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MAP 79
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IN 10001.01 !
E20257.19-
Ewew M
RESID'c,aTir1L
❑ 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 involvingthe structural elements of buildings
g
or structures, unless he 07 she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeclivner 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 here to do such work, that such Homeowner shall act as supervisor.
Fo
r the
s of f this purposes s section only, a Homeowner' is defined as follows: Perso
n(s) who owns a parcel of land on which he/she resides des 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 pieriod shall not be considered a Homeowner.
If you are applying sunder this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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
buildingpermit. Signed
p 9
Affidavit Attached: ❑ Yes ❑
N 0
❑ Deck
......:: S
.:... :... .:.: N.5 ...DESCRiP.TION OF. PROPOS ED WORK
❑ Pool
❑ New Construction*
(Energy report required)
❑ Addition
.(Energy report required)
❑ Repairs ❑Alteration
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows Doors
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
aeck�Ip licabie}
❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ Roofing/Siding
❑ Other
(Specify below)
❑ Demolition
(Specify below)
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
Description
roposed>yorr
ignature of Own e Date
! lvtV t� VVVNt:K1AU.1 HULARATION
C���
as Own authorized Agefl#-hereby declare that the statements and informa-ition
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the p,-xnd peng],#es of perjury.
c
Signature of Owne�a, uthorized
It
Total Permit Fee: $
TOTAL FE.`:
Permit Issued tc
Less Application Fee: $25.00
Other $Amount $
l Gross Area New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
,_ .�_ - •'"F`_ �" ��_. .=-sue --
IRemaining Balance: $
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$,2315,00) P,SDPY.SCATIO1@ FEE IS NON H6E-FUNH6AIB'H.E NON='H'&6t\19TSFEH6t@bbF.E
DATE.RECEIVIED
DARTMOUTH BUILDING DEPARTMENT
Z-oniny rceview:
Energy Report:
Fire Chief:
Board of Health:
Conservation Commission:
Other:
Brief description of work bein
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Feet:
01y11dLU1U:
Signature:
Signature:
Signature:
Signature:
Signature:
g performed:
1.4 Water Supply (MGL c40 s54):
� ❑Municipal ❑Private Well
1
All
GEC
Date:
Da
Date:
Date:
Date:
VIA
1.3 Historical District 0 Yes El No
Has application been submitted to the His:foric Commission?
0 Yes 0 No Date:
1.5 Sewage Disposal System:
0 Municipal 0 On Site Disposcl11 System
PLAN . [I ENERGY [,REPORT