BP-24427RESIDENTIAL
2002 RESIDENTIAL 2002
SECTION 2 - PROPERTY -OWN KiHIP / AUTHORIZED AGENT
2.1 Owner of Record: -
,2 /' /�C �/!(�S 4/1i
Nan- le (print)
Contact Address Phone Number
2.2 Authorized Agent:
s ee-1 A'lJrsC `'m'.111
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supen isor:
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)? Dyes ❑ no
If no, go to the next section)
Are ycu claiming exemption from the requirement? ❑ yes G'no
If yes, submit the
required affidavit!
Company Name �(��� {�`' C Q
Registration Number (if none, state "none")
//S
Address ,�d 7 Q 1'1�1+
Signature Tele hone �1��(
Gib L�' p C)t
Expiration Date c2 Q
1
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, 1M 02108, (617) 727-8598
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
3.4 H®meowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.11.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be. engaged indirectly 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 promulgated by the BBRS entitled Rules and Regulations for
Construction Supervisors. Licensing
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 to reside, on
which tl>here 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 applying under this section sign below:
Signature:
Your sign . ure canes certain respcn- ilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensedl(Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R53;2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to Wrovide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑i no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace ,
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ 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 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
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: I a U A) t QL)VQ
-
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $
E
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(pleas ejJlt)
j
esm Ina , as Owner of the subject property her authorize S
t"'
to a t 011 I y bel lf, in alI ma ters relative to work authorized by this building permit application.
/
Signature f Owne
g o Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
rn
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.
/
Y j
Signature of Owner/Authorized Agent DTate
C:\bldg.faRms'\Bldgapp.res.wpd Page 2
Rey. Jarman' 19, 2001 C:\b1d .fond Rl i aivt rOs WIld
RESIDENTIAL
2002 ; RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSF,'ERABLE
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(see project review worksheet):
5. DENIED (see project review worksheet):
6., HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8., Comments:
Date:
9. Inspector's Signature:
Date: ®(j(j
SECTION 9 - AP LICANT NOTIFICATION
Applicant informed!* ate: Time: 6vmClerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Tdtal Permit Fee: $
Less Application Fee: S 25.00
Remaining Balance: S.
TOTAL FEE:" Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To' r--�
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
r�
°`TH DARTMOUTH BUILDING DEPARTMENT
Jy
-4-PATE RECEIVED
(�
'°400 Slocum Road, P.O. Box 79399„
c i 4xr
Dartmouth, MA '02747
i SF . a i P....� e .�, I G.
!n, a
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
VIIIS SECTION FOR OFFICIAL USE ONLY `
RECEIVED BY: X zd I I
BUILDING PERMIT -
DATE SENT FOR REVIEW: ,��
NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE JUN 0 8 2002
ilding Commissioner/Inspector Buildings
Zoning District: Propose e: Zone: ❑ B ❑ A ❑ V Outside Flood Zone ❑ iAquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning, ❑ Other
hief 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: Signature: Date,,: `1
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
✓ ` ��✓
1.2 Assessors Plat & Lot Number:
('0
1.1 Property Address: 1 /C% el%f�5
Plat Lot -
Nearest Cross Street: %tn � C®c 19e,,,z
(� r 7
Subdivision Name: r )Uf.�/li!/) �)-�%l',iA �
13 Historical District El yes 9no
Has application been submitted to the, -:Historic Commission?
Total Land Area Sq. Ft.:
_.
❑ yes ❑ no :..Date:
1.4 Water Supply(MGL c 40 5 54):
1.5 Sewage Disposal System:
❑ Municipal❑ PrivwWwW ll
❑ Municipal Ors Site DisposalSystem
C:\hld(,T.forms\Bldgapp.res.wpd Paee4 Rev. January 19.'Of)I ;, a ,. ,
I