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BP-2005-40893 Permit No. BP-2005-40893 GIS# 417000 - LLrn omonwea DD// o F ISS aac a Lot 000 Sub-Lot: 0007 • TOWN OF DARTMOUTH Category: TO RENEW . 400 Slocum Road,Dartmouth,MA 02747 Project# JS-2006-0630 Phone: (508)910-1820 Fax: (508)910-1838 Est.Cost: $5000 .. .: Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Use Group: R4 Contractor: License: Phone#: Lot Size(sq.ft.) ` 1.39A Zoning: SRB Engineer: License: Phone#: New Const.: N/A Alt.Const: ' N/A Applicant: Phone#: Date Typed: 09-01-2005 FLORENTINO V PEREIRA (508)998-7816 OWNER: PEREIRA FLORENTINO V&,MARIA D PEREIRA DATE ISSUED: / ///(c• TO PERFORM THE FOLLOWING WORK: Renew building permit#BP-2003-28594 BUILDING PEIZMIT Project Location: 14 MEDEIROS LN By:Approved/Issued P � / RALP,4 SOUZA,LOCAL BUILDIN ' SPECTOR All work shall comply with 780 CMR 6TH Ed. (MGL Chap. 143) and any other applicable Mass. Laws or Codes and plans on file. POST THIS CARD SO IT IS VISIBLE FROM THE STREET SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. 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 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 withstanding the issuance of this Building/Zoni Permit. Signature of Owner/Agent: ,��., ;mot,�' i -( Comments: "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD TOWN, OP DARTMOUTH 9 3 BUILDING RECEIPTS ' ° COLLECTOI S OFFICE Name ` L 1!% i `_ 1 erty pate: #,1'f -f / 1 J>j .: Owner: - —"Z�~' '`-„ �'"� .x Job Location: L,_, ., ,-- 0'. t' te:Copy-Collector's Office Plot: ) G!�j Lot: i "-- i i 110 .Copy-Customer's Receipt C../:" / \SO P' k Copy-File Copy een Copy-Building Department Phone ISSUES , 7,,Y � Description General Ledger#'s ef.# ,•' Amount License&Permits-Building01000-44105 ` ` ' '1 .-71 " ' L.,.. 7,,1 s. .f5 fir'' cam' ''-' ,i License&Permits-Building Misc. 01000-44105 ,._ License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By: I RESIDENTIAL, , (� 0 FOUNDATION ONLY $2 .0 AP ICATION FEE IS NON-REFUNDABLE d�:NON-TRANSFERABLE t,�n��rrr;- 'DAfi RECEIVED �� DARTMOUTH BUILDING DEPARTMENT .f f 400 Slocum Road, P.O. Box 79399 `:n Dartmouth, MA 02747 .Hb�-�w'' 508-910-1820 FAX 508-910-1838 APPLICATION I CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING r THI EC O FOR OFFIICIAL USE©NI Y z. RECEIVES : I } DATE SENT FOR RE IEW NU t. e p. x s r- OK T.O ISSUE- GNATUR'E' %j ITE .f,.�.t.:.'...<��4`"�-'... .;=..:�>.•.'. - ,-<-:-Via. y:.......,`:. Zoning U st nosed Usk one i4 GI ❑A ❑'V. `''-+puts de Flare s e©A �i fe n' \s,ei ;:� - , < �., s r^'. a/ rs x ¢���,�'ny. 5,r,,'h u4L."i,�,^"i'�. f. HE;FOLLOWING:�GEI�QES SHOULD BE.NOTI3a"�D � rh -� v,p�,,,;.>^s';` `:;:u:: ' '❑Board of '. oard a ❑Con Cam ❑ o ❑DPW' J Elee 0 EnergyReport Appeals , 0Real1A ' ' Affi avit - ,- Card•S nt �� ut CIS follow up* Y Cl Fire , ©Gac ©Planning z ©Sews Card Water Card ©Oth r Chief r cut Board* x I Cut Of`f „ o Cut tltf 3 Zo g r' ,. z-, r .ia<2- ;��,;%,,,I .-g t �h3,� ' j rs'�' i 1 i 3 r r ' E 1*RE+QUIRES I•'''SPE"� S� BEFORE THE ISSUANCE O - E lT a' -.x� .tea I�NTAPPROVAI Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief Signature: Date: 'Board of Health: Signature: e7( .e -C") _Date: 4 Conservation Commission: Signature: Date: Other: Signature: J Date: Description of work being performed: l " ,�/ �' / / j%� SECTIONITE IN�FORMATIOiV 0 NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑yes 0 no -= 1.2 Assessors Mar Lot Number: Property Address: II // E/6 I j/ (�� L iv Map / Lot - Nearest Cross Street: C•Ql//'/1 ell/4.er !t oL- Subdivision Name: 1.3 Historical District ❑yes [(no Total Land Area Sq.Ft.: Has application been submitted to the Historic Commission? 