BP-19620ion Supervisor:
Supervisor
Telephone
[mprovement Contractor:
� ❑ es ❑ no
If no, gyo �ovement Contractor subject to (784 CMR-6)o the next section!
rnption from the requirement? o yes
�
If yes, bmit the
required affidavit!
temodel Work Only
Telephone
IrnNTR ACTORS D
---------------
2001
O NOT HAVE ACCESS
TO THE GUARANTY FUND:
�TING WITH LJNREU151 1nnL `'"'. - --- _ _ , MA 02108. (617) 727-8598
OneMPLAINTS call or write: AshburtonPlace -Room 1301, Boston�iprovemeContractorsRegistration,
-=R---- • ,o the Guaranty Fund
ere well be no elig�bilty t
r acknowledges that there
by signing, the above, the home own
• On, & Two Family only
xemptlon -
LE FOR TI-iEIR O�� PROJECT 82 no individual
RM AND BE RESPONSIBLE 1 � 6•0, effective July 1,19
RS �'HD INTEND TO PERFO coon Control in Section ructural elements of
FOR HO;vIEOWNE tures overned by Construction emolition involving the st
• • Exce t for those strut g re air, removal or d
Supervisors: p anon, p e ulations for Licensing
Construction Supervis reconstruction, alter
• n RS entitled Rules and g
f C in constructio ,
•engagedromu1 ate by the BB
1 supervising persons e rules and regulations p �
ect y p in accordance with the section; provides that if a
unles
s he or she is licensed revisions of this sec ,
• all be exempt from the p
• permit is required shall
fors. vork for which a Building
su ervisor. ides or intends to reside, on
Homeowner performing such Homeowner shall act as p f land on which he/she resides tracts
o do such work, that
hire t rson s who owns a parcel o structures. A person who cons
a person(s) for „ • as follows • Pe () use and/or farm
p "Homeowner"' is defined res accessory to such
this section only, a H ed or. detached structures of anvil d�vellin ,attach
to be, a one or two f
Mended considered a Homeowner.
eriod shall not be
in a two-yearp
,,,i,ril,ts section sign below:
your sg
i nature carries certain
limited to, general liability
. lv
6sibili&6sl i�icluding but not necessari
USIDENTIAL
'n the Rules and Regulations section that any licensed Ct�nstruction
Code provides 1 Appendix of 780 CMR R5.��.15)
taken the permit are responsible for code compliance. (see App
NOTICE TO LICENSED CONTRACTORS: The Building e 152 § 25)
Supervisor, whether or not they have iiiiiiiiiiiiiiiiiiiiiillillilllllllllllllllIIIIIIIIIIIIIII'SIII E11 C11 TIII ION 4 VVORK�R S COMPENSATION INSURANCE AFFIDAVIT(MGLaffidavit
-11111111111111111111111111
d subm1111111111111111111 itted with this application. Failure to pi-,.ovide this a
IIIIIIIIIIIIIIIIIIIIIillillillillillillilliIIIIIIIIIIIIIIillillillI be feted an p yes ❑ no
Workers Compensation Insurance affidavit must opermlt• S►gned Affidavit Attached:
RoposED wOxK check all applicable)
will result in the denial of the issuance of the building F P
SECTION 5 - DESCRIPTION O _ n ,.1,;mnev/ Ci Wo0C1StOVe
0 p new constructin* � addition (o
energy f'eport required)
(eilef'g)7 I"epof•t required)
b-od�eck b ool ❑ accessory bldg.
`" � (shed/garage)
* If new construction, please complete the following:
p alteration ❑ rep airs %.0lll,-----,
fireplace
o other
❑ replacement windowrs /door
dbelow):.
no. of windows__._MMMMM�
no. of baths
Single Family: no. of bedrooms
no. of baths unit I__
Two Family: no. of bedrooms unit 1 no. of baths unit 2__
no. of bedrooms unit 2 other (specify):_
fuel oil, electricity,
fuel gas (natural or propane),other (specify):, --a Fu
rnace (hot air) - fuel oil, electricity,
Boiler (heating) - fuel gas (natural or propane),
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):.-
13
❑ Air conditioning - (separate unit)
Other
o None of the above to be provided Electric Fuel Oil
o Hot Water: Gas �-
•ie Descriptioll of Proposed Work: � -- . ,ti p r�, EB�
IN
trotlea' � —
f"--) �
p demolition
(specify below):
- CONSTRUCTION COSTS
SECTION 6 ESTIMATED
Estimated Cost ($) to be completed by permit a1Pplicant
Item
]. Build' n
2, Electrical
3 plumber
4 Mechanical (HVACI
..................... ...........
