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BP-2000-17344 Permit No. BP-2000-17344 r e i #11 1 I `:c Lommonweat o n 1 p daX� a i TO`'VN,CIF I ,` IY ICI XInT4 ' V41H 4 0 j '' 400-Slocum Road,Dartmouth,MA: 02747' j s ', " Al _ Phone.(508)999-0720 Fax: 508 999 0738' 1.47` ,,,_.,.u, 7 ."ltf,IXl...l 1 1 ' J a- u,�.d �.$ v' "3 bti -7'k 7 a t+o`��s" �s a1`'r"fie" 9'y� -t"� +�+ xs �� s �.. �' �'.., �1+i� 3,- PERMISSION IS HEREBY GRA�NTFD O: 1 Ear r i i m..-s, m r 'Yu z ;. � "�,{a .as_ ,ak...»x I k,,.$ it , 'l A v i ' i ' i f:i' � wit Contractor , ; erase 3 i phone#: 3� U 3 ' `^ '(si t`d d' ' Engineer 1 y og ;4,�nse ; hone#: -Z`oniil : y '-7, e `� �,, 'New Const: ; 00s'f - Applicant. -- V �/ , Phone#: AIt.G�onst- ' a ty f _ STAPLES ROBBI&'JANE STAPLES ..(508)985-1941 '':Date Typed, . 45400 ' OWNER: STAPLES ROBBI&JANE STAPLES DATE ISSUED: /4"`4" - TO PERFORM THE FOLLOWING WORK: ' 16'x 25'addition to existing garage BUILDING PERMIT Project o ' tion: 27 PE ISLAND RI) + 9ArProved/Issued By: I' o► i • JOE S.REED,Loc B il1DING INSPE I R All work shall comply with 780 C i, I I Ed.(MGL Chap. 143)and any other applicable, ass.Laws or Codes and plans on file. POST THIS CARD SO IT IS VISIELEFRO/LM 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 ilding/Zon', ! Perm't. Signature of Owner/Agent: ,44 I ' / Comments: REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD COPY Towt4 OF DARTMOUTH 17511 BUILDING RECEIPTS COLLECTOR'S OFFICE f Name 4f ) i, ? Property r t Date: r f V>'_-, ) 4.°i t Owner: 4;` *" �` id z / r i.,' Job Location: �t '�^ ,-)0 `>e 1 i`�i i L.• A' _ .A :el:. .E. C.i � R 1' N White Copy-Collector's Office ! Plot: Lot i 1cC Yellow Copy-Customer's Receipt . t . 'Pi�Copy-File Copy b, �)'t'een Copy-Building Department — Phone: (,� 1 11‘Description General Ledger#'s Ref. t Amount License&Permitsk 'Ming -44105 J' i it i '` A) {! License&Permits Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By: _�'` TOWN OF DARTMOUTH 1714,4 BUILDING RECEIPTS COLLECTOR'S OFFICE Name Property Date: e ° Owner: Job Location: J t c. # '._--( _} ?TnwN nF DARTMOUTH COLLECTOR'S OFFICE Wh to Copy-Collector's Office Plot: Lot Yelbw Copy-Customer's Receipt i t Pin:Copy-File Copy SEP � Green Copy-Building Department Phone: tutu n n .4.:. ".g I sl, Description General Ledger#'s CS Qef.Q 7 Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 };;_ T. License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By: '� , RESIDENTIAL 2000 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE ��TH:' DATE RECEIVED � -1 -' DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 ` —� Dartmouth, MA 02747 , .; f.., i F• P 7 'Rhy� 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIUN FO Y >tE ::.;:.:::<2 ;:... .> :::: ::`< ` '>::. <>> ::>:: ''>:: >« ::::...gii.':? ::.. ` <';-..i :« : ;ij .i. is . " s`. .: <<' al; ll B.1 BUI1,Ai,:;: >lr 1<T . Bf1T'E: :::.�. ..:� :.:..:::: .::::::.::: :.. ::.':...;::::; : .::ter:..:' :::::::::::::.::..::::..:.J..>:.>:.>::.::.s:.::.>:..:.:::: : ..•:..:::. .... :.......:::......_...:........ ::::.... ....::..:::::.:...:..:.::..'::..�:.:::::..::::. A �s..' �+y yyr:y��. .:. :: .:.:•:: . ! K:TE3: AT UR DATE �ropused>�s ..::.. o>�ze,::: �l.,B,1����CwJ V.;;#Ju�sic�g:.�Iflvd..Zo4#.:u.;.A9:u�fer..��g.. x�.>F�Ial.;,a1:1:*� :V1;;TkiR::I31✓..N-�Irl �.. ... .:::..: .:. :;��'..eats.:..::.;:.::;:.;;.::.:;..oa.lih;:.; ::.::.. :. :,i ,..:.:::::::::.�:.A:ff.davtt :*..".:s'::- »:::::.:.. :.: ...:::i.i :::::.::...:: ..:.::::::::::::.:::::::: . : : :::: ... ..:.:::.:::. . .:.. ,::::::::.:: :.::::::..:. ::Gard,Sent,T......... . ..:..:.:�`�st CJ►f'f:.;:.:::.;lft`v1C�w.<tl ::..: .::.:.: . �L7:Plannin ::Board.::.::;�t:'.waver:.:;far..d:::::::...:;;:;L�131ater::Card..;:::: <:::: .;: :::.':�::�flnm ":::::::G�:: I�er<:::::.:::>.i::<: :::>:::::::: .:: .:::::..:.::. . ..:::.:.. :::.:.::::: ... .. .. ..... ....... re ::.. _...�u�.off . .:::..: .... .>::;::;":. ::.;::;:.. ;::....I:Guti�€i.:.. ..:..:.::... E..C�.Off::. :<;::;:.;:;:::>::<;:<;:.: ::.:;;.:::..:>: ::':: : ::;::::':;>: : :>:::>i>:r:<::<:::::::«:;;is :::;;;: :.;:.;:.:;.;::.;;:.;::;:R£. LliRE9:INSPE�IY)R::�':?R�T{IE��B£F RI;:Ti3E:I SIJ�N>I✓:: F.. ; . ......._...Q.. O :., � � g;;A PERMIT;:::;;i:>.:»:>:::::::::;:i> isi:': .....: :r;:::<<>: ': •:. T, ENT Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: lit/eDate:Board of Health:'/ Signature: — at . Conservation Commission:- Signature: Other: Signature: '/�?,,r ����nn Date: Description of work being performed:/`'o f, i )5 C�eleiC, Z 'i l'-0 ,4,e.zz 8/(___ NUMBER OF PLANS SUBMITTED: a SITE PLAN SUBMITTED: Er5./es 0 no � n 1.2 Assessors Plat& of Number: 1.1 Property Address: ,. 7 /' " 1 � � � 5/ Plat Lot - Nearest Cross Street: Hirt)I1 H,`/ :Wd( Subdivision Name: 1.3 Historical District 0 yes 0 no Has application been submitted to the Historic Commission? Total Land Area Sq. Ft.: 0 yes 0 no Date: 1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal 11 'rivate Well 0 Municipal ®On Site Disposal System C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev.Januar 13.2000 RESIDENTIAL 2000 SECTI }N2-:PROPERlYU'4VNERSI1 /Atj.Tfi.ORI7E1) AGENT 2.1 Owner of Record: -rt"J '1 R 0.9 b g 7 01/0 /L.J & 7 V iq C i S/0l n 4 !G / F S / %4// Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable 0 Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 yes 0 no If no,go to the next section! Are you claiming exemption from the requirement? 0 yes 0 no If yes,submit the required affidavit! Company Name Registration Number(if none,state"none") Address Signature Telephone Expiration Date 3.3 For Residential Remodel 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) Signature by signing the above,the home owner acknowledges that there will be no eligibilty to the Guaranty Fund Date 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 I, 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 sec t s n elow: r Signature: ' � /1/1. Your signature carries certain r'sponsibilities,including but not necessarily limited to,general liability C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January 13.2000 RESIDENTIAL 2000 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) . • ;: S�;!�'1!'1€�3I�4 .Ny©RC�E1t S CL�l�Pt1�f$A`l``C4:�1�':flx(STiA1��1�rtl�FlUA'4�1'C�MGi;.,�'t Workers Compensation Insurance affidavit must be completed and submitted with this application. Fai ure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: yes 0 no >;::.:.:i ]::.i:SECTIOI\5-DESCRHrTI01 OF PROPOSE14 WORK(check att a hca. P :;:::: _. o new construction* 0 addition 0 alteration 0 repairs 0 chimney/ 0 woodstove (energy report required) (energy report required) fireplace ❑deck 0 pool acces ••- bldg. 0 replacement window/door 0 other 0 demolition (s e•%arage) no. of windows_doors_ (specify below): (specify below): * If new construction,please complete the wing: 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 ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: , 0 Ili i X ,-)S" a 0(CIA-1A-OrX- -16 j 4 Z LA Wit 9/7 - 1--gre_ . ..:. .. i.ESTI Ir ' E]D:. O STI U I Ii : fl?:T°�s'`:i: >:: '.':::;:::::::.:.;:>.:.H. :` . .. Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Total=(1 +2+3 +4) *Estimated Total 5 ®O U $ Zzt:TION ':....... '' > i ' > >'>` ` ii ` > > >>2 <- ::. ::::::: ::::::::: :::::: ::: : : : ::. ; 'CT '.I3!