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BP-14680 VOID TOWN OF DARTMOUTH w. 4 14680 �, BI, L IN RECEIPTS Ti t COLLECTQR'S OFFICE / �Name: 1 I/_ Date: !Pro Proper /,.� C __-- '- � ( ' / Owner. �--� Job Location: f:;' --1 White Copy-Collectors Office Plot: ! Lot ` - Yellow Copy-Customer's Receipt / c Pink Copy-File Copy Green Copy-Building Department Phone: Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 ^` r t •n, r N License&Permits-Building Misc. 01000 44105 (T .g, cc__ < e-t _c.-i License&Permits-Electrical 01000-44106 J f' License&Permits-Plumbing&Gas 01000-44107 - c2 c/6 Other Department Revenue 01000-42420 ` This is not a Permit or License for Building.Plumbing or Gas Received By: : X - ' "G" /f -CZ-- '— — Atiebtel 0 Ic {{fa sr oc,L / ❑ FOUNDATION ONLY ,RESIDENTIAL 2000 $25.00 APPLICATION FEE IS NONREFUNDABLE&NON TRANSFERABLE "a'urit � ISA'I'E RECEIVED - • - r DARTMOUTH BUILDING DEPARTMENT . o ^I 400 Slocum Road, P.O. Box 79399 t"i0 .1,,n ' ; :.t '1_ II : . c Dartmouth, MA 02747 166a;y- 508-999-0720 FAX 508-999-0738 APPLICA ION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING RIS SECTION FOIL OFFICIAL US.E Ol'�`LY f }� BUIEDIND IxEi RECEIVED tlIJ14tIII R DAT4,r7/? E SENT FOR REV 4Y" I DATE ISSUED flit TO ISSUE SIGNATURE DATE 8wlcliag Comans ner+ tta .8atldmgs, Zontng Disfnet Proposed:Use CI C E3!B U 4 Q it Ottfsule:Flood Zone 0 Aqu.fbr Zone iE FOLL WII G AG.DIES .1tOULDBE:N;oT.FIEq 1. O Board of D Board of OCon Com U Demo 0 f).P 4V 0 Elec 0 Energy Report Appeals health::: Affidavd Card'Sent Cu€Off .Friilow-upx 37 Ftre 4 Das CI Plammog Board* 0$ewa Card.. Q WaterCard q Zoning C :Either Ghre€ Cat Oti t Cotet t Cut(}fi Review* RE{VIRES1NBr.SCrOR s REVIEW ULFORETHE 1SS.4xcl:•(FA PERMIT.. DEPARTMENTAL'APPROV A , 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: .. .. ?SECTION I.• SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: �es 0 no 1.2 Assessors Plat,&Lot Number cd 1.1 Property Address: OAK,2 (`I`ISE }�i21JG Plat 12 L�) Nearest Cross Street: �a 4 II ll c� Subdivision Name: 4'1 �b- i+.es 1.3 Historical District 0 yes -no Total Land Area Sq. Ft.: ����j'Illij���r�r ,3cj� Has application been submitted to the Historic Commission? 0 yes 0 no Date: 1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System: 0 Municipal O Private Well 0 Municipal 0 On Site Disposal System c\wpwin\forms\bIdeapp.res Paec I Rev Jarman,70 7000 1 • RESIDENTIAL 2000 SECTINV thOP flT OWNI tP/nUTORIzEiiiike yr 2.1 Owner of Record: / tp(Y�S Jf�\VC\ f 1S 0/9-KP bcr--E 7>i�, qrg- a3," i/ Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number .. SEaN3 E[9NSTRl7Ctdt�.SERY7C 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)? 0 yes 0 no If no,go to the next section! Are you claiming exemption from the requirement? ❑yes 0 no If yes, submit the required affidavit! CI"mpany 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 Owners Name(print) Signature by signing u..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 I, 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 promulgategy 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 prdvisionsA;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 residetor 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 appl dng under this section sign below: Signature Your siggature carries certain responsibilities,including but not necessarily limited to,general liability i ' c:\wpwin\forms\bldgapp.res Page 2 Rev.January 20,2000 I RESIDENTIAL 2000 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor.whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) SEGTiON 4- (3tOl UUElt'S COMPENSATICNI I ISV kANCE APF'CAAviT.MGL c i52§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: 0 yes 0 no $ECT N S-3nEscRl1 TIoN OF VRU1POSt 3 WORTc(Cheek ali applicable) ❑ new construction* 0 addition 0 alteration 0 repairs 0 chimney/ ❑woodstove (energy report required) (energy report required) fireplace ❑ deck 0 pool 0 accessory bldg. 0 replacement window/door 1 other 0 demolition , (shed/garage) no. of windows doors_ (specify below): (specify below): , ❑ If new construction, please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit I no. of baths unit I no. of bedrooms unit 2 no. of baths unit 2 ❑ Furnace(hot air)-fuel gas(natural or propane), fuel oil,electricity, other(specify): ❑ Boiler(heating)-fuel gas(natural or propane), fuel oil,electricity, other(specify): ❑ HVAC(combined unit)-primary fuel, natural gas,propane, electricity, other(specify): ❑ Air conditioning-(separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: sECTIati-5 ESTIMATED CONSTIRUCTIO:k COSTS Item Estimated Cost($)to be completed by permit applicant I. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1 + 2 +3 +4) *Estimated Total $ /r --- SECTIONYA OWNERAUTITORIZATION , (to btcotttpleted when owner's ageutorcontratter applies fvr building permit) (please print) I, W'tts— , At.iry> ,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 713-_d4v;kER}XE£TRfltkl2El}::1GEN7'fECLARATION '1")cjt2.:6 \-p v, \r w\S ,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. igned under the pains and penalties of perjury. Signature of Owne horized Agent ate c:\wpwin\forms\bldgapp.res Page 3 Rev.Janua 20,2000 I RESIDENTIAL 2000 sEcCItON 8—INsnna1'QRRS EVIE'k}/tOMNIENTS I. Date plan reviewed: 2. 30 days to review period expires: 3. OK jo 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: ate: 7. HOLD subiec oning Board of Appeals action: Date: 3-y&c- >To ee>. w 8. Comments: A _c f ) 9. Inspector's Signature: Date: SCTXEIN - iPFLTCAN htXTIIC4TlCxi Applicant informed of above Date: Time: Clerk: Comments: SECtION;I0.Or [Ct\livSPECT'+: wsNOTES Total Permit Fee: $ Less Application Fee: $25.00 Remaining Balance: $ TOTAL FEE: Gross Area-New Construction total sq. ft. Gross Area-Alteration total sq. ft. Permit Issued To S CI'IO :�I ADDfl1ONAGC+ M N"IS1$J<ETCRE&! c:\wpwin\forms\bldgapp.res Page 4 Rev.January 20.2000 a VOUCHER FOR PAYMENT VENDOR # 00 Q(0 D.13 0 VENDOR NAME Doris JenkinsC 14 Invoice # 14680 Org- Obj # 12412--44105 Amount $25.00 A, Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice# Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ Invoice # Org- Obj # -- Amount $ TOTAL FOR ALL INVOICES $25.00 - - - --- -- - TOWN OF DARTMOUTH 14680 a BUILDING RECEIPTS COLLECTOR'S OFFICE Name: /- (en l J S t-s�v.... Property ,..:...Ft-s . — /• ,✓% - Owner:,. Job Location: 4 `)- / % Plot: '7 1 �White Copy-Collector'sOffice 7 ` `Lot: Yellow Copy-Customer's Receipt G Pink Copy-File Copy Green Copy-Building DepartmentPhone: Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 -.^T "'ita License&Permits-Building Misc. 01000-44105 --- ; License&Permits-Electrical 01000-44106 v E.- License&Permits-Plumbing&Gas 01000-44107 q i Other Department Revenue 01000-42420 /,y j ;. / This is not a Permitt oror LicenseLi�Q for Building.Plumbing or Gas Received By: X _n-4<✓. /' -�r�- t_- AtQm_e' °K hs' c .L___ % TRV LOCvs ZONED G.I. irGE/VERAL. /N1741S7-,e1A G) NIF 'xET!"Y S O7=/D'�� ; pG=�~E' 296. '2,7 A ��� •�' � ,p p .sA r I I A 9 S.� O /t /0I f ... � ,tom; • .. rt A06F/N/T/ICE OLAN OF LAND /N OARTMOUTH, MA. ///Z z TOO ESTATES Applicant.and Present Owner: William J. and Lisa B. Gallagher 300 High Hill Road, No. Dartmouth, Mass. SCAL,E:• i��0� oEc. ,?7 i9B� 01 CO' 1201 ION/JVG : SR -A SINGLE' RESIDENCE' !Q~� DART/VDl1Ty AZAIVA111 6 6V4R0 APP.90Y.9G RF�U/REl� !/HOER I C 4-"�! -'7 n 7 G F, su�visicw �cwr.�ea� t,.4s•✓ . ft t� r �S�ll�` IITT" .�+i F• 7� �� •Y� si• L+�:. 'd K. 8"P'On Site �� �• *(yam f s y. C011.51-Iruc dinDatet {� t�• �a � 1) .Gs�TE.• - -r'A 11/if y �G�A�i , CLERle 42,4c" 7W-C Tt>l✓N 0Foi4ftT140417'.S/ HEREBY CERTIFY Ti7/AT 771E- NOTICE �A/�ioRDYi9L Gam" 71 /.r BAN BY 7WZ ' -.4NN/NG SO.9R0 WAS BEEN RECE/VEO ANO /PECCWI:�O AT Tiy/S G►FF/CE ANO NO ND TICE OF A/�i�EAL Wi9S •WCE/ VEO OUR/NG TfIE Tl✓ENTYOAYS NEXT AFTER SUCH RECE/PT ANp ,P.E'CORO/NG CF• S•9/Q NOTICE. �+ W077CE RECEATV Apr,L ll,l � 6 S TO j✓N CLERK �[/ l l ,0.4TE + , /._5_ .find.Mr 700 A CVVZVANr-fa B RECOROefl HERAW IIJH MAY If,, 1905' . aoTE.• G • 3o` BOARO 0hll,EAG Ty ARiROY.4L °-s jad/VOTL�.� GOAtGIGaTC /aOtiV*1.tNi'� 'rp- PyG ..'S-CST IViC-/gEZ- V "SAOA ,IYo Assoc, CIVIL ENGINEERS AND L AND SURVEYORS PO.. 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