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BP-81093 Permit No. BP-81093 BUILDING PERMIT GIS#: 4288.00 Commonwealth of Massachusetts Map: 0079 TOWN OF DART.MVIOUTH Lot: 0048 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot: - 0051 Phone:(508)910-1820• Fax:(508)910-1838 Category: AGP Project# JS-2016-002788 PERMISSION IS HEREBY GRANTED TO: Est.Cost: $2000.00 Contractor: License.„ Phone#: Fee: $80.00 Const.Class: Engineer: License: Phone,#: Use Group: U Lot Size(sq.ft.) 40000 Applicant. Phoise#: Zoning: SRB DEBORAH BOTELHO (401)743-8410 Aquifer Zone: ZONE 3 OWNER: Flood Zone: ZONE X BOTELHO DEBORAH L New Const.: N/A Alt.Const: N/A DATE ISSUED: - I r , Date Typed: 04-21-2016 TO PERFORM THE F NG WORK: Install a 15 x 30 above ground ool with pr er b iers Of c ion: NINE ! - E R RD Approved/Issued By: PAUL M MURPH ,DIRECTOR OF INSP ''VICES All work shall comply with 780 CMR 8111 Ed.(MGL Chap.143)and any other applicable ass.' 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 authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zoning Permit. Signature of Owner/Agent: , "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: 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 i TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 81101 PHONE: 508-910-1820 FAX: 508-910-1838 / i i , i • i " I/ -.7 1 1Name: Ii I Property Owner: ' Date: Job ,4y p , , Map: Lot: ,., pi t i Description Gene , • i .er#'s Ref. # Amount Building&Building Misc. 000 0414 4 ft '---) 0 Electrical 0, .4 00-44 1 0 65:4 = r p,e, Plumbing & Gas 010001-47./, 17 Trench Safety '44)1 10-44129 (4.1. Other Department Revenue 0 iv;:-- 420 ? i White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By (,,I,r(-7 THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL,POMBING OR GAS _ Al. TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 81093 '•.-,:k7f,' PHONE: 508- 102182e FAX: 508-910-1838 i-.. Name: r) , L .., .,, , Property Owner: )6 i A._ Date4 /(C '. Job Location: '' --- /, (it'' ',.,L.,6 (_, , .:-.---i':..:_t,.,' , /rL; Map: Description General Ledger#'s Ref. # Building &Building Misc. 01000-44105 1 ti.,,i ' Af-0.-r-;-:::=„', .,-, • ,e, Electrical 01000-44106 ,.•:%\ 1,--- i' 'A'. GN.',' \ •A,>'--:, - • ,,,--, g--,,,,„k,\-'..-•'-:. ; - Plumbing & Gas 01000-44107 i 1 ,-,,•- ,-,-.1(,,;, i: . ', I 1 Trench Safety 01000-44129 I .::4‘,''''''.. -•:, '\- Other Department Revenue 01000-42420f \\z:o,•,,fij *.,.... ‘\-, , cal-' •'. ,. ,.. • 2" , •-• White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By 2 -t r-Tr)zt,,,2 THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS . .. RESIDENTIAL ❑ Phased Approval t,'?106.3.3) $25.00 APPLICATION FEE IS NON BE-FU NbAULE NONaTRANSFEBABLE GATE REG- 1 E.D_.; i0 DARTMOUTH BUILDING DEPARTMENT �' 400 Slocum Road ` /C Dartmouth, MA 02747 S N. Phone: 508-910-1820 Fax: 508-910-1838 \\ www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE O WO FAMILY DWETTId THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY; BUILDING PER I UMB R: DATE ISSUED: �. SIGNATURE: DATE: Building Commissioner/Inspector of Buildings Zoning District: , S R Proposed Use a._ Zone: -Ef ( ❑B El A ❑V Aquifer Zone: THE FOLLOWING AGENCIES SHOULD BE NOTIFfED: - DPW ❑Board of 0 Board of 0 Cons. ❑Planning ❑Address 0 Engineering ❑Cross Appeals _ Health_ Commission Card Connection ❑Fire 0 Gas ❑Electric: 0 Other 0 Water Card 0 Sewer Card Chief Cut Off Cut Off Cut Off Cut Off .. DEPARTIUIENTAL APPROVAL(S) Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: at u2,( SECTION-,, SiTE CNQRMATIQN 1.1 Property Address: n ri ir, �1'�1 n���j�,�.y,� 1.2 Assessors Map&Lot Number: Contact Person: (7.(2, p i!LN-\--, _) )-vc) Map Lot Phone Number: } y '----OP i 1.3 Historical District 0 Yes No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built 0 Municipal 0 Municipal 0 Altering more than 25%per side of building Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission? 