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BP-58886 Permit No BP-13t 8ss j. BUILDING PERM�ITT -� : . �GIS;#: 6 g167I5 00 onwealt ,>of=Massachusetts .. �Map�,�.E�:� �,�-.�0079- �� _�'..-:.TO." A�DART OUTH �_.. ,. -.�s - ". ,+ >-:r�.E. ..- "... :.t . }T w ,' 2 .- ::.:.'"_,.. ?� ".f�a-.al.:��,ta- - ._,^'tc".,:-r _ -�� s�, _- _ ;`T : . .ki;b -'_`. -• - ' - .,'4 o ' fin'"'"- *'?` _-_▪ -'- - Lqt..: ':� ._��:.kOD27 .---a, _-•-._ .._ ,; - 400 Slocum.Road;D'a youth MA 02'14 ` -. :7 ;;Sub=Lot. :� •.U004 _,' 10= 820, • :axe 508 - 10-I838 Wiz. X ,.Cate o OINSTA1�� ▪: A: ,. �.=..r�r.,,. _,_a- r F 9 :_� ,+- ,n.�h.-_'- . ?�� --� r..,.=- xw.:: ,.h, a_m= - - - �7'_.. -- - -_ -_ Protecti# JS-2010-001227 e, PERMISSIONIS' BY GRANTED TO =r,s "7 - -A=:;,, Est.'Cost:�' 1=ZOOOOOr, - , -ti • 135.00 ntr etor:. _ Qt ceense_ ::Phone# .. ___ 'Copst Class; * a ROBER .F L- G x, ,,, GS-c1422� "�' :Y508. 95-8240.s,- -> - =, ,;:Use:.Grou ... -� -,-�123- A .�, o . ,....:, �_�.�a:`°� '.�.�� , � �:��::-�;:�sPhone.#� x .-.�;�,;,, • _" a . � to � �" - LofiS�ze s 963 ��.�.- 'nin g RB+�. �� Ehv `#:: lic;a 0 n A an . »- PP_ y. u►fer ne ...... ..�. LONG BUILTiHOMES;' ,--.� `�;,v �, (50.8}=9.9�=8240 " , . NEB . .. ,- --:--�. :; - � -- q��.:- �•.: LEE CASTIGNETTI�:� -/ ;(50$):�96`5=`3579 x ;At.Cos ONES _ _.. ._...,.. .. .. ... - " y .HQLDEN BRITCE.I1&a W ENE B.. ., - �-<:.' F i..,,s,„.-eTe.,' y::fe; .ed��r-12=24='-OU' ,.�'�" p. DATEISSUEDr• "- Ct-xw= x:c: .-:._°;,,ti ..i n ,: y., M1} _d TO PERFORM TIYEFOLLOWING WORK: n,: _., � - ' ' -;S ecial ermit,foundation'onl With"no: -" arariteei'a ermit,to>wild:'Will--bey`issued - '_.-;-`:_` > P P Y, �„ p, _ ._ -- _ -Pro ect=Location:=70 PINE ISLAND,RD - CL4 FERMI PE T PER 780 CMR 5111.13-'`;�- :- --:..- Approved/Issued By ETTE-LOCAL BUILDING INSPECTOR." :': ,: :'. -=, __.-; _-DAVIDBRUN , r` ode§and ans on:file::---,. .,:';tAll work shall coin 1'with-780 CNIIt_7:..:Ed:: GL;:�Cha�.=d43�andlan�.other:appficable p4lass.Laws o C p• - _- _. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED.;_UPON'COMPLETION OF WORK,FINAL INSPECTION IS REQUHiED. THIS PERMIT" :.,.. z WILL:EXPIRE PER-780•CMR 5110.9(Noy MORE THAN.3"EXTENSIONS:WILL,BE GRANTED)OR._ION ISSUANCE OF;A,REGULAR-OCCUPANCY:-_;:' t`=°` PERMIT. I hereby,-certify;that the proposed work is,authorized,by the owner'of record and-I.have'been authorized.by,�the;o•ner:to make this application as,his agent:,;'=.: . ,,, and.to-receive Rhin'permit, I further ,understand other-agencies may have reason to STOP_WORK-if►tems:under (heir'jurisdiction,.arer not met; not withstandingthe issuance of this Buildin o n P _ - =St nature of Owner/Agent: : -: . i ''RE UE . 'IN I, INSPECTI• S/RE- NSPECTIONFEES:MUSTBE=PAID Comments: PERMIT.-NUMBERIS-REQUII2ED; Q _ ' --BEFORE:RECEIVING.?ANOTHER NSPECTIONAREP NT.•FEE.'•':: , ,-::REQUIREDA 'LOSTrCARD i .