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BP-12182
i,3 r PERMIT 27 PINE ISLAND ROAD Dartmouth Building Department Plat : 80 400 Slocum Road-P.O. Box 79399 Lot (s) : 6 Dartmouth, MA 02747 Lot Size:42, 466 Telephone 508-999-0720 Zoning Dist . :SRB August 12, 1999 (typed) Permit No. : 4,1W- Issued Date: g /A/0lCf Clerk: BAS Project Location: 27 Pine Island Road Number Street Subdivision Name: Nearest Cross Street: High Hill Road Person Permit Issued To: Robbi Staples Address : 27 Pine Island Road, Dartmouth, MA 02747 Applicant/Agent: Same Contact Person Phone #: (508) 985-1941 Type of License: Owner: (x) Const. Superv. License # : ( Architect : ( ) Engineer: ( ) Other: ( Proposed Use: Residential Residential,Commercial,Industrial,etc. Permit Issued To: New Construction Type of Improvement,Add,Alter,New Const.,Demo,Land/Move,etc. 12 ' x 16 ' shed -- FIVE FEET SETBACK FROM PROPERTY LINE indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const. : 192 sq. ft . Cost of Const . $2 , 300 . 00 Cost-Other Const. : N/A TOTAL FEE: $ 50 . 00 Owner(s) of Record: Robbi Staples Address : 27 Pine Island Road, Dartmouth, MA 02747 All work shall comply with 780 CMR 6th Ed. (MGL Chap. 143) and any other applicable Mass. Laws or codes and plans on file. 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 of me • snot withstanding the issuance of this Building\Zoning P it. �� Signature of Owner/A e t: gat 4r . Address : ******************* * * **** *** ******************************* Signature: Approved/Issued By: Ra Sou a, le: Local Building Inspector COMMENTS : PLEASE POST PERMIT CARD S THAT IT IS VISIBLE FROM THE STREET.. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS 0 CLERK 0 TOWN OF DARTMOUTH 12182 BUILDING RECEIPTS COLLECTOR'S OFFICE Name: J • Property _.• Date: CD_ f/ o'; if L p ! , .> (r. f� Owner: 7 /j Job Location: . /t .`^� r �AR�O��v,E, White Copy Collectors Office Plot: `--,'i Lot: GO Ocjois Yellow Copy,-Customer's Receipt lr':- ti0 �Lt Pink Copy FA le Copy \5, Greed Copy )&wilding Department Phone: ° _:_ / u " ( v Description General Ledger#'s Amount License&Permits--Building 01000-44105 J L . t.1 / ` 0 License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 Y 1 This is not a Permit or License for Building,Plumbing or Gas Received By: : -� '�7/ ` TOWN r `DARTMOUTH g�q 1 Imo .. 1UaL1NG RECEIPTS COLLECTOR'S OFFICE Name • Property .� Date: 1 _ ll i i 4 JF f 1' i Owner: ( `/ Job Location: ,,I , ! t ( / = �`^ '*. ' f _ White Copy-Collector's Office Plot: C j Lot j , OF DARTMOUTH H Yellow Copy-Customer's Receipt I'f COLLECTOR'S' OFFICE Pink Copy File Copy Green Copy-Building Department Phone: /99 /-' Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 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: - -- Residential 0 FOUNDATION ONLY 1999 v:� , ��y7� � ice:- -/�a�_--7--4 ,---";1 /fc> Grte-eci- __- /�M 9� DARTMOUTH BUILDING DEPARTMENT G _DATE RECEIVED 'r *1-, 400 Slocum Road, P.O. Box 79399 3 � _ y Dartmouth, MA 02747 '` f rfi6, S' 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING :::THI: SECTION:>FOR>`..:FFU :...,US ,. 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Board of r. of ClCo 1 Demo C IWW ;::: ❑.L:lee £I 1nergy Report .. •ii.i::.: ...................... :::;;............. ;;.."