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SCALE: 112" = 9'
02
Name (print)
Contact Address
A a n A
&ecjeI f-as L
�?,- r, 01AS
Phone Number
2.2 Authorized Agent:
Name (print) Contact Address
Phone Number
I , N 3 CONS: _ . .. TRUCTION S :.
_ _ VICES
3.1 Licensed Construction Supervisor: N •
Not Applicable ❑
Licensed Construction Supervisor: .
License Number.
Address: i
•� Expiration Date:
UJ Signature: � Tele hone: p
3.2 Registered Ho
me ome Improvement Contractor. Not Applicable pplicable ❑
® Are you a Home Improvement Contractor subject to CMR-6 ? 0 Ye
(780 ) s ❑ No
If No, go to the next section!
U. Are you claming exemption from the requirements? ❑ Yes ❑ No
0 •
If Yes, submit the required affidavit!
>= Company Name: o Registration Number(if none sta " •
to none ).
0 Address:
Signature: Telephone:-- p Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND.
•
or write:
QUESTIONS OR COMPLAINTS call
Home Improvement Contractors Registration, One Ashburto
n Place -Room 1301, Boston, MA 02108 617-727-859 8
.I ❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
M. s.
By a1911illy ine araove, the homeowner acknowledges that there will be no eligibility to the Guarant Fun
Date:
y d
3.4 Homeowner Exemption - One & Two Famil
y only
/ FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE
109.1.1 Licensing of Construction Supervisors: Ex RESPONSIBLE FOR THEIR OWN PROJECT
P Except for those structures governed by Construction Control in Section 116.0 effective J
shall be engaged in d��ectly supervising persons engaged in construction, reconstruction al , my 1, 1982, no individual
terat�on, 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 ngs
Supervisors. g P gated by the BBRS entitled Rules and Regulations for LicensingConstruction
on
Exception: Any Homeowner performing work for which a BuildingPermit is required q ed shall be exempt from the provisions of this section; provides that if a
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. Homeowner
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
there is, or is intended to be, a one or two familydwelling, attach or intends to reside, on which
g, attached or detached structures accessory to such use and/or farm structures. A
one home in a two-ye�.r period shall not be considered a Homeowner. person who constructs more than
If you are applying under this section si n below:
#0, g
Signature:
Your signatN carries certain responsibilities, including —but not necessarily ecessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS
: The Building Code provides in the •
Supervisor, whether or not the h Rules and Regulations section that a ' y have taken the permit are responsible for any Ircense�d Construction
:.t P code compliance. (see Ap endix of 780 f
SECTION 4 WORKER'S'. P CMR R5.2..15
MPENSAT'ION :INSURANCE
AFFIDAVIT,-.(MGL'*c- � 52 25 -
Worker's Compensation Insuran ce Affidavit must be completed and submitted•
affidavit will result in the with this application. Failure to provide ' denial of the issuance of the buildingp de this
permit. Signed Affidavit Attached:
C7 Yes ❑ No
❑ New Construction*
(Energy report required)
❑ Addition
(Energy report required)
Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows _---- __ Doors _____•
*If new construction, please com lete the f oll'
P owing:
Single Family: No. of Bedrooms
No. of Baths
❑ Roofing/Siding
Two Family: No of Bedrooms Unit 1
No. of Baths Unit 1
No of Bedrooms Unit 2
No, of Baths Unit 2
Q Furnace (hot air) -fuel gas (natural orpropane),fu
. el oil, electricity, other (specify):
❑ Boiler (heating) -fuel gas (natural or propane),fuel -
oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural as r gas, Propane, electricity, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric
Fuel Oil Other
escripti
J�on of proposed work:
C AJ A n iA
r. .
oignature of owner
C
Date
SECTION 7B=-OWN
EWAUTHORIZED AGENT / DECLARATION_
❑ Other
(Specify below)
❑ Demolition
(Specify below)
as Owner/Authorized Agent herebydeclare that the •
on the foregoing a H�ation are e statements and informafiiion
P true and accurate, to the best of m knowledge '
- Y ge and belief.
Signed under the pains and -penalties•
.� P of penury.
Sign
Owner/authorized Agent
'v
Date r
�c °U TN''��'�
o
J '
Zoning Review:
Energy Report:
Fire Chief:
Board of Health:
❑ SPECIAL PERMIT (Per 780 CMR 9 91.93)
$25e00 APPLICATION FEE IS NON RE-I+'UNIBABLE NON-TIM�TSH+'ERABI.E ,
bsATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
Signature:
Signature:
Signature:
signa4�lre)
w
Conservation Commission: Signature:
Other: Signature:
Brief description of work being performec
-Subdivision Name:
Total Land Area Sq. Feet:
N
4 Water Supply (MGL c4Qo�54):
❑ Municipal C��nvate Well
i f
Date:/ � ✓�>
Date:
Dat
W
6,
t
Date: ''
1.3 Historical District 0 Yes ❑ Nro
Has application been submitted to the Historic .(Commission?
❑ Yes ❑ No Date:
5 Sewage Disposal Sy
❑ Municipal ❑stem: n Site Disposal S�,stem
1 SITE PLAN
13--COtNISTRUCTION PLANS w
•? I
0 ENERGY Rrw--,,,PORT
C�i