-; =, ,_, ',; -."Persons contracting with unregistered contractors do not have access-to the guaranty fund(as set forth in MGL c.I42A)": :_'._ = N_ Inspector of- '- Inspector of : i=-- :'D.P.W.;Inspector-:< Building Inspector. `_::;:,;rR,,,.;;:_;' Inspector of Gas__. Fire-Department _< Plumbing .---':': •.--''''--Wiring-„-----. - _ Water Service#:;--__ Footin s: Underground:-. ' Oil:;`s: "; `_ _ ......'._: :.:_ . .Under round:_':-: s= : Service: :....::- .' .,. ::: _�: ... ,. _ g _ - - Foundation - _ - - •'.�': • ngh_ • Smoke .Ro Sewer Service#• Rou g h F Janie:. Rou h:"_'::•� - -Rou h: � - g g r - - g ry� - ,"_ .Board of Health,.--=,. .,::.: -i,:=E-911` ::',�_ . .- ' .--. - . .; - '".-,< .-.,_.". :_� _ � Additional_Com e tsr�r'�� •�,-� - -- "= .:.. .:=-.." _= .;-. :: = : - a issuance:of Certificate of.Occu anc /Com letion,this'card must be returned to the Building Department with all necessary `_'-,- _ ns signed off. Department phone numbers are listed on the'white:_`Required Inspections"'document provided with'the issuance;of•::r = ='' `s_; �ng"permit = _ SIRI.,F:'FR(1M THF: CTRF,F,T; . pliii''''"'""'''' ae �T Y _ TOWN OF DARTMOUTH A BUILDING RE "IPTS T / PHONE: 508-910-1'$2O 'F 508-910.1838 0 ' r ; /: Name ,,'. I , .,r ;Pro erty / ; f e / (- Date: ,f�' { ) r /J u ✓✓t ! , ?r` � f t f , ;,'""' Owner: ` n ! 1 Job Location: "' 1 / 1/ White Copy-Collector's Office l ` -' Yellow Co Customer's Receipt -' i Pink Copy-File Copy Map: if< Lot: a"�- : - .....,�`, Green Copy-Building Department � Phone: Description General Ledger#'s Ref. # Amount License & Permits -Building 01000-44105 f d, >•- !'j 1'� 1 License & Permits - Building Misc. 01000-44105 A, "�r/�' HMO vi License & Permits - Electrical 01000-44106 License & Permits -Plumbing & Gas 01000-44107 J r. ,; \ License & Permits - Trench Safety 01000-44129 :Other Department Revenue 01000-42420it.+S%�3 THIS IS NOT A PERMIT OR LICENSE FOR BUILDING PLUMBING OR GAS fy Received By: f W=- 'SPECIAL PERMI7‘(Per 780 CMR 111.13) $'15.00 APPLICA . FEE IS ON RE-FITNDA_BIE eSc. tri:qt1,NSFEIIA.BLE Rgj :6 t3iskilYEf RECEIVED -. ,1'. ------ , , DARTMOUTH BUILDING DEPARTMENTf\P_' ':,-1( '- :- Pl :400 Slocum Road, P.O. Box 79399 • ,,!-, Ec 23 43 , i 2 to 17 0 • -• Zi Dartmouth, MA 02747 ii. .v.. ... 7- .;,,,../ ‘°,e• - .s;•-' Phone: 508-910-1820 Fax: 508-910-1838 • -......1..6 61.......... www.town.dartmouth.ma.us APPLICATION TO CONSTR CT, REPAIR, RENOVATE OR DEMOLISH A 0.,,,,E,,,,,R...;-.7..,. .„OE 77,21,,L:).(,:‘,1771-L17,,,,,, • '•'••••'-----•-••••••"...;"'.'. '-'-".-..THIS SECTION FOR.OFFICIALUSEONLY.-:::i...7.7•• ,, .. ,. ,, .‘ , ,,,..,..., '.' .-.:'.:,..'.,-,'. .-.. ,,,'- ,..:••••,.!-2.,..7 :-....::. :.•. •-:• -. ,.:.:..!.:. y•::2iA• :: . :•-,-,..-.:.. ' .::::::::,&.,.,:.i .. ''''''''';:. 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Zoning Review: Signature: • .,e..1 _,... i.,dre-11 i Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: • Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: - - Signature: Date: Brief description of work being performed: Cey......