0 yes ❑no Date: 1.4 Water Supply(MGL c 40 54): 1.5 Se. wage Disposal_System: V We/I �l Sfto C:\bldg.forms\Bldgapp.res.wpd Page 1 f Rev.January 2005 IDENTIAL ,. .M,r N. ._T „,S`u3 _ - Ali WV a G r xT: - 5 4 i•4 4 :� 1i,(';T N =liitQl1FR-11 Oi�' *03-R ,11( i7. ` 1 1 %,.�.. ,em.,. .. ... 2.1 Owner of Record: F(© A .//'j 1 l\(o ?Err I 4 ' es FOR r '_Z_ Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number , s.,.. i _ .., SECTIQ1 �O1l5.. IJ 1014"SERVICES, „� , x 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)? ❑yes ❑ no If no, go to the next section! Are you claiming exemption from the requirement? ❑yes ❑no If yes,submit the required affidavit! Company 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 the 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 PROTECT 109.1.1 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 in directly supervising persons engaged in construction,reconstruction,alteration,repair,removal or demolition involving the structural elements ofbuildings or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by 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 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 applyin wider this section sign below: Signature: t 1".- _e:A:— Your signature carries certain responsibilities,including but not necessarily limited to,general liability C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January'2005 RESIDENTIAL 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 Append ix of 780 CMR R5.2.15) 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: ❑yes ❑ n L��y f jam, 7, jam. ` 0 •[`a� _.; "'s°2_ ECTIO w7 �a p }(cbe k ajpueoule.,,,Y p ,W09�. s ❑ new construction* ❑addition ❑ alteration ❑repairs ❑ chimney/ ❑ woodstove (energy report required) (energy report required) fireplace ❑ deck ❑pool ❑ accessory bldg. 0 replacement window/door 0 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 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), el oil, electricity,other(specify): ❑ HVAC(combined unit)-primary fuel,natural as,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: 9.e,G n 5ECTIVN ' ES TEI%Ct31S1 ` Rt1CT1(31v'Cb l' .f s Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4.Mechanical(HVAC) 5. Total=(1 +2+3+4) *Estimated Total $ 6u x �,, , 4 SECT O 1A aA7`I N (to be completed when iyn ,j'age l'ti +.,ti to applres TIt�ht)dzng jfe >nIt) 11 pz 3 (please pri it) I, ,as Owner of the subject property hereby authorize to ac � II b hha i ,in all matters relative to work authorized by this building permit application. Sign:ture of•wner Date S CTTnN 71i n R/t t7Hf2f7 IT T"}FCTZI4 DECLARATION .• , � y I, ii—/01 i vr/ ale PEA if.-,R n ,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. Signature of Owner/Authorized Agent Date C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev.January 2005 RESIDENTIAL ,z . . . .�� .,� � � r�� ..��.�.• o ace ., �' �3 �;, �. u ' � �"�0 . , 1. Date plan reviewed: ?/ ?/O6 2. DENIED(see project review worksheet): Date: 3. HOLD reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: i Inspectors Signature / /f Date:_4( 4 SECT AI ,� W E NT1(iTIF•ATIO Applicant informed f a ove Date: / 6 ) Time: C�+G!