S.Total =(1+2 +3 +4)
C;
* Estimated Total
SECTION 7A -OWNER AUTHORIZATION - t)
ed when owner's agent or contractor applies for building permi
(to be comrletiiiiiiiiiiiiiiiiiiiiiillillill
of the subject property hereby authorize L"fr,--t �-�—
� G' /lam-'•-� �
(please print) � Is� � _ , . �.,.� , as Owner ermit applicatio .
I� � ��1 this building p
Tohalf, in all matters relative to work authorized by �to act on �Date-.0
v G
�ignliure of Owner
SECT
j N 7B_ _ OVVNE p HORTZED AgE.N
T DE LA�TjON Staatements and information
hereby declarethat t e asOwner/Authoriknowledge
dAgent and belief.
application are true and accurate, to the best o my
on the foregoing
-9
Signed under t e-wins and penalties of perjury.
;=P Af owner/Authorized Agent
...MMMMMMM
ate
Rev. January 19, 200
Page 3
C.\bld
T. forms\Bldgapp.res.wpd
Rev. January 1914.100 1
RESIDENTIAL
2001
RESIDENTIAL
2001
____ a
. . . :- . _ -1 . _
E
-
-- 'SECTION 8 -INSPECTOR'S REVIEW/COMMENTS
s. . • .I - - . .
.
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:
70 HOLD subject to Zoning Board of Appeals action:
Date •
8. Comments:
..111F.
-13V n 0!5e,^,/11�
9. Ins ector's Si nature:,)/J
p g
__
-
L' V V,04MH
Date:
V
111111111111111111111z 111111111111111111
_
..
C ON NOTIFICATION TI
T TFCA N 9 APPLICANT NO O
. SECTION -1.1.
- '-
_
I '
Applicant ppcant informed of above
- - ___
Date: Time:
Clerk: ,
Comments:
. _
_ _ - - • •
-
.:
-
E TI _-S C ON1 NP R N
OFFICE S C O S O ES
- - _ - r - -
_ _ .. -
-.. - ,' .
.
Total Permit Fee:
Les
s Application Fee. $2 5.00 -Rema
Remaining
����1�•�
• 1
T
TOTAL FEE.
1
jj
t;
• 3v
rq I-L
••
Gross Area w s ea New Construction n total s . ft. t0 [ d
I
;.
•
if
r
G oss Area Alteration
e ati n ft. o totals .
/
•
•
Permit Issued T oLr7l�
Q.
�. !
/
tl
�.
_
.J W..';
-.���°
_
__-444z*___ -.el.-- 2 ci:��. _* -
".. C/ I I .N. �1.1
_ _ z..� S=v , ��,-M-,�..
_.
`t-M!"MRS"Ok.
r
.
.. .
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
_ _ _ -
11
---
LZ_�,2�:� _��__'Z
a / -/ 'u-ice, 'd? -
11 ,_
--,! t- , , ,�� 0, )�:kee - =:� .. , C-(- ,--t�,C-
❑ FOUNDATION ONLY
$25nOO APPLECATEGIV FEE ES 1V01�,c'P=' REF WEDA LMOMmTRKIINTS& ERABLE
..-;..OL)T�; ..� DA �� E RECEIVED
... �-K. _0 : DARTMOUTH BUILDING DEPARTMENT
Q : 1 �. f I P --. -,. r"` ? L ? � * fit, t
_� _'o
F o = ___ y C 400 Slocum Road, P.O. Box 793991.
-- : { - r ' {�
.-1
%0 -. C. 1
1�_.
._ 1.
%_ z`1*1n.
