BP-2000-16475 T
Permit No. BP-2000-16475
„' P..1 t eommoiuuaart, o addaciiusetf�
n 3; -i _1 ;�. I QL�` _:f its+, .Y ; 'S�� -"I._• R_ Y� Al 2A:- - ,
F 4 'a T 1 M UTH
• q:400 Slocum I oad,Dartmouth,MA:"02T47 t I
' 00 Phone:(508)999-0720 Fax ((508)99947 ,8�` '. `i
_ ; ,.'
P. 1 ' Q 100.00 A ' gn a �.
Zgg•, ‘ .00 r .: : PERMISSIONISHEREBY GRANTB'p TO ,,
*y ram{ }{ I C4nst 4}aS R+R v� i&. '" Y i b +y ; s.._. p. ,' 3 j,' - . ,> i i
irliZoii a'''': ,i -;`}v.' 3 Contractor: _ , a :license: _Phone#:
`sue S F„i t1. I 896 4 µ. ALAN S ALVES =. CS-059463 (508)995-0729
;Zonin_; '" %v;;.`SRB Vxli-N't Asar4 Engineer: Li
'Nem%Const. 4''450 s' 'ft. i- 4,>t�i ,
License: Phone#:
i
KC � ''' Applicant: - Phone*
'Date'Typed' ''',' ' ;40 ,13-2000 *' ALVES PAUL&KIMBERLY ALVES . `' ?' (508)995-6907
OWNER: ,
ALVES PAUL&KIMBERLY ALVES
DATE ISSUED: /l 1S" .
TO PERFORM THE FOLLOWING WORK:
35'x 40'garage (3 stal4 with living space above
BUILDING PERMIT
- Projec Location: 18 MEDEIROS LN
Approved/Issued By:
OEL .REED, AL BUILDING INSPECTOR
All work shall comply with 78 C 6TH Ed.(MGL Chap. 143)and any other applicable Mass. Laws or Codes and plans on
file.
POST HIS CARD SO/T/S I//S/BLEFROM 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 's Building/Zoni ermit.
7
Signature of Owner/Agent: ��i4
iff----)
Comments:
REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD C 0 PY
TOWN OF DARTMOUTH 17 r.. -y
BtiDII1Q RECEIPTS
COLLECTOR'S OFFICE
Name r" y. Property ' Date: i ... ; --
_i Owner: ' °-'-- .' .1�ij t i,
Job Location: Jr
r ''' 0%S
V i ; L .CI to Copy-Collector's Office
Plot: C Lot:' 1` �� `-V��ellow Copy-Customer's Receipt
c; , `L Pink Copy-File Copy
A\"", Green Copy-Building Department
Phone: ei -"r /;
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105 (-4 ,' 1: ;.---e '> , '-;.
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:
TOWN OF. DARTMOUTH 18061
BUILDING RECEIPTS
COLLECTOR'S OFFICE
f
�j i
Name ice" / _,, fi Property Date: /r t '
';_ t +-' 1-�``- ' ` -- �- -. Owner: ...- : <„
Job Location: - r�-,
f r� White Copy-Collector's Office
Plot: f-1 s Lot �' �. i 'r-_ LL\ ‘ Yellow Copy-Customer's Receipt
/ / Li-, f; Pink Copy-File Copy
Green Copy-Building Department
Phone: '
f1 , , 3.
t
Description General Ledger#'s etef.4 Amount
License&Permits-Building 01000-44105 i' f " "�l 2_"t
License&Permits-Building Misc. 01000-44105 , "t./ I C_. '-.�,
License&Permits-Electrical 01000-44106 - ""',, �
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
c ( \
This is not.a Permit or License for Building,Plumbing or Gas Received By:
RESIDENTIAL 2000
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE&NON-TRANSFERABLE
� `^�vT1: s . - DATE'RECEIVED
DARTMOUTH BUILDING DEPARTMENT
o jr r _; 400 Slocum Road, P.O. Box 79399
' Dartmouth, MA 02747
IRfi3 :. - 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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: Itt R FS IN PE' 'I'..R> ':ItEV.IEk�::�S IEFfl12�'I'3�lE:IS»:;AN;. ;.... •� L�...... ...� C..Z3 ... 5U....CE(?F A::PIER"Iti7�'# s::>::::>::>::::>`::°.::>:;:::>:: '>::`:if:>:>.'.:....;::> ;z:>::
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Zoning Review: Signature: �y Date:
Energy Report: Signature: Ci G/�G-,�� Date:
Fire Chief: Signature: .2),,,f 4 ^9— Date:/0-.//- t:,--,-,
s
6
Hoard of Health: Signature: Date:
k...)..
