BP-28053RESIDENTIAL
RESIDENTIAL
2003
SECTION 2 - PROPERTY 0xNN7FF.SIHP / AUTHORIZED AGENT
2.1 Owrier of Record:
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D" P 6� 9'
s
Name (print)
Contact` Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
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 Homc Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claimigg exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Compzmy 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:
Horne 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 indirectlysupervising 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 za 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 you are apply& er this sect& n w:
7nsi
Signature: / �f
You natur cam certain responsibilities, including but not necessarily limited to, genera] liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructiorn
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. Failure to provide 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 Iteration ❑ repairs ❑ chimney/ ❑ woodistove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify below): (specifylbelow):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Famiiv: 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.590
NIX,/r. C S c r: E'd Cl G�1��1� `�a `�.e t 2 h Ste_
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. B iddinQ
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $
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, l` 6?✓t' c� cJ. v 1 ' as Owner"/Authorized Agent hereby declare that the statements and infornnation
on the foregoing applica ion are true and accurate, -to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Author& ed Agent - Date'
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RESIDENTIAL
SECTION 8 - I SSPEC I OR'S I'EVIE`r!'/C'0,�1:1IENTS
1. Date plan reviewed: V "
2. 30 drays to review period expires:
3. Oh to issue dater
4. OIL to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date: .
7. HOLD subject to Zoning Board of Appeals action: Date:
S. Comments:
12 l
9. Inspector's Signature: Oee,4' Date:
SECTION - AP LICA' T NOTIFICATION
Applicant inforrof abo e Dat : Timer Clerk:
Comments: _ r
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ �5
Less Application Fee: S 25.00
Remaining Balance: S 0
TOTAL, FEE:, Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. C
Permit Issued To
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
1,12
f�—'
7-71
IZESIDENTIAL . r 2003
❑ FOUNDATION ONLY
$25.00 APPLICATION 17£E IS NON-REFUNDABLE & NON-TRANsrERA.BLE
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road'P:O. Box 79399
DATE RECEIVI�D
-Dartmouth, MA 02747
508-910-1820 FAX 508 791'OT183�8'
APPLICATION TO CONST 2aPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEILLING
1 IS SECTION FOR OFFICIAL USE ONLY `
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW: V
NUMBER: 05
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE
_ =z ;
Bm ding Com ' sioner/Inspector of Bu' ing - f
Zoning District: 91�oposed Use: Zone: � C ❑ Flood Zone ❑ Aquifear
B ❑'A� V Outside Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec El Ennergy Report
Appeals Health Affidavit Card Sent: Cutoff w:Follosw-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Server Card ❑ Water Card ❑ Zoning ❑ Oeher
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: t nk ` ���� ��.�� Date: 3 9
01 "S Svc`) � �- \.�
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being perforated: \J � 7.
SE TiON 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes' ❑ no)
1.1 Property Address' ' �(t4i�26h Ltd
1.2 Assessors Plat & Lot Number:
Plat-- Lot
l • ...
Nearest Cross Street: ff �/r (� / ,J
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historicc Commission?
Total Land Area Sq. Ft.:
❑ yes El no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ On Site Diisposal System
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