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BP-2003-31637 Permit No. BP- 03-31637 GIS#: 434 ) Map: 0080 L ommonweatth ol!aidachuiet3 Lot: 0006 Sub-Lot: 0000 TOWN OF DARTMOUTH Category: NEI% 400 Slocum Road,Dartmouth,MA 02747 Project# JS-20-,44-0547 Phone:(508)910-1820 • Fax:(508)910-1838 Est.Cost: S2300.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Coast.Class: Use Group: R4 Contractor: License: Phone#: Lot Size(sq.ft.) 42466 TONY MARTINS HI 134079 (508)997-7098 Zoning: SRB Engineer: License: Phone#: New Const.: 270 sq.R. Alt.Coast: N/A Applicant: Phone#: Date Typed: 11/18/2003 MARTINS PAINTING&HOME IMPROVEMENT (508)997-7098 OWNER: STAPLES ROBBI& DATE ISSUED: /`/la/CVe7 TO PERFORM THE FOLLOWING WORK: Build 12'x 22.5'wooden deck attached to existing house BUILDING PERMIT Project Location: 27 PINE ISLAND RD Approved/Issued By: / LYNWOOD R.COMSTOCK, OCAL UILDING INSPECTOR All work shall comply with 780 CMR 6m Ed.(MGL Chap. 143)and any other applicable Mass. Laws or Codes and plans on file. POST THIS CARD SO IT/S VISIBLE FROM THE STREET SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. 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: �4 Comments: REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD COPY TOWN OF DARTVIOUTH dlligtIR P l 0 , el L BUILDING RECEIPTS 4 N. COLLECTOR'S OFFICE 3 f Name f l?roperly /t Date: / • , ,j' -ar e i t _. . L ,. Ow�x er. _ _ Job Location: r' ,^ '` �' > , j. White Copy Collector's Office Plot: .. i f Lot: Yellow Copy-Customer's Receipt 4 ' Pink Copy File Copy Green Copy-Building Department Phone: i Description General Ledger#'s 1 ; igtz#tiCE Amount r m.t t;,R-." License&Permits-Building 01000-44105 ILL. . , +' ,._ License&Permits-Building Misc. 01000-44105 !T." i 9 r__ "' License&Permits-Electrical 01000-44106 .t .., ,,, . License&Permits-Plumbing&Gas 01000-44107 tij, v Other Department Revenue 01000-42420 ,; apt_ This is not a Permit or License for Building.Plumbing or Gas Received By: t' TOWN OF `DARTMOUTH 31637 7 7`Qe 7 -t — --h BUILDaING RECEIPTS w COLLECTOR'S OFFICE r TOWN OF DARPo011iti Name ; ` t ., Property c i 1 3 O EC i OR'S OF CC Date {{''' Sri t r ;.. vz , - . iw Owner: f �i �'I Job Location ^', ) , . ,f ,_m,a-`; i ... .i,'w' /-/ j . .:I . NOV 14 4'vu White Copy-Collector's Office Plot: t;-- ': Lot: i :J ?' Yellow Copy-Customer's Receipt j .,,, (c.::"' Pink Copy-File Copy MR S 02 Green Copy-Building Department Phone: Description General Ledger#'s Ref.# Amount License&Permits-Building 01000 44105 , ;; ; v 2r , f ¢ A... License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 ' ,A ; , , This is not a Permit or License for Building,Plumbing or Gas Received By: f.J I tt `% • RESIDENTIAL ❑ FOUNDATION ONLY 2003 $25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE ��°�r"M` DARTMOUTH BUILDING DEPARTMENT ''�' DATE RC �E i OP�9 y' to,i' '"-4 400 Slocum Road, P.O. Box 79399 " �: "�' — • - zo �, Y, Dartmouth, MA 02747 tuba:% 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY ',WELLING Ewa S NE� FF+ iLUSEON t , n BUIL�G P T NUMBER:- ` Il DA�1 .E wti'E e.�k-"`" u scm,▪,5 .- 3 { k's`-AT Ii �l �' �.>, t,' ',z� OK ▪ ISS *; , Tl E: .. 1 gS'.e▪m A., " /' '" OAT .4. A'- aT 1' 't t't i Somas o of B e' M35 . r,�� � �o1A lf8rft �w �r � ' oi ' C A ` 1 s, iL�L i '4F _ -q Sr�l O : ^ '' t[ ram• oB o 3 * on f 4 ❑ P e,� t. , r E'n%r ep Appeals . t . Car Sent= _ ',cutoff _Follow ❑Firs . . :..' 