BP-32655RESIDENTIAL
20
04 RESIDENTIAL
200
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that an licensed Constructi
Y one
2.1 Owner of Record: Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
..1�s•f��,..c l..« ���� lei ���`/ °
.Name (print)
Contact Ad 'ess(� �; Phone Number Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide thi ,
will result in the denial of the issuance of the building permit. Si PP p affidavit
2.2 Authorized Agent:. g p Signed Affidavit Attached: El yes ❑ no
MINA,
❑ new construction* ❑ addition ❑
Contact Address alteration ❑repairs ❑chimney/ ❑,�uae�stov
Name (print) Phone Number n y
p q c report required)
re@ required) fireplace j�i
erg e
report u' ) (energy repo requ' d)
r' ❑ deck ❑ pool o accessory bldg. ❑ replacement window/door El other - ❑ demglition
3.1 Licensed Construction Supervisor: - Not Applicable ❑ (shed/garage) no. of windows_ doors (specify below): (specifyjlbelow):
Licensed Construction SupervisorLicense Number * If new construction, please complete the following:
Address
Expiration Date Single Family: no. of bedrooms no. of baths
x
Signature Telephone Two Family: no. of bedrooms unit 1 'no. of baths unit 1
3.2 Registered Home Improvement Contractor: Not Applicable ❑ no. of bedrooms unit 2 no. of baths unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no � ❑ Boiler (heating) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
If no, go to the next section! ❑ HVAC (combined unit) primary fuel, natural gas, propane, electricity, other (specify):
e you claiming exemption from the requirement? ❑ yes ❑ no ❑ Air conditioning - (separate unit)
If yes, submit the ❑ None of the above to be provided
required affidavit! ❑ Hot Water: Gas Electric Fuel Oil Other
'74l �'' t ove'S }"irepiiaces &S Brief Description of Proposed Work: r
ompany N2ttne r /
Registration Number (if none, state ❑ none❑)
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,Address r,F• t. ..2$ .� �4,e ltv ej�
cd�z.n�
�._. ;Signature (508)947 gg5 Telephone Expiration Date..'
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3.3 For Residential Remodel Work Only ,
Item Estimated Cost $) to be coin `leted b:..
( p Y permit applicant .. , .
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: 1 Rnilrlina
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 RlP.ntriral
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Owners Name (print)%�� Ve, C19M AC&G I Plumhino
. ! :g'�" .�1'°.�.``' /'
A MPnhnnionl (HVAC')
Signature �, � f,
*
by signing the ove, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund 5 Total (1 + 2 + 3 + 4) Estimated Total ,$ ' 700 67
F Date o2. '2a sr fq i
A .m �e
3.4 Homeowner Exemption -One &Two Family Y Onl �
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT (please print)
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 I' , as Owner Of the Subject property hereby authorize
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of to act on my behalf, in all matters relative to Work authorized by this buildingpermit application.
buildings or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and for Licensing
d RP
Construction Supervisors.
Signature of Owner
Exception: Army Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Date
Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. p A �_� am n °-r
sMod e fl o
�:
For the purposes of this section only, a "Homeowner" is defined as follows: Persons - a Owho owns a parcel of land on which he/she resides or intends to reside, on m®_a
which there is, oris 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 I, // l %1�t r / C3
more than one home in a two-year period shall not be considered a Homeowner. as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
If you are applying under this sec;ion sign below: Signed under the pains and penalties of perjury.
Signature:
Your signature carves certain responsibilities, including but not necessarily limited to, general liability
Signature of Owner/Authorized g Agent g ate '
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Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3
�, __
RESIDENTIAL
2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE NON -TRANSFERABLE
WIN-.
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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 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:
....m '_.4;: -:.x. mo .- ere_p�w.�"
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Applicant informed of above Date: Time:
Clerk:
Comments:
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�r Less Application Fee: 25.00 Remaining Balance: ®®
Total. Permit Fee. $ �� pp $ g $.�
r Area - New Construction total s . ft.
TOTAL FEE:' Goss q
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Gross Area -Alteration total sq. ft.
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Permit Issued To:
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RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDANLE Q,_NON-TRAN,ZFERABLE
DATE]RECEIVED
DARTMOi1TH BUILDING DEPARTMENT
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-- 400 Slocum Road, P.O. Box 79399
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Dartmouth, MA 02747
1664
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DrVEELLING
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Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: D%ate:
Other: Signature: Date:
Description of work being performed:
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NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1'Property Address: a ry e
1.2 Assessors Plat & lfo_t Numbe
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Plat � Lo�
Nearest Cross Street: Cam!/AAA Cer n e't.- r�c"O CI
1.3 Historical District ❑ yes ❑ nfo
Subdivision Name:
Has application been submitted to {he Historic Commission?
Total Land Area Sq. Ft.:
F.
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well
❑ Municipal 01(0n Site Disposal System
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