..:1:::•:.•••;:i ::::::.iV >:. ;:.::.;:.;:.;:.:::. ... ,:::...i :::. :i:::a::::»:.>>::::>:::• �.pP�;�!s.::::::..::.::.H..... . .:::.;;;:.;:.:;;:.:.. :.:::::-. :<::.::::::: A�'fda���#..:::::::::: :::::�ate..A�dr.�ss:Card:::::::::::::.�.ut:tJ�:.::::::::.:.�'vtlaw-.0 ::.;:;;:.;:.:.;:.:.;:.;:.:;:: ..... .. . . :................Q..Planriin .;::::>::::>::>Eriseilier.;..;:ar..d:.;; :.;.:.;:.;... :. .; .;. ;.;.;:.;:.;:.;:.;:.;:.;:.;:.;:.;:❑.:zonYn .;::;;:.;.;:.Q:Other..:.::.;;;:.;...; .::::.::. :.<: :.. . .::::: :::::.:.. ::.{<u .. :::.::.�::.::5 ref ;.;:.>.:.;;:.:>:.;:.;:.;:;.:: .;;;:.;;;:.;:.;:.;:::;::::::.:.;:..... ::. ............:.......... ........1:(�f€. ...............�a .. ..................taut.�ff........................ .:.::...:.:.:.;:.;:.;:.;;;:.>;:;.;:.;:.;:.;:.;:.;:.:;.;;:.;:1Lte���.:.;::.;:.;:.:;.;:.;::.;:<- ;::.;:;::.;;::-;;:.;«:: .: .:...:. ::. ::: . .......::.. ::..::.. :.::::.::: ::::::::::::::::::::::::::::::::::::::::::::.�:.:Cut:(4�:.: ::::.::::...................................:.:.....................:...................... ... :...:.. . ::.::.;:.:..::.:;: .<.::.;:.;:.;. : .;:::::::::;->: :�dut`it�.1�sriE�c���:�.Rtv#k1�:n1��on�:�nissuA�te�::rz�:A::e�>zl�tr:.::.:.;;: ::::>:..>::::>>:>:::::>::::>::;:::>:: ::::.::: >:DEPAR: ; , . > >s:>€€: ::::: :°:<»»< : <>::i....::> > :> > : :> ::::::;::...: :•.•::.;:;••;••:•.•:••••:•••--•::•:•••-••-••::.::.•;•;:;:.;;:;:;:-•-•:.;:.;;::<:;.;:.,v.. -•••••-••:<•-•••;::.;:::::;•::::.>.........------......•-••• .. I€'PR VA ............. ................. .....................................,,,,........... • • • • • • • • • • • • • • • Zoning Review: Signature: Date: Energy Report: Signature: Date:_ Fire Chief: Signature: Date: Lrioard of Health: Signature: ' `( Date: r,/Conservation Commission: Signature:_ Date: Other: Signature: Date: <::::»:;SSECTI�:.N:1:::-:SI: NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 0 yes 0 no 1.1 Property Address: c.f`7 pj,,P �� /q��1d RA 1.2 Assessors Plat&Lot Number: j f Nearest Cross Street: fit 511 // // 1 �r1 Plat RO Lot 4 - _ G" Subdivision Name: _ 1.3 Historical District 0 yes 0 no ,�ja Has application been submitted to the Historic Commission? Total Land Area Sq.Ft.: l• (� (1 6 0 yes 0 no Date: 1.4 Water Supply(MGL c 40§54): I.5 sewage Disposal System: 0 MunicipalfE'frivate Well L� 0 Municipal �On Site Disposal System ::.:.;:.:::. ::: :.:.:<.:.:. ;:.;:.:: :§:1~CTf4N>;::;»:p.g41E' 'ry:t}` NgZiSlCP:.I:.t111atfogl� NT:... :.: . .:...: .:::.::.::. ..::.:.. :..;::.::.. :. 2.1 Owner of Record: ''''Contact�p27 P I'H C t e Address f ©bar 5 apl�S - 9'95 -" Name(print) r; phone number c:',wpwin\forms\bldgapp.res Page 1 January 20. 1999 1 ' Residential 1999 2.2 Authorized Agent: ' . "^ontact Address t Name(print) \......_Y Telephone iiniiiiiiiIiiiiniiiiiiti #>:SEC >' .. :.... ................................................ :: : :::»>:: :>:::::�><.;;.;:.:�;:.:::. :. .......................::.:�R..0X0J41.s#.+v`:4:+:V;:.gA1,�+:0.4$::::n::>:::::si:'::::<:>::>:::<Sal:<:::si::>:`::::<::':::>::::'< :::<::<:::>�:>:::::::>:�:::::::>: ...... ..................................... 