BP-86962RESIDENTI ` ❑ Phased Approval (R106.3.3)
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RECEIVER
DARTMOUTH BUILDING DEPARTMENT
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400 Slocum Road
ga z; Dartmouth, MA 02747
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Phone: 508-910-1820 Fax: 508-910-1838
/6f=- www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY`DWELLI G
1.1 Property Address: IC
5 l S%'lyr%I4'� OJ% 1.2 Assessors Map Lot Number:
Contact Person =�, tAC 1= AA (o✓— Map Lot -
Phone Number: �
1.3 Historical District ❑Yes ❑ No
i Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal [I Municipal ❑Altering more than 25% per side of building
EVI:Irivate Well rn Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
movicarl 5 /13
2.1 Owner Record:
Name (print) Contact Adds �` Ph e Number
`�� e1 gof3 z �%
2.2 Authorized Agent: 6 �%
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Name (print) Contact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: License Number: �� / Q !S- Z Z
Company Name/Contractor Name: 7 70S
Address: S C , Expiration Date:
7Signature:
ture: Telephone: �Dfif
o e ner 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
ion: 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
a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
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
r 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
in a two-year period shall not be considered a Homeowner.
re applying under this section sign below:
re:
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: lPVYes ❑ No
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❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ;U Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): Pl'3umpster on site ❑ Dumpster On Street
Facility Name: Location: A
*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)
E3 None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other