+i;;::f}::»::Q�#�tER_:ALA'!'?�If1RJ......................... ...................... ..ne s::a ent:o:r::contractar::a . l:Ees::for:bwldln.. :: ermi�)..'. ':*::::>::::` ' ;:::.mii,i::>:::»: .::::`:. .;::::;:::;::.:::;:.>::;:::.:::::.>.::::::::.;.; ;.>::.:;:;::;.to.:be..corn Ieted.�hett.ew . r...... ..............................................................::. l�.l�.................................... ;:. (please print) I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date >:.>;:i:: :;';' .':;;.' « '.;:: : SE-diffo t 1 _(IW.Nktii'At1T110.RtiED A-GtNII:F ECIENRA't'CON. I, , 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 per'u . c oa Signature of Owner/Authorized Agent D e C:\bldg.torms\Bldgapp.res.wpd Paee 3 Rev.January 13.2000 RESIDENTIAL 2000 SECTION� INSPECTOR'S RE%'IEW/COMMENTS: 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: DarT 0 4 —110 T NOOT Applicant informed of above Date: Time: Clerk: Comments: ;: EC`I'>;ai��� di�1GE11\SI'>N�"I'(?E2'SvUT1N .:::....;.;. Total Permit Fee: $ ,t� Less Application Fee: $25.00 Remaining Balance: $ > 6 y TOTAL FEE 7 — _ >�0 - Gross Area-New Construction total sq. ft. 416.e., Gross Area-Alteration total sq. ft. Permit Issued To• / X e- e e%. SI✓CTIQI� 11€ Ab1?I;7TI.?NA�CU�;€��EV'CS'SkET�H • 111de.tbrms'B1dgapp.res.N\pd Page 4- Rev.January 13.2000 Project Location: 27 PINE ISLAND RD Permit No. BP-2000-17344 GIS#: 4349.00 Map: 0080 ith, 911 ILL a lid Commonwea (aodac_ Lot: 0006 Sub-Lot: 0000 TOWN OF DARTMOUTH Category: New 400 Slocum Road,Dartmouth,MA 02747 -Project# JS-2001-0309 Phone: (508)999.-0720 Fax: (508)999-0738 Est.Cost: $13000.00 Fee: $50.00 BUILDING PERMIT Const.Class: Use Group: R4 Lot Size(sq.ft.) 42466 Zoning: SRB FIELD INSPECTION NeW Const.: 400 sq.ft. Alt.Const: N/A Contractor: License: Phone#: Engineer: License: Phone#: Applicant: Phone#: d STAPLES ROBBI&JANE STAPLES (508) 985-1941 OWNER: STAPLES ROBBI&JANE STAPLES DATE ISSUED: id -6' `-t,1) TO PERFORM THE FOLLOWING WORK: 16'x 25' addition to existing garage DATE TIME TYPE OF INSPECTION&REMARKS INITIAL - - -- - - - - - - - -- - .15 Ot<,0-111141, //0 M •5.7S 0-7(__a-7 611-1-,77 oezi 3 u ,sa, T �__�r_ The Commonwealth of Massachusetts _ - _i., Department of Industrial Acciden ZE St--- - ,41/ ILE 1)0pv Workers' Com ensation Insurance p s Affidavit name: 12 dvb b t' .S�/ /d-/'ll e location: roc 7 P, ,-1 e �.S/Gt A ui &v' ci V. 0tAri'MOv.f 11 phone# 9 d 5 " ' I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working,on this job. company name: address: city: phone#: insurance co. policy# I am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: ' city: phone#: insurance co. policy# company name: address: city: phone#: in%%suu�rann�ce>co. policy# Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify unde thee,ns an' .i nalties i f perjury that the information provided above is true and corr ct. Signature "l' 71 7' / / Date O- L � / Print name {C Cd bh,. S of,A/e 3 Phone# .:..,...i ,..;k "'� .t .` .`,- ._. ..,'�2� `'e 's�.S;•:'��>jfE 'zahV,:`: �F _�.�•�".r..3,.$. ,3i Y.> official use only do not write in this area to be completed by city or town official . city or town: permit/license# Building Department Licensing Board ❑check if immediate response is required ❑Selectmen's Office , ❑Health Department contact person: phone#; ❑Other y. (revised 3/95 PJA) 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 employes 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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance 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 insurance requirements of this chapter have been presented to the contracting authority. 