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisorl'\,..:) License Number AddressCI:N\\\ Expiration Date Signature Te pho 1 3.2 Registered Home Improvement Contractor: Not Applicable 0 Are you a Home Improvement Contractor subject to(780 -6)? 0 yes 0 no no,go to the next section! Are you claiming exemption from the requirement? D yes 0 no e \ If yes,submit the required \ \affidavit! Company Name ) Registration Number(if none,state"none") Address Signature ephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH \JNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPL - S\call or write: Home Improvement Contractors Regt ation, One Ashburton Place-Room 1301,Boston,MA 02108, (617) 727-8598 - Ov1rners Name(print) Signature ` by signing the above,the home owner acknowledges that there will be no eli ibiity 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 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: Perms 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. f you are applying under thi ection sign b lqw: i Signature: 4 ft. Your signature carries certain responsibilities, including but not necessarily limited to,general liability c:\wpwin\forms\bldgapp.res Page 2 January 20, 1999 Residential 1999 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) ._... to.t.josf.4gwjjit %ttikokiokkowisioikksitt wkwoit fivideiwi$2;::§,]ipyi;.ipiMii.ii.::NE:::.i.iiMiiNi . '::iiii: ::::,::::::]::::::i:i*:::::imaammbii'ii;ii:omm Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: aces 0 no stertomsi:-IltgekttittoNiioptiltOlicogglAivokiti(0)04;41t applicable) : ' --.,:.:,,,,,,;A:gi:iwi:i:i:;:.::::::::: :iii-m::i:im:::::::.md,..,..,.:]].ift,]:;*,:mmmimiimani=]:=.:::;mi] 0 new 0 addition 0 alteration 0 repairs 0 chimney/fireplace 0 woodstove irconstruction* 0 deck 0 pool P11c-;-essory bldg. 0 replacement window/door 0 other 0 demolition (shed/garage) no. of windows doors (specify below): (specify below): * If new construction,please complete the following: Single Family: no. of bedrooms no.of baths Two Family: no.of bedrooms unit 1 no.of baths unit 1 no. of bedrooms unit 2 no.of baths unit 2 - / ./ Brief Description of Proposed Work: --- I-et// )1/ I c-1 0 '--C c- _ :-.18pgit, 3 A / (_d)rc -F 6 ) :r,i..-,.io::..:..:.i.E.mvmoo•:E:: :i.::mm:i.mmngmwSECTIONgot$*pwNp:go.i.o-otitotwctkjoitwtit.imomomgnoimomom::;i:$!iiiiiiii!ivigi Item Estimated Cost($)to be completed by permit applicant _ 1.Building 2.Electrical 3.Plumbing 4.Mechanical(HVAC) 5.Total---(1 +2+3+4) .5- * Estimated Total $ --, - eTtio.SetegbitqiitAiitititiiiitgiiiiiiigiROMMEMEN:ggigniiiMMininitiniiii$Piii :,:::.:*:*i:]:]*.:,: :,. .:::::,:ii:omi:,,,•.,...,i,,:::: ,i-,-,:,],:.,,,:,i,i,,:::::,. ,:.-., . : , .,, i :, ,: :. . ,, ,, ....:: ;:...,.....::; .:i . ... .,:]:]:i..::.:-.:K::::: :::::i*:::*:*K*,],.:i.::::*::K::.::x: ttoine..:]enintrijeteemnetcnoners:ialgeniTi:or.conna00:r.:Applies.51orronnonng::pertnity:•::m:::]::::::.:x:::::ii::::::::*::::: ::::K:K, i.iiiiii:iviim:iiiiiiiui:ii:iini:i::.:::iiiiiim:ii:ii:::: :::iii: iii:iiiiiii.m:::::.::.:. .:::: :A]iigiia:-:•: ::ifi-.:iii.a.: imiiiiii::.::iii,.-:iiii::mmim::i:i:aii..i:i,,i..ii:i:i]i:i:iiii:.: a,.:iiiiiiii::.*igiiiii.5.:::: :i-:im:::.,:i:.:i.,.:iiin..i:::.ff:::oimiiiiiiimiiiiii.o:i:imiimiiiiiiiii:i:uim I (please tint) I, /re) / ,S.