BP-37621RESIDENTYAL 2003 RESInENTiaL - 2003
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
T IS s; 7
Name: (print) ' -
(p )
Contact Address Phone Number
2.2 Authorized Agent:
Name- (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ 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:
Hoine Iinpi-oveinent Contractors Reglstratloil, One Ashburton Place - Rootft 1301, Boston, MA 02108, (617) 727-8598
Owners Name rintfA\
df
OIL-
5 -
S ignature
signing Y the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date ? `� � �' �`
3.4 Ho _neowner 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 i f a
Homeoxv-ner 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 th-.1re 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 appl ing under this section sign below:
Signature: ,_
o ` signature crrie certain responsibilities, including but not necessarily limited to, general liability
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)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MG'LC 152'§ 25)S_
affidavit must be completed and submitted with this application. Failure to rovi(.Je this affidavit
Workers Compensation Insurance p pp p
It in the denial of the issuance of the building permit. Signed Affidavit Attached: Dyes ❑ no
will result g p g
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ Ell woodstove
(energjl re re d) (enej gy report required) fireplace
report required)
❑ deck ❑pool D accessorybldg. . ❑ replacement window/door ❑ other C] demolition
g
(shed/garage) no. of windows doors (specify below): (s.,Tecify 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
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler(heatin - fuel as(natural or ro ane), fuel oil, electricity, other (specify):
g) g propane),
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
D Hot Water: Gas Electric Fuel Oil Other
BHef Desct'Iptloll of Proposed Woi*k: ;f
_ r<
/�� 7o7 �7,
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant;
L Buildinfy
2. Electrical
3. Plumbinfr
4. Mechanical HVAC
S. Total = 1 + 2 + 3 + 4
* Estimated Total $ .
SECTION 7A - OWNER AUTHORIZATION
be com leted when owner's agent or contractor applies fobuilding permit)
(to for.building _.
(please print)
I, , as Owner of the subject property hereby authorize
to act on m behalf, in all matters relative to work authorized by this building permit application.
y
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
as. Owner/Authorized Agent hereby declare that the statements anrd information
on the fore oil application are true and accurate, to the best of m knowledge and belief.
g gY
Signed under the pains and penalties of perjury.
Z.,
cov. 0
Signature of ner/ ffiorized Agent Date%
-
0
C:\bldg.fo: s\Bldgapp.res.wpd Page 2 Rev. June 26, 2003
C:\bldg.f6mis\Bldgapp.res.wpd
Page 3
Rev. June 26, 2003
RESIDENTIAL
2003
SECTION 8 - INSPECTOR'S REVIEW/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:
S. Comments:
9. Inspector's Signature:
nature: r---
p g - Date:
•
-6LWCTION 9 - APPLICANT NOTIFICATION
'e `
Clerk: informedof aboveDate. Time. f
.
Comments • �i �. =� f
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: Less Application Fee: Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total
ota . s ft.
q
Gross Area - Alteration total sq. ft.
Permit Issue To
� ` `1 '.�
_ .>�
-�
ZZ All'
SECTION 11- ADDITIONAL C MENTS/SKETCHES
t
t
RESIl3ENTIAL 2003
❑ FO UNDA"T
ION ONLY
$25w00 APPLICATIGIV F EE IS 19GIVoREFUNDABLE &s 1V01V=TRA1VSFM-RA13LE-
.....
••"'-" DATERECJEIVED
DARTMOUTH BUILDING DEPARTMENT
I
400 Slocum Road, P.O. Box 79399
*40
Dartmouth, MA 02747�€
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO. FAMILY TDWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: - BUILDING PER344T r
DATE SENT FOR REVIEW. NUMBER:
DATE'ISSUED:
OK TO ISSUE - SIGNATURE. DATE
Buil n ommissioner/Inspector of Buildings
ZoningDistrict:4C _ Proposed Use:8/c�--
p �- Zone. ❑ B ❑ A ❑ V Outside Flood Zone ❑ .tluifer
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: t
0 Board of ❑ Board of ❑Con. Com. 0 Demo 0 DPW ❑ Elee, ❑ Ener Re ort
gy P
Appeals Health Affidavit Card Sent: =' = Cut Off Follow-ups
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning 1 Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OFA PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature. •
Date:
Descriptiou of fvork beilrg performed:
SECTION 1- SITE INFORMATION .
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes no
l .l Property Address:"_C
Nearest Cross Street:
Subdivision Name:
Total Land Area S q. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal❑ Private Well
1.2 Assessors 'J
Plat
e
umbe
Lot
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Hi storic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ On Si��e Disposal System
C:\b1dg.forms\B1dgapp.res.wpd Page 4 Rev. June 26 2003
C:\bldg.forms\Bldgapp.res.wpd
V
Page I
3 007
Rev. June 26, 2003