BP-79659RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE alit NON-TRAN,[S�T +
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� pUTy.�. DARTMOUTH BUILDING DEPARTMENT � ' -
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r ° 400 Slocum Road2M5 NOV0 PH f (. 31
SZ N Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
1614 1www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed:
1
1.1 Property Address:/ d t,- tha � 11; � 1.2 Assessors Map &Lot Number:
Contact Person: /�e� r• ``^�'f w c, t �C Map Lot 17--
Phone Number: 774/ 9.30 41 Y 9-
1.3 Historical District ❑Yes ❑ No
Year Built P? ?
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
0 Municipal ❑ Municipal ❑Altering more than 25% per side of building
d& Private Well O.On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes 9No Date:
Revised 5 113
El CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent. %1
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Name (print)
Contact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: (_15 07 yqS—%
License Number: CfS- G741 5 7
Company Name/Contractor Name: I&avrq 04>9-Cr®
Address: 75-6 ID a'fio SKI IZpl! 5. � a
Expiration Date:
1(13/1Co
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:
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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: ❑ Yes ❑ No
❑ Deck ❑ Pool 1R Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑. New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows_ Doors
Neu—, 16 ba,��'1
❑ DEMOLITION (specify): -tteVt
Location of debris removal (per MGL C.40 Sec 54): VIDumpster on site ❑ Dumpster On Street
Facility Name: l" makes Location:y�
*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
Item
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Estimated Cost $ to be com leted b e ml a
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1. Building
!O K
2. Electrical
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3. Plumbing
4. Mechanical (HVAC)
2
5. Total=(1+2+3+4)
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I, K" ta* Owner the hereby
,�o% v� lro ha fir s as of subject property
authorize
to act on my behalf, in all matters relativ ork authorized by this building permit application.
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Date
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I, yr y 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 under the pains and penalties of perjury.
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Signature of Owner/Authorized Agent
Date
Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq, ft.
Permit Issued to:
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