.,_?� Dartmouth, MA 02747-A
•. O%� yy r
••- 508-999-0720 FAX 508-999-0738.... . ... `�h4 ' �'
I .
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FA.IHn,y DWELLING
r -
' 4 l
_ �..�_7
!
"Y
1.
Y
_ 1J !•
Jr _ J
TH S SECTION : FOR OFFICIAL USE 40 _.: �, - ��11 x . z a %w ,
Y Y , • a
_ _ .. 2-,- -._;_,!�`
- ,
�_
�:•
. I. r :. 1.- r.,:r-, . • J.. ,c -.. > �: it r
J J r • G v - M ...L. �, ...
i si "a
yr JY M . ae-. +- -• .... it L < .c. I Tt' i
t r . .' t r . tC
r
w ta'
t t a'. t . L Y r
.. ,. 1 !.•
r i� r y. :.✓ .ems - "hn •'" "♦ . i"Lt a _.- w,�r -•r oC �" .•. .t,. _ •• a.- •,t..' .\. ,,y , {t ,s �: ,
-.� :f. ^I� - r. +. - r.a> ►• it a _t•1- ,�
_ :r } - =r
J 1^ ki.
t 1 'Y _ _
• ar i..
-� . « [ :+. '.
v a
.'
�Nlh-.11% •rt i' 7 - , ,..,.
t CEIV _
RE ED ,T
B _- .:
BUILDING 1 _ t x.
-,
�IIT ;�_:
a : - ; r,, { o f ; s n -; - - a • __a ,`
- - _ - _ r. t: a .;;!'rrt .aN. ,5 :,' ..l+.ta"•• ! _-• i- s.... 71• f _a-jC:i. Y- t�1.
.i,r a'y, �'` -,e
-_ _ .. - - - ♦: .,q� . JJ, ♦ •.-..•aye•, •i•._.•-_•[ , y^', J : a•,yt rs ,1 Y`' ' a -e . t• .- - 1 . -� •J -
.... _ ...
It
- v r♦- -
y/ _ i T -
�a�;-
7 •! ` f'
t' .%_ems'
•.y
y.:`. .
• f' .T' ,.
H
♦ Y Y ..L
�� s ti'.
DATE EN - :� _ 4 L. ..: :�:.• -} SENT FORREVIE . , ,_ .. . • - �:,� . -� -� � • � '.... _ _ _._ ... - - _ � _, .,N �::r �..-
1.
_. �_ .. 7 JY �._., ri.w .-.
- - - _
w
• , - - ....-.- , _ * I<.• - -•,� n Ns,.-1. i •. ''..N +P. s- _a•.. - ': {„R ,. ar tK r .-1:.q.,..
- - - .. . _ - '••.+'^ r.,uT• ..a.•s.«,...r .ar. - tc..: k: .r•.•; h..:...,>,.• a`.. __...a r.r s-•'..,:..r'f +.
_ ?,•• T -<. _.. -«- ... t<..,v_.t-r.- _..,_.•.,•-... tr• Jo•+Jv.:...r+a.ria�t rs'"++:,isr.-. - ..._ •. -. ./a y�. _ _S^ .; ..�w,•.t-
. .. :.. - �.: _ _ .: ......w,..,r, ..__ .•---- _ .'r._.; _ _ ..<. - J. 1"'_Y.. '�•♦r<: T.,+•:: ",r ya.' ,. .ti_.,.. i�,.` .f• .ate_ -l•• .}r.
a... -...-.:. -
41 .
< ....•
. rr
iy
Y
f
` ` J ]r ,♦
• r. -
r.. .. .. - � - - , -,.. �. _ m ..- ins: _ _ `.L• -t'. :.+.•, r
.v
J y
rs Ys 1n
r• \
J -
..: -+. - 1
M
- .�, ___..Y .. _ •:•,.i .. _ .- :, .. a:�•a'�_Yr i � yf•r• �• •J iai}l:K,♦ .S.. Nta �L i.,c_�'_ ,C•
• e - - � •:>N _ - • ..`w. .air :. ,-._:..!-., . . .. - w. , . - -
.. •r. - - ._v• - - •. - -I Yw T., ^'•I •�. Yy. _..r,¢.,. .a'.'1r/ - rA:.. �'f 1. .r• . ,,, .r.I ..Jr .l. i Ii 'i^. . 'r.tJ \ �;tc._ r. ,�. _.,[`- •✓,...µ'."a.♦e.
