BP-434 BUILDING PERMIT 1///
FIELD INSPECTION
Dartmouth Building Department Plat: 079
400 Slocum Road-P.O. Box 9399 1 Lot(s) : 30
North Dartmouth, MA 02747 _. Lot Size: 2. 77A
Telephone 508-999-0720 Zone Dist. : SRB
Issued Date: 12/29/95 Permit No. : 434
Project Location: 112 Pine Island Road
Number Street
Subdivision Name:
Nearest Cross Street:
Applicant/Agent: Robert & Karen Peckham
Contact Person Phone #: (508 ) -995-9137
Proposed Use: Residential
Residential,Commercial,Industrial,etc.
Permit Issued To: Alteration
Type of Improvement,Add,Alter,New Const.,Demo,Land/Move,etc.
enclose sunroom ( 117 sq. ft. )
indicate no.of bedrooms and bathrooms and other rooms
owner(s) of Record: Robert & Karen Peckham
Address: 112 Pine Island Road, North Dartmouth, MA 02747
DATE TIME TYPE OF INSPECTION REMARKS I INITIAL
Lva�-f-
PUG 1 3 1996 _ . i /44
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1-1 ii ii: L 0 I NG r-----.47. 1411 I i
400 SLOCUW Road-PO.
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North Dart:fp o ut h, t.,-10 02747 Lot Si z e :
T e•1 P dl:0 e e 501---1--994-)-0720
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be'7'. 29, 1 9'5 yl s,.,n,fro,-., __ ,
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Pro 4ct Locat i or : 11pe l_s land Road_SU bd v i s 1 o it N.3 VI E.? ;Nearest Croce Street :
__-
Applicant /Agent : _ Robert, nPrec_i-ctia;r!Addrss : 112 Pine Island Road_, Nprth Drtmouth, MA Lit2'74}7 .
Cott
c'- P'ersrr Phone
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ype of License : Owner: (x) Const. Suerv. License # ; ( i
Prchatebt : ( ) Endineer; ( ) Other : ( i
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Arop.oc•Poi Use: Resident -.Lai
------7-47:cerrt :-;Lazz*,---tal, --
C. ,3r t-fi t 1 s d T.o : _ Alteration
Ty, ,,,,F 7 epro,•mant,74e—r7"., ial tg.";:., rie:..4 r.:41rIct., botma. Liketzt.`ril-ket, e:trz.
,.a. -::1' bear m s in0 .tathr t -zrs ant. a P-2,4,
of Chnst. ; 117 sq f t lost _of Lost -lit h er 1 'c.)1-1 st, : TnTpL pE,r--. : $ .3 .
Owner ( s of Rernord : Robert aarenC-?eckham,
Ad d re. es ; 11E' P a n e 1 s land Ro ad No t h D Tout , r10?)47 _
Pll woy'k eheill comply with 760 DYIR 5-th Ed. ('IGL. Chap. 14,-T'.) arc anY
other applic.-able Mass. Laws or codes orb plans or fileL
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1 hereby cer-tify that the proposed work is authorized by the oner of record and 1 have been authnrized by the ner to m_ k=- tha -.
application 3e his ailtborize, aoent.
S i on at IA r ia 0 f Own e:7 er4 0 n t ,_ AiOr oillw, -
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pprovod/ IssueC B : -.Tool t'D. Reed, 1.-. .--:3' Ruilding incdector
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Required approval Approvals received
please (X) :approvals Please (X) approvals and
required for this project Initial as received
DATE INITIALS
Zoning
1/ Building Comm. DEC 2 8 1995 pt/C._
Board of Appeals
Water Card
Sewer Card
Board of Health
Bond
Selectmen
Conservation
Fire Chief
Cross Connections
Licensed Contractor
Controlled Const. Affid.
-106 /Other information required 17);`y
S
s uTK U.,- p i_ (/v, r---- PERMIT NO.
4 -MA TOWN 0 DARTMOUTH DATE ISSUED 3a
o TOTAL COST
wi APPLICA' ION FOR ��
'16yy` ,, LESS APPLICATION FEE "�.
