BP-21518COMMERCIAL
2001
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable O
Name of Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKER'S C011'IPENSATION INSURANCE AFFIDAVIT MGLC 152 52
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result ire the denial of the issuance of the building permit (MGL 152 Section 25A) Signed Affidavit Attached: ❑yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK check all applicable)
❑ new construction ❑addition ❑alteration ❑repairs ❑ accessory bldg. (shed/garage)
❑ other (sp=.cify Sec. 6): ❑demolition ❑sign O replacement window/door no. of windows doors
SECTION 6 -PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
The following descriptions are based on the Massaclrrrsetts State Building 6tli Edition, Code Article 3, as noted. See the Code
o Assemble -restaurant, lounge, theater, school, etc. (see Code Section 302.0)
Describe:
13 Business -office, assembly with less than 50 occupants -indicate Medical or other professional (see Code Section 303.00)
o Education -structure for training including child day care for those over 2 years 9 months (see Code Section 304.0)
Factory /Industrial (see Code Section 305.0)
❑ High Hazard - (see Code Section 306.0)
Institutio,ial -hospital, nursing home, infant day care (see Code Section 307.0)
o` Mercantile -retail stores (see Code Section 308.0)
o Residential -three or more family, hotel (see Code Section 309.0)
❑ Storage -includes garage (see Code Section 309.0)
o Ut'.lity &Miscellaneous Structures -includes tents and agricultural structures (see Code Section 311.0)
o New Tenant -for any of the above, please indicate (see Code Section 119.0 and Zoning By -Law Section 35)
o Tent or Trailer -temporary
purpose?
o Otheri,,._ �
Describe the proposal briefly, INCLU umber of dwelling units and bedroom r occupant load as applicable also xisting
condition (�f extra space is eeded, attach an additional sheet): � vk�,N
1 Lk
,NL C� r`Zh\, I V
ECTION - 7 TYPE OF CONSTRUCTION OR WO TO BE PERFORMED �
❑ New Construction and/or A ition (total gross cubic feet proposed) -indicate
If the project is an addition to existing structure -total gross square feet of existing:
❑ Alterationof existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑yes ❑ no
If yes, see bode Section 116.0. Designer to submit Code Synopsis in addition to original plans.
Will this project require Peer Review (over 400,000 cu. ft.) oyes ❑ no (see 110.1 Code &Appendix I)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR.
❑ Demolition* -describe structure:
o Moving* - (provide copy of DPW moving license)
* Type of structure: from where (plat/lot or address):
to where. (plat/lot or address): number of dwelling units:
number of bedrooms per dwelling unit:
COMMERCIAL 2001
o Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged) Ec;gESS
dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered as an alteration, ottherwise will
be included in new construction. (see Code Section 3603.21 for residential and Article 10 for commercial).
❑ Temporary structure -includes, when allowed, trailers, tents and the like and only for limited periods of time. Describe:_
SECTION - 8 MECHANICAL &PRIMARY FUEL
❑ 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
o Hot Water: Gas Electric Fuel Oil Other
SECTION - 9 SPRINKLERS AND/OR FIRE PROTECTION
❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why?
SECTION - 10 RE UIRED OFF-STREET PARKING for Zoninar and Architectural Access
❑ Parking plan submitted to: Building Dept. Planning Board date submitted
Number of spaces - indoors outside total provided
Handicap spaces -required yes no if yes, how many as a part of the total required number
Is Route 6 (State Road) entrance permit required? yes no if yes, has it been issued? yes -no)
-
Submit copy of application and/or permit as soon as available.
SECTION -11 IDENTTFICATiON
11.1 Architect/Engineer -for overall design
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, a ffidavits. & other documents SHALL BE originals and not reproductioms.
11.2 Architect/Engineer -project supervision and reports
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits. &other documents SHALL BE originals and not reproductioins.