. �
C'_ r. T.. 7-'. • :,'Y_5� "ter. 'Lrw f:w•
-
T t
:ti:
9"
�e 'sw
'ate ,
}. 1-'
.. l
L s �.
.t
c 7
•Sr -
. Yr:. J -.-..a.:. 3}.
r :! . d
♦ T ,.
�.
L JC
•Y _
. A♦. r
y j
I • 1 r r
, ,
a a 4^- ♦ I G • '
Y' y..
•'S .i �w N
.r a-
Y' t
- '4 V P-
f ='L •t. .'.�-. .r` rt- »Zi �:� �Z. :.: �- tii- ,I�: �,. .y' �i ^ ni i * -.re:�, ;:•.'•c J' r b
+.
�•
- ar.
J
z
a• .:.<
OK TO I S SUE SIG
s+
-,SI
GNATURE* - - I
.. r
1.
F >F ...V -
_ i . f .� _
_;. • • •.war.-_. .C>.,a. _,. .. [♦;--.'"' t?y.+ -� F --`da• _ >t. +>-t•r J.. _r.
A" r_ r,i , .,y .1' _t.
•. a
n
,_ e_.. _ .�� -�._.
iI a. _ u din minis i r `B o s n� n C oe Is, / >ec r I to oft dins s.J
N JI
'a•� V i y ^'t'•• '»� Y
•f - - .I� _ +..��.• �}7 i "�� .:• .?'. }. •< a. �L' '
♦.1.. L - t..a
- Y . ,. r
•a ..y � r'
r:f
w
.4.
''2. . rz , r . «�. - t _
l' t _ .♦ y _
T.f Y
. ,.fi -. .M .A t. .�• +1 a
Il
i
Zone District• Pr
�. o* os se. _ Zone. C�-0 B 0 A :Q ^V Outs�de:Flood Zoiie� - .,.
g - P .:4 �.� Qj «A uifer Zone
r _ s +s. t .r,�«_'_- -..r_ ;J t.-_:V �_,v �, .->:. s_ . ..: Y:•r,._a-1 .�• .Ifc �•-sL .i•... .. -� .. `r ;_`rv� .a. - . -j 4
.. _: - h. -
. , :: _ .. „_ • :-..: 4..�.: ,'•.: -. j, ' :'T'.w;.i�. L�' :.j�:.r,=.t'.cc �.FF 1 __y'• ••a-s.. ..�.� t_ ,.i x`} :`:.r.--as't7- ;`a 1a� >. a s - >' - - -.1 w ;c;;. - L ti a La, • . 4'• - ,. ? , -. y}.•.>f'` _ ,,. - ,,.�-. , J`.s-, L -.•1 , rJ `► • ei. +.j '•': n'• .J'�< < r.♦^. t.''.,}.
t!'I ..ma's Tt: ''i t r-a r.'i'�c :t• . Y- - Y= .
.r, ✓
• r a-•sJ -v - t' • �3 x
THE FOLLOWING ., _ - -
OWI .
NG A _ GENCIE ..: - _ .,tir =, r L ,'_.. >� .�r ;
S SHOULD BE NOTIFIED.. r._ i_: r'.- .. _f f a,� a. Js r-
.. iJ- .,.�. '-. i s-. r., raa rv� .csf.T.ir.•fa .-a. - :♦ -b. - •w
. _ .. _ - - - y :a ?
t `
_ _. _ .. N- , a _i w :. - . --- - JT i 1 a - _ • 1 ,:• , t J :a ► •V a /.T .� . _ l� • x`'si
-. � � y/`'
_
F _. :: ..:. L _ - lt.: .iw - 'i --,n - A.r Ka. - _.t `a "•S '1`..
e �, ! s
Y- ,t ., •i•e .n -
4 "r•. s a r -r .i
.r • s 'r- • T t w-
t•- J _9
Y I i -t �• j :/ L Z:
..N �H'- t .tip. -y ,,
,r -
a _
+ 1 ♦i - w -:� ac
r s . . .. �,: rrl;'. ': f>:_ • .r •h<7 i a:2 Yri _ - ra yia w'- ," 1 ^7 .✓.: 'j`':,'
'r. ... _ Yt-♦ - - 'J ~,,}'!' ]a _ 6v _ .G. r.e t •V w, 1. ..0 .1,
.- _ - -'. _
-*)
_-w_.�-.
