Permit Fee. i;
TOTAL FEE: .Dross Area - New Construction total s . ft.
�� q
Dross Area - Alt ration total sq. ft.
=C '4,
Permit Issued To,�;-�.-�
� dt�- r � zn�n
GAL, C�
� TION I I ADDITIONAL COtYIl4 ENTSISKETCHES
03
OU'
0, o 0
70. W
RESIDENTIAL 2003
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFi RABLE
DATE`REfCEi '
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 Luc., Ja.== �-r, 1: 2
v. Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEt;LING
tZ OCIAL USE ONLY, u`
TR�SECTIONOIt
NOWN. _., m
RECEIVED BY � r BIIII��ING PERMIT
DATE SENT F'ORRE?IEW �: •, �a� h
i�7HaaN { t�fi { het r! lass,�i i'
OIL (� ISSUE S r i Ci r i, y 2 K lA1 E 4
tr' L �, y R drd4 ea, 11 zj.
1
i,,16 9
Ei
i{ n l f f
E§,b
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m +�'�� m iE}, pat ,Plgaax=� ,A �;ai
xtF= " fl
» HI it„= +4'�' ,.ia () 1 J•�j �
L�ln I"a C � a it►� SeJatl ,e t Q ,, t* 11 , Ili AZC� i
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zg�F. - e'er,:.. s ;:, :', , :"; r • a a a •.,€a a
tt }
A S p; �F � E F° LI.O"fr�i�` - �,OULD BE ED r O NOTTFI m �M a r � e
t h(, e(+.x3'�ti i.�ls cram x 'e�`i9E
.... .. ,xr-k :, _. _, P P ..,,�„ :.. �x.Pa.:ia , U„ _., .. �. . i.. ,, ( fire gx -P- a,,.
`_; to L�';.,mS, �� ,� ,-", as: �' -:x,e
"�ih
���
-�c.m .. ,s: , xw: mmyd,.. - �„
i �� t=t(fi ?���( �:mx°I"��;§uma
in,e' � ' - ry�lt�h i "� '�Rp �.
•Board of rt ort®f 3i� Con Coin` etnd ❑DPW lec ❑ EnergyRelsoi';'
Al - , '� 4 `r - -i
Appealsea1t- Adat Card Sent Cut Off FoIIvw np
�s I,a 4 u"r�r�anf
5 - i ,N„
AN i4i,r,,�i :a _ , y `G�khi y �`A+i } i[ Qst
E
I+R J nL . i L
8 �a :
e G� lan m':Board e e d r._. _ � m a. . Fir n Water Carcl.., �,. o n m �Lr ct
�,..: � ...., ..-.. ...... - Other. .,
,P , ,� _ 4fi
, ,_..: ..: •. _.,_..mac_..., re .....
na,,. �Mxihp, i ,
Cylnef �a � ?a n, n, �. �t�u(�ff„,�, � Lri Cut ol'f
s., a 5@:.iP xdat::: �', viey}t• ..,'.,: ii:....a,Yi, .. a „ , :�.. a. i.'.e. (, t. ea3l .:xl .,µ; ri., .
r tx�L i=si kivF=:,yX �i,P fie•,w :: k 4`. 4 ,N: i I —
as 4 6 k b Iu
e r, e a i
fia i 2I � � ii m. u ilky :k:P i
��„��r=n,�la�, °, k , n �4ihfi a x,u
a �a, ;>n ,..,.:•9„�,:::� ,, „.,,n .xa,� � "a'�r
a:. ,�..sa 45 af• � � mm mom :,: a'a�i � .:x i:.. :�'k", �" A.. §. �;'
�c
's, ::I'ePig`,„y,�g
a+ y�aLs'A� TIA Qn NL .iX+Ny any 'rJ a Ir�{�af,e ;(ihe.,, •yia�sn::. i,,4nW a®i i::a, eE ;mi't+,k I n,:, @ =sIHPt, 4
fl .t!i,e „ai ....,:rfi a.m�r.,
>; e 4 F,•.'i�i'; i fi t fiat' t{ t n'
�e E(UIRS TIVSPERE'III ISCAIEC1I'r LI21T[I'» i ai
a, aE(r I.a +:i t.: is Now
-vG s[PrF td6 tHeP3 �y:5,4 L�.p�cIIDLi 'i"AR +�}�Y Ls6 s�„;i. y: L { itg
tf ".,i8y `:!ir@erekh�"S i."_.'llli i, y t +ila tl iu �:p la s -; ` ,._i,, t {; 's,. x,.14
.:: ::n ,m::m, n�. .:r .., ,,Y _::r ,., x., .'. ,:: WP s ,1. R� i.:
(i a_Ft'ii' t i ire s _i I , " .� �,vi ,. { a :: it P �. .:i"" m_ , F .., s,:..T is y 'fi +` u ..�_.. x :. ... .:' ..P'...a .-., n.. PIZ
a u tom.-�.- _., ma.xA, aixln. ,fin G- .n,.�,_� .-_�fi_ _, .�._..m. ,�„ �� J.u�� ice, a -� �� -,�, ...-.....�y..�, a.:.:
f
Zoning Review: (9 `z Signature: Date: V
�
Energy Report: Signature: Date!
Fire Chief: 13 Signature: Date::_ cs
Board of Health: Signature: Date:;
Conservation Commission: Signature: Date:•
Other: Signatur4pL, Dater
/
Description of work being performed: .J
FghSECS IOC SITE INFORMATION fi
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
j1.2
1.1 Property Address:
Nearest Cross Street:
Assessors P of Number: t
Plat
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the 1Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal rivate Well .
❑ Municipal kn Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd
Page 1
Rev. January 1, 2003