-=)svu...citx:Arv.. olA 11--c3.)-4,, ct.--\--‘ ,......... ..„•.,..:::„_..,.,::,,,.,...:....„......i,.- _..,::.,„..„...:.........:..,:. :.:.,.:.• • ... ..... ........ . • • •..,...."--..:-...,,,,-..,.,..,,,-.•;...,..,:,::.....,,::.,. .:._:......,••:„;:-.:,.;,::::,....,,•)....:,. .,::.4.,_ • ' — '-'''---. -'-'-' - ---- ---- - ,.... --- • •.- -."--:•-•-•-•''::;,'-::,.SECTION'1.,:-SITEINFORMATION :.'-!.;:.,,,,...,..,..............„...,....._........ ,... . . . 1 Property Addr s) k v.e._ I.- &v.-A'..- ..0 0._64 1.2 Assessors Map&Lot Number: Nearest Cross Street: \-\'‘,..3\/\A-V\\.\ Koca-a, Map l'ek Lot ii - 4 Subdivision Name: 0-Ne.e- 1.3 Historical District 0 Yes 0 No Total Land Area Sq. Feet: \\R, C.;1:k c'. .V. 9 Has application been submitted to the Historic Commission. 0 Yes El No Date: 1 1.4 Water Supply(MGL c4(01s5°,4):- .1--%<: C: ..)1)\c'°Ase') 1.5 Sewage Disposal System: 0 Municipal Private Well . 0 Municipal XOn Site Disposal System E3 CONSTRUCTION PLANS 0 SITE PLAN E] ENERGY REPORT RESIDENTIAL /1 ... .'SECTION 2--PROPERTY OWNERSHHIIP,GAUTHORIZED AGENT 2.1 Owner Record: 41 e(3, '.,e- _e'j c_e 0\cKev\ Pia \Nqq -a. PSI 02 Oto Name (print) Contact Addre Phone Number 2.2 Authored Agent: 0$ �°'c�i�M� �+ Blvd. �� cit,a &,R'�� \.2e� S-I-i c ckz Ni..a �c�, M 0-1 1k-1S 5C$-Ot�tS-Vl.40 �-3/ Name(print) Contact Address o ;LL Phone Number SECTION -'CONSTRUCTIONSERVICES -` 3.1 Licensed Construction LupeLisor:::3L2-4:va - Not Applicable 0 (\ icensed Construction Sup ,A S,T . License Number: ��S Oa��cil ddressiS � , �� y MA 004.r. j Expiration Date: I -/7,0k` ILI Signature:re-Q.}... .- F >. Telephone:S-0S 19 S-q'`{O K I3/ak - 00 Ste -244.- k�k ' �� NotA Ilcable Z 3.2 Registered Home Improvem-- Con actor: PP 11( 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 darning exemption from the requirements? 0 Yes 0 No If Yes, submit the required affidavit! > Company Name: Registration Number(if none, state"none"): -Ai Tess: `� 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 ❑ 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. If you are applying under this section sign below: Signature: Your signature carries certain responsibilities,including but not necessarily limited to,general liability i 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.AFFIDAVITi(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: Yes ❑ No ..:; . e._. ..:--._SECTION.5. DESCRIPTION OF PROPOSED;:WORK;(Check:all.applicable). is ❑Deck ❑Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove \gINEew Construction* 0 Accessory Bldg. 0 Roofing/Siding 0 Other nergy 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 4 No. of Baths 2'it 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) uel oil -lectricity,other(specify): ❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other( )g(Air conditioning-(separate unit) ❑None of the above to be provided / '(Hot Water: Gas Electric Fuel Oil ✓ Other Description of proposed.works „.. ,,,. ��,,` + ;v` (� ,, as' r{ t v i (r"Qck Rice. 1.Y(A �.:.1 ". i�h, k. 1/\� C C p . 