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BP-71899r Permit No. BP-71899 BUILDING a-iri -- . GIS#: 4350.00- CO[)11 S iDT�INP Ssach fs Map: 0080 ,,., TIO. UUTII - .. . Lot: 0007 J 400 SJoc ,Read,Dartmoth �l 4-� Sub-Lot. 0000 S n 47 Category: GARAGE ,,,;,,- Project# JS 2014-001384 PERMISSION L h `RE 33' ' D TO: \."—AC' 1 st.Cost $10000.00 Contractor: -„; ��_ nse 't i ff one Fee: S350.00 .� A t om,`` - ., Const.Class: -1 r s i gn Engineer. � � Use Group: R3 ` d 4- 1 Lot (sq.ft.} 47916 9 1' -' 4 i a_2, v, 1 Applicants 5 o e zoning: ;SRB PETER Ritzy t 7 38 Aquifer Zone ZONE 3 OWNER: ' Flood Zone: ZONE A el ,t',v } 0 RILEY PETER11' 4 # New Const.: 576 sq.ft. ,1� Alt.Const:= N/A DATE ISSUED ' - ��� t., Date Typed: 11-20 20137. t ' vs -----,. ,gib t TO PERFORM THE FOLLOWING WORK: 2 # Construct a 24'x 24' attached garage on existing foundation - ._ Poroj Locati : 11 PINE ISLAND RD Approved/Issued By: �,` /I � . . AVID BR E,LOCAL BU DING INSPECTOR All work shall comply with 780 CMR 8TH Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion of work,final inspection is required. 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: � � :„„7 / "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: !: Rough- Rough: Smoke: Roc. gh . Sewer Service#: 1 Rough Frame: Insulation: Final: Filial' Final: Cross Connection Final: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET i i • A k I ' -TME UTH - BUILDING DEPARTMENT RECEIPT 7 d � i 910.1820 F,X: 508-910-1838 fr Name: G' -i Property Owner: Date/ J /'' Job Location: ! ., {t r"i f Map: XL) _ Lot: 7 Description General Ledger#'s Ref.# Amount Building & Building Misc. 01000-44105 n z f '�. j Electrical 01000-44106 4ty,t fob _ Plumbing & Gas 01000-44107 r� b�' �. Trench Safety 01000-44129 r ��� �� Other Department Revenue 01000-42420 _l•` pi r° Z .1(i/,-li White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department 4 ed By a l(-•• 't»-e-_j THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS 0 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 71899 P 5 8- 10 1820 FAX 508-9101838 j '`� i ' /„ Name: ` -/ 2, / --LA-1'1_ ' Property Owner: } / / ) Date: :' Y t //// �'.1 ��'" ' ,,� +� �( � Lot:Job Location: f I � --- Map: -T------ I .. z ,t < < , . ORDescription GeneralYedger# s . r) T Amount Building & Building Misc. 01000-44105 j . (' Electrical 01000-44106 NOV Plumbing & Gas 01 "0'+- r • 4A Nlltjzf ` Trench Safety 01000-44129 Other Department Revenue 01000-42420 P ,- i { --a" White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received$y -,:•'- ' - ,r " , THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL ❑ Phased Approval(R106.3.3) k $25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRARMFIRIR9LE ia,-C� 9:. DARTMOUTH BUILDING DEPARTMENT 1� p 400 Slocum Road 2013 NOV 15 PM I: 47 IZ Dartmouth, MA 02747 ��� yv:' Phone: 508-910-1820 Fax: 508-910-1838 "- " www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY - RECEIVED BY: BUILDING PERMIT NUMB R: DATE I SUET : f SIGNATURE: C>C�.-...ep' DATE:', NOV 2 0 2013 Building Commissioner/Inspector of Buildings. Zoning District: S .L� Proposed Use: Zone: ❑X ❑B IH"`A 0 V Aquifer Zone: .� THE FOLLOWING GENCIES SHOULD BE NOTIFIED: DPW ❑Board of oard of r: i , 0 Planning 0 Address ()Engineering 0 Cross it oicfAppeals Health s * ission Card ' -. connection ,. 