' Ia__ BUILDING P RMIT FINAL PERMIT FEE
fl 4 r7
4
LOCATION OF BUILDING
01 Number & Street /, l' a"'; 5'R� ,; /7t// ! 01.1 Zoning District
•
02 Cross Streets(be 6Ten) and
03 Lot `C Plat _,)----1(4 Subdivision Lot
OWN, RSHIP COST
05 DI/Private (individual, corporation, 36 Cost of Improvement 'T ' 'C_%
non-profit institution, etc.) 36.1 To be installed but not
06 ❑ Public (Federal, State, or local government) included in the above cost
-4 TYPE OF CONSTRUCTION 36.2 Electrical
07 ❑ New Construction 36.3 Plumbing
08 ❑ Addition -Type of Room(s) 36.4 HVAC
09 ( Iteration 36.5 Other - Specify
10 ❑ Foundation Only example: elevator
11 ❑ Demolition (#of units if residential) 37 TOTAL C6-1()
12 ❑ Moving (relocation)
STRUCTURE
STATISTICS 38 food Frame
13 Number of Bedrooms �� 39 ❑ Masonry (wall bearing)
14 Number of Bathrooms (Total) 40 ❑ Structural Steel
Full-Tub _< 41 ❑ Reinforced concrete
3/4 - Shower 42 ❑ Other - Specify
1/2 - Toilet Only
RESIDENTIAL-PROPOSED USE DIMENSIONS
15ne-Family 43 Number of stories
16 ❑ Two or more families 44 Total square feet of floor area, all floors, a ,
Number of units based on exterior dimensions ` ° 5�
17 ❑ Garage
18 ❑ Shed 45 Total land area, square feet :.,cikfeZ_S
19 ❑ Carport - --;,. .3 ---laa
20 ❑ Swimming Pool SEWAGE DISPOSAL
In-Ground Above-Ground
21 ❑ Woodstove 46 ❑ P is or private company
22 ❑ Fireplace 47 nvate (septic tank, etc.)
23 4eOther - Specify, J 4,1 ie 4. ` ) e(.;„.,_mit;y�,`-
WATER SUPPLY
48 ❑ Public or private company
NON-RESIDENTIAL - PROPOSED USE 49ivate, (well, cistern)
24 ❑ Amusement, recreational 25 ❑ Church, other religious PRINCIPAL TYPE OF HEATING FUEL
26 ❑ Industrial 50 ❑ Gas
27 ❑ Parking Garage 51 PS-Oil
' 28 ❑ Service station, Repair garage 52 ❑ Electricity
29 ❑ Hospital, institutional 53 ❑ Coal 4
30 ❑ Office, bank, professional 54 ❑ Other - Specify f
31 ❑ Public utility
32 ❑ School, library, other educational TYPE OF MECHANICAL
33 ❑ Stores, mercantile 55 Will there be central air conditioning? ❑Yes CY"N
34 ❑ Tanks, towers 56 Will there be an elevator? ❑Yes ! to
35 ❑ Other- Specify
PARKING PER ZONING BY-LAWS
57 ❑ Enclosed 58 0 Outside
59 Does this building contain asbestos? E YES E .IX NO If yes complete the following: ,- F
Name & Address of Asbestos Removal Firm:
IDENTIFICATION - To be completed by all applicants PLEASE PRINT
60 Owner (print) G C % r7 !e,6/s/fi '1 / /. 5s'/7
/NAME MAILING ADDRESS TELEPHONE NO
61 Signature fGtF': _ r s7r.: DATE ZAj :.
Builder's
62 Contractor (print) '' ' License No.
NAME MAILING ADDRESS TELEPHONE NO.
63 Signature DATE
64 Architect or Engineer (print)
NAME MAILING ADDRESS TELEPHONE NO.
65 Signature DATE
CERTIFICATION TO PERFORM WORK
66 I/We hereby appoint
NAME ADDRESS
as my/our agent for the purpose of applying for and obtaining a building permit for the work to be done described in this ",
application.
Signature DATE
ADDITIONAL INFORMATION
67 Has A-1 or Determination been issued by Conservation Commission? ❑ YES ❑ NO
Submit copy of notification sent to DEQE and the State Dept. of Labor Industries and result of air sample analysis after
asbestos removal is complete.
68 Owner or Agent - I certify under peril of the penalties of perjury that the information herein is accurate to the best of
my knowledge./ /
Signature /.' DATE t= /:?
Owner or Agent
69 BOARD OF HEALTH REVIEW DATE
Inspector or Authorized Person
COMMENTS:
70 DPW- WATER Service No. SEWER Service No.
To be completed upon issuance of permit- (if applicable)
71 I will post permit and address so as to be visi from street.
Signature
DATE -1, ./. l/D
,f'a— •-•�' Owner or Agent
72 I have received list of required inspections
Signature DATE
Owner or Agent
73 FOR RESIDENTIAL PROJECTS OTHER THAN NEW DWELLINGS:
Are you a Home Improvement Contractor subject to the registration law(780 CMR-6)? YES NO
Are you claiming an exemption from the law by homeowner sign-off? YES NO (if yes,submit required signed affidavit)
Contractor's Signature: Date
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND
(780 CMR-6) QUESTIONS or COMPLAINTS?
