BP-19925RESIDENTIAL
2001
RESIDENTIAL
2001
ON 2 - PROP
2.1 Owner of Record:
f ! ,n
Name (print)
2.2 Authorized Agent:
Name (print)
RSHIP / AUTHORIZED AGENT
Contact Address Phone Number
Contact Address
Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address
Signature
3.2 Registered Home Improvement Contractor:
Telephone
Are you a Dome Improvement Contractor subject to (780 CMR-6)? ❑ yes 0 no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑yes ❑ no
If yes, submit the
required affidavit!
Company I�?ame
Address
I Signature
Telephone
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
1,
3.3 For Res idential Remodel Work Only
v
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTION' OR COMPLAINTS call or write:
Hoine In p -oveinent Conti -actors Registi-atlon, One Ashbui-ton Place - Roonr 1301, Boston, jVA 02108, (617) 727-8598
Owners Nan7e (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeo,�z-ner 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 en -ages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the pur,oses of this section only, a "Homeowner" is defined as follovvs: 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 tome in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature: r
Your signature carries certain respobsibilities, 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 Constfuction
Supervisor,
whether or not they have taken the permit
are responsible
for code compliance. (see Appendix of 780
CMR R5.2.15).
I SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to providiP this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑yes ❑ no
SECTION 5 -DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction*
(energy report required)
O addition
(energy report required)
❑ deck ❑pool 0 accessory bldg.
(shed/garage)
* If new construction, please complete the following:
❑ alteration ❑repairs 0 chimney/
fireplace
❑ replacement window/door ':M:other
no. of windows . doors (specify below):
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 (specify):
❑ Air conditioning - (separate unit)
o None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: A_J�- t � � �/ D
Item
. Buildin
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
El 'woodstove
El demolition
(specify below):
Estimated Cost ($) to be completed by permit applicant
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) *Estimated Total $
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 mat ers relative to work authorized by this building permit application.
`Q��; � S z�
Signature o�Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
60A. ITIf as Owner/Authorized Agent hereby declare that the statements and iinformation
on the foregoing application Art true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
L Z2�
Signature of Owner/Authorized A eni
tl-
Date
C:\bldg.forms\Bl( ,(Tapp.res.«,pd Page ' Rev. January 19, 2001
C:\bldg.forms\Bldgapp.res.wpd
Page 3
Rev..?January119, 2001-
RESIDENTIAL
. . * -.._ : -
. . "� . . . I . �-. - .� - --. . .. � -.�I_ -. Y . -" "SECTION 8 - INSPECTOR'S REVIEW/COMMENTS -' - I - - - - . . - -I �
. - . . .. ��
1. Date plan reviewed: ,wn.--, C- q10010 � / I
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:
Date: •
7. HOLD subject to Board of Appeals action:
.
Date.
•
8. Comments: .
Co
, '
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9. Inspector's Signature: �:
JA eA
Date.
�� 6 i
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PPLI NOTIFICATION ON -VSECTION9 A NO CA
.
App '_scant informed of above Date: Time: Clerk:
•
Corru-nents •
_ - _-
I S N E C `I CTOR S O S
- - ' 'SECTION 10MFFE N PE T ' . -
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, - _ . . . .SO
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Total. i Fee. f
Permit3C,.;,,),
$ �o
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Less A licatl n F e. 5.0
Application e 0
•
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Remaining Balance
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TOTAL Grossre ew
O Area N Construction totals ft.
q
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- .SECTION I I - ADDITIONAL COMMENTS/SKETCHES I
_ - _ _ .
IZESIDENTIAE 1 2001
o FO UNDA TION ONL Y
. *
$25w00 APIPLECATRON FE E ES IDDIVoREFUNDAMT TZ.. & X0XwWRA1VSF1E;-'1"RABL1:
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. .....-OLI��-.... DATE REC�� IVED
N %1. DARTMO UTH BUILDING DEPARTMENT • _.- I . .
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%_____ 400 Slocum Road P.O. Box 79399 : . _
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APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY E`WELLING
THIS SECTION.FOR OFFICIAL USE ONLY _� .
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. _ REQUIRES INSPECTORS REVIEW BEFORE THE"ISSUANCE.OF A PERMIT ` J. ~ . r. �~
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DEPARTMENTAL r - - -
APPROVAL _ ��,
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Zoning Review: Signature: Date: L.
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: L Date:
Other: Signature: Date:
Description of work being performed:
_ _ -
SECTION -SITE INFORMATION .e: - : , - - - : _ .
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NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes 011 no
1.1 Property Address:lbe7AI,r; e �.�-:5 fise.�J/C."6'
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Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
0 Municipals Private Well
1.2 Assessors Plat &Lot Number:
Plat4 'jC� of y �, r
-
1.3 Historical District ❑yes Ono
Has application been submitted to the Histforic Commission?
0 yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site; Disposal System
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