'A-L.A.-re e ( / CPr Z.i 0 -TCA.""2/3 ava.) .Vy..i. 4 T tsE'- \L,AIN 0.' EEC.LLCA u3 0-Cris q a. 2. SECTION 6: ESTIMATED-CONSTRUCTION SV -.-1 ` Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) � 5 Total (1 +2+3+4) $i` 0 C5U---(-iA- Q.xs.-_0,Nick- .6.... c'..v.d,cOvv.tk.al" c'`x � SECTION 7A OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building-.permit)" N. (Please Print) ii ,, `` -- I, S:'v. \R R. --to\�2w � , as Owner of the subject property hereby authorize ee_ ` mS'R�'✓� c to act on my behalf, in all matters relative to work authorized by this building permit application. L�t•,.�-ey' �V- Date �, 'I mac. S n of Owner �7, .,.—. v'� DS I I Os 9 SECTION 7B:-OWNER/AUTHORIZED AGENT:DECLARATION, I, ' iti , as Owner/ thorized Agen hereby declare that the statements and information 1 on the foregoing appl' ion are true and accurate,to the best of my now edge and belief. LSign nder th ains and penalties of perjury. Si nature of Owner/ orized A n Date SECTION 8 INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: DEC 2 4 2009 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: /LiG27,tsC Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: --4" Date: DEC 2 4 2009 SECTION 9` APP A NOTIFIC TIO Applicant informed of above: Date: / T' e:/2 v 4,1A Comments: 6/7/1/1/ • SECTION 10 :`.OFFICE/INSPECTOR'S.NOTES a 3 A Less Application Ferr$757) Remaining Balance: "L.- ' Total Permit Fee: $ j/ J Other$Amount$ I �} TOTAL FEE: Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: � J'�'��''Y�L�l j.�4 AsmirLifirim _.ate � SECT! .1.1.=ADDITIONAL:COMMENTS/SKETCHES, /1 ,,L oUTH ••. 0 �� 4 1 y•E Dartmouth Building Department ....'ht•<..... 400 Slocum Road P.O. Box 79399 508-910-1820 Dartmouth, MA 02747 FAX 508-910-1838 RESIDENTIAL STATEMENT OF REQUEST FOR SPECIAL PERMIT PER 780 CMR 5111.0 PERMITS I, hereby request a Special Permit pursuant to 780 CMR Section 5111.13 for the below described project. I understand that I assume all responsibility for proper compliance of Zoning and 780 CMR The State Building Code. This is pursuant to 5111.13 Approval in part and will, if required,make any necessary corrections for failure to comply with the applicable code and regulations including but not limited to removal in its entirety of any work performed. Location of Project: � 1�, \-0A 3-1-4 ' Description of Project: ,,Uk-vu,sit.cs,.• �� „+� "�.cy+��. k�cZ `reT;J\,r-eA GZ1CC�v ccV� i.. c k2� At ,4'L .C .. c. S��$t 1.1/4,1/43- 0.