Conservation Commission: . Signature: Date:
Other: Signature: i Date:
Th Description of work being performed: ��' ' ,l/t 4_- Gil 6. 2 a,,6
N::: :'._. ,
NUMBER OF PLANS SUBMITTED: ..:-; SITE PLAN SUBMITTED: Oyes ❑ no
;�r��� 1.2 Assessors Plat&Lot Number:
1.1 Property Address: ! IC I e_rj<2,1(C (Czne: Plat let Lot -
6 -...' '''
Nearest Cross Street: 1.1 j &)y-o may' --
W c1
Subdivision Name: )11 Uarl ,c _ I0(35 1.3 Historical District ❑yes ono
Total Land Area Sq. Ft.: . ( 1 Has application been submitted to the Historic Commission?
❑yes ❑ no Date:
1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System:
0 Municipal C'rPrivate Well 0 Municipal E-On Site Disposal System
C:`bldg.forms\Bldgapp res.v..pd Page 1 Rev Januar, 13.2000
r
RESIDENTIAL 2000
s��'r1Q�2 �lzol�l�xr�f3�YiV��SE11P!> t_��1xo�ilzEt),�c>��r
2.1 Owner of Record:PAIR- rC- At v S °41 /i�ke'llf 11A1/6..S 11 r`t , DA..er ou-n1 9 15=6Ro7
Name(print) Contact Address Phone Number
2.2 Authorized Agent:
ALA-rJ S• /42vtS 2)-1 c w7a-si•e-D. , bA-)27-nr,crTh R495-07 ?
Name(print) Contact Address Phone Number
3.1 Licensed Construction Supervisor: Not Applicable 0
Licensed Construction Supervisor AL fl,,,1 S, License Number GS ogc 3
Address 2 (.,,Z+A- —3 • Expiration Date 5 )5)2pc�
Signature Telephone -�C15-O 7�9 /
3.2 Registered Home Improvement Contractor: Not Applicable 0
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? 0 yes 0 no
If yes,submit the
required affidavit!
Company Name Registration Number(if none, state"none")
Address
Signature Telephone Expiration Date
3.3 Fcx 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, HA 02108, (617) 727-8598
Owners Na e(print)
, \
Signature Wt �
by signing a above,the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date--4\-1- 4
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 1, 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 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 applying unde is section si ow:
S ignature20
Your signat e carries certain responsibilities,including but not necessarily limited to,general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January 13,2000
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.
1
5
ON4i 048'
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure o provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: , es 0 no
SECTION 5-DESCRIPTION OF PROPOSEI WORK(ebeek all appheabIe
0 new construction* 0 addition 0 alteration 0 repairs 0 chimney/ 0 woodstove
(energy report required) (energy report required) • fireplace
0 deck 0 pool accprig. 0 replacement window/door 0 other 0 demolition
(shet 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
o Furnace(hot air)-fuel gas(natural or propane), fuel oil,electricity, other(specify):
O Boiler(heating)-fuel gas(natural or propane), fuel oil,electricity, other(specify):
O HVAC(combined unit)-primary fuel, natural gas,propane, electricity, other(specify):
o Air conditioning-(separate unit)
o None of the above to be provided
o Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
14-17 A ? 2C 40 ni e-00,7 A--as ov
SECTION-6 ESTI1ATED CONSTRUCTION COSTS
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 $ .50,000
(please print)
PA-VL, , (4-Li/GS , as Owner of the subject property hereby authorize
•
to act y b I • all rs elative to work authorized by this building permit application.
$- C)3
Signature of Own Date
,41141-/1/ 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.
Signed under e mains and penalties f perjury.
