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BP-83805r7---- / Perrnit No. y� " � j S ` 405 0 CO i._lI a R '`moo _ Uri c d02C - ,_'400 'tt c 704719o0 Sub Lot - 0000, - 'm444 s: - 8 4' ,.Category I EMO TO: Yroject# JS'2D17-001596 PERMISSIONI ,, v use. one Cost $5000 00 Contractor: ,,,, e 7c 00 f * I - _ 1- p 1 £onst.Glass Engineer: ; m f .r �u - 4 0 s 3 3 Use Group R3, i i Lot Size(sq ft,) 40%65 APpticant: a t- 'I is Zoning * SR11:' JERKY ROG a , $ 1 = (7 :A4uiferLone -i ZONE 3 OwN R: 1 „„„pl X '-.:',-;„1 - -,1.7.--s:--- ''''' .±'--''-';'. -tt fIL.P4 I] `Mood Zone ZONE X . SUPRENANT E A New Const. N/Afr �� x (,Const Nti DATE ISSUED Date Typed 12- 0-2016 a , ` '" _ _ _ 4 '. ,.� �y '9d _ TO PERFORM THE - : , G WORK: $ "- . .41,044,6 . Demo single family home and .arage -". ",,�"� ` .o : 115 P. ' SLAND RD 1 Approved/Issued By: 'A ` •,r` jr-SERVICES PP PA i ' HY, ► ri r - OF INSPECTIII All work shall comply with 780 CMR 8'$Ed.(MGL Chap.143)and any othe. I plicable Mass.L s or Codes and plans on file. Schedule appropriate inspections as required. Upon completion of work,final inspection is required. I hereby certify that the proposed work is orized by th owner.of cdr I have been authorized by the owner to make this application as his agent and to receive this permit, I furth nderstand other en ' may have rea n to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this uilding/Zoning Permit. Signature of Owner/Agen . "Persons contracting with unregistered contractors do not have access to the guaranty fund(III set fo orrth o in MGL L c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Department • Plumbing Wiring Underground: Oil: Water Service#: Footings: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET It;; TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8380 5 PHONE: 508-910-1820 FAX: 508-910-1838 Name: (el � 1 (lie_ Property Owner: t I ern-{fit i... t Date: le_ /t(, Job Location: // Lj !'1 r' ,,,t. /Ci''!,. /e.jf: .,.... Map: 7 4/ Lot: 2 j CART 2,› Description General WW;N Ref. # Amount Building &Building Misc. 01600-44105 jrt;;.Ci lit -7 Electrical 0 000-44106 Plumbing & Gas 0100-44107 s Trench Safety 01000=4 '2§- : Other Department Revenue 01000-42420 ,/ r White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By — l t,• 0, t. '" THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS IESIDENTIAL 0 Phased Approval(R106.3.3) • $25.00 APPLICATION FEE IS NON RE-FUNDABLE&NON-TRANSFERABLE r DATE RECEIVED ���;._•7� DARTMOUTH BUILDING DEPARTMENT fr= 400 Slocum Road, P.O. Box 79399 L -° Dartmouth, MA 02747 �° y Phone: 508-910-1820 Fax: 508-910-1838 !66•' — www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TW!�,1 � ,}gyp F AIG THIS SECTION FOR OFFICIAL USE ONLY _.`a. "---- - "` ` RECEIVED BY: BUILDING PERMIT NUMBER: v OU}e DATE ISSUED: ' 1/61 & ' .,- a,2e, SIGNATURE: DATE: / J Building CornT7' r9f3? o ctor of Buildings Zoning District: Proposed Use: Zone: 0 X 0 B ❑A 0 V Aquifer Zone: THE FOLLOWING AG CIES SHOULD BE NOTIFIED: Z"( I ❑Board of Q f r A, Cons. 0 Demo 0 DPW L/Elec. 0 Energy Report Appeals Health Commission Affidavit Card Sent: Cut Off -up' • 0 Fire Gas a Planning 0 Sewer Card 0 Water Card Other Chief Cut Off Boar Cut Off Cut Off �'R Eel'' S WEC R'S REVIEW BEFORE THE ISSUANCE OF A PE MIT, C DEPARTMENTAL APPROVAL + 4 /� v Board of Health: Signature: _4t4 c c i—e -- Date: /�/ ►/g i Conservation Commission: Signature: Date: Other. Signature: Date: Signature: Date: Signature: Date: Brief description of work being performed: . s l .,- k'v rt t•- I f rg-fd"i 1 J SECTION 1 -SITE INFORMATION 1.1 Property Address: I I PI e, �I—s lan cI '�cl 1.2 Assessors Map&Lot Number: Lot Area(sf.) y co, £ i Frontage 010 (a9 Map '1 1 Lot Jt I - Reauired Provided / Front Yard (PO eai- e)II°5J Yt a 1.3 Historical�B7tst?re4 IH Yes 0 No Side Yard Ji 47 f«l- I,+,a, z i" Year Built (:heft I050 Rear Yard n roeE CIS' reek l2'Altering more than 25%per side of building 1.4 Water Supplyly(MGL c40 s54): 1.5 Sewage Disposal System: Has applicati n been submitted to the Historic Commission? !, CI Municipal 4d Private Well ❑Municipal 0/On Site Disposal System i Yes ❑ No Date: ( I L. Revised 10/11 0 CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT RESIDENTIAL 77 `f f- /C22 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: . .- e) or Ater 4- I--lice d StrS V( 0.61,4( i� Rc'° ill'`15 ,- qic)35 Name(print) on13�t ddre s Phone Number eti',/i! PRO ;?,der, elter, Mtk. � 1'3O 2.2 Authorized Agent: 4� it tit (tckr{,1•Ae► 50e,—G4,1'q19© Name(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES -6:..SiCsS L_' 3.1 Licensed Construction Supervisor/Specialty License: Lic se Number: Company Name/Contractor Name: N i i Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner perfonning 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 ou are ap ing under th' ion gn elow: 7 Signature: a i —ter (s SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(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: 0 Yes ❑No SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) ❑ Deck ❑ Pool 0 Repairs Cl Alteration 0 Chimney/Fireplace ❑Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Roofing/Siding ❑Other (Energy report required) (Shed/Garage) (Specify below) ❑Addition 0 Replacement window/door ® Demolition (Energy report required) No. of windows Doors (Specify below) atstcr on C *If new construction,please complete the following: Single Family: No.of Bedrooms C No. of Baths OZ Two Family: No of Bedrooms Unit 1 No.of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 fit/Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): o Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): O HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): ©Air conditioning-(separate unit) ©None of the above to be pyovided riff-lot Water: Gas V' Electric Fuel Oil Other SECTION 6-ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant • 1. Building 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Total=(1 +2+3+4) t1 �' SECTION 7A-OWNER AUTHORIZATION r (to be completed when owners agent or contractor applies for building permit) (Please Print) �.� I, c A -f S as Owner of the subject property hereby authorize 71I I f,(ct tviNf i .f to act y be aif,i al matters relative work authorized by this building permit application. lot/I 4 11(o u r Date SECTION 78-OWNER/AUTHORIZED AGENT DECLARATION I, `err,1 ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoitig appcation are true and accurate,to the best of my knowledge and belief. Signed under the papfi an napes of pe ' ry. � �� lato Si e u Agent Date SECTION 8-OFFICE/INSPECTOR'S NOTES Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee:$ Other$Amount$ Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: ne/fiVLD(- 6 dtll 4—efrret-e2. SECTION 9-ADDITIONAL COMMENTS/SKETCHES di'iocct C34 ss .eo 0 q id. 1l,- C( f Permit No. BP-83805 Project Location: 115 PINE ISLAND RD Commonwea, h :.. �a sachusetts 110/.',„---„t:-' ;i.'