❑ Boar =�y _ _ _ d of _ _ �. Board-.z. :�: �,_ _
of CIC1.on. Coin. L7 Demo s _ i..
I . t: _ r r:I�=�DP.W_. _ � : i:..� _ D El.i.� rier
'^ ar ✓.
1
- P
iti � ✓.♦y:' t.�r 'K rl4 ,rrTt _
�t
1
' i' -aft. __ t r�� Y:. i j 4`
_ T- !
J 1 '• -
,t. a -
t F% l.«.
�y. .�at } _ ...
-i•S '7
af:
-1 at
t, t 0.
'\" max. : a-. ti r. '.•Y : f •-4^'
Appeals Y -, ..
-He I ~r'
a th �- .,-
•ffi -
. � �A dav�.t - _. r Cards Sent. .~} Cut N.
ll -
�ff o ovv F u
T� wi - i
- x,Y L f :
. . Mc� •:4 tYa
- r -
r..':
�y
7' +
:u i' •4
1 -r•
a .Y• l .. (' a:':a .FJ Y.
3. t M1 w�
/• ' ✓
J t
f. , r i C Y .�e
-ti r `'
. . J
Y'
L- r r -
a w• �J ar u l
eY r w s w J �• -...� 1'•.• '1'
2'
A_ t Y ♦ • 4 1 s ♦ ?`. . s 1 •L t 7 v•
r c: x
r Z f K
= I 1. , a r' a st �T > n. e
.. L a 1 c - . - .Z � r T r: s
in r.
i t x _ r 1, -t
i rl.. ♦- :
it7r - : •.-. E
TY N Jr i •+H ..I• it ' �A
t u [♦' - _
:•'t L. i is y <e
f r' f: 6 _
v t . J^;
�' i `i - ..✓ V
7 [. .{
i
(- T'''rc ! x
Z ai
L_
ri:♦
. .. v . _: ' .-: ...:a . ,.. :.. -.,. v t as ,•_, a,i : Y: t - _1 I�'. - : y. y
Y _. ... .. :. _ ... : - . , .1-' .. . i _ _ :._•'� + - t•- •rr ti, w-:.:L .�.=v.-1J - iw .. �r-JY;.A.:• Yi-:"i.1i "f
_ .: .- :-. :..._ _ ... . J .i..' _ -•. .'•a"'=.. re -r`.a F.- «t: be :�::' Y x " •Y'4 �.:.i -\. "7' - %� rR
. _ - J_ - __.. .-a,._/.1. ..: t:. v...« _s._.., a y...- 'r' rr '+ �. 'i.,7 -:'Y.. -
.ri. �. ._ _ - .. - - '- .. .._. .../,-, ♦ , _ -.i - _ -.*, 'L.,Y_ - .T -,ti. ., ..aw-,W' .�a+ <L f-`i% �r -s J_t .s
Y_ - t s•
." :' 1-
. ... Y ;•f'- C•• T.' ..11l �':. l:-�'ir.: .♦, ♦i.'w-M\'i ,] _�,. .;i - ..,.. .''J a`4. !f.., Y
-la- %. - .'�� t`
'.,•w .i-•' >. a Sid-• _-.t..�.... ti. ,♦,
J,. L-Jt...,.:--.:. ••ry An 1' . ,S a e'4 a/"T. .>'- _ ,/t . i jr ,
. . , "_,... _. . - _ : ., --a .:_ t _,. .: .- .rT- ,..•t as L =P' x6y -
Y- r Y . }i, fit'. -p;t_
-.,,g _c.,c.a_ d .f-. .-+ .r. .. -_.., r.... .. a. -.rL - -, ._-}- -'.'i. �L...i a,+
<__«. t
' i >
♦
- - ..
