BP-74926RESIDENTIAL ❑Phased approval (R106.3.3)
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DATE RECEIVED
1P r \ DARTMOUTH BUILDING DEPARTMENT
;o 400 Slocum Road I �.:
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i Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 11�{I{ ITi
6 P'rl { 50
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
# t r � ° tTHIS SECTION FOR OFFICIAL USE ONLY x ". s "' • a '
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FiEGEIVED BY.' f # r "`
BUILDING PERMIT NUMB R:
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5b a 4 \' , DEPARTMENTALAPPROVAL(S)*
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: 1G?G 4ZV4*.l AAIZ
Contact Person: 4.'% r so-f2G�t
Phone Number: Sdts 679
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
14 Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map. Lot_ C�-_
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:
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
USI®ENTIAL
SECTION -„P OPERTYOWNERSHIP/AUTHORIZEDAGENT"
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2.1 Owner Record:
4&6eell
Name (print)
Contact Address Phone Number
2.2 Authon ad Agent:
�116tiy 9e�S
.SSaS .ST
Name (print)
Contact Address Phone Number
vir f ai t I t a # SECTION 3 p CONSTRUCTION SERVICES # 1. * r 1 M a 4 ' 1
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3.1 Licensed Construction Supervisor/Specialty License: License Number: `s / 7 7 C
Company Name/Contractor Name: 99e.A-5
Address: t%5.�e"
piration Date:
Signatur
Teleph e:
3.2 Homeo emption -One &Two Family Only S coon 110.R5.1.3.1 Ex�cep.[Idn�:
FOR HOMEOWNERS WHO INTEND TO PERF REUSE SPONSIBLE 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 defned as follows: Person(s) who awns a parcel of land on which hefshe resides or intends to reside. on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessoryto 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:
* if lv + SECTION A� WORKER'S„COMPENSATION INSURANCE AFFIDAVIT''(MGL c f52 § 25) L
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
.q g ` " ' A 14 &-SECTION 5*- DESOFbPtIONI OF PRO POSED WORK (Check all applicable)-... 1/ "' $ t .r....
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition - koofing/Siding ❑ Replacement window/door
(Ene y report required) (Shed/Garage) (Energy report required) No. of windows Doors
DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): XDumpster 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
❑ Hot Water: Gas Electric Fuel Oil Other
7+ e c x"I t t SECTION 6- ESTIMATED CONSTRUCTIOWCOST.
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
rid
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4)
* a a + f p $ SECTION 7A -OWNER AUTHORIZATION
f r t x to be completed when owner'svagent or con%ractor applies for buildin'p4mrgit) , a
(Please Print) T
LL//�/y as Owner of the subject property hereby authorize 4-r/• yO *geg S
to act on my behalf, in all matters relative to wor authorized by this building permit application. //�,j /
0-L'-rfL % —?-Of
Signature of Owner Date
a It x , '..` " t ' + ''i I ` * ,. SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION 1 . G a " * 4 1'
I, A1717(aA-Y S044? J , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true nd accurate, to the best of my knowledge and belief.
Signedund he aim an p nalti of perjury.
Sig to Ow /A o zed Agent Date
r 1.....f.. '" r 3 x SECTION 8:-OFFICE/INSPECTOR'S NOTES„
111
Total Permit Fee: $
Less Application Fee: $25.00
Other $Amount $
Remaining Balance: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. /
161 Permit Issued to: _ A% LJ /
f ;e SECTION 9.- DESCRIPTION, OF'WORK BEING PERFORMED
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