-7(ei i)it'S ,as Owner of the subject property hereby authorize teT to act on my be f, ' eii ma I-.. rela,'ye to work authorized by this building permit application. .-Ge Signature of 0 er Date IiiiliiMEINMENimmiffiggionimi$goi.017.00WiNgftat..V.Pf9ggegAtiCN.V:II.X. .08RATAOkugmongagMiONINEMM I R,6Z,/ 5 /e - tp , ,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 underi e pains and penalties of perjury. yo b, S 71 el /es Print Name pyvgi Signature of Oiener/Authorized gent Date c:\wpwin\forms\bldgapp.res Page 3 January 20, 1999 I Residential 1999 . .. . ....................................................................... 1. Date plan reviewed: q 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: 8. Comments: 9. Inspector's Signature: (...'P '� � '° — Date: g`q 9? Applicant inform. .;:.;:.; � �:.;;;:. d ofabove Date: ,;/�� Time._, Afri Clerk:_Lit Comments: ,11` j, , PY:d - Total Pe rmit ermit Fee: $ Less Application Fee: $25.00 Remaining Balance: $_ e" ) TOTAL FEE: 570, d3 Gross Area-New Construction total sq. ft. Gross Area-Alteration total sq. ft. Permit Issued To• /01.- $ /6 SECTION.U DIT[OJvr t..c!�'I141M NTSJSKETCT E c:\wpwin\forms\bldgapp.res Page 4 January 20, 1999 BUILDING PERMIT 27 PINE ISLAND ROAD Dartmouth Building Department Plat : 80 400 Slocum Road-P.O. Box 79399 Lot (s) : 6 Dartmouth, MA 02747 Lot Size :42, 466 Telephone 508-999-0720 Zoning Dist . :SRB August 12, 1999 (typed) Permit No. : /2/4'c Issued Date : //_h/O/C/ Clerk: BAS Project Location: 27 Pine Island Road Number Street Subdivision Name: Nearest Cross Street : High Hill Road Person Permit Issued To: Robbi Staples Address : 27 Pine Island Road, Dartmouth, MA 02747 Applicant/Agent : Same Contact Person Phone # : (508) 985-1941 Type of License: Owner: (x) Const . . Superv. License # : ( Architect : ( ) Engineer: ( ) Other: ( Proposed Use : Residential Residential,Commercial,Industrial,etc. Permit Issued To: New Construction Type of Improvement;Add,filter;New Conn.,Demo;Land/Move,etc,. — 12 ' x 16 ' shed -- FIVE FEET SETBACK FROM PROPERTY LINE indicate no.of bedrooms and bathrooms and other rooms Gross Area of Const . : 192 sct. ft . Cost of Const . $2 , 300 . 00 Cost-Other Const . : N/A TOTAL FEE: $ 50 . 00 Owner (s) of Record: Robbi Staples Address : 27 Pine Island Road, Dartmouth, MA 02747 All work shall comply with 780 CMR 6th Ed. (MGL Chap. 143) and any other applicable Mass . Laws or codes and plans on file. 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 ar a not withstanding the issuance of this Building\Zoning P mit. Signature of Owner/A e t : Address : ******************* * * **** *** ******************************* Signature: Approved/Issued By: Ra Sou a, T. le: Local Building Inspector COMMENTS : PLEASE POST PERMIT CARD S THAT IT IS VISIBLE FROM THE STREET. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. 0 ORIGINAL 0 APPLICANT 0 ASSESSORS CLERK 0 COPY CURRENT MESSAGES • • .... •........:•:.....:„.„.:.:.:.:.,,,,,:::::::::::::::::::::::,,:„,,,:,:,,,,,,,:,::„„„,:„,„:::,,,:,,,a &, :tiqi;ii:Ti """::::. ----- ---- ------:.::":::"":'':'"""'':'''''''''"':':':''''''''''''''''' ia'm.'