1 Y
,r ' _ - :.
Y. -
.. r .. T r:: ..i✓ wr �` . a t •aaw • n �e : r a.. a.
❑ Fire I� Gas . 0 Plannin Board "� Sewer Catrd . M--. C7 -Water Card r _ r._ r , CI �Zo .t,- _ �-
cf _ , j/yl�� >r:. �t _ -,K�. � ,nin ❑Other
c :v'
a
_ _ ♦ :�_., g
iti o
L � i-
.
n7
.. r. ':.T.--- - -.
Chief Cut Off _ _
-/-Cu O t Y� r
Cu Off _
_ • _f ,~.:� w' ,
F 1 T J
J1 _y -i . - 1, ♦ ✓ L
1. 'AI t "Y'
- c ,.. x ' r
w`' 1..: ` a h L. r 2, i Y
-_ ♦ l
:t
- T r a -r-i - ' 4
J ] �" Y r � _
L - 1 " •J i 1.
t X .♦
1' F
- -^, r ,a
♦ ' YS J
J Z. ✓ i V _t
Y / i 1 ].
_ [ v > K"•' S r Y fir: Y , '. i.
� v - i 4 'a 1 t K
t f -Y• r s- t a- __
- Y' +r-' r L b LL T �+ Y , v♦ .S s
t 1' a t x R
- t' c a )�
l t h s
a "h
_ i- S :j�' r r
t t r a .r s / c a K s i
ti ._ M r i S Y � � L Y r • r: t 7 M
I. Ya : Y. J
t
r ? t _
. -J f �. S Yr
r _ t 'L-$
♦ �- %.
J`
v s 1 r
a 7 a
♦ }s
r L ] a:
w [ : 3
✓ .
.; x - -
..' C `. - r. s .. n .l .i ' 1 - ' \ r , '-
,
� a..Yr ,r
:' i
;� f
rT
t
. 1. " - - .. v -
i
_ * .RE UIRES INSPECTOR'S REVIEW BEFORE THE�ISSUANCE_OF:A PERMIT. - - - '
_ _ Q -t _.
L Y
t Y _t r 10111
a. -
s, "' • L• I. T
+:. - .. - - F •-n_ ~ .+ Y•• 'Yfa. . T y. . K � r�� .,_.et. 4 `•!- - Y i�: * � : r.Y. -,r y t . -
1.
6
1111
�a
, r
_ , -
:. ,r
t.
_rr
TAL AP
PROVAL V
_ a - `.., _
•
.
,a.., ,; -
'- -;tZ '�- <` �'a
•
ZoningReview: Signature: •
g C �.1--� Date•
rf
Energy Report: Signature: J ate:
Fire Chief: Signature: TDate:
Board of Health: Signature: mate:
g
Conservation Commission: Signature: T7ate:
Other: Signature: Tate:
Description of work being performed:�r�; t�- �� .. t � r` `r it -� j _
7 _ f ` it
_ - SECTION 1 SITE INFORMATION - t - --� .. :� a* _
-- -
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Pla & of Number:
1.1 Property Address: PLC. 111--c i •- it iD�_t U
C-
�, Plat Lot -
Nearest Cross Street: `` ,(' ,� �.,�. ;�
Subdivision Na '' -yam' - --`-o".M. '.�5 144, 1.3 Historical District ❑ yes ❑ mo
Has application been submitted to i'the Historic Commission?
Total Land Area Sq. Ft.: -
❑ yes ❑ no Date: .
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: -
//
g p Y
❑ Munici al,2�rivate Well ❑ Municipal 1
p p �n Site DisposalSystem
. ,. i
/1-
«60-.1 1/--- 0
C:`,bld(-Y. forms\Bld`�app.res.wpd
Page 4 Rev. January 19. 2001 (''•\hlrio f♦nrmc\Rlrionnn rPc xvntl Dnnn 1
I (0?1�,%N3
qI