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BP-80982RESIDENTIAL ❑ Phased Approval (R106.3.3) REE Is INUN ME -FUNDABLE & N0N�TR y DMA RE DARTMOUTH BUILDING DEPARTMENT = `"����• N 400 Slocum Road jl r4 - n _� 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 P K BLIILI3ING )�ERMI�3�IUB�R :. iY�T�1{SStEi.�, tGNATEIFE DATE Ouiidiri Comrrrtsioaerinseet oftiOdings T Z(mtr1� t�istCl�t` � : � (proposed -Use, oc�� _ � � �l � ICI V , �fiquifer Zone 1� F(7Lt tfil AOf~#�CC(HCJkif BE M1i1IFlb DPf Biard of fD hoard of ©Cohn ❑ Plarinanc CI Address 13 Engrncenng Q Cross RPeals i�le I h rn fission Gas ❑ Etectac Q Qther WaYbrCard ... tl5ewer"Card G>�ief ;Gut Dif; Cut'(3fr Cux OfF: Cut_Oft All 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 Property Address: %G y A%S aam A011114fi l'o -A /o.AK 1x•2 Assesso p & Lot Numb Contact Person: !3a l'rGJ & i' Map L Phone Number. Z Z Y 93y q oygo 1.3 Historical District ❑ Yes Q No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building M-Private Well W-On Site Disposal System Has application been submitted to the Historic Commission? ❑ Yes )R-No Date: RPviaPri 5 /13 1 CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPO.-1 RESIDENTIAL NS�CX)b 1 fLl)� At% x 2.1 Owner Record: = 4f53ei<l l�z��rAir,�� I7 9�T� 5fi 1U�t �I Y 360 Name (print) Contact Address Phone Number 2.2 Authorized Agent: / �a�/�v� 7S�C9 Cofomn9k, Rod %,77 930 - yVeo f3av�y Name (print) Contact Address Phone Number y / 3.1 Licensed Construction Supervisor/Specialty License: License Number: C S p D 7 e/ Z/ S 7 Company Name/Contractor Name: t3a l e.v Address: 7 5-6 Po -fop" kcc go( S• ID , Expiration Date: 1 J U 3� b /G Signature: ✓ Telephone: 7 7 Ci 43o q LfFo 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: 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 � L� � R �p•� p s r yea r {.^,yv,_ ❑ Deck ❑ Pool ❑ Repairs 19 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 ❑. DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ 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 11 Hot Water. Gas Electric Fuel Oil Other _�. 4 _. a .... , Item a Estimated Cost ($) to be completed by permitapplicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) %C f+a+stflrci±,ct�,_ g 1� Mitt § v. Re (Ple Print)f. as Owner of the subject property hereby authorize'i to act on my behalf, in all matters relative to work authorized by this building permit application. vhO / Signature of Owne Date ST(�1 7Ei 4�i1(=l !f►C�EF 1"13k`1:At�A C!�?I r I, 13ar.r 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. !1 � "�L r Signature of Owner/Authorized Agent Date Less Application Fee--$26-00r- Remaining Balance: $ Total Permit Fee: $ Other $Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: �i2i L 1�emodrI '011- '.'ti5 brl�rot, waJet- e_�0,e , A,