-,-Lip'-.--i---.:--.,:-. -i,..,-•:1''..i;.::::',-:-:-.7, ,,..,:„i3O„.31.,4;:,,,„,„,,, £3 "0J- 4`+3dtH. g itilit� it Y: g.- ,§. F 0 Contra e.ly 44 :o g Architect' ', _ , . 1 � - �_ hone#: v.gx S;W #s y ; � Architepplicnt: � a Phone#: t *''k JERKY RO _ ry _ � (774)454-4628 T 3r % ' OWNER:` PPS s`., ,x9� „.'-- a ->,rn. F ,. ,< " SUPRENANT C &.� g'' � DATE ISSUED: J j ? I�''U 'u 'LiL L7i���1:/ TO PERFORM THE FOLLOWING WORK: Demo single family home and garage D/ATE TIME/ /j/J TYPE OF INSPECTION&REMARKS INITIAL rilTrl 7r „ : ' L-��,� �� ��_ a L„< FRANKLIN ANALYTICAL SERVICES, INC. 401 DELANO ROAD MARION,MA 02738 (508) 748-3156 phone (z ( (508) 748-9713 fax amccoog@comcast.net December 14, 2016 To Whom It May Concern, Franklin Analytical Services, Inc. has properly removed and disposV s Lied asbestos containing materials at 115 Pine Island Rd Dartmouth MA. Franklin Analytical Services, Inc. completed the abatement in accordance with all State, Federal and Local regulations. Within 6 to 8 weeks, Minerva Enterprises, Inc., Waynesburg, Ohio will return a signed waste manifest, which we will forward to you. If you have any questions, please contact me at 508-748-3156. Thank you. Sincerely, Amy Franklin President b rn O RESIDENTIAL ❑ o Phased Approval(R106.3.3) •, r $25.00 APPLICATION FEE IS NON RE-FUNDABLE&NON-TRANSFERABLE A °n - - DATE RECEIVED o ovarNy DARTMOUTH BUILDING DEPARTMENT fi r.lk 400 Slocum Road, P.O. Box 79399 u, -I. "` ^ Dartmouth, MA 02747 b ,664 Phone: 508-910-1820 Fax: 508-910-1838rii www.town.dartmouth.ma.us In r APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TW• FG, z> THIS SECTION FOR OFFICIAL USE ONLY ,�d - RECEIVED BY: u `'C+�� g BUILDING PERMIT NUMBER: 0 v ' 1 DATE ISSUED: a f ,, _.,-,-.7- SIGNATURE: ' Ufa its ,' DATE: i Building Comm'-:boner/In ector of Buildings I Zoning District: Proposed Use: Zone: 0 X 0 B ❑A 0 V Aquifer Zone: 4 a �, .02, 2 fHE FOLLOWING AG CIES SHOULD BE NOTIFIED: / , I( ❑Board of til f 11 Cons. 0 Demo 0 DPW SI Elec. ❑Energy Report ten',, Appeals Health Commission Affidavit Card Sent: Cut Off _up,� to ❑Fire Gas a Planning CI Sewer Card CI Water Card ( Other T >F. Chief Cut Off Board Cut Off Cut Off "RERi S EC R S REVIEW BEFORE THE ISSUANCE OF A PE IT. DEPARTMENTAL APPROVAL board of Health: Signature: '(.lei c, 1—e- a Date: ��1� , / u) et. tO ;onservation Commission: Signature: Date: CMO. — z )then: Signature: Date: 0 Signature: Date: Signature: Date: rief description of work being performed: tt1,fie q or ex►s i,,,el 11 ru;.1- e A-v 1.rI r,- t'1 ,,( 6�"f, °r1 SECTION 1 -SITE INFORMATION `r 1 Property Address: I 15 P (1 e, 'sknel ,'AA 1.2 Assessors Map&Lot Number: o Lot Area(sf.) 4 O, 04.9 Frontage 010 to Map "7 q Lot 4 I - — Required Provided Front Yard WO eel. e)1,S of 1.3 Historical I'Yes 0 No Side Yard 3 0 Feel, Lo r•A- b c. Rear Yard di) pzc1" -F,, re ak Year Built (`.e r r,rk I 050 ,' rt t7 fD MI/Altering more than 25%per side of building 0 5 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has applicattii n been submitted to the