7 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. 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 you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 1 L 11'J.CLfN 11AL 2000 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE h edoLi3mLy:-.1;;!,;:sr'S,;,.s. DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED I. - = 400 Slocum Road, P.O. Box 79399.�zE COPN .30 *../66470 Dartmouth, MA 02747 � `�--� ,.:; ; �?508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i..il If>S::SECTIt3.N F.O GFI ] t3Y. :":::.::::::::1,i.giliiii:i.:.::::.011..i .::.i.:....1.1.....!!iiii.:..........:::: ;:ii.... ........ii....:......?!..1:....-i--.,..; .. A.: . ill BII.i)I1G F 1« .... eg ...........:.......:::::::::.::::.::::..::.:::::.:::::.....................:.�::::::._:::.::........... ................. Bitiltli:::'•:C..--ioae•rlln :::. . :::::::•••-•::- .:.:. . ;;:::.;:.::.::.;••••-- >:<:::z::::::.: :_::::. :::.......•• • . o:.:ing Urstrtet Proposed Use Zone ::0 Ir`:,„R ©:A ❑V iOutside Flood Zone © .Aquifer Zone:. 1 T E O : :>�: :IN, ;ENCI _,:SII0>, : :: :. N.;.: ;: ' :::<.:::: :>:>.M.@:>:<:.iigi>::»::: >::»:::>:;::>:::::..T..P.::>::»::::: ..:...-»-: : :>::::;::::»::>:::: ::'a::>::»::; >:.;:::.d ::::;:. ....��#1!#.�I..��'I1�G:r��+E�>€�S�Rt)IttI.,O..BIv.I�i�T[FiI"�...'.;::.:.;: :.:.::::::..:::...:;;'::.::.::.;'.:' ....::.:::::.....::.: ...::.':.::.::::'.. :.;.;':. ...:.�._:._... ..:..:.::: ..::::.;:;;::.::.::.;:.:". LP";"""""""::"."."::"..:".""":::::::':'"""".:""".""" :.i.""::".:::.i."""::."'""::."::"""'.."""""""::::"::::::i.R"'.."""""""'.::::" "".i":"'."""""::"..:""""1:.":1".i."..:::'"'."..:."::i."..:"ii..".".'.".'':::::''""::"::.":""."""";:""".""::.::""""""":".::""" '"" "":g""..::"": morel o€ .11:. ..:## af' 1 Gom E Demo l DP . . Q EIee. 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C7 V....: .71�.1 8£EpRI:'#'IiE.I�Stl�:��i~:a?E Aa?ER_t�frT::: :>::::::: �;<::z:<:::::::::::>:<:::>:.;':::>:<:::>:::i::;� <:>'' . .:: :..:.:5::::._::.: :.::.:::::: : ::::._::. ::::.:::..EPART11PFTAAPPItL?VAL:..: .:: :::..::..:::.::: ::: :.5; ::::::.�:::::::::::.::::_.: .:.... .:.:::::.::: :: Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: / Signature: — Date: Conservation Commission:/ Signature: Date: Other: Signature: ���j,�,�� Date: Description of work being performed:J I, , `���i'1.�;(,L1 2'1--0 fly .. ...SITE INFt� .:. .. ;;>::>>. >:>:;..:: : :.; :;::..<:::>; <.:.. >::::: >;.:.:... :... :. ..:. NUMBER OF PLANS SUBMITTED: , SITE PLAN SUBMITTED: Eyes 0 no I 1.2 Assessors Plat& of Number: 1.1 Property Address: 07 7 j(2�,) e 15//i n N R Plat t�J Lot - Nearest Cross Street: J//•�r` 11 ,L/11( g61 n Subdivision Name: 1.3 Historical District 0 yes 0 no Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission? 0 yes 0 no Date: 1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System: 0 Municipal private Well 0 Municipal ®On Site Disposal System C:\.bIde.forms\Bldgapp.res 1vpd Page 1 Rev January 1=.2000 • • Plot Plan Of Land In DARTMOUTII Ho (4Se -- /012 sf F? Prepared For TOM BELL Oroky �t — 575 Si A"{ February 18, 1987 Scale: 1" 4 60' 1S6 s, Arthur C. Thompson, Inc. ,Orire w&y Engineers & Surveyors sA e r,( — / 9.Z SIP Marion,MA, SIc%p /e3 4,27 i en c Is I a,,in of �/. O tirt IYJA (,?'ot 7 y7 1 R'o, PI PC '- CFe10 •a` 9. �►\vs , . irrw" PI (FtJD FDUtJ DATiON Ada, at?� Fri'silos 44, A/A e 54/ 558I et � rAY'G • 1/1/4if Note: 1.1J0IL1. 1 I rr-ti_. ZUUU ❑ FOUNDATION ONL Y -. $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERABLE 4. ���,�GT�:y DATE RECEIVED a rf" r�N: DARTMOUTH BUILDING DEPARTMENT . -A 400 Slocum Road, P.O. 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