BP-25238RESIDENTIAL
2002
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2. i of Reco d:
i
,
Name (print)
Contact Address Phone Number
2.2 Authorizec agent: ,
Name (print}
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Constriction Supervisor: A6 CXJ Z4/
QNot Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
12 Registered Home Improvement Co rt ractor: gof
Not Applicable ❑
Are you a Houle Improvement Contractor subject to (780 CMR-6)? eyes o
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the ;
required affidavit!
Company Name r biZ. -,<S C
Registration Number (if none, state "none")
Address
I1> f -2,70
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 OIL COMPLAINTS call or write:
Horne Improv�elpe Contractol'rs Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Oi ners Name ( t f C t}g
Signature
"Y /�/Z&y signing the above, the homeowner 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 Licensin - of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
1rectly
shall be engaged in 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 by
promulgated 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 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 "Homeowner" is defined as follows. Person(s) who owns a parcel of land on which he/she resides or intends reside, on
which there is, or is untended 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 applying emder thKsect
Signature:
Your rttu certain response ,, i+is.,.neluding but not necessarily limited to, general liability
k. T
RESIDENTIAL
2002
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations Section that any licensed Constructiion
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.215)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (�Gc15�f
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide thus affidavit
will result in the denial of the issuance of the building pen -nit. Signed Affidavit Attached: ❑ yes Q no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check allapplicably
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woc3dstove
(energy report required) (energy report required) fireplace
❑ deck pool ❑ accessory bldg. ❑ replacement window/door ❑ other _ _: ❑ dennolition
(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 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: c--?V f jj
4�f k67
SECTION - 6 ESTIMATED CONSTRUCTION COSTS, a
Item
Estimated Cost (S) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (I + 2 + 3 + 4)
* Estimated Total $ �(
SECTION 7A - OWNER AUTHORIZATION # s 4a Y
(to be completed when
owner's agent or contractor applies for buildm pernnrt
(please print)
1, , as Owner of the subject property hereby authorize
to act on my b alf, tters relative to work authorized by this building permit applicati 'n.
Signature -of O r Date
SECTION 7B - OWNER/AUTHORIZED `.
AGENT DECLARATI NJmn �
1, , as Owner/Authorized Agent hereby declare that the statements and inf6i-.oration
on the foregoing applicatioLttie nd accurate, to the b st of my'knowledge and belief
Signed under the pains andf perjury.
2ZI z
Signature of Own e uthorVied Agent Date
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Page Rev. January 19, _001 ar
RESIDENTIAL 2002 RESIDENTIAL 2002
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(seeproject 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:
Y ECTION 9 - APPL AN NOTIFICATION
Applicant informed of above Date: Time: -
Clerk:
Comments:
SECTION 10- OF FICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. t.
Perini Issued To
SECTION 11 -ADDITIONAL COMMENTS/ TCHES
.007
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE'& NON-'I'RANSI711RABLE �
DARTMOUTH BUILDING DEPARTMENT
,o 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
DATE RE'CCEIVED ,
" zL
fi 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY',DWELLING -
THIS SECTIO OR OFFICIALUSE ONLY
RECEIVED BY: ,
BUILDING PE
DATE SENT FOR REVIEW:
NUMBER:c_
DATE ISSUED:
OK TO ISSUE - SIGNATURE: ~' DATES"-"
Building Com ssioner/Insp to f Buil ngs
Zoning District: roposed Use: Zone: C ❑ B ❑ A ON Outside Flood Zone ❑ Aquifer'zone
THE FOLLOWING AGENCIES/SHOULD BE NOTIFIED:
❑ Board of Boa ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals Affidavit ' Card Sent: Cut Off Follow-up*,
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other -
Chief Cut Off - / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date::
Energy Report: Signature: Date;_
Fire Chief: Signature: Date,:
Board of Health: Signatur : V Date;:--�-(�� =.
Conservation Commission; Signature: Date_
Other: Signature: Date::
Description of work being performed:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
y
1.1 Property Address:-���!�'t�
1.2 Assessors Plat & Lot Number:
"1 Plat " /� Lot (J
Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.:
Has application been submitted to the hrlistoric Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ Onieisp St Disposal System
�C
Rev. January 19, 2001
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Rev. January 19, 2001
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