6 h -7Ci-/c1/ i 1, ❑Yes 1 No Date: Revised 5/13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENE RGY REPORT RESIDENTIAL SECTION 2-PROPER1CY.OV)t►dERSHIPIAUTHQRIZEQ AaE1VT.. 2.1 Owner Record: L • 3 S , Yt L)Q 1 `)3-1))1. Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number SECTION 3=COIV:�rTRUCTIQN SERVICES 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: 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 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: :EQTIOid WORKE O,'.0- 10tNSATION INSURANCE PPTOAVITAMGL §2,$) 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 0 No $:tefi iN 5 4'_bSSCRIPTIONCiF.PtUOPQ$EA NORK,(Gheci aIt Oitca6le) ❑ Deck /Pool 0 Repairs ❑ Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding ❑ Replacement window/door Er,er report required) (Shed/Garage) (Energyreport required) No.of windows Doors ( 9Y P q ) ( 9 ) ❑ DEMOLITION (specify): Location of debris removal(per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street Facility Name: Location: *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 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(specify): ❑Air conditioning-(separate unit) ❑None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other SECTION-s .E5TtMATED CONS RUCT#ON POST' Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) nn f��,,ujj 5. Total=(1 +2+3+4) Z `t SECTION 7A OWNER AU CHORI ION - __ (Please Pri , as Owner of the subject property hereby authorize to act on my behalf, in to work authorized by this building permit application. 4 Signature of Owner Date SECTION 7E3-OWNER/AUTHORIZED AGENT DECLARATION Y2s2Ac2 ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ')*IDJ Signature of Owner/Authorized Agent Date SECTION 8=`OFF4CEINSPECTOR`f;NOTES Total Permit Fee:$ ea — Less Application Fee: $25.00 Remaining Balance: $ Other$Amount$ Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: "t%• i Sys 3 Z ,l�t�•.Z�C1�,� } \\,,cy Cc- I Permit No. BP-81093 Project Location: 35 RUNNING DEER RD CommonweajMassachusetts Sr A' UTH `*40Q�S1_ t—D4rtmo t A 4/ ` �� ss' . i ne (508)0 -1�2O s 50 R 8 10= � • ' MAZIA N. A i <•, ai Contras4 1 °' B e: one#: w ef #, g^ h r ., rya ac Engineers% 'hone#: 'kt '' d k9 • Applicant1relaRtql !"41,111fWgr."1-,14 -A AU e . «,'ems a y . Phone#: `d t # 9 g DEBORAH BO�� O - 4 .- q � }' (401) 743-8410 '.{ ` BOTELHO DEBO - f-> DATE ISSUED: 1enNp UET 1 7 TO PERFORM THE F LLOWING WORK. Install a 15 x 30 above ground pool with proper barriers DATE TIME TYPE OF INSPECTION&REMARKS INITIAL `#/2' .X 2/6 i�t c 7 � �i� c0??-.A. ,C3L47":40..- ".4.411 02.077 o--& v cv45 l y N/ �C Grp , . ._ _ • _ `E w 04/21/2016 12: 11 5086762330 SERJOBS PAGE 01/01 Vill -tzi &S JI.,:\ `I 1)-) .?'- rc-c- ,,,,,,, ,,,,,,,, il T I , i 0 7- r 7 i .124.) ‹........ 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N COCO b a A A Z ccoo — _O N O O N © ('I W The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 3C iLAr,Y1.-;-� � �` City/State/Zip: 'l', Qe- Yb\—*)-) ANA Phone#: '� 13'1\)) Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.U)I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.nRoof repairs These sub-contractors have employees and have workers'comp.insurance. �q-� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.IL\J Other �p e �gDLJa` 152,§1(4),and we have no employees.[No workers'comp.insurance required.] QIY.'"N y\ *Any 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 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t 'pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: p —� } 3--$))c3 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)also states that"every state or local 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,MGL chapter 152,§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 information(if necessary)and under"Job Site Address"the applicant should write"all locations 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia