BP-58123PENSATION INS URAN CE�AFFIDAVIT. `(MGL�'c'152
on- Effltlr
;... ,-SECTION. 2 =: PROPERT.Y;OWNERSHIPIAUTHORIZED. AGENT. - ..
/12-1 Owner Record:
Vontact Address Phone Number
wart tte, `Pin ILI
2.2 .Authorize,
�ent:Ell
L! � Phone Number
Name (print) _ Contact Address .-
�tit� c�J tbVMr,,0At GAIIP6,
•SECTIONS.=CONSTRUCTION°SERVICES.
- 3.1 Licensed Construction Supervisor. Not Applicable El
� Licensed Construction Supervisor:
License Number: �ZZ�
Addy ess: I l � l .� Expiration Date:
wnwmmww�
� =mom"=
Signature: _xe Telephone:Sd
6 0- Not Applicable ❑
3.2 Registered Home I provement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)?��l'es []No
%J � If No, go to the next section!
Are you claming exemption from the requirements? ❑Yes No
If Yes, submit the required affidavit!
Company Name:
Address: &O �LI
Signature:
3.3 For Residential Remo
Registration Number (if none, state "none"):
/0
Expiration Date:
C�
PERSONS CONTRACTING WITH UNREGISI tKtu �:uIv I rv-+�, i vr�O DO NOT HAVE ACCESS TO THE GUARAN FUND:
QUESTIONS OR COMPLAINTS call or write:
Ashburton Place -Room �301, Boston, MA 02908, 617-727-8598
Home Improvement Contractors Registration, One
Work Only
AJ 1— S Ve 1 � /UA-.,.
oz7�
Telephone: � ��J��-99�&�#-
7/Q d
am a Homeowner performing all the work myself.
1
Oviners Name (print):
Snature: r e•
Sig �a
v
Le•
By signing the above, the homeowner acknowledges owled es that there will be no eligibility to the uuaraniy rune
3.4 Homeowner Exemption -'One & Two Family Only
FOR HOMEOWNERS WHO IN
TEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
- � for those structures governed by Construction Control in Section 1'16.0, effective July, 1, '1982, no individual
5'i ��8.3.5 Licensing of Construction Supervisors. Except g • • the structural elements of buildings
• supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving
is � engaged �n directly superv�s�ng pConstruction
sha be
• regulations promulgated by the BBRS entitled Rules and Regulations for Licensing ors
or s��uctures, unless he or she �s licensed in accordance with the rules and reg p 9
Supre,ririsors.
which Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
Ex-�,ption. Any Homeowner performing work forwhi a 9
enga.- es a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
• "Homeowner"is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
Fc-the purposes of this section only, a Homeowner' �s d farm structures. A person who constructs more than
• o be a one or two family dwelling, attached or detached structures accessory to such use and/or fa p
them.. is, or �s intended t ,
one some in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
- �cr-r�nA��=�. _= nRKER'S: Cam
- - application. Failure to pro�r+ide this
• submitted with this
' nce Affidavit must be completed and s
Workers Compensation Insura Affidavit attached: es ❑ No
• the building permit. Signed Affid
' result in the denial of the issuance of 9
affidavit will Of
CT10N 5 _='DESCRIPTION �F PROPOSED WORK (Check:atl:.�A
appticabte)
Pool CI Repairs ❑Alteration ❑Chimney/Fireplace
11 Woc:idstove/Pellet Stove
(� Deck
❑ New Construction*
(Energy report required)
❑ Addition
(Energy report required)
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows __ Doors
If new cons, please lease complete the following:
❑ Roofing/Siding
Single Family.No. of Bedrooms No. of Baths
.
• 1 No. of Baths Unit 1
Two Fami1 No of Bedrooms Unit -
y . No. of Baths Unit 2
No of Bedrooms 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)
O None of the above to be provided Electric Fuel Oil Other
❑ Hot Water: Gas
e�cripiion of proposed uwor6c:
/4�7 X ' // - l'�OGI �/ V
❑ Oth e; r
(Spencify below)
❑ Derrnolition
(Spe3cify below)
z. ST[MATEL�: CONSTRUCTION COST - -
-40�aWSECTION:..6.; E . _j• •
Estimated Cast (s) to be completed by permi� applicant
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 -� 3 + 4) r:A10_
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to be::corn [etdd-:Then` owner .s ag
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(Pleas rant) .�L2
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roe hereby authorize
e4o' , as Owner of the subject p p �Y
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pp building permit a lication.