Call or write: Home Improvement Contractor Registration
One Ashburton Place-Room 1301
Boston,MA 02108
617-727-8598
Owner's Signature: Date:
1
1 RECEIPT FOR PERMIT
TOWN OF DARTMOUTH L13 Li
ouTR.M PERMIT O.
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o No
64 18 / Date n / ' dQ q 4
in Y
Received From ktAJ. /f-Ita r `'_
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Owner ,•'~ j I
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Location i ' r u ..-4_ " .. _. '`�-.:)- \J_-1,,_�.(`. - ) y`
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Type _ -.• 1
'7,.• C. �f
Amount Paid (� , ��--,''`___
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Received By, ___ ! f _ L k._,L I J ._
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RECEIPT FOR PERMIT /
ouTR.,y TOWN OF DARTMOUTH F'
e��� R ,
MIT NO.
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if,y s L
3
Date
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Received From -( u&
1 � -s
Owner /j
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4.11 Location 41 �� 1 ._ it__C: fA,„. 1
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Type I 1?. rJ -.,1 A_r- (-...7I
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Amount Paid '," i - `-' ;(? :! ]
Received By ,J A ,fc , , ! t ;,.
'. `„'�� The Commonwealth of Massachusetts
kri ~ _�e Department of Industrial Accidents
�! =- _ Offlceof/ni2Sffg�ODS
:� i 600 Washington Street
_ '% Boston, Mass. 02111
`"� Workers' Compensation Insurance Affidavit
pplicnnt-inTormatton-- ;rt:.-,.. :. _. .._,..�_,- 1Pl ...,.._-„....::w.::.:.
. =ma`s �'r' ,✓',�• I A(._ 7
loc_.:o
cin• ,r';/1%', 1 24 ''a, > .7:1 7 ' ohons ;„ .. _
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.g I am a homeowner performing all work myself.
E I am a sole proprietor and have no one working in any capacity •
i am an employer providing workers' compensation for my empioyees working on this job.
company name:
. .
address: _
cin':
ohonc#:
insurance co. policy#
_ -
I am a sole proprietor. general cnntractJr. or homeowner(circle one) and have hired the contractors listed beiow wh.2
the following workers' compensation polices:
company name:
address:
city: . . . ohone-Or
insurance co. policy-#::. _
•
company name:
address
city: phone•#r -
insurance co. policy#':> '
Attica additioa'ii sheet ifaeeessan _- -_ ' -- __ __ 3- . „� :-" .c.- - ,, - - -_ -
' .r•.�.rr .+. ..'.. s_ -'.. -ate a,. _..� _ �__� �. •-.-.• ••_.�:�-y:Y ;r-:`i:'c:'��.' _._'•--=.T.�--..sue._ .;,--!;—
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminai penalties ofa fine up to S1.500.00 a.
one.ears' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand t
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby renin• nder the pains and en • f perjury that the information provided above is Hate and meet
Signature /l46f.p,_ -i1 Date /' l/' -7
Print name /�j/. / Aei e7/ Phone* - . 2
official use only do not write in this area to be completed by city or town official
city or town: permit/license# riBuilding Department
[(Licensing Board
check if immediate response is required [(Selectmen's Office
[(Health Department
contact person: phone#; rtOther_______--.
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for :
employees. As quoted from the "law", 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 m
the foregoing engaged in a joint enterprise, and including the legai representatives of a deceased employer. or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However ::
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 ::_
or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe
MCI chapter 152 section 25 also states that every state or IocaI 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, 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
been presented to the contracting authority.
ppiicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation ar:d
supplying company names, address and phone numbers as all affidavits 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 require.
to obtain a workers' nompensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has providea-a:space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pis-
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned
the Department by mail or FAX unless other arrangements have been made.
The Off:.e of Investigations would like to thank you in advance for you cooperation and should you have any questic.
please :o not hesitate to give us a call.
•
T :e Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone 4: (617) . 2 ,-4900 ext. 406. 409 or 375
TOWN OF DARTMOUTH BUILDING DEPARTMENT
TELEPHONE 508-999-0720 FAX 508-999-0738
•
•
TO:
Fire Chief Dist. 1, 2, 3 ❑ Board of Appeals
( // Tax Collector D.P.W. Engineering
__I Board of Health ❑ D.P.W. Water/Sewer
❑ Conservation Comm. ❑ Cross Conn./Water Div.