-C\-N-e- U. S' Atn o- v tS.j _V Q Sr° 40q Signature of Owne o ut o • ed gen Date Excerpt from 780 CMR The Massachusetts State Building Code 7th Edition: 5111.13 Approval in part:The building official may issue a permit for the construction of foundations or any other part of a building or structure before the construction documents for the whole building or structure have been submitted, provided that adequate infoiniation and detailed statements have been filed complying with all the pertinent requirements of 780 CMR. Work shall be limited to that work approved by the partial approval and further work shall proceed only when the building permit is amended in accordance with 780 CMR 5110.13. The holder of such permit for the foundation or other parts of a building or structure shall proceed at the holder's own risk with the building operation and without assurance that a permit for the entire building or structure will be granted. c:I wpdocs(forms(special.wpd Massachusetts- Department of Public Safeth - { s Board of Building Regulations and Standards Construction Supervisor License License: CS 51422 Restricted to; 00 , ROBERT F LONG 158 CHARLES McCcifilBS BLVD NEW BEDFORD, Mb\02745 Expiration: 5/12/2011 ( I Imnissioner Tr#: 15141 Fik :, COY o Q x 41 O 0 z al ` CI le.:) '- A cn cn P-4 LI-{ : 70-3 7-1 .---, ,r.01 Fr-, , , �' 0 �;��"x?,i. +,\ Z O ■ Ste" •-; .) a ^. r r��j Q Z - �� _ v� v) 0 c. d NO v a o 0 w ❑ - ❑ _ z w Z ._..• a> Z b .� a> 4• v Z c. z \ 3 a �n ao cdo 0 o o o o o o -"".' o o o g c'' g c.; c, ,,,, ©© ,,, 0,0,=... c, 0;,.. © ,_ 00 00 01. , •Tr ,-, tn `4 `*) ,e• 'ee ,.., ,... ,..1 el 4t . z ".•..; 4) c O C ,' Q) '-?..4 ,--• E.-• - ..-.: c, c ..1., .4 ;... , ,......, . , ' :8 ;,... o c,., r.... ,.., ;.. -.... E. , o eq ,-' r •er E-,•• o " -- - V en el 4:4"8 ,E24 g4 • c el a; a; E:::, c ',.k El, • i ,,-7x== ,,,,...._,'-.:',:'." r 4: 4 'cl . ,., (..) c.., E. w.:. cii 7-. 2 72; ,r er © 0 al* 4,:i -* ''',:i 4,_.8, ,4[.,,.,,.4•,.'--E',1.i-,, 4g--- go,..1,-io.,,,.--rw,4-ofia1-, .. , >,., -. . C..z,„ , n — ,-, . ,---, ^ > 7 4'i-i."21 ....7(:'.)''M 'E Zy'I , CO •- . < 0 7 .R.7 --•2 '"Z " '-i-s- ,..= F,,,,..°,4 .,$,) ___, 5 , - "' Fi cEi cEi c, .c,t ....-..,. en C4 IT,' sa y • . — - . u — FS-01"0- •er •-) 2 '1:3 -, •tC -, cn H ?. ....; ....., F E- ,'-:, `•; •..., .. E :.. • o o ,: p i' . u o :.-',.• "•,c o O ot c, 4 -,:s o -' X c,en 9' C.>H ot,: ,, ,--4 ,- i- ,. '' .. rx• - - C.) C.)c,)',--, a O . . ' : . ,44 6,,ct ''' 4- Cr,e‘li, ' ::C.,_): •'U''' 0 0 ,--i ...i C.0, o o • ''' -,t E.a o o 'q • • tre 'T 44 W tel 4:Ze Tt ,4 1:1 1 w c-) ,- • c i---.: IA E--• ., 4k 4 .... e4 o E-. • -•••,-.. a c.) t..,0, - .2 If•ZI ;4 o ,..1:i E4^a •••4 t'. '-' to 7 i7-n• :ES, '0 C:ks., ' Q f.',', t,.> z .-- o c... "o4.— eA 'al c.) ' ris, ,-, 1.-••• cn..,A C•I ', ti W ' ka^-, ''l ct a, , , Q ..-:-C%' 1-,..'. •..' 'C' rip.•/! -ot to/ )•••4 44 o in 44 14, 0..4 14 [••••., 44-,44 ....,,A.,, , •(.„- H it) 64 col ...": *4(q e...1 * o ••, 44 v) c, = © ., C tjwa= cs.' CT IC"-.... .. ..:.:: C.) '''' avt g: , •• = P..-. E 9., .. .... t : Li., cl A „ c..) , ,.. o g .4 (IDe ,,,,, , z., t.t z - = co E-, A ' 5,,, • , •:,. (41 't1 -- ,...,°V Z CID -... IQ ..„...., ,., i-T k 4 CZ ,...-.. 4 ' -44 . ..... 