7/.2 5 1(:)"
Signature of Owner/Authoriz d Agent Date
C:\blda.forms\Bldgapp.reswpd Page 3 Rev.January 13,2000
I
RESIDENTIAL 2000
SECTIOV S INSPECTOR'S RREVICWV/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): Date:
5. DENIED(see project review worksheet): Date:
�
6. HOLD reason: �Q
7. HOLD subject to Zoning Board of A pp on.ea sl action: 9( :/
9 e. //46 Cr) /� 0~`y
7—.4^2— date.•
8. Comments:
9. Inspector's Signature:
Date:
P
S777. EC '1ON AI'1'I,Ioi4.N.00.ncATIoN
.win.W.ii::: iiiimin.m,:sni]:F.:i:o:'. i:i.o:4:•.1::ii .::.:::i",q .
Applicant inform f above Date: 6 �lV � `
Time: Clerk: 09
Co ents:
•
ION 1 OH CE:1ll\SPEGTOiv.§: OTES
To..... _�eimit Fee: $ ----
Less Application Fee: $25.00 Remaining Balance: $_)c:
TflT A T ..„E:
t .'EE: /� � Gross Area-New Construction total sq. ft. /'�9—O
Gross Area-Alteration total sq. ft.
Permit Issued To• J'5 X ya e=�c��-/=e� "
SEE''T'ICIN I)€ t1b7.ITIi?A31c oivi aE'#'CS(SI�E'C TLS
_ S/961._42, kii>1-44 //(//0'7 — Zei is.z,,,,....::
//IC'. cr° iy '61' iv. P4191
iore:,"i::fr/ui 41„,„„,,,_„„c„„e_
C. Hd2.forms''131dgapp.res.wpd Page 4
— Rev.January 13.2000 ,
Project Location: 18 MEDEIROS LN Permit No. BP-2000-16475
GIS# 4171.00 D,/
Map: 0079 Commonwealth o�Fadiachude
Lot: 0006
Sub-Lot: 0008. TOWN OF DARTMOUTH
Category: New 400 Slocum Road,Dartmouth,MA 02747
Project::# JS-2001-0333 Phone: (508)999-0720 Fax: (508)999-0738
Est.Cost: $50000.00 Fee: $145.00 BUILDING PERMIT
Const:=-Class:
Use Group:; ;' R4
Lot Size(sq.ft.) 81896agft.Zoning; SRB FIELD INSPECTION
.
New Const.: 1,450 sq.ft.
Alt.Const: . N/A Contractor: License.: Phone#:
ALAN S ALVES CS-059463 (508)995-0729
Engineer: License. Phone#.•
Applicant: Phone#:
ALVES PAUL&KIMBERLY ALVES (508)995-6907
OWNER: ALVES PAUL&KIMBERLY ALVES
DATE ISSUED: 11 l 5 11D
TO PERFORM THE FOLLOWING WORK: nr (�
E did
35'x 40' garage (3 stall) with living space above O tliiiAm 5 -
( T ♦TE I I TYPE_/�F INSPECTION -71TT T nK S I :n ITT 1 T I
DATE - - TIME _ _- - TYPE c�c-r►, ..i�-uuw--- _ _ --_--- - ii�rrYrit.
3/Kii/ S' 1--(1-ce-re_tie -1, 0
AUG 3 1 2001 4 - � k �--
Z
AUG 3 1 2001 n
/3 0 //,'%r2- 4 cam°
2/3/ 3, 0 oej ,
MAP P LOT C
,,,tIT �
/ a- - t� c e: TOWN OF DARTMOUTH
r.
'
3 INSPECTION CHECKLIST
'rnna
Date: S/VG C ❑ New Home ri: ddition 0 Alteration ❑ Deck or Shed
Permit # / 6 / ? --C Address: /k .0*§ d'I T e/x a s / ic/
Inspector: LO // ��-�, - 2�G
.• FINAL
Pass Fail ! Description T Code Section
/ Permit & approved plans on site 1 1 1.1 1 & 1 1 1.1-1
LA Final plumbing, electrical, fire and gas inspections completed 1 115.9
I, T House number posted 115.0
/K//)- Chimney height 3610.2.5
General site grading away from foundation. for 1st 10' 3310.0
Stair/deck rails i 3603.13 j
{
Proper garage/house fire protection (walls, doors & beam) 3603.5 —!