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to act on my behalf, in all matters relative to work authorized by this
J
Date
azure of ner
RATION`:
=DECLA `
GENT�: -S T
- ED:�A
- �aRiZ
ERIi4l!
- :SECTION=7B. OVi�N
.. . - .• - - - r - - as Owner/Authorizedg y -
Agent hereby declare that the statem(:�.ints and information
t = and belief.
are true and accurate, to the best of my knowledge
the foregoing�pplication
under the pains and penalties of penury.
Signed
Agent
Sig nature:
Your signature carries certain responsibilities, including but not necessarily limited to, general iiaoiiir
Z)1gndiu1G ui %__IYYI
- - _
C ! .ON• 11,V S P E CTO R:S�: E VI l�f E NT S
S E T
.. -
•
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason:
Date: -
subject to Zoning Board of Appeals action:
4. HOLD subs g PP
Date: „ t_
Comments:
Si
f
•
Date. !,V
nature:
or' sgnature:
Inspector's, g
_ -
•
• • 1.
_
soft N OT_ ! O _ -
F I CAT�SE PLf ANT
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informed of above: Date:
Applicant
i•me.
ay.
r--k.
Clerk.
rwa
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Comm e..nt s••
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aP-
_ 0. =0-F.-. VOTE SFIG / NS�EToRt � -=.. -
.Y -
-.SECTION'
c atton Fee: $25. o
Less. Application
In Balance:
Remaining
•
Fee: •
�.rm tt F
IP $
Total
Other Amount
_ New Cons•on to
FEE: Gros truction ct r
AL F
TOT
Gross Area - Alteration total sq. ft.
Permit Issued to:
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w TV • NLV V A. J• &] JI tea.• i-ta• vas aL ...� r� v w � ��
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• �- DATE RECP:IVED
•r•OUTN•�~•' �EP��T
-��': D RT MOUT`H BUILDIN
4 � �� .ram
.� 9#
:Q 17M9
i� 400 Slocum Road, P.O. Box 79399
'o z=
�. • Dartmouth, MA 02747
_
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�..°.� Phone: 508-910-1820 Fax: 508-910-1838
, 5y'.=•�
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'••. 664
vmw.town. dartmout . ma. us
APPLICATION TO CONSTRUCT, REPAIR, -RENOVATE OR DEMOLISH A ONE OR Two FAMILY Dwr_�LLING
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:.REQUI.RE8��INSPECTOR'S':.*'REVI*E'RERM- I
:T..
_
-
MM�M�~�z����DEC)j&RTMENTAL-:APPRO
f
ZoningReview: Signature: s .�' Date:
Date:
Energy Report: Signature:
Date:
Fire Chief: Signature: _ _ _
Board of Health: Signature. Date:
Date:
Conservation Commission: Signature:--
Other: Signature: Date:
Brief description of work being performed:
- i• i•
•1
••t •
t.
S E CT ! ON :'I•
-SI
TE:
•MATI O
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/Property Address: o\J
Lot Area (sf.) 99 7 D3 Frontage 7
Required
Front Yard
Side Yard
Rear Yard
Provided
�tD
�mom* If
1201
1.2 Assessors Map & Lot Number:
Map FO Lot
f _
1.3 Historical District
❑ Yes M-,,No
Has application been submitted to the Hlistoric Commission?
❑ Yes ❑ No Date:
1.4 ater Supply (MGL c40 s54): 1.5 •swage Disposal System:
J/ ❑ Municipal Private Well f/��0 Municipal On Site Dispr-;sal System
7..i•t•Y
� 1 _
CONSTr"?UCTION PLANSS.
J:wlt•f1.a
S 1
Ste..,,•.,; • ;1 � r s e.._. �i • L�
- NE
�����-�1t i is _