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BP-33609- max! •� +J 3 �' 5 S F-- C5 W- CD c) 03 o O N O J z LL- O0- N 5� O m V) � , m o�-; W��^ cn�Z� Cl- W W •A\ Z 11 2 PH N J W Qo A �J �Ojs YO S C, r. O O 03 s W Y LL m—)ZD 0 M N Q h 00 9 RESIDENTIAL 2004 RESIDENTIAL 2004 51 a t/ , s. . e� e ��mm q e e. )tsi i 1 k'RT N1RR (RIEITCNI i a b.. .m,.�a-l. e . P P , 2.1 Owner of Record: V00i� �e,�-�ft, /D �%44.1tvn W!! �tl'clS©�, y-l76-31610 Name (print) Contact Address Phone Number 2.2 Authorized Agent: Contact Address Phone Number Name (print) M �®a m§ � `d i � � ECTt NSdA� C ®:. € � slit 1 gg I 08 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 ( wrlers Nam riot)[/ 13 ' Stature by signing thhT above, t1le home owner ackno edges 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 1'09.1.1 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: An Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a P y P g g 9 P P 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: Persons) 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 ap nder this seFtn be w: Signature: You s natu cam ertain responsibilities, including but not necessarily limited to, general liability ED CONTRACTORS: The Building Code provides in the Rules and Regulations section that an licensed Con NOTICE TO LICENSED O g p g y s�truction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.1 5) �',"EOIfQN4 VtQfd S CQMFEFT f)Ne1NSIiRiiL� AIDAVIT 1TG1✓ c. 5� 5 -� Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proviide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: yes ❑ no P TIOEIIQN I1ca) rid m �� m ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ I❑ woodstove (energy report required) (energy report required) fireplace ❑ deck ool ❑ accessory bldg. ❑ replacement window/door ❑ other I❑ 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 Des riptign of Pryposed Work: n - P S +"1'iON 6'EStIATII COWit)1� CQS, ,r Item Estimated Cost ($) to be completed by permit applicarnt 1 Rnilrlinv � F.1Prtrical I Plnmhinu d MPchaniral (14VAC') 5. Total = (1 + 2 + 3 + 4) * Estimated Total $MIN f1WNER AUTII©RI7 ITION -m fo 'trn1:0— aprbmldinbe comple novners ageut rps g pe rmrf ,111111 (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 d �ry f P r Qu, hAmUaC qaI� � � :.. as Own Authorized Agent hereby declare that the statements a;nd information on the foregoing application afe true and accurate, to the best of my knowledge and belief. Signed under the pains d enalties of perjury. Signature of Own r/Authoriz Agent Daite C:\bldg.:forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 1, 2003 RESIDENTIAL 2004 RESIDENTIAL 200 ❑ FOUNDATION ONLY ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE $25.00 APPLICATION FEE IS NON-REFUNDABLE NON--T Ak9rrL; AOLE mvtrMN m.�.®mom 1. Date plan reviewed: ZOT 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: 5. DENIED (see project review worksheet): Date: 6. HOLD reason: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Signature: Date � �� vm. ®, D ;00, � ON 110 Applicant informed abov D e: Time; Clerk: Comments: r, ' d y $, a Total Permit Fee: $ �� Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE: Gross Area - New Construction total ft. sq. Gross Area -Alteration total sq. ft. Permit Issued To: C 'tom OR go �I I+l� ADITOA CfIEVT e ZOO g �. DARTMOUTII BUILDING DEPARTMENT DATE RECEIVED ti .� .� - 400 Slocum Road, P.O. Box 79399 - C, °� syy Dartmouth, MA 02747 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELL ING �PRO 14 �� gym.a �m �_ �. MOWN FINE We SRI - m a_- �� G �. omp ,.7 g NN TOM, � �1�y��5 � 3a'a ai g�5a'`;x,,� s gAlbffd i�� t �Mra"E M-11119 ��®S ki�agg _ [[,, n'iL.. e��.,d' iASII\A`s�� ¢ .a.—a4e 9w,.:�..",ea R. a a Ta � . r �.,a', �� n �� s �� , �s.a_a.m..a.�...aiat¢Yas& 9'�„a,�,,, ®au, �, 9.&s' de"ad4�m4�,,,.m�r�se,us: auim$�a�6a�Pwa6er.�'�.� r'� Zoning Review: Signature: Date:_ Energy Report: Signature: Dater Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date:: ram' !�'t d 0 P 4hdVe 64 U Pee Description of work being performed: cd M�� - NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Property Address: �D ��/7 es rl 1.2 Assessors Pl.a Lot Number: y �� Plat Lott _ Ja Nearest Cross Street: Jul fi l� �CUF 1.3 Historical District ❑yes lino Subdivision Name: Has application been submitted to the historic Commission? Total Land Area Sq. Ft.: 10,600 ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal `'Private Well El Municipal `�bn bite Disposal System :\bldg.forms\Bldgapp.res.wpd Page 4 i Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 1, 2003