BP-24462JO SE A I\\ID
F01�
GA YLE
30 MEDEIROS LAI\\[E
RTH DARTMOUTH MA,
WAM
02147
L
Ee "ORD C
A Copy Of This Endorsed
Plan Must Be Kept On Site
Date ue'SOP12",r-�j20
-TUBE SIZE AND Pg.pTH
':RFD M-,Fope
POURED.
L D! INI G 'D 2 P/I, R
Own
IWUIST ME r-r-,"Pl,
G D FRHN G 1-1 1 f.-
NI; G RE S 'OF TNS WORK.
'MMITUIT
k"�, C-If Dozfmt�uf-,-
JoI�
SCALE: 1/2'=l'
SCALE. 1/2'=l'
" ON CENTER
RE TREATED
2X12 16' ON CENTER
PRESSURE: TREATED
SUNATUP,)S
- 2X12 PR
ESSURE TREATED
2X12 F?RESSURE TREATED
2002
2002 RESIDENTIAL
RESIDENTIAL
HORTZED AGENT LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed
R5.2o15tmetion
SECTION 2 -PROPERTY O�VNERSHtP / AUT NOTICE TO
s Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CM ))
2.1 Owner of Record:
` SECTION' 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT {MGL � 152 § 25)
\2. •
Phone Number Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proviz'de this affidavit
Name (print
t J� Contact Address es ❑ no
\\ill result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ y
2.2 Authorized Agent: SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ !M woodstove
Phone Number El new construction fireplace
Contact Address (energy r e ort
Name (print)
(energy report required) ( prequired)
SECTION 3 - CONSTI2UCTTON SERVICES LQJdeck ❑pool ❑ accessory bldg. ❑ replacement window/door ❑ other demolition
shed/garage) no. of windows_ doors_ (specify below): (sppecify below):
Not Applicable ❑
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor License Number * If new construction, please complete the following:
Expiration Date Single Family: no. of bedrooms no. of baths
Address
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):
❑ es ❑ no Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Are you a Home Improvement Contractor subject to (780 CNIR-6). y ro ane electricity, other (specify):
If no, go to the next section � HVAC (combined unit) primary fuel, natural gas, p p tY
Lj Air conditioning - (separate unit)
Are yoit claiming exemption from the requirement? ❑yes El no None of the above to be provided
If yes, submit the Fuel Oil Other
Hot Water: Gas Electric
required affidavit. ,
Registration Number (if none, state "none")
Brief Description of Proposed Work:
Company Name X, e Lit
Address
Telephone Expiration Date SECTION - 6 ESTIMATED CONSTRUCTION' COSTS
Stana ire
h
Item
3.3 For Residential Remodel Work Only Estimated Cost (S) to be completed by permit applicaint
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: 1 Buildina
QUESTIONS OR COMPLAINTS call or write: �, Electrical
G Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, :1fd 02108, (617) 7_'7-8598
3: PlittnbinR
Owners Name (print) 1. Mechanical HVACI i }
� . Total =(1+2+3+4)
* Estimated Total $ ' 1
Signature
signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund SECTION 7A - OWNER AUTHORIZATION
Date. ]5 (to be completed when owner's agent or contractor applies for building permit)
3.4 homeowner Exemption - One'& Two Family Only
(please print) _
as Owner of the subject property hereby authorize
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR O\\ N PROJECT I
• structures governed b Construction Control in Section 116:0, effective July 1, 1982, no individual
]09.Im1 Licensor of Construction Supervisors. Except for struc g y pion involving the structural elements of to act on my behalf, in all matters relative to work authorized by this building permit application,
g or
shall be engaged indirectly supervising persons engaged in construction, reconstruction, ionsalteration, repair,removal
by BBRS en itled Rules and Regulations for Licensing,
buildings or structures, unless he or she is licensed in accordance with the rules and regulations promulgated Y Date
Signature of Owner �$
Construction Supervisors.
• • n Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a SFCTTON 7B - OWNER/AUTHORIZED AGENT DECLARATION
Exception: Any P
Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.\•hich he/she resides or intends to reside, on hereby declare that the Statements `and information
g
Fo `lie purposes of this section only, a "Homeowner" is defined as follows: Person(s) who Ices a parcel of land n structures. person who constructs I: �1 � i tp. , as Owner/Authorized Agenty
Forthe p rp
which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use an "or farm P on the fo egoing application are true and accurate, to the best of my knowledge and belief.
more than one home in a two-year period shall not be considered a Homeowner.
if you are apply'ng rider this section sign below: Signed under the pains and penalties of perjury.
Signature: ` \✓V v v - C%` d\
our signature carries certain responsibilities, including but not necessarily limited to, general liability
Siina tire o Auer/Authorized Agent
�'. ,bld�,.fornisvBid,�a i i i�5 w id
Page 3 Rev. January 19, 2001
PP Innnary i- Nol _ 1 p- s 1
RESIDENTIAL
2002 RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRAl 'SWERADLE
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue dates
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:
S. Comments:
i
9. Inspector's Signature:
Date:
SECTION? :- AP ' LICANT NOTIFICATION
a
:V
J
06
Applicant informed f bove e: ' Time
t
� \
Clerk: <�J
r
Comments: -r ran
e,//U
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ '
Less Application Fee: $ 25.00
Remaining Balake� )
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To
SECTION 11 - ADDITIONALL CO \IMENTS/SKETCHES
s-
--
DARTMOUTH BUILDING DEPARTMENT"
DATE 1.0,BCEIVED
-
400 Slocum Road, P.O. Box 79399
Y Dartmouth MA 02747:
' 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING P
DATE SENT FOR REVIEW: ✓ ✓
NUMBER:
DATE ISSUED: v�
JU 1
OK TO ISSUE -SIGNATURE: A- DATE ®Z®OZ
_Peding Commi'sioner Insp ctor of Buildings
Zoning District: Proposed Zone: C ❑ B ❑ A ❑ V Outside Flood Zone ❑t Aquifer Zone
THE FOLLOWING A ENCIES SHOULD BE NOTIFIED:
❑ Board of oard of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec., ❑ Energy Report
Appeals ealth Affidavit _Card Sent: Cut Off< Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Server Card ❑ Water Card ❑ Zoning ' ❑ Other
Chief Cut Off / Cut Off / Cut Off Review'*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTbIENTAL APPROVAL
Zoning Review: Signature: D ite: .
Energy Report: Signature: Date:
Fire Chief. Signature: Date:
Board Health: Signat �'t� `Dante: C)
of ,� GO���
Conservation Commission: Signature: Dante:
Other: Signature: Drt-ite:
Descril)l[on of work bein- pel forined:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address: �® M,4e3(p � Ln
1.2 Assessors PlapyTot Number:
Plat_ Lot -�
1',,1ca7 est Cross Street:
Subaivision Name:
1.3 Historical District ❑ yes ❑ nra
Has application been submitted to tlhe Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1 A Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System: `
0 Municipal Private Well
❑ Municipal )�(On Site Disposal System
V� Gi
C :,bldg.fonils\Bldgapp.res.wpd Page 4 Rev. January 19, ?0o I :�b1d,.1orms1131dgapp.res.�i pd Page I Rev. January 19,2001
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