Proper floor berm in garage 3603.5.3 1
All ceiling & wall penetrations in garage sealed i 3603.5.1
c/ — i Interior stair rails/protection in place 3603.14
A/4 Proper clearances for attic access (22" x 30") 3603.9.2
Safety_ glazing protection where required 3603.20.4 —I
v, ! ,�-.,` Interior doors where required i 3603.11
i✓/4 Cellar/basement insulation if not previously inspected—check ER J5.21 B
Insulation at attic. eves access & pull down stairway 14.3.1
.Al4- I
tBathroom/toilet rooms fans working 3603.6
VHouse conforms to approved construction documents 113.3
All exterior work is done 3607.3
t/ Means of egress 3603.10
Photo electric smoke detectors 3603.16.11
v Smoke detectors in working order 3603.16.3
Doorway landings 3603.12
/v/9 Service water heating system(pipe insulation) J4.4.9
_
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CURRENT MESSAGES
DATE MESSAGE BY
SBS
aetti gAix icada7 60/(
y.,()J /fir" Ai_iyptLez-i4)7 ,6ce-24L.L,_,
3 z , ;C/ � �r
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ENERGY CONSERVATION APPLICATION FORM FOR
a:
LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS
FILEcopy , 780 CMR Appendix J (effective 3/1/98)
APP is tae: ' SSite Address:
Applicant Address: City/Town: .L1//'"f/lL//
Use Group:
Date of Application:
Applicant Phone: - Applicant Signature: —
Compliance Path(check one): /
El Prescriptive Package(Limited to 1-or 2-family wood frame buildings heated with fossil fuels only)
Package(A through KK from Table J5.2.1b): Heating Degree Days(HDD65) from Table J5.2.la:
(For items d.through i.,fill in all values that apply from Table J5.2.1b:)
a. Gross Wall Area sq.ft f. Wall R-value R-
b. Glazing Area' sq.ft. g. Floor R-value R-
c. Glazing%(l00 x b+a) % h. Basement wall R-
d. Glazing U-value U- i. Slab Perimeter R-
e. Ceiling R-value R- j. Heating AFUE
0 Component Performance: "Manual Trade-Off' (Limited to wood or metal framed buildings only)
Climate Zone(from Figure J6.2.2) S.Zone 12 El Zone 13 EJ Zone 14
Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet,t apOlc ire 6 7c 1"r � g
MAScheck Software
i (e m 8 ti 4 ; r '� .y
Attach Compliance Report and Inspection Checklist printouts. p u� A F , :: n �- -', se0'
: SPf'
El Systems Analysis OR Renewable Energy Sources Dur1�` r r' 4 . ,, !� PI
Attach Mass Registered Architect or Engineer Analysis ' �CT.O 4 7^`,f!
ALTERNATIVE FOR ADDITIONS ONLY:
XADDITION
a.Gross Wall+Ceiling Area�4o4- sq.ft. b.Glazing Area'.300 sq.ft. c.Glazing%(100 x b+a) I %
with Glazing % (c.) up to 40% may use 780 CMR Table J1.1.2.3.1 below:
MAXIMUM U-value MINIMUM R-Values
Fenestration' Ceiling' Wall Floor Basement Wall Slab Perimeter,Depth
0.39 R-37 R-13 R-I9 R-I0 R-10,4 ft
I Glazing Area may be either Rough Opening or Unit dimensions.
2 Based on NFRC listing. Applies either to every unit,or to area-weighted average of all units.
3 R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area
(i.e.-not compressed over exterior walls,and including any access openings.)
0 "SUNROOM"addition (greater than 40% glazing-to-wall and ceiling gross area)
Attach"Consumer Information Form" from 780 CMR Appendix B.