% Clerk Comments: CA /7L-Ciirit„, 3,, ... ' I4 -: s *mil 1 oOF E §fkef- S Il T S Syr ,f** Total Permit Fee: $ : "� . Less Application Fee• $25.00 Remaining Balance: $ TOTAL FEE: L) Gross Area-New Construction total sq. ft. Gross Area-Alteration total sq. R. Permit Issued To /� f �/ 1'�?✓ {d (7(L2--,) ' ` v ° ; e 4P , * rbgiUliO1NT L1: �1X)fii - �1++T' SI TCHFS �4 /et,/ C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev.January 2005 ---------mimmmiiim_ ,. , 'ermit No. BP-2005-40893 Projec Loc n:1 CommonwealtFi o•f JKassacFiusetts TOWN OFARTOUTH cts 4170 -- " napgE na , 079 ''i'f. :,,,„:,:„:,„.M,„..„,.: ,,,,,,„„ ,,,,,:: ,,,, 400 Slocum Road,Dartmouth,'-=MA 02747. H �� �x x s lx z. r wr Phone:Y(508)910,.1820 Fax•(508)910-1838 :S77rh ,44..,,a gyti 1 r BUILDING PER MIT " : 1`O E 7 ' Prflil � 06 Sim c i 5- i FIELD IPF 4 ,��fi, s CTION ll g �. ' _ Contractor License: Phone#: ,, y Engineer. * Phone#: ,� ' w License yir f Applicant Phone#: tvt Iiio )0t LF ! FLORENTINO V PEREIRA z ,,., (508) 998-7816 `` "t OWNER: u ' -, o * f ":rt PEREIRA FLORENTINO V&,MARIA D PEREIRA _ 4 DATE ISSUED: 6 !- �,1r?nn„ �'i �(�• TO PERFORM THE FOLLOWING WORK: Renew building permit#BP-2003-28594 DATE TIME TYPE OF INSPECTION&REMARKS INITIAL 9 s 3• /e //''<✓ G- 0 A ,00 L C k S te'. O • • rat n n ' ��i _F.. L.�I���3tj d . I ,po�TH. \\,,\\ \D\ ,_,------I 1 #21 e`���'� ' S • '` $50.00 t Y •Litt'' THE ALTH MASSACHUSE'1"1 S COMMONWEALTH Town of Dartmouth-BoardOF of Health Type of Pool Above ground Pool ¢°'�' Location: 14 Medeiros ne-Plat 79— Owner: LotC---7,14/FlorentinoPereiraLa �j Contractor Self D ui UST April�29, 2003 BE CO S D AS DESCRIBED IN PPLI •TION O' THE SWIlVIMIIVGPOOL 41'pect /a/ ,. if,,a . Situff+of Applicant Ina I ,ice ,:� '"! Via (j.- x '" ' v _ c 3 :askr k 1 -,- °I _ mot, t } z All �ti-` v yam; Please attach a p ons and approximate distances between o�ol and house, septic system, property line, and accessory structures. If there is no plan on file, please use the space : : above. SETBACK REQUIREMENTS(MINIMUM): POOL TO SEPTIC TANK: 10' POOL TO FOUNDATION: 0' POOL TO LEACHING AREA: 20' POOL TO BUILDING SHED, GARAGE, ETC. 10' APPLICANTS SIGNATURE: 1)7€71.24..-t .6;,c_,tv , uz;i A.,• DATE: DATE SUBMITTED: APPLICATION APPROVED: APPLICATION DISAPPROVED: INSP.: Swimming Pool C:IMSOFFICE\WINwoRD10RIG\P00LAPP.Doc� Application-res- idential pools I The Commonwealth of Massachusetts Department of Industrial Accidents tigirilii ' Office of Investigations w, 600 Washington Street a Boston, MA 02111 s�° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nam usiness/Organization/Individual): (o 4 i.`//'T i )`to ri f/�i it ddress: / Li l7 r D i/4'as N City/State/Zip: 'be/izTpvi v 0 t/1 Phone #: :Co g 5`v' ,r/ ‘ 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 wo' ing for me in any capacity. workers' comp. insurance. 9. 0 Building addition F.o workers' comp. insurance 5. ❑ We are a corporation and its equired.] officers have exercised their 1011 Electrical repairs or additions 3. 0 I 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.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *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. I 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: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy 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. iI o hereby certify under the pains and penalties of perjury that the information provided above is true and correct ignature: �CLi1u l •re) i-c�.t.. Phone#: 5-1-7 7 9 a'`? 1 C Date: , ` — i '?_ c' 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia