BP-44059RESIDENTIAL
2003
RESIDENTIAL 2003 j
SECTION 2 - PROPERTY QWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
'
- rX�
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
-le
&.0001, 0 -A./ le-2—
Name (pant)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable F�
Licensed Con�.tructlon Supervisor _ J
,��� �� ��, -,� � �..�w._.
License Number
Address
Expiration Date`,
Signature -�- Telephones/�.,��
3.2 Register ome Improvement Contractor:
Not Applicable 0
Are you a Home Improvement Contractor subject to 780 CMR-6)? �S"yes 1:1 no
If no, go to the next section!
Are you claiming exemption from the requirement? 0 yes �'no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
S i gnatuf `�-- -� Telephone%�)11,-yqEx
iration Date _
3.3 For Resid : emodel Work Only
PERSONS CON7TRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Hclme Improvement Conti-actol's Registration, One Ashburton Place - Room 1301, Boston, L11A 02108, (617) 727-8598
J
1 Owners Name (print)
' �ignature
by signing the above, the home owner acknowledges that there will be no eligibilty 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 supen•isor.
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who mvns a parcel of land on which he/she resides or intends to reside. on
«-Bich there is, or is intended to be, a one or tNvo 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
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construc�ttfion
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)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide tliiis 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* 0 addition ❑alteration drepairs ❑chimney/ ❑ wmdstove
(energi; report regtrif•ed) (enei-g3� report mgzcb•ed) fireplace
O deck ❑pool ❑ accessory bldg. replacement window/door O other O de molition
(shed/garage) no. of windowsJ F doors 0 (specify below): (speciffy 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
v I10. of bedrooms unit 2 no. of baths unit 2
❑ Furnace (hot air) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
El Boiler (Beating) -fuel as (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) -primary fuel, natural gas, propane, electricity, other (specify):
o Air conditioning - (separate unit)
❑ Node of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
I3i•icf Desci-iptioii of Pr-oposed Work.*
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildinm
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) *Estimated Total $ / � d77� , eo
SECTION 7A -OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(pleasrj print)
I, /;9,,, as Owner of the subject property hereby authorize
to act on m ehalf, ' a14'`, atters relative to work authorized by this building permit application
Signature of Owner Date
SECTION 7B -OWNER/AUTHORIZED AGENT DECLARATION -
I as 19r/Authorized Agent hereby declare that the statements and information
on the fore oing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature � •/Authorized Agent ate
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Rev. TJanuary 19, 2001
RESIDENTIAL 2003 RESIDENTIAL 2003
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
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:
d. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
Z.
9. Insp ector's Sig nature: Date: /49 1
SECTION °- A PLICANT NOTIFICATION
40
AClerk:
f
licant lnfor e ofabove ve Tim
pp
Id
Comments:
41
/ / J .. U./
CTION 10OFFICEVNSPECTOR'S NOTES
4
Total Permit Fee: % Remainin Balance
Less Application Fee�5-0( g
TOTAL FEE:_ a Gross Area - New Construction totals . ft.
Gross Area - Alteration total sq. ft.
Permit Issued To • 7 A /V S e L 14� = 4e �ef
-C ' 1v 7 i�v t � �� � �' � So
T
Z-7 C V X /,I z7,4/ C e 4e **�7
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
Z A
/000" ez_ 6X
�i
❑ FO UNDA T101\ I ONL Y
$25wOO APPLICATION FE E ES IVGI'JnRE F UNDABLE &s IVOlVoTRANNISFERABLE-
DARTMOUTH AUILDING DEPARTMENT
400 Slocum. Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
H b.• _ _ T 1.-M
DATLJ RECEI-VD
7"
sit 21 P
.APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAn./'1ILY DWELLING
THIS ECTION FOR OFFICIAL USE ONLY
RECEIVED BY: , BUILDING PE �JT
DATE SENT FOR REVIEW: �.� ,� �- NUMBER:
DATE ISSUED:
OK TO ISSUE -SIGNATURE: DATE =r 11
Building Commissioner/Inspector of Buildings
,�
6
Zoning District. Proposed Use: Zone: Ic ❑ B ❑ A ❑ V Outside Flood Zone [J Aquifer Zone
THE FOLLOWING AGTENCIES SHOULD BE NOTIFIED:
❑ Board of 0 Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Energy Report
Appeals Health Affidavit Card Sent: = - :Cut C'�ff -.....Follow-up*
❑ Fire
Chief
Zoning Review:
Energy Report:
Fire Chief. -
Board of Health:
❑ Gas
Cut Off
❑ Planning Board*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL _._... _._._._ .....
/`) _
Signature:
Signature:
Signature:
•
Signature:
41
Late: 11g I-Ime C
L7ate:
Late:
Late
Conservation Commission: Signature: - ate:
Other: Signature: mate:
Descr )doll of ivork being performed: Lo�-Z7�' ,!
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes f, -no
1.2 Assessors Plat` -tot Number: r�
1.1 Property Address: //Deer'
p y '-" Plat ffL__�
-
Nearest Cross Street:
1.3 Historical District Elyes PE':rno
Subdivision Name:
Total Land Area Sq. Ft.: Has application been submitted to lthe Historic Commission?
❑ yes ❑ no Date:
1 1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
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❑ Municipal❑ Private Well
Page 1
❑ Municipal >1�1, �n Site Disposal System
Rev. January 19, 2001