BP-53132IV 4-1-1 11
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SECTION 4.- WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL'c 152 § 25)
EC S TION 2 PROPERTT.OWNERSHiPIAUTH4RIZED-AGENT..
2.1 Owner Record:aowm" I
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' � 1
15-, Qt,�, vt V-�
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
C& rN V t S �_, 3
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C4,"VIS
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Name (print)
Contact Address Phone Number
_ -
=SEC ION3 CONSTRUCTION ONSERVIcES ::
3.1 Licensed Construction Supervisor: ;� ,� ` _�'
Not Applicable 0
Licensed Construction Supervisor: PO- '
License Number: L4 -Z:-52:
; -
Add. ress. .,Expiration
Date:
Telephone: natur . \ 6
3.2 Registered Home Improvement Con ractor: -
Not Applicable ❑
Are you a Home Improvement Contractor subject- to (780 CMR.110.R6)? ❑ -Yes ❑ No
If No, go to the -next section!
Are you claming exemption from the requirements? ❑ Yes CI No
If Yes, submit the required affidavit!
Company Name:
Registration -Number (if none, state "none"):
Adc
ress:
.
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:
Contractor's Registration, - - -
Home Improvementrs One Ashburton Place Room 13D 1, Boston, MA D2 � 08, 5� 7 727 8598
f r 0 1 am a Homeowner performing all the work myself.
P 9 Y
L' !.,rners Name (print):
.
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
DatA:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
510;8.3.5 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 st~uctures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Sup...;�visors.
Ex,. option: 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
engai,oes a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
Fa- 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
Worker's Compensation
insurance Affidavit must be completed and submitted with
this application. Failure to provride
this
affidavit will result in the
denial of the issuance of the building permit. Signed
Affidavit Attached: ❑ Yes ❑
No
SECTION
5 -'DESCRIPTION
OF : PROPOSED
VNORK(Check--all a licablePP
❑ Deck Pool
❑Repairs
❑Alteration
❑Chimney/Fireplace ❑ WoeSdstove/Pellet Stove
❑ New Construction"
(Energy report required)
❑ Addition
(Energy report required)
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door-
No. of windows Doors _
*If new construction, please complete the following:
Single Family: No. of Bedrooms
No. of Baths
❑ Roofing/Siding
❑ 0thf,;r
S� e� -
( P
cibelow)
❑ Demriolition
(Spe.1-cify below)
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
❑
Air conditioning - (separate unit)
❑
None of the above to be provided
❑
Hot Water: Gas
Electric
Fuel Oil Other
Description of drop
C�1
osed work: rn-yV
(U,
s
G, VON K�lOo
�-c.
•
f 0 C.L tL
-- 'SECTION 6 -ESTIMATED CONSTRUCTION -COST -
Item- Estimated Cost ($) to be completed by permit applicant
Signqfure of Owner
Date
v -
r -
SECTION 7B OWNERIAUTHORIZED AGENT. DECLARATION
"� as Owner/Authorized Agent hereby declare that the statemer� and information
I, g y .ts
on the foregoing application are. true and accurate, to t e est of my knowledge and belief.
Signed u the pains and penalties of perjury.
s
Signature o` '0wn-er/Aut orized Agent ,, Date
SECTION 8 INSPECTOR'S REVIEWICOMMENTS
Energy Report:
Fire Cbitff:
bard of .Health:
❑ Approval in Part (Per 780 CMR. 5111.13)
$25,00 APPLICATION SEE IS NON JR*E- � iNDABLE 1QTON-TRA14TSFEiMABLE;
DATE RECEV;IED
DARTMOUTH BUILDING DEPARTMENT
Signature:
Signature:
Signature:
Conservation Commission: Signature:
Other: Signature:
.
Brief description of work being performed., -
Lot Area (sf.) Frontage
Required Provided
Front Yard
Side Yard
Rear Yard
1.4 Water Supply (MGL c40 ):
❑ Municipal rivate Well
CONSTRUCTION PLANS
"v'
Date:
Date:
Date: lc;2 f
Date:
Date:
- 616FMap__2 Lot -
1.3 Historical District L Yes 0 No
Has application been submitted to the Hiskoric Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System•
❑ Municipal n Site Disposail System