Official's Name: Official's Signature: '
Application Approved 0 Denied 0 Date of Approval/Denial:
Reason(s) for Denial: (provide additional details as needed on back side)
BBRS 7/15/98
CURRENT MESSAGES
•
1-017-ff.1) (,(Ct6teL- L4 d,lav)
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P-44n .;17/
��`. j 2 5 2000 l`
\i• Q� 400 Slocum Road • P. O. Box 79399 i I
166• - Dartmouth,,Massachusetts 02747-0985 „ Ti
CONSERVATION COMMISSION CC,SF IV:T.e�,C� 08 9
(508)999-0722
A-1 Site Inspe o FAX: (508)999-0797
E
copy
jaqa/ ///,l,,dkj. lAkeS
/
,7 02c_ fr
me of Person Making Request Date /
/1. �iLf- 4 ���// S .47-
Mailing Address Street Location Of Property To Be Viewed
/y/ ‘ ,01'67OlJ City/Town, State /� i47,4
Dartmouth Assessors Map and Lot Number
9?"570 .a2__________ 6a/-a- ,.-
Telephone-Day Proposed Use of Lund(house, addition,garage, etc.)
,s9/.7x......
/fi.1-J/ZiCA -
Telephone -Evening kinSignature f Person Making Request
rh'L he,=/ 79k/s
Name of Owner of Site To Be Viewed / Print Name
Saj77 (__.
Owner's address Signature of Owner of Site to be Viewed
Print Name
Site Inspection Fees:
1-5 Acres $50.00; 5-10 Acres $75.00; 10-100 Acres $200.00; Above 100 acres $400.00
All filing forms are available in the Conservation Commission office,room 107 at the Dartmouth Town Hall,400 Slocum Rd.from
9AM-4PM Monday and 8:45AM-4:30PM Tuesday through Friday.
For parcels from I to 5 acres only,the Conservation Inspector is available to flag the wetland edge. However it is the Applicant's
option to acquire the services of a private consultant to delineate the wetlands on a parcel of that size. The Inspector has the right
to require the Applicant to obtain the services of a private consultant to perform a wetland delineation on areas less than 5 acres
where abnormal site conditions or extensive use of soils evaluation would require an excessive amount of time be spent by the
Conservation Inspector in making a determination of the wetland areas present. Sites over 5 acres must be flagged by a wetland
scientist,botanist or other qualified person prior to submitting the A-I site inspection form. The Conservation Inspector will then
review the flagging in the field and make adjustments where necessary. The Conservation Commission may require proof of the
qualifications of the person performing the delineation.
Note:The A-I Site Inspection is a procedure outlined in the Dartmouth Wetlands Protection Bylaw. It is a service available Ibr the
purpose of identifying wetland areas on a site. The issuance of this completed Site Inspection is NOT a final determination of
wetland boundaries or their jurisdictional status wider the Massachusetts Wetlands Protection Act(MGL Ch. 131 §4U)or the
Dartmouth Wetlands Protection Bylaw. Only the issuance of a Determination of Applicability or Order of Conditions by the
Conservation Commission finalizes the determination of wetland boundaries anchor their jurisdictional status under these Laws.
The completion of this Site Inspection is not an authorization to proceed with work.This site inspection expires three(31 years from
the date of issuance.
CONSERVATION COMMISSION INSPECTOR COMMENTS AND RECOMMENDATIONS.
No wetlands or other areas subject to the jurisdiction of the Conservation Commission exist on site or within 100 fee,
of site. No other filing with the Conservation Commission required
The proposed work is not located within 100-feet of a wetland area. Other wetlands may exist on site. Any further
work to be located outside of inspected area requires the filing of an additional A-1.
Wetlands exist on( No Sout s ast, West )of site.Please refer to drawing(if provided by inspector)for location
information. All locations on sketch irov ded by.inst ctor are approximate.
/17 Edge of wetland has been marked on site b} tor+t Flag numbers:
wet / Through 63,C-7„Bret-
Additional wetlands marked
wet Through wet wet Through wet
wet Through wet • wet Through wet
Wetland ciPlineated using: Vegetation only Soils and vegetation
Any activity (clearing, digging, removal of vegetation. etc.) in a wetland or within 100 feet of a wetland requires a
permit from the Conservation Commission. No work shall begin until permit is received. This completed form
is not a permit.
A Request for Determination should be filed with the Conservation Commission before any work begins on site.
J A Notice of Intent should be filed with the Conservation Commission before am,work begins on site.