0. .. c:)el .... co c> Q !"..,) , ; 1.' •• ,-.1 E...!g Z -04 il4 ' `...] -•-• q W4;), = n .t 44 ..rj V, t... a 0\ ---4 G.T.4 ct Pz• 6- 4 x,.t ...:: cn en .., - ,., .,. ::, A ,,,.,, '2 cs..!) en,•-, z ,- o i,.'"--;', Ce.• 0.0. L• H in ,. N o ti o © -, © o N_ G O N enN 0> 0� q Zi v] dr I U O 1 1' r N Q cy t W u y ---I y .. o 000 0 0 0 0 ti CL. Er ' q E. 41 p U W i I f�E n d e C2" C.) aA 1! ! � U a� a w o >` > qCG o It V Le) •z o = 0 p U o ,. = E H:ti o moo O o o m o c Q cn Z C4 d W L 1:4 > 4, wV U U. 0 Q(21 U U 1 c tit;N et L. ri q.a o 4 G fir C.)z y m a c U o ,•, o a El o O © •a, I •�,I U y A U © y O ti q 0 o W 0 o o :.' o U The Commonwealth of Massachusetts Department of Industrial Accidents Ise Office of Investigations k - 600 Washington Street ft �+ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): �jc 4cZ WasT Address: 1.58 CMA-R 14. CaASS '44.141$. City/State/Zip: t j 4 '&jp65tZp11,41. eely,5 Phone #: 9,`3,5 `f3?M Are you an employer? Check the appropriate box: Type of project(required): 1. 'I am a employer with Li* 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp insurance. 9. ❑ Building addition [No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have theirrepairs or additions 3.❑ I am a homeowner doing all work exercised 11.❑ Plumbing myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] r*Any applicant that checks b mu3lso ill�cont;the seen below showing their workers'compensation policy information. t Homeowners who submit 0 'QAiikandiUthig they ar&ddoing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: U �Q1�. '111„ _ (3c Policy#or Self-ins.Lic.#: Welkin� Expiration Date: 1{ 101 zp I o Job Site Address: t. X QLW _ 1..�,tz skVb '�jp1 City/State/Zip:'l.R' evZbl t Maw 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 hereb certify nder the pains and penalties of perjury that the information provided above is true and correct. .ram._ S i ature: `' _ Date: 1. e 7g. `- ZOO e1 Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# 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)alsp,states that"every state or locallicensing.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 chapter152, §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 infor`ruatioi(i€necessary)and under"Job Site Address"the applicant should write"alllocations 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 4-24-07 www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE DATE )04/09/2009 PRODUCER 508-923-2220 FAX 508-947-9559 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION -. Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 Paula Schwartz INSURERS AFFORDING COVERAGE NAIC# INSURED Long Built Homes Inc INSURER A: Acadia Insurance Company 158 Charles McComb Blvd INSURER B: Union Insurance Co New Bedford, MA 02745 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR� RATE(MM/f1f1/Yxi DATF(MM/DD/YY1 LIMITS GENERAL LIABILITY CPA0210420 03/09/2009 03/09/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 250 000 PRFMISFS(Fa a urPncP) CLAIMS MADE X OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,006 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —I POLICY I—I JEC°T- n LOC AUTOMOBILE LIABILITY MAA0210421 03/09/2009 03/09/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,006 ALL OWNED AUTOS BODILY INJURY B X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CUA0210422 03/09/2009 03/09/2010 EACH OCCURRENCE $ 5,000,000 X I OCCUR I I CLAIMS MADE AGGREGATE $ 5,000,006 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCA0212243 04/10/2009 04/10/2010 X TORY LIMITS °Eli EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL TOWN OF DARTMOUTH 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUILDING DEPARTMENT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 71 ALLEN STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. NORTH DARTMOUTH, MA 02747 AUTHORIZED REPRESENTATIVE /"'� Rosemary Fulham/PESf* J�j ACORD 25(2001/08) ©ACORD CORPORATION 1988 permit No. BP-2006-5$886A+ Project Location: 70 PINE ISLAND RD Commonwealth of ;` Ma,mass nub GIS#• 16715:00 TOWN OF DARTMOUTH 1VIap. 0079 400 Slocum Road,Dartmouth,MA 02747 Lot: 0027 Phone: (508)910-1820 •. Fax: (508)`.910-1838 Sublot 0004=...;, BUILDING PERMIT category 20 o 0 27 SPECIAL.PERMIT PER 780 CMR 5111.13 Es Cost $12000.00 Fee: $135.00' FIELD' INSPECTION Cbnst.Class Use Group: f,_> R3 :~ Lot Size(sq.ft.) " 119637 Contractor• License: Phone#: Zonmg.,� � S12B ROBERT F LONG CS-51422 (508)995-8240 Aquifier Zone ZONE 3 Engineer: License: Phone#: Flood Zone ZONE A Applicant: Phone#: New Const:° N/A LONG BUILT HOMES (508) 995-8240 Alt.Const.: N/A LEE CASTIGNETTI (508)965-3579 OWNER: HOLDEN BRUCE R&, B TO PERFORM dELWING WORK: O �� yED Special permits foundation only, wit:no guarantee a permit to 1 u'Id_will be 1 SUeC�..__.. DATE TIME TYPE OF INSPECTION&REMARKS• INITIAL \, l�-�� . � L-,zs�i7 / s &t �t� 2(3. \ D . pracw 5 QMP TD%%1\c\ r f _# MAP LOT • 1 7N y OF RTMOU q H INSPECTION CHECKLIST Date: i'/ Permit# 0 New Home ❑Addition ❑ Alteration 0 Dedk or Shed Address: . bpi- Inspector: EO UNDATION4'O O TING/S ONO-TUBES Pass Iral Description Code Section As-built& approved 110.10 Frost Depth 11111 Foundation walls braced 3604.3.1A#1 'MOM Footings on undisturbed soil 3604.4.1.3.1 111..11111 Spread footings 3604.3.1A#4 11 3604.3.1A#3 31111111111111111 Foundation wall grade clearance 3604.4.1.3 Pad location size and size per plan IIMM3605.2.3.313 (table) Damp proofing/waterproofing . 3604.E 111M111111 Anchor bolts/ties &straps IIIIIIIIIIIIII Thermal break/insulation.in place 3604.3.1A#5 .1 MEM All footings &pads free of foreign material 3604.3 1111111111111111 3604.9.3 Columns rust-inhibitive paint& structure =M.• Crawl space ventilation/ 1 sq. ft. = 150 sq. ft. 3604.8 3604.9 Sono-tubes Comments: 3504.3.1 �. 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