0 Gas 0 'lan Boar 0 der Cara eater rd - a; 0 ning v I Oche? Chief Gut Off 1 CuOff f Cut Off Review* *RE.QUIR SPE.y�T�'OR�S v WD 'ORE THE ISSUA"I CE OF A PERMIT'`, - - �: _.„ ..▪ .U. . . , .. � ,_ .:▪ �_.� :. . � , :.�..� . ._�:.x. _�.z„t ,a sue_... _a Hi ..:�: .'' � .- .._�.� . Zoning Review: Signature: Date: Energy Report: Signature: Date: • Fire Chief: Signature: Date: % i o dofHealth: Signature: ('�1}�1C1 t ��-C l C% Date: // ���t� Conservation Commission: Signature: �1 ,�1,ttLC - A-- Date: /f/�/�' Other: Signature: Date: N.Description of work being perf -k";;(- titer.:ormed r d- � SECTION ▪ T 'ORMA ON UMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes 0 no _ 1.2 Assessors Plat&Lot Number: 1.1 Property Address:-� P-:ram -1,-S� -r'ck Ck--\ Plat Lot - Nearest Cross Street: Subdivision Name: 1.3 Historical District 0 yes ❑ no Has application been submitted to the Historic Commission? otal Land Area Sq.Ft.: CI yes ❑ no Date: • 1.4 Water Supply (MGL c 40§54): 1.5 Sewage Disposal System: ❑Municipal Priv Well" \ 0 Municipal - On Site Disposal System C:\bldg.forms\Bldgapp-res.wpd Page 1 Rev.January 1,2003 R SIDENTIAL 2003 sa,i "�; .r`" P (”12SI# &ii6 l j„, N: j_ 2.1 Owner of Record: Name(pri�it) Contact Address Phone ber 'QO 6 h i S/4/01,_5 2.2 Authorized Agent: VAP•r\--- \v''N Contact Address Phone Number Name(print)k # x i� -� s - s� t74 4:t4AI-it ��s Lit sJ' t r�i s t "�xk`A- , «.9I�� rock ikotat, , , ,: v, ,dtp0-t, v'3r,z-4. zh,0 U,. ov,a � . a ttz , il ,,-To «_waaitF`:'�, ...��14, /Th3.1 Licensed Construction Supervisor: l o 'pi Ica.e ■ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable IDAre you a Home Improvement Contractor subject to(780 CMR-6)? Elyes Elno If no,go to the next section! Are you claiming exemption from the requirement? ❑yes Elno If yes,submit the required affidavit! Company Name \- — - cirAi�},� \ _c10 a4i Registration Number(if none,state 0 none❑) 5.'', Address C� t. ,,C� Signature 'X�'�.—Z c\c Telephone ---\--1 <' Expiration Date 3., / 3 For Residential}model Work Only /" PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place-Room 1301,Boston,MA 02108, (617)727-8598 Owners Name(print) 1-0 'C---AN1r'\\\,-v Signatuet by signing the above,the h/t e owner acknowledges that there will be no eligibilty to the Guaranty Fund Date \ \-- \\-- 0 3.4 Homeowner Exemption-One&Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 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 structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. 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: Your signature carries certain responsibilities,including but not necessarily limited to,general liability C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January 1,2003 RESIDENTIAL 2003 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) 'SMIW.*4AV14.7.:.S: d“:,1:*::N::gA*:SMt.1TMge,g4A-rM(tq:G,-„t;,e1,52::-§..,'25),,'„,.,:',i'' . ,,I,i'lf,ik,,,,, Workers 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 ;',4;4,1$4347,;.4,t1',740 .1:,'.,•],:2;;;;;•r: :— ;--•-,,, 0X . , ,,,'.-.&:.:eitts:;Ss- mi t#:.. ,,i:''';-ktok-Alkoottc4pley::: r-i,-:v,vt-n:iNwz--v,----xtzt-t-:,,,A4.,:-4- ,.n:T':',:,.,mze.'4,-'=4,-;'E',Th-...,:•-2-1.-q,,,',,,-,...„ „'J',. .;',,fl-v-1;.,!,-.