BP-86961_ �.6
RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25:40 APPLICATION FEE IS NON BE- LE V& 1\ ON TBAllTSEEBABLE
_. _DATE`RECEIVED
;QTH-`, DARTMOUTH BUILDING DEPARTMENT
fO 400 Slocum Road
° z Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
166 = www.town.dartmouth.ma.us I
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APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINJ
� ■ A
Board of Health: Signature:
r
Conservation Commission: Signature:
D.P.W.: Signature:
Fire Chief: Signature:
Other: Signature:
Brief description of work being performed:
Date: _
Date: _
Date:
Date:
Date:
1.1 Property Address: 16
L(5 /� %✓
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1.2 Assessors Map & Lot Number:
Contact Person4�
�-� 1�'J�
Map — Lot
-
Phone dumber:
1.3 Historical District ❑ Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
0 CONSTRUCTION PLANS 0 SITE PLAN ❑
Item
Cost ($) to be
2.1 Owner Record: Y
Name (punt)
Contact Address Phone Number
�2.g2Ahorized Age #l�
AIM
Name (pant) Contact Addre C3 2 Cl hone Number
3.1 Licensed Construction Su ervisor/Specialty Lice se: —
Company Name/Contractor ame: i�
Address. id 01
Expiration Date: Q
Signature: Telephone; T101 6 '— 2!^ l 1
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:
13
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: I� es ❑ No
❑ Deck b Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding PEF-Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windowsDoors
DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): CdOumpster 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 orpropane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
p }{/Ainerf+�nit}" primartt fttr f rrattrraFgas; prune: electricity, other(specify):
❑ Air conditioning - (separate unit)
None of the above to be provided
0 Hot Water. ; Gas Electric Fuel Oil Other
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC
5. Total=(1+2+3+
G G Ci
(Please Print)
I +e e r as -Owner of the subject propertyhereby authorize t r
to act on my behal in all matters relative to work authorized by this building permit application.
of Owner
Date
l ��---- 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 ► n er the pains and penalties of perjury.
of
Total Permit Fee: $
Agent
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
i
a
Less Application Fee:
t
Other $ Amount $
Date
Remaining Balance: $