BP-23668RESIDENTIAL 2002
SECTION`2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Re rd:
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Natrre (print)
Contact Address Phone Number
2.2 Authorized Agent:
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sl ; e C,--332--; j
Name (print) v
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor mko"'o �`�
Not Applicable ❑
Licensed Construction Supervisor gzwj"
LicenseNumber ®13 -Z;
Address? �s (Z� , ���
Expiration Date A_
Signatur _ Telephone-5'�G-5,320
3.2 Registered Home Improvement ontractor:
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 '4Ai2,_- a
Registration Number (if none, state "none")
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Address �7 ,.�, VS).
Signatures Telephone ��Z� -
Expiration Date 02
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 .
1109.1.1 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 dwelline, attached or detached structures accessory to such use and/or farm structures. A person who constructs
moue 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 2002
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensedlConstruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR K&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 pprovide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes 01 no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report re it ( nergy report required) fireplace
❑ deck pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows_ doors_ (specify below): (specify below):
* If new co struction, phase 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
Brie�Description of Proposed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit appllicant
1. Buildin
2. Electrical
3. Plumbin
4: Mechanical HVAC
5. Total= (1 + 2 + 3 + 4)
* Estimated Total $ c�
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please Drint)
I , as Owner of the subject roperhhereb authorize�d�;1� , �S
to act n my ehalf, in all matt rs re tive o uthorized by this building permit application.
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f C.2
Si ature of Owner L Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I,' .MA 4 W% -s 'T ' S(241 , as Owner/Authorized Agent hereby declare that the statements and information
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on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si un er the pains and penalties of perjury,
Z �7 Z
tgnature of Owner/Authors d Agent Date
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RESIDENTIAL 2002
SECTION
$ -INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:' v
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. DENP,ED (see project review worksheet):
6. HOLD reason:
Dater
Date:
Date:
7. HOLD subject -too o ng Board of Appeals action: A
8. Comments: `f `� �� 7 •r�
Date:
74
9. Inspector's Signature:
Date:C�
SECTION- AP ANT NOTIFICATTII�ON
19
Applicant, infoTed of ab ve ate: l Time: Clerk: 10 .y
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ e � \1�
Less Application Fee: $ 25.00
Remaining Balancer
TOTAL FEE: ��" Gross Area - New Construction total sq. ft.
' Gross Area - Alteration total sq. ft.
Permit Issued T 6L,0
ECTION I - ADDITIONAL COMMENTS/SKETCHES
RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANsrERAM"LE
....._.....
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O.Box 79399
DATE RECEIV,EDj .1
.,'�
Dartmouth, MA 02747
16fi�..-' 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELI_;ING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE l)
uilding Co missioner//IInsp/ector of B ngs
Zoning District: � posed User Zone: IGlC ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer -,Zone-
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Ene3rgy Report
Appeals Health Affidavit Card Sent: Cut Off Followv-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Othier
Chief Cut Off / Cut Off / Cut Off Review*
`n
* 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:
Description of work being performed: e:. 1
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
�
1.2 Assessors Plat & Lot Number: -'
1.1 Property Address: ' ✓e
Plat Lot -
Nearest Cross Street: E W.. e
1.3 Historical District ❑ yes no
Subdivision Name: �,,^—(' �; iV
�!
Total Land Area Sq. Ft.:
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 rivate Well
Q Municipal An Site Ditsposal System
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