.'imqmnl.imMEs.skGgiiiigiim:iiiiigiiiiiiii,:mimqomanmi:Nmom_p;::::::,i:i:i,:g,:s!iii,,!tAfi,.:i_i............1 F3 1-77 -S pi 2: 59 el • n / 3i al--72/?7e /7,/1// oitie, 7 1,6)/lie _Z-3-1009Ai,-.0 vet AZ ))9/e7ive--/--/CLIT 1 Etytise — / 0 3,2 s0 F/ 6-0-.--.;0,-5-c. — S 75 Sl ci . IRON PIPE Di-, v e kin/ — 1156 S/ 11 3 (FND) 1.2x/6 shed — 19 sa, PI IT ,_„,,----ii—,-;,,,r/ .Z 9,s / 42,460(D rti II: 0 0 iivirf . . 7 ' O I - ,, awe Se -.1kact\ ,.--- ' 1 . 1.6 ....1.- ,... n 0 ,,,,,t . • � �j � ,lc' r0 ,per ,I n ,. c,�,'f l f 9.U- • , - ID bu� 3..59 - ' - k --- IRON PI TD7' OF ! V e (FWD) FOUNDATION % c�S/ , f Vl E id,44t � xpgivE .„ /_,, , 50;yi 55:81 o'.7 2/°11/77 (/e • / i •.1 J%' fit•: ,e-, • / / .,, ..., , -f"4/ o :,: 69d 4 Note: I certify that the foundation location is by instrument survey on February 18,1987. ��'�Registere�Lana Surv�eyory, !�'—°°+k�, T 'S lNofOt, .4� is R* u T OMPON W) i Ol Jr s ;,„ [?44.2.tp �tt 4' 1 Residential a FOUNDATION ONLY 1999 g‘, --....„-Trb..e....„0aci..../.6„:_d_,./..„..,.....i.s.„.....t.., DATE RECEIVED /i ,\ DARTMOUTH BUILDING DEPARTMENT , • ./. _- %,px • - (li Ir-ITV':'721 400 Slocum Road, P.O. Box 79399 Dartmouth, MA 02747 \0 , .,,../ •• ••/664../... , 508-999-0720 FAX 508-999-0738 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ANNINEMENNENNE.MiggaggEgMIOSECTIONVOROMCWRSMONpiiiim:K:E:i:wx:33!****N*N:KomE:K:i:x:Nm:E:Kom-,im:i:i*.::.::E:mi.::ii:K:E* : iliNfaiiMiiEei:: iii .E. .iiniZEEEEi:i.ElE;M:.%.:E.Ein.ir.i.:M.igailinili.ininaEE;EEi ::iigi:,i;E.:.NiMiNi.iii.]i.iiMi.: PRKOEIMNratVggggan::MgMEiii::MgiggEegingnfiliagaii:giiiEN:MiiNiiiiq litaDIEWIERNR.NAIBERzimainimi.:::i.ii.o .s:iiliggimonlowni::Enoi.i-iiIiiii::ilii:i:iniiiiii.iiiii.t:E:::::iiiiiiEEEEiiiiiiiiiiniimiiiiimiiiaiiimEigime;E::E.: :: ::::.i .a. nimaiggiyosetRagnEwtigismiiimilgi.iiiimonfogEmEngigmagagmaging:iimeigaii: DATE ISSUED 0l:tiONSMOSigia0igkVt.NiffaRMEMONgiiilgiateignaiE jeukts,sxrggsiGtixwrtgtkkge?:MEggMMENREMEnik::lk ONNgs::mtMMWEmanaiiamile.Krtz.iilii;ii.mlmi.immaimmifEfo.iii.:.ifEiUi::wa:::::::i. : itnnigaintelliadignaningenniiiigINOWNOMOOMIMMONIftwimommimemE::•:.iimi !i:sommii. 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Zoning Review: Signature: Date: Energy Report: Signature: '""-- Date: Fire Chief: Signature: Date: .....--7 .. oard of Health: Signature: AlAe. .,;........s_ L-1,'Ik--- -)".PAZ,Cr,_j, Date: ? ' 6' -.9:7 v Conservation Commission: Signature: Date: g.&-Fy Other: Signature: Date: .-.................................................................................................................................................................................................... . ......................... ........... ... ..... ................. ......... .. sgellostwitnenterigtonoNeiniiiiiiiiiiiiiiiiiiiiiiiii!iiiiiiii.:iii.,i.:iiii:iii;.:.:iiiiiiiiiiiiiiiiiiiimii':iiiiiiii!.:iiiiiii:iiiiiiiiEi.:.:.giiiiii:iiiiii;:.:iiiiiiia.:i.:iiiiimi:: NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: 0 yes , 0 no 1.1 Property Address: c2 7 101.,,,e, zgyel et d pd 1.2 Assessors Plat&Lot Number: VNearest Cross Street: /4'311 It// k a Plat Lot - Subdivision Name: 1.3 Historical District 0 yes 0 no Total Land Area Sq.Ft: 11.2( 966 Has application been submitted to the Historic Commission? 0 yes 0 no Date: 1.4 Water Supply(MGL c 40§54): 2........