BP-86999/(e9
RESIDENTIAL ® Phased Approval (R106.3,3)
$25.00 APPLI[CATI[ON FTE IS NON BE -FUNDABLE a& 1! ON -TRANS E
_ DATE RECEIVED
M1�,°uro DA►RTMOUTH BUILDING DEPARTMENT
ifOg 400 Slocum Road
O �I Dartmouth, MA 02747
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
. _ . . - -Nib TCC3 d 1<Of I IFlC 41 _ SE`QN Y: _..
Board of Health: Signature:
Conservation Commission: Signature:
D.P.W = Signature:
Fire Chief. Signature:
Other. Signature:
Brief description of work being performed.
11.1 Property Address:
Contact Person = M�
Phone Number: - S7) `�j 71 GSL
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
arivate Well On Site Disposal System
Date:
Date:
Date:
Date:
Date:
1.2 Assessors Map & Lot Number:
Map 7 Lot�7
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per'side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
0 CONSTRUCTION PLANS SITE PLAN 0`:
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2.1 Owner Record:
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Russell P&n no � e -
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Name (print)
Contact Address Phone Number
2.2 Authorize ent:
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Name (print)
Contacl Address Phone Number
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S�fi<�Irv�� -
3.1 Licensed Construction Supervisor/Specialty- License:- — - - License Number: --
Company Name/Contractor Name: f V lew,
Address: G� y d G�/
Expiration Date:
Signature: Telephone:
3.2 Ho 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
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:
Worker's Compensation insurance Affidavit must be completed and submitted with this application. Failure Jo provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: d&es ❑ No
_ _ ..itTttI f+StFtkT RrD>�tca
❑ Deck Cl Pool ❑ Repairs ❑ Alteration ❑Chimney/Fireplace ❑ WoodstovelPellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofin Si ing ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) , -. of windows_ Doors
DEMOLITION (specify):
Location of debris removal (per MGL G.40 Sec 54): *mpster on site [IDumpster 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
0 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):
-G-hi,�mbine"n"ranry-ktel, naturafgas;-prop-ane, e1ectr[t-dy,-other (specify):
0 Air conditioning - (separate unit)
0 None of the above to be provided
13 Hot Water: Gas Electric Fuel Oil Other
Item w stimated Cost ($) to be completed by permit applicant
Gc c 7k
1. Building
2. Electrical
3. Plumbing
VAC
4. Mechanical H}
5 Total (1 + 2 + 3 + 4) NfERAE#`T ( 1Tft
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(Please Print) ice_
I, h, U 55 e f i �t h� as Owner of the subject property hereby authori �
Wnre
behalf, in all matters relative to work authorized by this building permit application.
fibb
Owner Date
SETff3ht'7f3 fili'1fN12%?�ll�l3Ffl=f]G�+IT CIECL4RATl91 _ ,
(� 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 u er the pains and penalties of perjury.
Sign ur of Date
Ovvner/Authori4edAgne��nt
:CTtZ�N $
I�f�-�tse��`�o>���r�r�Tf:�t
_ 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:
WN
WIN
i