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BP-258 BUILDING PERMIT FIELD INSPECTION Dartmouth Building Department Plat: 80 400 Slocum Road-P.O. Box 9399 Lot(s) : 06 North Dartmouth, MA 02747 Lot Size: 42, 466 Telephone 508-999-0720 Zone Dist. : SRA Issued Date: 10/21/93 Permit No. : 258 Project Location: 27 Pine Island Road Number Street Subdivision Name: Nearest Cross Street: Applicant/Agent: Thomas Bell Contact Person Phone #: ( ) 508-992-9733 or 998-3740 Proposed Use: Residential Residential, Commercial, Industrial,etc. Permit Issued To: Install p'fype'o"I"Tinproement,MTAter,New Const.,Demo,Land/Move,etc. Woodstove indicate no of bedrooms and bathrooms and other rooms Owner(s) of Record: Thomas Bell _ Address: 27 Pine Island Road, North Dartmouth, MA 02747 DATE TIME TYPE OF INSPECTION REMARKS INITIAL 1 BUILDING PERMIT Dartmouth Building Department Plat: A0 400 Slocum Road-P.O. Box 9399 Lot (s) : 006 North Dartmouth, MA 02747 Lot Size: 42, 466 Telephone 508-999-0720 Zoning Dist. :SRA October 20, 1993 (typed) Permit No. : 258 Issued Date: 1021 03 Clerk: lls Project Location: 27 Pine Island Road Muebse Street Subdivision Name: Nearest Cross Street: Applicant/Agent : Thomas Bell Address: 27 Pine Island Road. North Dartmouth, MA 02747 Contact Person Phone #: ( ) 508-992-9733 or 998-3740 Type of License: Owner: (x) Const. Superv. License #: ( ) Architect : ( ) Engineer: ( ) Other: t ) Proposed Use: Residential M,id..li.i. Geetres.t. 1wdratri.4. .tc. Permit Issued To: Install — O r�tt_1.y ,nt..-9m+._Alt Mow Coedit.. Woodstove i Mie.t. w.. of Mdr...a .we ..thr..s .M *Wm,. room. Gross Area of Const. : sa. ft. Cost of Const. $ 200. 00 Cost-Other Const. : TOTAL FEE: $ $ 30.00 Owner(s) of Record: Thomas Bell Address: 27 Pine Island Road. North Dartmouth. MA 02747 All work shall comply with 780 CMR 5th Ed. (MGL Chap. 142) 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 autho ' z agent. Signature of Owner/Agent : n, f, ,{ 64k--411 Address: l ************************* * *************** *********************** Signature: Approved/Issued By: William A. Braga, Local 06ilding Inspector COMMENTS:, ORIGINAL El APPLICANT E ASSESSORS I] CLERK El COPY I ; . .. i. :1).1 ) t : - • - p. , . . . „ . 4 Required approval Approvals received please (X) approvals Please (X) approvals and required for this project Initial as received DATE INITIALS Board of Appeals _ Water Card Sever Card Board of Health Bond Selectmen Conservation Fire Chief Cross Connections Licensed Contractor 4 Controlled Conet. Affid. _ Other information required _ _ .1 , • ci.776? A jz....44.4.- /744..g....4144-40 ' . -5---K :40.,'I it.'1 PERMIT NO. /�f'S' `E °u `41\ TOWN OF DARTMOUTH DATE ISSUED %��� �9, l.• ? ‘)V 'J.\ Q: TOTAL COST _j!?. t ?\ VA APPLICATION FOR:�, yLESS APPLICATION FEE 0__..•'O BUILDING PERMITf�V�'••••.1Ha4 FINAL PERMIT FEE L'C'. " LOCATION OF BUILDING 0 Number & Street 2..1 P,u .L-re. c.41jO /2-0 01.1 Zoning District 5 R A f f.2 Cross Streets(between) H K.14 PIA-L.. and FL44 Nwll-0-4P f ,_;// 3 Lot o6 Plat g° 04 Subdivision Lot 0' NERSHIP COST 05 R'Private (individual, corporation, 36 Cost of Improvement non-profit institution, etc.) 36.1 To be installed but not 06 ❑ Public (Federal, State, or local government) included in the above cost TYPE OF CONSTRUCTION 36.2 Electrical 07 ❑ New Construction 36.3 Plumbing 08 ❑ Addition -Type of Room(s) 36.4 HVAC 09 II?Alteration 36.5 Other - Specify 10 ❑ Foundation Only example: elevator 11 ❑ Demolition (#of units if residential) 37 TOTAL • $'2ov _ 12 ❑ Moving (relocation) STRUCTURE STATISTICS 38 ❑ Wood Frame 13 Number of Bedrooms 39 ❑ Masonry (wall bearing) 14 Number of Bathrooms (Total) 40 ❑ Structural Steel Full-Tub 41 ❑ Reinforced concrete 3/4 - Shower 42 ❑ Other - Specify 1/2 - Toilet Only RESIDENTIAL-PROPOSED USE DIMENSIONS 15 ❑ One-Family 43 Number of stories 16 ❑ Two or more families 44 Total square feet of floor area, all floors, Number of units based on exterior dimensions 17 ❑ Garage 18 ❑ Shed 45 Total land area, square feet cco HZ yG6 19 ❑ Carport —, 20 ❑ Swimming Pool SEWAGE DISPOSAL €.•�` � In-Ground Above-Ground �-- 21 © Woodstove 46 ❑ Public or private company 1� a CD 22 ❑ Fireplace 47 1 --Private (septic tank, etc.) c ;71 23 ❑ Other- Specify c WATER SUPPLY Q i 1 48 ❑ Public or private company v NON-RESIDENTIAL - PROPOSED USE 49 Ikr Private, (well, cistern) r 24 ❑ Amusement, recreational PRINCIPAL TYPE OF HEATING FUEL m c 25 ❑ Church, other religious -19 26 ❑ Industrial 50 ❑ Gas -a 27 ❑ Parking Garage 51 ❑pill • 28 ❑ Service station, Repair garage 52 LE-Electricity 29 ❑ Hospital, institutional 53 ❑ Coal 30 ❑ Office, bank, professional 54 ❑ Other- Specify 31 ❑ Public utility 32 ❑ School, library, other educational TYPE OF MECHANICAL 33 ❑ Stores, mercantile 55 Will there be central air conditioning? El Yes ❑ No 34 ❑ Tanks, towers 56 Will there beelevator? 35 ❑ Other - Specify an ❑Yes ❑ No PARKING PER ZONING BY-LAWS 57 0 Enclosed 58 0 Outside RECEIPT FOR PERMIT TOWN OF DARTMOUTH O�OUTH•M - r PERMIT NO. No o 1e Date , Received From _ t.: - Owner„. Location :�_ , :-� P , Type Amount Paid Received By COMMONWEALTH OF MASSACHUSETT'S DErAmmENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James Carnabe:; BOSTON, MASSACHUSI 1b 02111 '-omm!ssrone' WORKERS' COMPENSATION INSURANCE AFFIDAVIT I, (Iicenseei permittee) with a principal place of business/residence an V (Cry/Sta*.n;p) do hereby certify, under the pains and penalties of perjury, that: [ ] I am an employer providing the following workers' compensation coverage for my employe=working on tr. job. Insurance Company • Policy Number [ H I am a sole proprietor and have no one working for me. [ ] I am a sole proprietor, general contactor or homeowner(circle one) and have hired the contractors listed b: who have the following workers' compensation insurance policies Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number am a homeowner performing all the work myself NOTE Please be aware that while homeowners who employ persons to do t,,,;,,,,K,=noe construction or repair work on dwelling of not more than three units in which the homeowner also rides or on the grounds appurtenant thereto are not gener:IF considered to be employers under the Workers' Compensation Act(GL C 152.sect. 1(5)),application by a homeowner for a Iice: or permit may evidence the legal sums of an employer under the Workers' Compensation Act. I understand that a copy of this statement will be forwarded to the Department of t,,,,,.r.;,.I Accidents'Office of-Insurance for cover- verification and that failure to secure coverage as required under Section 25A of MCL 152 an lad to the imposition of criminal per.- consisting of a fine of up to SI 500.00 and/or imprisonment of up to one year and civil+••aloe in form of a Stop Work Ord=an fine of S100.00 a day against me. "`� Signed-this CTA.--. 01 8p day of I0-15-93 19 cer.set-?crrnirec Licensor/Permittor TOWN OF DARTMOUTH BUILDING DEPARTMENT TO: a' oard of Health X Fire Chief Dist. 1, 2 4) Conservation Comm. El DPW Engineering 0 Selectmen-Licensing ❑ DPW Water/Sewer ❑ /Selectmen-Special Permit 0 Planning Board ErTown Clerk f Tax Collector 0 Police Department _ Other The following is forwarded to your office for your information only - no response is required. The Building Department is in receipt of an application for Plat Il 0 Lot d Co Address c:q : 0-1-u. _ by 1t-a- to i- ownor/applicant demo. construct. sltor, occupy, eta. atn) The plan was received by this office on /0 '-/'E 3 at. s This office will review said plans and subject to availability of potable water, where required, the provisions of Zoning By-law per MGL Chapter 40A and MSBC 780 CMR 5th Edition will have available to issue or will deny a permit for the above-mentioned work within 30 days of date of receipt. The applicant has been advised that your office as indicated above may require them to apply for licenses or permits subject to your jurisdiction and that they should contact your office, as indicated, for specific information. It is not necessary to respond to this notice unless the e is a specific issue at hand or you wish to forward material or information required for permitting. When required, an Occupancy Permit will not be issued until all Town Agencies have had the opportunity to *sign off* that the work under their jurisdiction is -complete to their satisfaction. To The Applicant: Be advised that this notice will be sent to the Agencies checked above as they may have separate jurisdiction for your project. Any questions about the Agencies Regulations & Policy should be addressed to the individual Agency. Your signature only acknowledges your receipt of a copy of this notice and provides a contact phone number. "a„ R4 Z-1"I3. '.'L vILZCAYT Cnigniature) ►SC= • DATE TOWN OF DARTMOUTH BUILDING DEPARTMENT TO: 91:-Board of Health X Fire Chief Dist. 1, 2 4100 urConservation Comm. Ll DPW Engineering 0 Selectmen-Licensing 0 DPW Water/Sewer 0 electmen-Special Permit 0 Planning Board Town Clerk (_ Tax Collector ❑ Police Department _ Other The following is forwarded to your office for your information only - no response is required. The Buildingr� Department is in receipt of an application for 11 Plat 0 Lot d (0 Address oZ 7 01,1_4__ by •--7-"A---*--~.--st_.4 )6 to ...„ti "..Q_;12- , own.rlappLLe.as e.... a.nstruat. alter. eocupy. eta. a(n) The plan was received by this office on /0 /4F--- 2. 3 • ct. This office will review said plans and subject to availability of potable water, where required, the provisions of Zoning By-law per MGL Chapter 40A and MSBC 780 CMR 5th Edition will have available to issue or will deny a permit for the above-mentioned work within 30 days of date of receipt. The applicant has been advised that your office as indicated above may require them to apply for licenses or permits subject to your jurisdiction and that they should contact your office, as indicated, for specific information. ; 1 It is not necessary to respond to this notice unless the e is a specific issue at hand or you wish to forward material or information required for permitting. When required, an Occupancy Permit will not be issued until all Town Agencies have had the opportunity to "sign off" that the work under their jurisdiction is -complete to their satisfaction. To The Applicant: Be advised that this notice will be sent to the Agencies checked above as they may have separate jurisdiction for your project. Any questions about the Agencies Regulations & Policy should be addressed to the individual Agency. Your signature only acknowledges your receipt of�.,a copy of this notice and provides a contact phone number. :, ge,— I4rt 4t 8 -S 74 t o g 4 APPLICANT tournLlnr.1 PRONN • ores 59 Does this building contain asbestos? ❑ YES ❑ NO If yes complete the following: Name & Address of Asbestos Removal Firm: IDENTIFICATION - To be completed by all applicants PLEASE PRINT wd24 Z-61733 60 Owner (print)�[tov-1, 2.1 Poop 17w./v/) Lo. I4a"1• ??8-374(v NAME MAILING ADDRESS TELEPHONE NO. 61 Signature `ji.. M• g DATE it."-I -13 Builder's 62 Contractor (print) License No. NAME MAILING ADDRESS TELEPHONE NO. 63 Signature DATE 64 Architect or Engineer (print) NAME MAILING ADDRESS TELEPHONE NO. 65 Signature DATE CERTIFICATION TO PERFORM WORK 66 I/We hereby appoint NAME ADDRESS as my/our agent for the purpose of applying for and obtaining a building permit for the work to be done described in this application. Signature DATE ADDITIONAL INFORMATION 67 Has A-1 or Determination been issued by Conservation Commission? ❑ YES ❑ NO Submit copy of notification sent to DEQE and the State Dept. of Labor Industries and result of air sample analysis after asbestos removal is complete. 68 Owner or Agent - I certify under peril of the penalties of perjury that the information herein is accurate to the best of my knowledge. Signature DATE Owner or Agent 69 BOARD OF HEALTH REVIEW DATE Inspector or Authorized Person COMMENTS: 70 DPW- WATER Service No. SEWER Service No. To be completed upon issuance of permit- (if applicable) 71 I will post permit and address so as be visible from street. Signature 0J,�.--- P • DATE 1°-16-9' Owner or Agent 72 I have received list of required ins ection Signature r-fDATE /0-/8-p3 Owner or Agent 4.)562;r0 1110 ra rxtt i,NG F-iR PL/}c.,c a4 1 J4C.- of -t fart