Hist ric Commission? N o Municipal Private Well 0 Municipal dOn Site Disposal System teYes 0 No Date: q I t o N O Revised 10/11 a J CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT One NSTAR Way Westwood,MA 02090 EVERS=URCE ENERGY Sif"/ Jill Grammer Re: 115 Pine Island Rd,Dartmouth,MA Dear Ms. Grammer: 7y, This is to inform you that there is no Eversource gas(formally NSTAR gas)at 115 Pine Island Rd, Dartmouth,Massachusetts. We have no gas on this street that is owned by Eversource Energy. Sincerely, Cindy Boisjolie Cindy Boisjolie Planning and Scheduling Supervisor Eversource Energy 175 MacArthur Dr. New Bedford,MA 02740 508-441-583.5 DEC.20.2016 10:11 #4614 P.001 /001 le ctnc, EVERS= JRCE wes���Masasssachusetts02090 ENERGY November 16, 2016 -) ,,o\> Jill Grammer 115 Pine Island Rd N Dartmouth, Ma 02747 =- RE: 115 Pine Island Rd N Dartmouth, Ma 02747 Dear Mrs. 3rammer: At Eversource, were committed to delivering great service. This letter Serves as confirmation that,as of November 16, 2016, the electric service to 115 Pine Island Rd N. Dartmouth, Ma 02747, has been removed. Based on this information, there is no electric power at this address and you may proceed with the demolition. If you have any questions, please contact me at (888) 633-3797. Sincerely, Michelle S. Electric Services Support Center ,� r N z �� yz z C ro ►+ n m op n �G09G0ab Y QC �► O o' o �m 3 C" A ' ' �7V7Zz oa H Z b t7 A� kz CA CsJ m 0. �e tila� - ›»►3 4� ram" g �riy b y_ b �; t} ►r-]H H A Z �r-7 ms. Z'* 6, a ti1 trJ trf m• C CrJ� N O pOP lai t=1 t=1 tl7 t- b trJ - N M. ��1 ,"O OIN) tea... V, t til y A tt 'S7 O 8 04 p b n trJ tilI'" Ai cn-51,0 Hi CA r, o to b .� .►r"y� Y rb w b l'--*k. gi l� `�n Y-1 , t t'-. cn f c• 2_,E•'-,%. w9 g tl V. C" x £o. b C A co L y ,�. p N Z C E. .+ p fl k. (..)-,:, .co 49 c0= ,44 43 iiii OF hil t' o ! ... C ` WNN\ �m ,, A ; + 1+\N N N Q4.t..-- -'9 4 to 000 u,-,via b n � Nco �o g o ` A O. 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N - A,€y: y ►" CA) Z..'" o N �S r� �n V _ VC) W a �p �p aU,V 01 O O r ''e O O O O O 4 0 000 O O n O 0 0 0 0 0 A' 5 N , G N ,, h ;xi A - w 02 a, 'a 0 to 0 LLLL o Ce C v 0 of 00 o U) c Q CO a_N N N 0 Z U " m N O 61) a0 ci 3 w O Y.: en 00 7 tinti c,0 0,en70 0 C . oaoc� N ,- p M M 0) en } 00 ' uO ,' - so ais ,17 rl y ',,,„,0.' O ''a, M C M 7 N _ d 4 M M ,U 'a O, D\co C O N00 OO 00 V'i l� OHO U ® ' A 8 O ,-,,O0-0 0�0 00 ti VG 1.0 G C z iQ�i a cD ON N 00 O00 w U O G aJ iT�� {y b!67 N I!) - 000. 1,151.1 Q.a G N c o � 00 N ou�v orr o p ��nu�� o0o r C7 - 0 O ti w ° o > >00 0 0 w oM Vn IZ'�O M Y o3. o 0 's ' m 0.1 � U ,- EEvo ,- MapUU t o It W U C k, +U�r r ; ybn� � vv = � K000si� s _ _ ° OO= : N '‘Z V N r N,a Ong 0 A Z. U O A h V c g7:0 3 s *q -, g aC7 w d a, e W > O y d hi L y i C y O y O c"R O In •: LE N U rU Joao " o C: r. 04 !� N N 0 r3 W W L °� O N lr,.y U O O O N .-+ o 0 0 0 Q\ N d' '-I Z u d d E .-i O O O O O N O 00 O O A c 3 3 > 3 3 w u T a o � .� V. o a' o m �: o .2 .o U o 0 0 o w F > W co x >G u v�i "c C).)C,. x C' W ° b 'o Z ° "' ''J w° ° .Y .Y ''' '� 8 8 H 5 5 0 ' m .� <U Q W.. Ra A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ,4 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (V ;N ty L.-c-rvascc/1 (.`.t 57Ltt„ 1-i'6' Address: '?A i�) ve j 74— City/State/Zip: R 0 A e- f-, M ew 10 Phone #: 26 3 ‘.2‘..2 Are y n employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees and/or part-time).