0 Fire 0 Gas ❑Electric 0 Other 0 Water Card 0 Sewer Card `` Chief ,Cut Off Cut Off Cut Off Cut Off. DEPARTMENTAL APPROVAL(S) Board of Health: Signature: C /< SQL te� ' Date://' Conservation Commission: Signature: �1(/4 `f'YI `a�,5 / Date: J D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: 11741-7 7'. k ' . , 1q} SECTION I :SITORMATION 1.1 Property Address:// 441 . ''�� 1.2 Assessors Map&Lot Number: Contact Person: /i ` f i'f`l / Map P� Lot 7 - Phone Number: 77 7- 9'7.�—JD 7.-t 7 1.3 Historical District 0 Yes 0 No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal 0 Municipal 0 Altering more than 25% per side of building G]-lsrivate Well 21 On Site Disposal System Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Revised 5 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPOF , i RESIDENTIAL SECTION 2-- ROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: Name (print) tact Address y� Phone Number •L)4rf' (:'4 ..7 2.2 Authorized Agent: Name (print) Contact Address Phone Number SECTION-3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 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: `:SECTION 4-INORKEWA4ploppNATION INSURANCE::AFFIDAVIT(MGL c 152.§2a)=; << Worker's 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 77.77, SECTION Nam`# ( 5 ?Tf J O I RO`PQ +Ek WO sc all apptic . . ❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* Accessory Bldg. 0 Addition 0 Roofing/Siding replacement window/d r (Energy report required) (Shed/Garage) (Energy report required) No.ofwindows3. Doors fie Z2oof GCfm�± ❑ DEMOLITION (specify): �" Location of debris removal (per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street Facility Name: Location: *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 ❑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 SECTIOP16-ESTIMATED CONSTRUCTI©N COST << Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total = (1 +2 +3+4) SAC t1C)N ° *0 R At1T O IZIT1 N (to be completed when owners agent or contractor applies for building permit) (Please Print) , 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 S TION, >-,OWIVIlR/AUTH RIZEp ► ANT£ECLARAI R)N L I, j t er R cdu , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and arate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. // '5.7/3 Signature of Owner/Authoriz Agent ( Date m ON I FFICi MSPEI QR'S I TES _.. _,4 3 ._- , Less Application Fee: $25.00 Remaining Balance: $� . Total Permit Fee: $_ Other$Amount$ Gross Area- New Construction total sq.ft. 7 Gross Area-Alteration total sq.ft. Permit Issued to: (1);./ ZA•e7 -' (2 t t_ c1, , Cap. Cl�c�r C1) 7 14-,P/ - 3 1/1-)n J( ikICk) 5 CiOf'.r'S L Uked 1,-4- I z- '1-//"v 5 C A 5 lie. • f9 `-- - S1,F GC�`�a 6Oy' G cry 6etc 0 , ` �, '�'-� �h, Fes -- 3 0-7 A:/1 --- /3/ 'ermit No. BP-71899 Project Location: 11 PINE ISLAND RD Commonwealth of Massachusetts TOWN OF DARTMOUTH GIS M #: 4350.0 400 Slocum Road,Dartmouth,MA 02747 Lot: 0007 Phone: (508)910-1820 • Fax: (508)910-1838 Sublot: 0000 .. BUILDING PERMIT Category: GA"--„22RAGE 4-001384 Project# FIELD INSPECTION Fee.Cost' $35000.00 Const.Class: Use Group: R3 Contractor. License: Phone#: Lot Size(sq.- 47916. Engineer: License: Phone#. Zoning: SRE Applicant. Phone#: Aquifer Zone: ZONE 3 PETER RILEY (774) 473-0938 Flood Zone: ZONE X OWNER: New Const.: 576 sq.ft. RILEY PETER M& I{/�{ Alt.Const.: N/A DATE ISSUED: [ ` TO PERFORM THE FOLLOWING WORK: Construct a 24' x 24' attached garage on existing foundation '.(------'41 /4)."