§rwage Disposal System: 0 MunicipalErPrivate Well 0 Municipal [eon Site Disposal System f§M:ZA'.gigggNMig,gZigigg:NNM:r::::gttdititk* Ottititt::d*diUiit*Mt)ttttlkttiiidt:N:t::,:gmsgma"."Em: :m'a;:Ni'aj.:::::-'.:m-',: 2.1 Owner of Record: (77_422._ sle_aid___ R 01341 Sjetple_s • Contact Address i, ?5 / W Name(print) phone number c:',wpwin\fomis\bIdgapp.res Page 1 . iantinnt'7(1 1000 #, rkt, COPY ELEVATION CERTIFICATE O.M.B. No. 3067-0077 FEDERAL EMERGENCY MANAGEMENT AGENCY Expires July 31, 1999 NATIONAL FLOOD INSURANCE PROGRAM ATTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement.This form is used only to pro- vide elevation information necessary to ensure compliance with applicable community floodplain management ordinances,to determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revision (LOMA or LOMR).You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Instructions for completing this form can be found on the following pages. SECTION A PROPERTY INFORMATION FOR INSURANCE COMPANY USE BUILDING OWNER'S NAME POLICY NUMBER STREET ADDRESS(Includin Apt..Unit,Suite and/or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY NAIC NUMBER 27 (1y_t I5L-$1 0 1Q'N OTHER DESCRIPTION(Lot and Block Numbers,etc.) "M. ?T $Q Lt"3Z" f, CITY fl RTMot�r tt STATE ZIP CODE SECTION B FLOOD INSURANCE RATE MAP(FIRM)INFORMATION Provide the following from the proper FIRM (See Instructions): 1 COMMUNITY NUMBER 2.PANEL NUMBER 3.SUFFIX 4.DATE OF FIRM INDEX 5.FIRM ZONE 6.BASE FLOOD ELEVATION 2 S 0 O S ( O O I S 3 --1 - g 3 (in AO Zones,use depth) e A 9Nal 7. Indicate the elevation datum system used on the FIRM for Base Flood Elevations(BFE): I XI NGVD'29 I I Other(describe on back) 8. For Zones A or V, where no BFE is provided on the FIRM,and the community has established a BFE for this building site, indicate 1 the community's BFE:! I I I I 1.1 I feet NGVD(or other FIRM datum-see Section B, Item 7). SECTION C BUILDING ELEVATION INFORMATION 1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best describes the subject building's reference level . 2(a). FIRM Zones Al-A30,AE,AH,and A(with BFE). The top of the reference level floor from the selected diagram is at an elevation of ' 1 i.Ll feet NGVD (or other FIRM datum-see Section B, Item 7). t (b). FIRM Zones V1-V30, VE, and V(with BFE). The bottom of the lowest horizontal structural member of the reference level from the selected diagram, is at an elevation of I 1 1 I I 1.1 I feet NGVD(or other FIRM datum-see Section B, Item 7). (c). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is 1-IZ I.I`I feet above Z or below 1 (check one) the highest grade adjacent to the building. (d). FIRM Zone AO. The floor used as the reference level from the selected diagram is 19 Ig I.I6 feet above Xi or below I I (check one)the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor(reference level)elevated in accordance with the community's floodplain management ordinance? IX Yes 1 I No I 1 Unknown 3. Indicate the elevation datum system used in determining the above reference level elevations:IX! NGVD'29 1 Other(describe under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on the FIRM [see Section B, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion equation under Comments on Page 2.) 