* have hired the sub-contractors (fullP ) listed on the attached $ 7• ❑ Remodeling 2. I am a soleproprietor ❑ orpartner-ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. [' Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L 1Y) T I f Policy#or Self-ins. Lic.#: t'vr — 3/5 — q3 7 — i1-I C Expiration Date: e /.2 i! / 7 Job Site Address: 1 1 5 p Rie _S mac=v' i City/State/Zip: Nor;-d p r �. 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 hereby certify�un r the pai is air satities of perjury that the information provided above is true and correct. Signature: 1 Date: / 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#: FE'7EIVEE+ 12/13/2016 20:54 al5l8 76 3'6'la INFINITY IT, AC(T R1" CERTIFICATE OF LIABILITY INSURANCE DAtE(MMIDDIYYYY) 12/13/2016 4.THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRooucER GH DUNN INSURANCE CON IACI 64 FAIRHAVEN RD PHONE — _NAME 1 FAX MATTAPOISETT, MA 02739 (NC,No,tal) (A L',Nu} E-MAIL ADDRESS INSURERS)AFFORDING COVERAGE NAIC# INSURER A LM Insurance Corporal on 33600 — INSURED - INSURER H- INFINITY LANDSCAPE CONSTRUCTION LLC 92 PINE ST INSURERC ROCHESTER MA 02770 INSURER INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 33202195 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW I IAVE BEEN ISSUED TO TILE INSURED NAMED ABOVE FOR TIIE POLICY PERIOD INDICATED NOT.P ITFIETANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VvIIIGI I TIIE. CERTIFICATE MAY BE ISSUED OR '-JAY PERTAIN, THE INSURANCE AFFORDED BY TIIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER'J,'., EXCLUSIONS ANC CONDITIONS OF SUCH POLICIES.LIMITS SHOWN VAY HAVE BEEN REDUCED BY PAID I CLAWS. mow _.. LTR 1 YEE OF INSURANCE INSD MD POLICY NUMBER POLICY EFF POLICY EXP _ (MM/OD/YYYY)-(MMIDD.N YYY) LIMITS iCOMMERCIAL GENERAL LIABILITY FA('H CC-CIIRRFNC'F S I _ .Is r,1- E ix, IAt E T 7 RENTFt I ) rERLI r1' A y n� r i.:•l c i. MEDF fiAr .v1 'i I N. R —. I t F:i r i-RP:,TF I MT,,PPI.Ps r'FR CFNFRAl ALI RF!JATF i mc) rCt .J L T 1_..-.1 LCC PRODUCTS C Cfdf'{:r ACC ': I - OTHER _-._._. ..---_... 1 AUTOSA]BILE LIABILITY Ct.I IR'NFD S NI 1 F I M'T -- iEa c Kler0 AN'LIST, RCM I 'INAIR trA,p,,,si I > I , NPr r S:`HECUI Ft; 80CItv-M,;l1R 6 :,,.:rtl 1 - �----- IrIT C -A'!TCSOWNFI:GNI Y FR PFRT+riot,;I;F NeN --_....--- ....__-_.... I. f ul1TCS C-N(-'.' f,!!TC'. ,�-N1'� UMBRELLA LIAR I F CCC-,JR ! FACH rr-r FIG 11RRFF ;. IIII EXCESS LIAR C1A.I15 MACF AL 'RFr';iTF ^-EC RFTEt,fT`Cf7-j A WORKERS COMPENSATION WC5-31 S-608976-026 6'21/2016 6/21/201/ I f FR I CmAND EPW LOYERS'LIABILITY �,I N FTf,T ITF FR _ AN,TICOFR-1 SRrfiPTt rr I XF 'r-' F I. FCC! ACCOFFIT - h00000 TF UI FrLtEFREa iMI I' [Y , NIA --, (Mandatory in NH) - F L G.SFASF FA FIAlI )-EF-S SO CFS':P FT CN CF CPFR/T,,C S!siis.x F I. C,SFASF Pet'.^v L-t.1-T 5, 5000(1(1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addllionel Remarks Schedule,may be,,tuu,d if more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA Th s cart f,Cale cancels and supersedes all prev'ously ssued cert f'cates,oniy AS they relate to workers compensaton coverage. CERTIFICATE HOLDER CANCELLATION WILLOW CREEK BUILDERS LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE WILLOW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3 ONNETBER STT WOODS LLC