-.f.,-Jcs,::-:-,,,,T1, O new construction* 0 addition 0 alteration 0 repairs 10 chimney/ 10 woodstove (energy report required) (energy report required) fireplace O deck El pool 0 accessory bldg. 0 replacement window/door 10 other 10 demolition (shed/garage) no.of windows doors (specify below): (specify below): *If new construction,please complete the following: Single Family: no.of bedrooms no.of baths Two Family: no.of bedrooms unit 1 no.of baths unit 1 no.of bedrooms unit 2 no.of baths unit 2 O Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): D Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): O HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): O Air conditioning-(separate unit) El None of the above to be provided O Hot Water: Gas Electric Fuel Oil Other -. \ Brief Description of Proposed Work. ,.. .. ÷''' ''' ...,j... CNPQ,N-- X.' (-)..C. - -_-_---:-'s5;--iief:W---j---&'-'-ii• -ii.17-if,zi, ..,4:.1,-.,:-_-5:--,i-A„,,,,:c.:46-1 -:- - -2-,- - 7---:.--,wioo-e----ov-----x.,e- g.=:--tr-x-T,,:-:-..::,-:- -r; -,-,-.- --.Item Estimated Estimated Cost($)to be completed by permit applicant 1 Rnildino 9 Flertrical 1 Plrunhina 4 Mechanical (HVAC1 5.Total=(1 +2+3 +4) *Estimated Total $ SEC7**14:!,:-0WN,VKAPT.-.-P9RIZA. ,-TION (bibiiii*ptited when oinees:agent or contractor applies for buil ! . pérnu 41casyrini) ,, i1, a 1,./ 57,--,,,/e_s ,as Owner of the subject property hereby authorize -7(3)7 to act on b9half,in , , .2.4 r rs relative to work authorized by this building permit application. t- -" ``" ' ``°- „/„/, , Signatu e of Owner Date SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION I, 6 17)-2 ' ', ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing applicatithi are true and accurate,to the best of my knowledge and belief. Signed der the ' s and,penalties of perjury. n. // 7 e..)-13 ---' - Signature of Owner/A thorized Agent 0 Date cmidg.forms\Biciz27-_-7.-iv.pd Page 3 Rev.January 1,2003 RESIDENTIAL 2002 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERABLE , 1 ff-6148 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: 6. HOLD reason: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Signature: Date/44% • "TION A ,UCA-mI €TI i AT I Applicant informed of above Date: / ' .r .1 Time: Clerk: Comments: T 1 --OE E m O*'SNO S _ r .. Total Permit Fee: $ '063. 00 Less Application Fee: $25.00 Remaining Balance: $ /5 TOTAL FEE:( "%d ("L./ Gross Area-New Construction total sq.ft. 76, Gross Area-Alteration total sq.ft. // Permit Issued To: 5 ,/d' /0 ' )( 2'.,� / t. Q�t,c.. elec,„/ T iecp ;-1 h�js -v i el! ,n YtoG I �' C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev.January 1,2003 'erm it No. BP-2003-31637 Project Location: 27 PINE ISLAND RD Commonwealth of!Massachusetts TOWN OF DARTMOUTH p#: 43�00 400 Slocum Road,Dartmouth,MA 02747 Lot: 0006 Phone: (508)910-1820 . Fax:(508)910-1838 Sublot: 0000 BUILDING PERMIT Category: � �47 FIELD INSPECTION F Cost: $4o Const.Class: Contractor: License: Phone#: Use Group: R4 TONY MARTINS III 134079 (508)997-7098 Lot Size(sq.ft.) 42466.00 Engineer: License: Phone#: Zoning:; SRB New Const.: 270 sq.ft. Alt.Const.: N/A Applicant: Phone#: Ceiling: MARTINS PAINTING& HOME IMPROVEMENT (508)997-7098 Walls: OWNER: Floor: STAPLES ROBBI & Glazing: DATE ISSUED: /AA rF 29Lii TO PERFORM THE FOLLOWING WORK: Build 12'x 22.5' wooden deck attached to existing house DATE TIME TYPE OF INSPECTION&REMARKS INITIAL > JJ I#44 3 �'43- 6,7,:► i�c:4e$ -C> ? - 7- /O 4 ' // /1,2,2/0.3 3.65- At,,, t 12/1 ©© LTiLCORPLETero ..P • ' . --,. .-„,77:441..zw-7,7„Atc .,..).- _,v.,..zw.f. 77_7 :- . .....---- ..,, 6 . (I irA "...o, ( , ------ — -, , kir% • ‘. I . - — — ---------1 I 1 1 1 •- '-',-.•- f s---...cioc ;c ,• i C , —_ , , , „.., , , ,....._ , od i : .., • — - • c rn rn z rki i ci(- , If if? ':... 4 fi 1 ...4 0 `i7 ir' u) I ---, :-.-... •..... .. ..,... -r1 t .,.:. 0 . a) 17.1 T. o c > 0 -,1 - • ---1 v r 1 ,-. .,:::-: FriD —4:::-r 7i3 .,C7.7 0 • i 0 t 1 4 .-;,-' cn .-.., t... c ‘7 1 1 ''''''.1' r" :"•el-.. 1!,I4 .4 ; M g ' ' C • CliN i ,•1 ••••i• tg i ;4;ZZ •'-4 ..I. 1 -.'"1 411 t 9) ' rj • g gl; 11 -71: Co.Z. s92 ,,, 0 i 1 . v , _ i • 1 • . . -ri ...,! 1 : 6 P 1 -ki •, • ; , ., ' c v P -4 -0 X rn rn 2 - r, i ve 1 1 I § 9 -a' ti z 0 _ to) • —_-----_,/ I 5 a 0 xi 0 rn 0 m A te 1 ...• • . - c. i d (1 SI rn in4 ri4 i • „. . cP z 03 rri -4 MI fr -t • ) ... 4. 111 , . . •-,..: ....wi-,;.; ,.... . . . .1. t t :.z , 3: 5 5 �fze eanvo oweveald ok✓ rasaeluzaelta Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR r- - Registration: 134079 Expiration: 9/21/2005 . � Type: Individual TONY MARTINS TONY MARTINS pA,T" 12 GARFIELD ST. 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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to$1,500.00' and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I ' and Q � rstand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I hereby certify that under the pains and penalties of perjury that the information provided above is true and correct. ignature: Date Print Name: V "�vG�`c1�i K1 S Phone # qe\`' —"1©O official use only do not write in this area to be completed by city or town official ❑Buildin Department city or town: permit/license# ❑Licensmg Board ❑ check if immediate response is required ❑Selectmen s Office ❑Health Department contact person: phone# ❑Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted from the "law", 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 section 25 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 corn-- monwealth for any applicant who has not produced acceptable evidence of compliance with the insur- ance coverage required. Additionally, 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 insur- ance requirements of this chapter have been presented to the contracting authority. :•YnijT.:v v:i->'::: ::yp::.::>::........:T. r.A:v..�.,.::............::;;3}>:•}:!t;3}}';;:t t3:tti}ii:iii i>t i3':.:3T}::i'�;TT 5:3::-::::::vi?ttT,..i Applicants Please fill in the workers' compensation affidavit completely; by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits 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. ♦ A ?t'y�. } },. ti tE'�' Y :::::,-.::�::::.v.:>.�.::.Y...............:...v.... ...:.::. ,.t............l n.........:.t.......ny::.nw::>::::::.^:::.n.:...:.n. .?y't. :.n:�n..::. ... ...... ... .?:.....:..:-v ..:((.::,... ......n..}. ,....:nn,. n..wn�n.......... ....... ..'i.rc....,.x.nn,v::.,:.:yi}:>:•; ...........?......v.:\ ............... .. ..:.�::::. ...................n......x..n.........:....., n...{>.>........n.......:...v....n.i..,.t........ .. .. .. n:............... .. .......:...t�..n.....r...n.............»..:....n ,.rn... . ::.:•::.�::.�:v.A.:::.: ::;: ;.T:. .t...... ,.....:.... :...........,.vt.: .vu,3.c:.:n+.:.::�:n,:v�v:v:.::.:>':3}:'..vw:3:.y':.}v.>':::>.vv.::..v......t .?.:.mom::n:,r.:.::>::,?.}:: .:t.:v. .v, .::r:x ......::. v}:• ?.�:::: .:.v:. r:31{.. ::.>t \ •nY.+ n\.m ::.r,}T::}}?;v}»}»»: \ fkS City or Towns 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. the affidavits may be returned to the Department by mail or FAX unless other arrangements have been'made. The Office of Investigations would like to thank you in advance for your cooperation and'should'you-have-any ' questions,,please do not hesitate to call. The Department's address, telephone,'and fax number: The ,Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " • 600 Washington Street Boston, Mass. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. .406, 409, or 375 000 O O 00 O Cr‘O O C O C C O O O O O O 7 7 ti O.-" 7 ca . M ri �W.�-� h .-" �N N N C N GA r" CQ O a N O Ca Q C en *at PO Osi Or. r^ •N V1 y O C O: R �l N ti A OS ,�000 �U V W.. 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N UI., r 1 \ C7 o cn:n r'.1 Z m,-C w y c.,)v) o Z Z �CD)( �1 �0 7y() tro's1,x ti p c, C k 0 C.g'b 0 C ,M,,0 a `' N O 0 0 p. 0 0 O co w " co co 0 0 A.�..... y _ m m 5 Q..: C 0 �� yao a cro- �, - ", c0o m..nno �w Cd 0 9n' coo a y� x x � N 0 kb h ono oo�oo m w b b b7 0 0 o N'o� ,, �w rn Zi&W ,0, 0 :X .9 '•L.<a M tti b 0o m c '4 �C o 0 o t:$ n on 0 c .-. m io X c.-- bc,© r 0 rn y' P ti 00 P~ ah7 vovOs.o � 0 �] O n ,o o A n ,. a NAOQ ti: a �t w ocNa 0 b y * `O n O b CZ b n Z.' a h s ti z b 01 WO bJJOC A b A W n ' a ,40 OO U Noo AWAU Wor oam° yC OU 'OUt l C OOC S Cry ti b t y m a _ n 0 o W H+W W N A CD Vl 0100N WWA A vLAAA ..-+00 0, W A J N o 0 0 �l N0\� OOo csi W _b C44 ,-. C m A 0 W N g R o by y n W b 0 0• b A w F+ N N N O O W O N RESIDENTIAL 2003 0 FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE it NON-TRANSFERABLE 41W:1 '",r�,N DARTMOUTH BUILDING DEPARTMENT ` " - DATE QED _I'll 400 Slocum Road, P.O. Box 79399 ?x -; �, \���s: vY� Dartmouth, MA 02747 I R-h4'� 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMIL'Y^DWt L NG - g : : > SECTION FOR OFFICIAL USE ONLY 14 ` < . l- �'i �•c ' � t-' I C of-a`,), t Ih '�� RECEIVE ?B `' BUILDING PERMIT NU . . , DA FO I?A'TE ISSUED - '`Y v OK TO ISSUE SIG ,, :... W, DATE" `s' _. hiding onerllnspector-of Buildings V .; . t.. - . � ��" E Zoning District ; ►ne. <=fit Cz.B 0 .,.0 V Outside Flood Zone `cl ' Aquifer Zone 4FOLLOWING AGENCIES"SHOULD BE NOTIFIED. r s` '. r am' *� " V :' -, -" w ❑Board o oard ef Demo n DPW 0 Elec. 0 Energy Report Appeals � iealth Affi4vit Card Sent. «t Cut Off Follow-up' ,:p ❑ Fire x Gas »g *. 1 Sew-erCarsd' 0 Water Card ,` ❑Zoning 0 Other Chief ',Cu- t Olf /Cnt Off I Cut Off Review* ',RBQBTRES IN 'S SPECTOR REVIEW BEFORE THE ISSUANCE OF A PERMIT \ '_- `DEPART NTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: d of Health: Signature: Date: iCer Conservation Commission: Signature: AIrio4r Date: it'r"mret_____ --k Other: Signature: Date: Description of work being performed: t. c3- t)Th c .Th BECIOL I "SITE°Il)TFQRRiATION BER OF PLANS SUBMIT LED: SITE PLAN SUBMIT lED: 0 yes ❑no 1.2 Assessors Plat&Lot Number: 1.1 Property Address: .9-.•� �S�Y�, Plat Lot Nearest Cross Street: Subdivision Name: 1.3 Historical District 0 yes 0 no Has application been submitted to the Historic Commission? otal Land Area Sq.Ft.: \: ❑yes ❑no Date: 1.4 Water Supply(MGL c 40§54): / 1.5 Sewage Disposal System: 0 Municipal 'Private Well ❑Municipal • On Site Disposal System C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev Tamianr 1 '7(1l12 . 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