Loading...
BP-44075 Permit No. BP-44075 6, .v.. ,xc e " e('''':#10.'''Iititi- 419a4.ii7Tiyht4d -cic-k**44.6 Hf �!IIIIFIIIIII! TO N0 b �TMo 40Sim Road, �010 TH s i . i P,h°pe (50801 1820 Fax 59910 1 $PAVIIIIUVIIJJ PERMISS O �' TERFil gt M k `� ,,, Contractor - i L �sC k .., Ph n #: i Engineer �`' E els a Fh rye#: ' , �,� �� � = . ; .AP Applicant: � . ' , ` �1 . ' � e( 8 998-5571 FRANK P EVA* 4HO iR, , 1 ,� t�, - D )R OWNER: ; EVANGELHO A IK�P' SU:Zi NE LE RI � FR DATE ISSUED: r-- TO PERFORM THE FOLLOWING WORK: Add new deck to rear of home, 12'x 16'and 10'x 12'(one deck); TO BE IN ACCORDANCE WITH 780 CMR OF THE MASS STATE BUILDING CODE ,B IJI Project Location: 9 MEDEIROS LN i Approved/Issued By: -7,‘----- 7� DAVID W MATTOS,LOCAL BUILDING INSPECTOR&ZONING ENFORCEMENT OFFICER All work shall comply with 780 CMR 6Tn 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 111.8(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 W if items under their jurisdiction are not met; not withstanding the issuance of this Bu' in on° g Perm' Signature of Owner/Agent. Comments: P i?- 1' Bii t, 4 I "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 OF DARZMOUTH • BUILDING RECEIPTS , 2 1 r. , / / COLLECTOR'S OFFICE ) i• fA i , c , -; Name: „..-:-' i r ,41.,7, . ' ,,t4Property ,.::'; --- - Date: , / „( '-- - L --' * .---Ti-: k-7, f-,,"--- '6der: ./ - , _ , %..,../,,, / 1 Job Location: /-.,.-7;;' , ( / , - k 1 - i , -,------ 1 , .., / ---------White Cop -Collector's Office , 1 , ,- , .------ XellowtCop -Customer's Receipt Plot: ,- I , i Lot ,,,7 -- - v i \ - L, i , i i , ‘ _ B2.10(cApy- ile Copy k 1, 1 , Greenapy-Building Department Phone: NO TAX ISSUES \ L___--------- , 4., , „. ... _ ______ Description General Ledger#'s \--lr—ef.# • Amount License&Permits-Building 01000-44105 '''" License&Permits-Building Misc. 01000-44105 \. ,...,, „- License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 if This is not a Permit or License for Building.Plumbing or Gas Received By:/ - -- - - - - - -TOWN OF DARTMOUTH : 440 79 BUILDING RECEIPTS COLLECTOR'S OFEICE- -— Name --2 .,,. , , ,7, -,-,.., : .,,, ,I-Property , , Date: ' '—'-'- ''• ' t ' ' ' . —— Owner: - , Job Location: I , / , - .,...., -, • „• _ .,,. White Copy-Collector's Office Plot Lot ,1 i _.-.----- , • ,,,- _,„„-- / il i , --- _ ,.- ;Yellow Copy-Customer's Receipt .1 _-t !,y-- i i , ::-.,: ,.....‘ I Pink Copy-File Copy ------ / Green Copy-Building Department Phone: ‘ No TAX ISSU - , % \ '+?\ ' —1 ‘ — Description General Ledger Vs\ _13...ef.-#; ,---1 - -- Amount License&Permits-Building 01000-44105 , \ , 11,,...-0"'-- License&Permits-Building Misc. 01000-44105 1,,=-1- i - , ...._ 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: 1- ---' 4i4. " ..." 0 SPECIAL PERMIT(Pqc28,0 CMR 111.13) $')5.00 APPLICATION FEE IS NOrr1 *. 171q4411 11?--ek NON-TRANSFERABLE DATE RECEIVED DARTMOUTH BUILDING DEPARTNIF-4,. VT 02 - - - - • t _ . .. . , 4 4 i-',; 3: (1:6 Dartmouth, MA '62747. Phone: 508-910-1820 Fax: 508-910-1838 C ....q. s)...- -.......L.........- www.town.dartmouth.ma.us APPLICATION TO CONSTRU T, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY 4 zi,_.7„______,.., RECEIVED BY: . BUILDING PERMIT NUMBER:Y—tila/\-- DATE SENT FOR REVIEW: DATE ISSUED: / t /.4i -) - O.K.TO ISSUE-SIGNATURE: ' DATE: , ,-- — Zoning District: -C/? t 5 Proposed Use:R* .,.‘. Zone: 'a C 0 B 0 A CI V Aquifer Zone THE FOLLOWING AGENCIES SH D BE NOTIFIED: 0 Board of Boa Of 0 Cons. . . 0 Demo Empliv Li Elec. ID Energy Report ;Appeals alth Commission Affidavitdavit Card Sent Cut Off Follow-up El Fire _ 13 Gas 0 Planning ' 0 Sewer Card CI Water Card 0 Zoning I=1 Other Chief ' ' Cut Off Board Cut Off Cut Off , *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. ..... DEPARTMENTAL APPROVAL Zoning Review: Signature: ,e - _, , Date: 0 A. 4..- Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Conservation Commission: Signature: 0 Date: Other: Signature: Date: Brief description of work being performed: SECTION 1 -SITE INFORMATION .1 Property Address: 9 ific/pAtz6-)....5- z...„,...A,,,--, 1.2 Assessors t Numb # ,. 7:,, Nearest Cross Street: (701Z/AAD c_it , Map Lot V - Subdivision Name: Syi".ilt+N Total Land Area Sq. Feet: /7///, /i2Z 4 1.3 Historical District 0 Yes 0 No Has application been submitted to the Historic Commission, 0 Yes 0 No Date: 1. Water Supply(MGli_pc24)s54): 0 Municipal Private Well 1. ewage Disposal i S))2pti: 0 Municipal On Site Disposal System El CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT RESIDENTIAL SECTION 2-PRDPERTY OWNERSH /AUTHORIZED AGENT .1 Owner Record: �'7i�t 4iul &I1Nc�� eci�v /96i i $ tvC N ���y� 557/ Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: License Number: O Address: Expiration Date: LLI Signature: Telephone: Z 3.2 Registered Home Improvement Contractor: Not Applicable 0 W VAre you a Home Improvement Contractor subject to(780 CMR-6)? 0 Yes 0 No —I If No,go to the next section! U. Are you darning exemption from the requirements? 0 Yes 0 No O If Yes,submit the required affidavit! Company Name: Registration Number(if none,state"none"): O : Addrs: V 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 0 I am a Homeowner performing all the work myself. Owners Name(print): Signature: By signing the above,the homeowner acknowledges that there will be no eligibility 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 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. ::::: pplying nder this sect' below: j� 4/l /- '0 Your signature carries rtain responsibilities,including but not necessarily limited to,general liability 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 R5.2.15) SECTION 4 WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25) Worker's 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: 0 Yes 0 No SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) 67 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑New Construction* 0 Accessory Bldg. 0 Roofing/Siding 0 Other (Energy report required) (Shed/Garage) (Specify below) ❑Addition 0 Replacement window/door 0 Demolition (Energy report required) No.of windows_ Doors_ (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 ❑Air conditioning-(separate unit) ❑None of the above to be provided ❑Hot Water: Gas Electric Fuel Oil Other De ription of proposed work: � 5?X/t) /2f'M i7Z ZiL SECTION 6-ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5 Total (1 +2+3+4) e%20,sv /L SECTION 7A-OWNER AUTHORIZATION(to be completed when owner's agent or contractor applies for building permit) (Please Print) I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION /,/I, et;I ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application aie true and accurate,to the best of my knowledge and belief. Sig under the p ' nd penall s of perjury. '''/P ik v-dy:-0‘ Signature of Owner/Authori d Agent Date SECTION 8 INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: 2. DENIED(see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: -(:i: s ���G� Date: Y� G e' SEC ION APPLICANT NOTIFICATION Applicant informed of above: Date: P✓(1. .„ Clerk:L�J� f Comments: C ��, SECTION 10-OFFICE/INSPECTOR'S NOTES Less Application Fee:$25.00 Remaining Balance: $ o�� .OC) Total Permit Fee:$ . 