ACCORDANCE WITH THE POLICY PROVISIONS. PLAINVILLE MA 02762 AUTHORISED REPRESEN IA1IVE . .1 1 LM Insurance Corporal on @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Dartmouth Historical Commission dCif �q- Demolition Permit Review Application— • Supplementary Form to Demolish or Substantially Alter a Building Application must be completed when demolition or alteration of more than 25%of home/property facade is specified on the Building Permit—Section 5— for buildings 75 years or older or of an unknown age. Pursuant to Dartmouth's Demolition Review By-law,Section 4,please complete both sides of this application. The attachments to be included with the Demolition Permit Review Application-Supplementary Form to Demolish or Substantially Alter a Building:a current scaled set of plans,documenting all changes to be made to the home/property,and a current set of project photographs(no photocopies) of the home/property with a written description of all details pertaining to the alteration and/or addition of the home/property. A completed Demolition Permit Review Application-Supplementary Form to Demolish or Substantially Alter a Building must contain a copy of current photographs of the structure to be demolished(no photocopies)and a set of scaled drawings must be included as part of the Application Package submitted to the Dartmouth Building Department in order to be accepted for review.All attachments will be filed with the Dartmouth Historical Commission. DHC will only consider applications filed 5 days or more prior to their scheduled meeting. If you have any questions about this application,contact the Building Department at(508)910-1820 or the Dartmouth Historical Commission(508)910-1890 x595. The Assessor's Office can assist with the building's age and details of the property or by visiting the Town's website www.town.dartmouth.ma.us. Please complete both sides of this form BFILE COPY Property Information Address of Building(s)to be Demolished Assessors Map and Lot Number Age of Building(s) Property Ownership/Authorized Agent Owner of Record -�— �� Name(print) / Contact Add ess / Phone Number Authorized Agent Name(print) Contact Address Phone Number A.Provide a brief description of the building(s)to be demolishe ' r ac lt B.State the reason for o.tthe Demolition Permit request: �j p (4v� it e (7pr l� ...L 4irr I t C I'` e -- -11•,r1 ('Oi S+r't, r E' 'UK./ `7G 171 at. • t Dartmouth Historical Commission Supplementary Application (continued) C.Provide description of proposed reuse,reconstruction,and replacement following guidelines of the Dartmouth Historical Commission Demolition Bylaws: KCIAIri I' t --o IA Sc `'rr•al-e-r-I-y .- 6 l`'JnS1-ruc.1- e .. f.)e 4 hA 1.1e a F--(-e.r' cleiln i ch on o F e Xis+ 1 oi i-s1 6 Nit(.. - `fix‘si,n c� yr fki--ut 1 ci..( - no:i - ii4Q.coo I Owner I Authorized Agent Declaration I, =---":t: o Z.r> as Owner/Authorized Agent hereby declare that the statements and information I have provided on thi applicat on ar ue and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Date This.e on for Official Use Only AI Dartmouth Building Department Date Received: / / By: Dartmouth Historical Commission Date Received: 9/ (1 co By: ist i rical Commissio 's Review be reco ed ow. tioApproval to Issue Demolition Permii•� By: y Comments: DHC Revised March 6,2013