-- DATE TIME TYPE OF INSPECTION&REMARKS INITIAL ie d;? �i —tT fi; u:Li, RESIDENTIAL ❑ Phased Approval(R106.3.3) $ ,APPLICATION FEE IS NON RE-FIINDADLE &HON-TRANSFERABLE �'� i9 DATE RECEIVED ` DARTMOUTH BUILDING DEPARTMENT r -6157 aP �`.. o =—`rlt=', 400 Slocum Road •i ? _- c Dartmouth, MA 02747 °� `T vy' Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTI©N`FOR O3FFICIAL t SE ONL Y FECEIVE1 BYE B IIILt31NG PERittIITIVUi�1BER DATI=ISSUED - Nr- - -'1:::;-- ---iik-i:,-i.,'---t71., :::'-';::--'--irii- i---;:-.-:Tr.-t 1 Building Cornrnissfo,T_-::nspeotor'of Bu�ldinge Zoning District Proposed Use: Zane D X ❑B :0 A 0 V - 4qui er Zone - , THE FOLD} It NCIES SHOULD BE N€�TIFIED DPW Q Board of and r r Appeals ealth isslon • L i�lanr►tng LI Address 0 Engmeenng 0 Cross Gard Connecfion ❑F►re . ❑`Elected L Other_ - ❑Water Card 0 SewerCard Chief. Gilt Off , cut Off; Cut Off -- _Cuf off>- 1 DEPAR▪ TME1 tAL R F t !►1 5) Eioard of Health: Signature: vi //-/�� j j� �-, gt.� Conservation Commission: Signature: �i/,2 etici 1-/ ` v,L7?jir f- a0.4616-e....Date: � D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: / SE Tf N ! :Sly 1t 0Rl ll# I�dM - :- . _7 , 1.1 Property Address: � �/� � Y 1 1.2 Assessors Map&Lot Number: Contact Person: Y �,`l c,I Map po Lot 7 - Phorre Number: 77(7- 4/'7 -^l 2 �� 1.3 Historical District 0 Yes 0 No Year Built • 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: CI ❑ Site Disposal System Municipal ❑Altering more than 25% per side of building private Well On Has application been submitted to the Historic;Commission? ❑Yes 0 No Date: Revised 5/13 ❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations :: 4'I. - 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): v- eK >�� 1/ Address:/ iPihe S/A e a-I City/State/Zip: -64r7/1I d 474.4,27V7 Phone#: '7'7 L/- 3/ 7 3 36e Are you an employer? Check the appropriate box: Type of project(required): 1.n I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. 7. ❑ Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.1-1 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.Ef Other k I"r4 tjln.r d 64-02-y comp. insurance required.] s� *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 Policy#or Self in , 4,6# , Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of erjury that the information provided above is'true and correct. • Signature: • Date. //1/5.�/3 Phone#: "7"7 l 3, Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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, §25C(6)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,MGL chapter 152, §25C(7)states"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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 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 give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia ' . . z3x KEPT. 7014 FEB -6 AM 9: I 1 ?-26! 7 Dyx, , 130c LD1i" & .rsFECra AT 1 1 T'l N t' IsLiIt DFrZ1At0D-r - yo r&av / 1E& TI6Y To 0 11 THERE ) S t/® L- ! v U r 1 n16-) r`HA r S L44 8 i IJ o l d/r th It o 3 " o O L b JU t jc calvtEorr, } T �. L.E0 l�1 if r vim- LOAM , �I,our� v�/.� 5 IUST�L MIS S BE Ttk • ce-Go lu OUt LP/ & T+ E-P " To 'FALL- povJ tif b ( D ° C JM?I T SLAG ( s cro K. C e-4c-iC G O &) ®c/e/e 5-e.77LED r 7- JO%o(< 14-A P / C To SFe" The `-#.Ai < 5 r � 111� Ava i�- ��T��/ WHEV ,:L T tl`Lr714y 64i?J46c7 YOLi ./1/1 D e )S P G'i i4 17-00 06- jyot) yArD Td . 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