11.3 General Contrac o
Company Na � w
Address: d
Phone #:
Construction Supervisors License Number
Note: Signatures and seals on all plans, affidavits,
„ &other docannents SHALL BE originals and not reproductioms.
c:\bldg, forms"Udgapp.com Page 2 rev. January 19 2001
c:\bldg. forms\bldgapp.com
Page 3
rev:, January 19, 2001
1JUJ KN.t...' IPiL
COMMERCIAL
$Z 5. 0 0 APPLICATION FEE Is X0r4mRErur4DA13LE des ivorq=TP.A14SFERA13LE
2001
Item
1. Building
2. Electrical
- 1 Z ESTIMATED CONSTRUCTION COSTS
Estimated Cost (S) to nearest dollar. To be completed by permit applicant
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) Estimated Total Cost Including Labor: • ,
SECTION 13A - OWNER AUTHORIZATION to be completed when owner's a ent
or contractor aDplies for buildin ermit
aa
rint)
as Owner of the sub• - �
• ject property hereby authorize am r ehalf n 'll atters rel • ative to work authorized by this building permit a Kati n.
pp
SiwfahT,d of Own
Date
rN XX S13CVION 13B - OWNER/AUTHORIZED AGENT DECLARATION
C`
as Owner/Authorized Agent hereby declare that the statements and information
6n�t e forehding appl cat o are true and accurate, to the best of my knowledge and belief.
Sianed unde the pains a � enalties of perjury.
S Kn �Aure �f 0vIner/4gent
14 - INSPE
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 p Jro project
review `vrorksheet): Date:
8. Comments:
9. Inspector's Signature:
Applicant informed of above-
Comments:'
�- k r •
'NEC TION 1.) - APPL
Date. or
%-- :>-,C r-� '�N -
Date
'S REVIEW/COMMENTS
5. DENIED (see project review worksheet):
Date:
6. HOLD reason:
Date:
7. HOLD
subject to Zoning Board of Appeals action:
NOTIFICATION
Time:
Date:
Clerk: �
` /,
SECTION 16 - FEE/PERMIT NOTES
Total Permit Fee: -
Less Application F pp Fee: S 25.00 Remaining Balance.
Gross Area -\tew Construction
Gross Area - Alteration
Permit Issued To:
.•;����Tk-: •..,
:•� ~DARTMOUTH BUILDING DEPARTMENT
DATE RECEIVED
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
•'�{-'• 508-910-1820 FAX
AX
t 9 A
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING (includes 3 or more family,i,dwellings)
HIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: LL BUILDING PERMIT ER: (71
l r
DATE SENT FOR REVIEW: �; jf( Ij! DATE ISSUED:
OK TO ISSUE - SIGNATURE: ` - DATE:
Building Col issioner/Inspector of Buildings -
Zoning District: Proposed Use: Zone: ❑ C ❑ B ❑ A [IV Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: - --
❑ Board of ❑ Board of ❑ Con. ❑ Demo ❑ DPW ❑ Elec. Energy Report
Appeals Health Com. Affidavit Card Sent Cut Of = : Follow-up* w"
❑ Fire ❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card Vater Division... 13'Zoning ❑ Other
. r
Chief Cut Off Board* i Cut Off I Cut Off Cross Connection """."-Review*
QUIRES INSPECTORS REVIEW BEFORE THE ISSUANCE OF A PERMIT _
DEPARTMENTAL APPROVAL = -
Review: Signature: Dat . l —0
Zoning g
Energy Report: Signature: Date:
Fire Chief: Signatur : �-�, ,, _ • j�'711 '' Date•
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other. �,, ! . 4�10Signature: Date.
Descri Lion of Work BeinE Per ornied:
SECTION 1- SITE INFORMATION
1.1 NUMBER OF PLANS SUBMITTED:
1.2 SITE PLAN SUBMITTED: ❑ yes Elno
<et* r
S
1.3 Property Address:—",5 Z>7
1.4 Assessors Plat &Lot Number:
19
Nearest Cro Street: 0 :
Bus. Name•i' Phon #
r
Plat Lot -
Total Land Area Sq. Ft.:
1.5 Water Supply (MGLc40 § 54):
1.6 Sewage Disposal System:
❑ Municipal ❑ Private Well
❑ Municipal ❑ On Site Dispmsal System
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
:1
A �Z'
-�s
Name(prin
ne
Contact Address r--� Telephone
2.2 Authorized Agent:
'
ame (lint)
_
Contact Address Telephone
c:\bldg. forms\bldgapp.com Page 4
V. January 19, 2001
c:\bldg. forms\bldgapp.com
rev. Jalouary 19, 2001