BP-71690 Permit No. BP-71690 BUILDING PERMIT .•
•
GIS#: 4030.00 Commonwealth olMassachgsetts
Map: 0076 TOWNOFDARTMOUTH..
Lot: 0022 400 Slocum Road;,Dartmouth,MA 02747
Sub-Lot: _ 0011 Phone.,(508)910-1820 _•-Fat(SOS)9104838
Category: WINDOWS/DOORS
Project# JS-2014-001172 PERMISSION ISAEREBIGRANTED TO: - '
Est.Cost: $6000.00 Contractor. License , -Phone#:
Fee: $75.00
Const.Class: Engineer License Phone.#:
Use Group: R3
Lot Size(sq.ft.) 40000 Applicant: , j Phone#:.
Zoning: I SEE MATHEW VANGEL (508)998-6990 Aquifer Zone: _ NIAFlood Zone: ZONE X VANGEL JACQUELINE
New Const.: N/A - •
Alt.Coast N/A DATE ISSUED: 1 0/1//
Date Typed: 10-31-2013 - -
TO PERFORM.THE FOLLOWING WORK
Nineteen replacement windows and one door; SAME SIZE, SAME OPENINGS
!�Proje%�cation,l 15 SUNDANCE RD
Approved/Issued By:
PAUL MN 4Ii OF INSPECTIONAL SERVICES
All work shall comply with 780 CMR 8"'Ed.(NMGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file.
Schedule appropriate inspections as required. Upon completion of work,final inspection is required.
I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent
i... and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not
i - withstanding the issuance of this Building/ZoningPeermiitt.. -- 2 ///,
Signature of Owner/Agent:
/✓N��eu l��y i
"Persons contracting with unregistered contractors do not have access to the guaranty fund (as set forth in MGL c.142A)"
Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department
Plumbing Wiring
Water Service#: Footings: Underground: Oil:
Underground: Service:
Foundation:
Rough: Suthke:
Rough; - -Rough: .... . Sewer Servlee#: .. . .^a:,� .o.--•
....
fusulation: Final:
Final:
Cross Connection Final: Final:
Board of Health E-911
Additional Comments:
Planning Board ,
Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary
inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of
the building permit.
POST CARD SO IT IS VISIBLE FROM THE STREET
t RTMQUTH BUILDING DEPARTMENT RECEIPT 71630
I • , -HONE: 508-910.1820e. FAX: 508.910.1838n�oritS
2f7a
Name: / i ` Property Ow"�er: { C! t7 ...'e Date:�3/2 //S
/ J
p L
Job Location: / 5 )(i t G(it/<? I l Map: Lot: Z -1 7
Description General Ledge*,Ws Ref. # 4iii
Amouyt
Building & Building Misc. 01000-4410 ( i ti /-
Electrical 01000-44106 hpF p�' D��rffe
Plumbing & Gas 01000-44107 � ' MC G),
5
Trench Safety 01000-44129 OCT 3 12013
Other Department Revenue 01000-42420 >.
White-Collector's Office Yellow CopyReceiptCopy p C. 1_I.5;\''By /�i �w -�/sit t"'�'-Customer's Pink Co Building Department ed
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
RESIDENTIAL ❑ Phased Approval(R106.3.3) .
$25.00 APPLICATION FEE IS NON IIE-FUNDABLE &NON-TB �y,s FEBABLE
Ma�r�.., RECE1V . U�' EcEIVED
,�s�� ry DARTMOUTH BUILDING DEPARTMENT pAR1 ,
r . 400 Slocum Road, P.O. Box 79399
;o _ _ aMla52
1 ,°;' Dartmouth, MA 02747 20I3 OCT 31
`O.,fis� �,` Phone: 508-910-1820 Fax: 508-91(5-1838 '
-- www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
"
p - THIS SECTION FOR OFFICIAL USE ONLY -7 //
RECEIVED BY: -D -5 BUILDING PERMIT N MMB : .7/ (3
DATE ISSUED: /° ✓t g
SIGNATURE: F6/111 DATE: 31
Building Commissioner/ pect Buildings
Zoning District: Proposed Use: Zone: 0 X 0 B ❑A ❑V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of 0 Board of 0 Cons. ❑Demo 0 DPW 0 Elec. 0 Energy Report
Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up*
O Fire 0 Gas 0 Planning 0 Sewer Card 0 Water Card 0 Zoning 0 Other
Chief Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other Signature: Date:
Signature: Date:
Signature: Date:
Brief description of work being performed: (,()ik`(..vuv,S /CAD a 12i •
SECTION 1 -SITE INFORMATION
1.1 Property Address: /3 51144i41 47, ., 1.2 Assessors Map & Lot Number: /I
Lot Area (sf.) Frontage Map 7 P Lot 22 4
-
Required Provided
Front Yard 1.3 Historical District ❑Yes 'No
Side Yard
Rear Yard Year Built
0 Altering more than 25%per side of building
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal APrivate Well 0 Municipal KOn Site Disposal System 0 Yes A No Date:
Revised 10/11
0 CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
Name(print) Contact Address Phone Number
2.2 Authorized Agent:
Name(print) Contact Address Phone Number
SECTION 3-CONSTRUCTION SERVICES
a
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
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"Homeowne?'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 apptyingg���gction gn below:
Signature:
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provid 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)
❑ Deck ❑ Pool 0 Repairs 0 Alteration DJ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ,,Accessory Bldg. ❑'P\oofing/Siding Other
(Energy report required) (Shed/Garage) N`� (Specify below)
Does-Ls- AI _0.-
❑ Addition IXReplacement window/door 0 Demolition
(Energy report required) No. of windows Doors - / (Specify below)
i9 y1 �� � rd�al �01
W" c
*If new construction, please complete t : following: � �,/> 'es-
Single Family: No.of Bedrooms • _. _ .. ems/_'
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
0 Hot Water: Gas Electric Fuel Oil Other
SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5. Total=(1 +2+3+4) (Q 6I cam)d
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
, 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
/� M SEECCTIO/N7B-OWNER/AUTHORIZED AGENT DECLARATION
I, J,���J�/Fi Y e( �l 11e'D !/G/'t / , 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.
Signed under the pains and penalties of perjury.
/SO4
Signature of Owner/Authori ed Agent Date
SECTION 8-OFFICE/INSPECTOR'sNOTES
�) 1 Less Application Fee:425.00 Remaining Balancer-1 /
Total Permit Fee: $ J
Other$Amotrnt$
Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq. ft. [6l
/"
Permit Issued to: t,�///I cl!,(f3 / /, 7
r s
(�� ✓
- I U L
SECTION 9-ADDITIONAL COMMENTS/SKETCHES
gi yi sE ,,62fr Awealtg.xe,&
''ermit No. BP-71690 Project Location: 15 SUNDANCE RD
Commonwealth of Massachusetts
TOWN OF DARTMOUTH M P#` 4030.00
076
400 Slocum Road,Dartmouth,MA 02747 Lot ' 0022
Phone: (508)910-1820 • Fax: (508)910-1838 Sublot: 0011
BUILDING PERMIT Category: WINDOWS/
DOORS
FIELD INSPECTION Project# JS-2014-001172
Est.Cost: $6000.00
Fee: C $75.00
Contractor: License: Phone#: Const.Class:
Use Group: R3
Lot Size(sq. ft.)' 40000
Engineer: License: Phone#: Zoning: SRB
'Applicant Phone#:
Aquifer Zone: N/A ,
MATHEW VANGEL (508)998-6990 Flood Zone: ZONE X
OWNER: New Const.: N/A
VANGEL JACQUELINE M Alt.Const.: N/A
DATE ISSUED: f[: 3 0
TO PERFORM THE FOLLOWING WORK:
Nineteen replacement windows and one door; SAME SIZE, SAME OPENINGS
DATE TIME TYPE OF INSPECTION& REMARKS INITIAL
04
G' ! a "4 (A-1
The Commonwealth of Massachusetts
Department of Industrial Accidents
1* ff
;E'thl Office of Investigations
_iE,dti-
_ 600 Washington Street
Boston, MA 02111
<krz, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,/ Please Print Legibly
Name (Business/Organization/Individual): 4?//71/v' gay/WC
Address: /1—(i- ,%
02)7 City/State/Zip: , ,1/4/ /"" Phone#: SSG ffev:1y 6l
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. « 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
,,� required.] officers have exercised their 10.0 Electrical repairs or additions
%CI am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' / � ���
comp. insurance required.] 13.I Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: /l7 ]�- ,t�1O a u7 i2ii City/State/Zip: �x'/rvet L(n c'z 777
Attach a copy of the workers' compensation policy declaration page(showing the poli number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: '�Ira
Date: /�}-17ld/3
Phone#: L Gf(�
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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