Coastal Bank exists on site. Engineer must delineate Coastal Bank per DEP Wetland Program Policy 92-1.
Delineation must be submitted to the Conservation Commission office for review and approval.
100-v ear flood plain may be present on site. Engineer or Dartmouth Building Department must determine if proposed
work is located within flood plain. If work is located in flood plain then a further filing with Conservation Commission
is required.
A survey plan of the wetland delineation should be submitted to the Conservation Commission office.
Due to abnormal site conditions and/or the necessity of gathering an extensive amount of soils information to
adequately describe the wetlands on site the applicant must obtain the services of a private consultant to perform a
wetland delineation. The delineation must be submitted to the Conservation Commission for review and approval.
1/4 Other Co ents:► G C /JADr-e_ fir• , a-c �j C LI J (�
(7---e-skc if77>1 fry
1//7-6
Date o9Issuance Michael O'Reilly
Environmental Affairs Coordinator
• izabeth H. Leidhold l/
Conservation Officer
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DATE OF AERIAL PHOTOGRAPHY' J_2s- MI6' I.I7 se.
es OF COMPLETION 1-r-,4 .r•l.
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LEGEND DATEofs_ro-es rre5ARCEL KAISERS...... ...2MATCH LINE. . . --2_+_9� ), T6O?LDTS
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/ FILECOPY
__ ___ _ . _ _
_............___
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- ..°ige -620,„....za cv,/waoackaeat
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR i
Number: CS 059463
Birttidate: 05/05/1966
Expires:05/05/2002 Tr.no: 24357
� i
Restricted TO: 00
ALA►N S ALVES
221 CHASE ROAD .*-
DARTMOUTH, MA 02747 Administrator
0 60----_-_ The Commonwealth of Massachusetts `�
4 "} ;}(7' Department of Industrial Accidents Gi� -
== Office of Investigations
_ 600 Washington Street
-7 Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
A fCc rfair filarfQt:fV%/; 27', ;?" 7. "'(7 le1Si 1' C ltil ' /%% a ,4/
name: PMit_ rt. .41,,/o_.s
location: /8 ftt�AEE' etm L4n,
city N ` D"27 ltwo✓Trt , II ✓t 02 7 4 7 phone# Sol-995-1,907
.g4, I am a homeowner performing all work myself.
O I am a sole proprietor and have no one working in any capacity
O I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: phone#:
insurance co. policy#
O I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone#:
insurance co. policy#
frO'� �iJrDO/Gl0/ , %,Aff 7-a ,;.;- 7 / ;/ /'//%6i z ////� �G,,//// ,
company name:
address:
city: phone#:
insurance co policy#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby ce ' under he pains and alties of perjury that the information provided above is true and correct.
Signature Date 7 01 6O _0 D
Print name ipsr-vL. n• /4-1-/1 S Phone# 5Op -f1,9 s- j,9 o 7
M official use only do not write in this area to be completed by city or town official
city or town: permit/license# ['Building Department
['Licensing Board
s= ['check if immediate response is required ['Selectmen's Office
['Health Department
contact person: phone#; ['Other
h
,,_.
(revised 3/95 PJA) .v m6i
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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.
/✓%/��yr3. //�%j /3/93 j���%
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
� 'r / Z//ip r / ri rr ri • r
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
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
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This plan is hereby endorsed for construction subject to submission
detailed Fire Protection Plans certified as to compliance o
& Regulations (527CMR & 780 CMR) to the District Chief prior to
start of construction of any such system. You or your representative
must contact the District Chief prior to start of Fire Prot
ection Work.
Chiefs �•el-
District
Date e /-- rr
777
!rk�A I�%. a. ty'�.L 1 Lz r `)e �^p F`�•jT Ci :i pL'}y�
. �:. 7101" to
foundat--off
Zen orany const'ruct-jorl,
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exleEtIng roof
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YOUR . DRA),",f!Nt MUST BE KEPI
AT �- E 3c l�4_Dii`:G D:J11-ili G THE
PROGRESS Of' t- .S WOR!;'*
J3UIJJ\1rG xD� ,PAII MZTz1
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be sable as garage pads. I top elevation to be 6,* 1
betow top of 61
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