4. Elevation reference mark used appears on FIRM: 1 Yes I 1 No (See Instructions on Page 4) 5. The reference level elevation is based on: I I<1 actual construction 1 1 construction drawings (NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which case this certificate will only be valid for the building during the course of construction. A post-construction Elevation Certificate will be required once construction is complete.) 6.The elevation of the lowest grade immediately adjacent to the building is:I--I-I-IT! !.La feet NGVD (or other FIRM datum-see Section B, Item 7). SECTION D COMMUNITY INFORMATION 1. If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C, Item 1 is not the"lowest floor"as defined in the community's floodplain management ordinance,the elevation of the building's"lowest floor"as defined by the ordinance is: 1 I I 1 1.1 1 feet NGVD (or other FIRM datum-see Section B, Item 7). 2. Date of the start of construction or substantial improvement NOIJ• (Z/ 4 I8ko . FEMA Form 81-31, AUG 96 REPLACES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION 200 0 200 400 600 800 1000 Feet N Dartmouth rH. t Geographic =� W _. Information ; ,o % . System ��•1664•,,. Floodplain Relative to Plat 80 The Commonwealth of Massachusetts Department of Industrial Accidents xi =gIlf OIIICDDIID/VStJ OOS € 600 Washington Street ,. ,:, Boston,Mass. 02111 Workers' Compensation Insurance Affidavit •:Vali tt iV IIIrt�811i:111 iM_!r4*J_`. `� . r ," J_dr+�T4:df\1�'_11 1i,;: — e. - v hbl" S/ti.f)les .1 • //ication: ,-2 p 7 U i ri-v. 1 S/ei n d0 iR ci city ) . Dot r- 11,1 o A..PI �. � phone# � l / Er I am a homeowner performing all work myself. 0 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: :.. : :. ; .:.;:;. -;.> . : :-:.:; ;:;-;<:::.;;.:..;.._..;:>: msarancr.co. ;:. .... .:,. .:.: :. _,_: . >:::::;:;;:.::lietlrt...#:::«<:>:=::::>:;;:::>a:::;;»:;:<:;::<»:>»>:;<;::<>:> Ej I am a sole proprietor,general contractor,o homeowner circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: 4/,Q4 . .1 Sin e; /" 1f • {{ address: ��b :g cL.5 e hop!#' < : iJ City: !�1 .� Gt r: �'i'�" ��: .. )• �� V .. • .:.: ;lic ......... .. insurance co. :. noUcv#r:;<>:i::<::;«<::>::;... ::- ;; :. ;....Y 'i.,-.+`v,<cw:r u—r+,r> r�r rxe, k;.,.,....s,.' ':-.,*y....;..Y 6't s> ;e->,i;;;._ :rK'%.,•fl•.+.-.,,.t.- - ..... . ...-.s.. ...^^zt-.,•,.---".`'+_s.'�... �'e4 • • comoagv name: .:. . . .: . -_ Address: city: phone-#: insurance co. :' ::;gottcy#.; : ... .e�: rli;,ri ?'Li.�t ..l 1pS�Sri*.•s ,"ys 'a;": ..?' ,s"Yn... <Y"h -,:... . . Failure to secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 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 der the p 'n and p nalties of perjury that the information provided above is true and correct ✓Si azure/” Print name ioib f S�4i ik5 1.....1 # C e 6 / /� ...... ...�Y�........ti...-.r<... ..10•.�..-__rin;"A'.:i�Lr%'..'a .�':f�4o+�+e.<.a,�- - - .. ........_. .... ., - ;' official use only do not write in this area to be completed by city or town official city or town: • permit/license# nBuilding Department check if immediate response is required ['Selectmen's sing Board 0 P q OSelectmen's Office • contact person: phone#; Dothech Department a (rev,sed 3/95 P]A) - r and Instr uctions Information n Ins bons Massachusettscompensation for thei General Laws chapter 152 section 25 requires all employers to provide workers' 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 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 hot 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'- been presented to the contracting authority. ;� �¢ 'Y r.s+7"a4D+' .. H�,,pn3-srtr ;�-b's✓f'd»�v?v3 .sa<. y�rr z -aa. is 3 5'�• _ • 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 requirec to obtain a workers' compensation policy, please call the Department at the number listed below. Fy✓''q �'PA .a". �Y n+ j� frww. Ys ,j :?4�,s,4�� � 5 ra �.G ,d 'Y€`5`�3�1� 3:- ..r...a rZ'f,„ ?'w ". •`:,Yi,.�*xf �x'. �" �i�.. ,.� '_.M�'!i:.._tr`�'�.f � � � .. ,_ ..-Fs*v: �; City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned 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 questic please do not hesitate to give us a call. '--`� ""�'�'^. .a, *��'��"�r � ��.� ��`.�..:+,ea2•n... �t .sa'.Y 7'��s3"^�-c'wi. : ,+F.t -`�.''<Y: � �g ^"'?F .r r a"a -.sslxr. '. �.e.`-_�s'i" �'s`*+?F1,Tzu'�� -. .Sxs :-=4-�'fi a:;.xaF ..., <:�'�-'.��.�e,w ��,:M*..rs^-_r,a,r• 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 she Basic Shed r t r 5 r ! O • a r ka • . , - , . , - , ,, ,,-) .:;-v . :. ,--,-,,__ ,,,,,:,,,,,3 1:-;,,-..„..;,,,,-,':: 0-‘, 1 1,+"si g)/(P cVi i _ n.3',m .s S 9 roilm f` ' .e-, t', ys. e'=, i.+3u s-i SE KEPT •�•CDI.A.plywodo • Sh inpips r 4, er,Y,W',o = i fl- en,., a,),a°.o� 7 �, ;•�, ix8 Ridge board � • 15 lb. 'bit paper¢3�,;s.;f €� r=¢ . #'s4� . I - . / • ; 2x6 Ratters I : . +r���"� ` :�� Metal clap edge • \S‘:. Gavle studs a '4\ • i ha Fascia ''N !a ir---•••i,ftil°4 a‘,:• : 50-A at.:\••• • ..;. .:; --1 Z 2 t 11!;" •ti Y.•3 I k_.4'4 IA g 11& •• r•II; bu 1 uf -' lc" .• ..::.:•':at.. .er:ik.- 1(V 1 i ft&NO 51% • V - t . °1431t ii ••• .... .\ • .8 . '''' 7:reipo:•gSkil6 vraM _IefLI5 . I lisiiiii liii:.. i \7... • place i':F. i ` • • y 4x6 II S .:611 i ..: 1 itli II 1- 1 111 ea - de Id ... 1 IL I • 11 _ i • ; . i . II I I ' I 1 I / Roufln sill : .1 , . , ; a. l I = I 1 fI.. 1 I-1 • 1.114- ! .1 !I • 1•111 I 1 : . HI " 1 1t .i 41111111116 114 ,444441. ‘1,] ..iti. •i iii .4d 4. PIywooc Sob. I , 1. kr -._ j ' 22.8 End pity 110/0. ; • ` ��. Ooor Irdcf. ;t�2xa Trimmer etude \�,, {011 . t ._ •II-00111•. ;i.f• '• •. i�.." •b.= .inV Rite, .fftrI:=1.,.jl Ns ., /: b. • • • _ __ w Tad e»c • -t ��t� 1 plywood sublloor • t 2,x8 Rim 1joist 1 I Blockingq 2xat: Entry rcultp 67.8 Pressure-treated skid s.•en.t esrase delimit Pfessc iv-treated turnbzr ,;7t ttSe / v 3) 1 ff =a.rc19e 5 75 $p P1 . J / �,� f RON PIPE Dr1 veW��' — l /5 Sr , (F1JD) '1></6 sAeti — / 9,2 spy Pi 03 5- -'-------'---:7-1-----1 lic-s Ati /_.._._ // 42,4 60(0 fi A..v . --7.-- , er"..„1„... ,5:.., . . i_, :.1......- 6 cro"^fil: ..--,,,---- /1 ,,iz f // v ,✓ i • 39.69 • ' raoNvl TOY OF IV • � , FOUNDATION • c- 5'. . K1-. 96.t.4 c! t. /°�� /S 300 / 55.81 �20. ' ; 'i C14i l Note: • I certify that the foundation location is by instrument survey on February 18,1987. �1temsfered�La tSuurvveyof�y, '? , .4,Y' li!. •� w1� ;J p �ia.B�eQ'I3�Q` �1�� A f ~. .t T 0 SllR 0/ .