0 6 Other$Amount$ TOTAL FEE�'r O_49 e Gross Area-New Construction total sq.ft. / >C 6i /`" Gross Area-Alteration total sq.ft. Permit Issued to: /9 0 O /✓ lc L .' c , To k'` /'f © p /4/0.' E / x, /G X/.2 frr /5/c C c /9/9-4/C p ►.c//'7774 C"07 der / f'�S' S S /17/ SECTION 11 -ADDITIONAL COMMENTS/SKETCHES / X / / 9Z / V-X /`c� 1 'ermit No. BP-44075 jectLocation: 9 MEDEIROS LN Commonwealth o,,,flassacfiusetts TO N JF DARTMM�OUTH F 1 400 Slticum Road,Dartmouth,AMA 02747 az1k t. ,,;:,��f�� sip , gin Phone '(5n8)91.0-1820 Fax (50810 1838TT , a ,� € s t� ,,;,:7 , s a rNG f 409® § g FIELD INSPECTION ree ,:,,,,,,, ... .,,,,,,„,,,,,,,,,. ,,,,,„..., ,,, ,,,,„ <„,,., , , fan * f , ,,,, ,„,,,,,,,,,,,,_,,„,,,,„cro---, ,,,,, .... Contractor: Ltce se• Phone#: ,�I�ze4 ,n a k% FCC lam. 6 3 4 F 1 9 °^ s Engineer s Lrcens hone#. < . ft a,� , �� �k ,, m '� s3t ,i a �. v Applicant.. pplicant :mow Phone#: � f � FRANK P EANGELHO JR (508)998-5571 OWNER: ;� EVANGELHO FRAM „ J & SUZANNE LERIAS " , k° '' DATE ISSUED: TO PERFORM THE FOLLOWING WORKC(01,1P '-' 7-- -,,. Add new deck to rear of home, 12' x 16' and 10'x 12' (one deck); TO BE IN ACCORDANCE WITH 780 CMR OF THE MASS STATE BUILDING CODE „egrt-i D TE TIME � ��- F INSPECTION&REMARK -- INITIALTr tq G glo6 1/:a° P" /o Y Q in �� v J� D,� 0 SPECIAL PERMIT(Pec,z O CMR 111.13) $25.00 APPLICATION FEE IS NO ` � ' NON-TRANSFERABLE OUTH. - DATE RECEIVED �a� DARTMOUTH BUILDING DEPAR T 442 11';_ :1, 400 Slocum Road, P.Qo* ' Dartmouth, MA-2747 °�..' syy' Phone: 508-910-1820 Fax: 508-910-1838 /fi64 'V www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ' THIS SECTION FOR OFFICIAL USE ONLY T "RECEIVED BY , ` BUILDING PERMIT NUMBER:.- DATE SENT FOR REVIEW: DATE ISSUED: O.K.TO ISSUE-SIGNATURE - -- DATE: Zoning District: - Proposed Use _ Zone:" t7 C ❑'B ❑A ❑V Aquifer Zone: THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:`, , ❑Board of ❑Board of ❑Cons ❑Demo ,p DPW-_ __ ❑Elec. - 0 Energy Report '. Appeals Health Commission, Affidavit Card Sent: Cut Off Follow-up`. ❑Fire f p Gas ❑Planning ®Sewer Card ❑Water Card . ❑Zoning 0 Other Chief Cut Otf Board Cut Off Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: ,�, Date: tIAAA' +wkiL a,--4--137i-;,,/1-1,,e. 6.,--6( Board of Health: Signature: ,47.),/, ' { 1�( � Date: Conservation Commission: Signature: Date: Other: Signature: Date: Brief description of work being performed: A79R L)e'z=k 4TT ct,icv 7o ref 156— ��x`� . - SECTION 1 -SITE INFORMATION .1 Property Address: % /ye //cO$ �;� 1.2 Assessors t Numb Nearest Cross Street: ( /S Cit'. Map Lot V - �/ it/ Subdivision Name: 'T L I/g¢,J 6pk'/1(/a— ss�� 1.3 Historical District 0 Yes 0 No Total Land Area Sq. Feet: 7/ '2b 9/ Has application been submitted to the Historic Commission? 0 Yes 0 No Date: 1. Water Supply(MGL c4 s54): IL 1. ewage Disposal Syst : 0 Municipal Private Well 0 Municipal On Site Disposal System ❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT The Commonwealth of Massachusetts Department of Industrial Accidents luto, r Office of Investigations 600 Washington Street �, < Boston,MA 02111 5�•"� wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ap I 'cant Information Please Print Legibly ' . of.�e (Business/Organization/Individual): �47ti4 /Tc/47t/L Z/,,1 Askire HOC j 2OS /4wc /State/Zip: A/d ofl-T Ateiz> Phone #: 3 JY-7/ 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. t 7. n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in anycapacity. workers' comp. insurance. g P tY• 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its • required.] officers have exercised their 10.0 Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ 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 tContractors 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. I do ereby certi nder the cn and pe lees of perjury that the information prov' ed above is true and correct Signatur-. - 1 te: y—a Phone#:#.,O /9s 33?/ 6e2 ?/ 7 2 7'Jof" 4 lc Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# FILE „ y 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 burn 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 L,- ITS_ F- .1 1- -, 1( rf RA N'll 1 1". R RT Lv P11, of q tit f. E N T WA. SLI D(- '7 4A, kt7t a' 17� i - > Loll 1;j • •4 0, Lo it 0 m c"�,,, . ' � a •' � f U, rk,4 ro) Amr _ _ - - - -- - I 1.�___ _ _ _ _ � _ ._._ - -