•
Selectmen-Licensing ❑ Planning Board
Town Clerk ❑ 9-1-i Police Department
The following is forwarded to your office for your information
only - no response is required. PLEASE PRINT
The Building Department is in receipt of an application for
Plat 2e,7 Lot _TO , Address irfZ /;%1 cc / 7
by 1,�� 926 /3 % to
CONTACT PERSON&TELEPHONE gj�
mac/-• "�/- l • demo,construct, alter. occupy,
a(n)
•
The plan was received by this office on ,
• date
This office will review said plans and subject to availability of potable
water, where required, the provisions of Zoning By-law per MGL Chapter 40A and
MEEC 780 CMR 5th Edition will have available to issue or will deny a permit for
the above-mentioned work within 30 days of date of receipt.
The applicant has been advised that your office as indicated above may
rewire them to apply for licenses or permits subject to your jurisdiction and
that they should contact your office, as indicated, for specific information.
It is not necessary to respond to this notice unless there is a specifi=
issue at hand or you wish to forward material or information required for
Permitting. When required, an Occupancy Permit will not be issued until all Town
Agencies have had the opportunity to "sign off" that the work under their
jurisdiction is complete to their satisfaction.
To The Applicant:
Be advised that this notice will be sent to the Agencies checked above as
they may have separate jurisdiction for your project. Any questions about the
Agencies Regulations & Policy should be addressed to the individual Agency.
Your signature acknowledges your receipt of a copy of this notice.
2;445-1,67 ,
APPL1CaNTTELEPHONE iPLEASE PRINT SIGNATURE DATE
LICENSED CONTRAC.T OR'S NAME.TELEPHONE tPLLASE PRINT SATE
• .
THE COLLECTOR'S OFFICE
DATE= / i1j 02 lb
TO: BUJ: IING DEPART!LEMT
FROM: COLLECTOR`'S
RE : PAYM.E1 T OF PAST DGE arras
P. SE' BE ADVhSED ON TSI3 DAY ._
PROP £OC Tm ON // P R #
HAVE BEEN PAID D. WE Pz z' w zca• 5 BE$T $z:cUZSTED My .tea
ISSZJ,ED. III' YOU BAYE ANY QUES211'01 .5° CONCH T833 PI1E SZ
cc DEBORALT L. PIVA
1 v III 111 yr L#1 11 II IVIVv III o JNUL/ gri LOGI- AR I IVIci�
TELEPHONE 508-999-0720 FAX 508-999-0738
•
TO: g
Fire Chief Dist. 1, 2, 3 D Bo id of Appea- s
Q '
Tam Collector D.P.W. n9 ineering
C 'Board of Health W,-ewer
•
Conservation Comm. EJ Cross Conn./Water Div.
•
Selectmen-Licensing Q Planning Board
QTown Clerk Q 9-1-1 Police Department
The following is forwarded to your office for your informatioi
only - no response is required. PLEASE PRINr.
The Building Department is in receipt ofan application for
Plat 9 , Lot 37 , Address /4o2 ripe zs41/7c✓p . ,
by e..s-rri 9,5-913 7 to e/ese- v,� &;;
CONTACT PERSON le TELEPHONE# !/b/ 9/- 3/7 ) �7�.s y s� deem co-..r,ct occupy,
alter. ocev etc.
a(n) •
The plan was received by this office on /Q c9
• • • deft
This office will review said plans and subject to availability of potable
water, where required, the provisions of Zoning Hy-law per MGI, Chapter 40A arc
MSEC 780 c11R Sth Edition will have available to issue or will deny a permit fcr
the above-mentioned work within 30 days of date of receipt. ti
The applicant has been advised that your office as indicated above may
require them to apply for licenses or permits subject to your jurisdiction and
that they should contact your office, as indicated, for specific information.
It is not necessary to respond to this notice unless there is a specific
issue at hand or you wish to forward material or information required for
permitting. When required, an Occupancy-Permit will not be issued until all Town
Agencies have had the opportunity to "sign off" that the work under their
jurisdiction is complete to their satisfaction.
To The Applicant:
Be advised that this notice will be sent to the Agencies checked above as
they may have separate jurisdiction for your project. Any questions about the
Agencies Regulations & Policy should be addressed to the individual Agency.
Your signature acknowledges your receipt of a copy of this notice.
As9 G_ -aTeZh,
59 7-71,r)45-
.APPl1CA\1 ELEPHON'E(PLEASE PRINT SIGNATLBE DATE
-:LENSED' TOR'S N.imE-ELE?F?ONE,PLEASE PRINT -._
, •
FILEL
I r 0.•
TOWN IF rl7.P.90U111
RECORD PLAN
A Copy Of This Endorsed
Plan Must Be Kept On Site
DuringAgskroion
Date
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