BP-91586RESIDENTIAL ❑ Phased Approval (R106.3.2)
S2S-00 APP1,1CATION FEE IN NON IRE -FUNDABLE h NON -TRANSFERABLE
DATE RECEIVED
UTM
".' DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
" -- Dartmouth, MA 02747
Phone: 508-810-1820 Fax::50508-910-1838
'
66
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THlS GTIO "FOROFFICIALUSEONLY
RECENEDBY:
BUILDINGnRMITNUMBS .
DATE ISSUED: `.
SIG NA
DATE: S'
Building CommImlonedfnspecfor of Buildings
Zoningpistnst: •` Proposed Use: Zone: {7X ❑B
A ❑V-'-AgliferZone: "- ✓"��
_ THE FOLLOWINGAGENCIE$$HOULDBENOTIFIED.
DPW "
-" .❑ Board of ❑,Boerd of - O Cons.. -,- ❑ Planning
., :Cy Address '
J3 Engineering 13 Cross
Appeals -.. -Health CoMmissldn
Card " -
- connection
.�_ 13, 1*& " "� 13Gas 17 Eleetilc 11 Other
❑ WalerCard. .D Sewer Card PD F
.'.:.,Chief - Cutoff Cut Off
Cutoff
- Cut off
— : DEPARTMENTAL APPROVAL 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:
::SECTION 1--SITEtNFORMATION
1.1 Property Address: 274 Jordan Rd. 1.2 Assessors Ma & Lot Number.
Contact Person: Robert Powell Map Lot -
Phone Number: (435) 640-3600
11.4 Water Supply (MGL c40 s54):I 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
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:
%me X `5 Revised 5113
❑ CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT
BESIDE=
-'SECT11ON241PROPERTY-
_OWNERSHIPIAUTHORIZED AGENT.
2.1 Owner Record:
Robert Powell 274 Jordan Rd. (435) 640-3600
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Superior Energy Solutions, Inc. 2780 GAR Hwy #28 Swansea, MA 02777 (508) 5674109 x2
Name (print) Contact Address Phone Number
S '
ECTJON.14VAU0NGTION SERVICES,`,
3.1 Licensed Construction Supervisor/Specialty License:
License Number.
Company Name/Contractor Name: Superior Energy Solutions, Inc. / Carl Rebello 1846721CS-0843 E
Address: 2780 GAR Hwy #28, Swansea, MA 02777
Expiration Date:
Signature
one: (508) 5674109 X2
02/25/2018 1 04120/2019
3.2 Homeowner Exemption - One & Two Family Only Section I I O.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Emeplion: Any Homeowner perrornnfng work for which a Building Pennil Is required shall be "ampt from the provisions of this seclion: provides that If a Homeowner
engages a pmson(s) for hire to do such work, that such Homeowner shaft act as supervisor.
For the purposes of this section only, it'momeawer- is defined as follows Person(s) who owns a parcel of land an which he/she resides or intends to reside, an which
them 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 conslrucfs more than
one home in a ftvo-year period shaft not be amsidered a Homeowner.
If you are applying under this section sign Wow:
Signature:
-::-SalanoN 4�•-YlFbRkelira-ooiliifp 'f1pF—
ftbl,5A -j"UoNcrz ArPinDAV1T.(MGLifi'.1U §25)
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: IN Yes 0 No
SECT] )F.POOPOSEIDWOkK(Chidk_all'i able
pp
• Deck 0 Pool M Repairs 13 Alteration 0 Chimney/Fireplace 13 Woodstove/Pellet Stove
Weatherization
• New Construction* 0 Accessory Bldg, 0 Addition 11 Roofing/Siding 13 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
0 DEMOLITION (specify): none
Location of debris removal (per MGL C.40 Sec 54): 13 Dumpsteron site 13 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
0 Furnace (hot air) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
13 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity. other (specify):
• WAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
• Air conditioning - (separate uril)
• None of the alv�-
[11-10twater 0 —•— Electric— Fuel Oil Other
DON 0 wOTIMA N
I TEA:CO sTVIDTION COS
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
1,772
2. Electrical
0.00
3. Plumbing
4. Mechanical (WAC)
0.00
5. Total + 2 + 3 + 4)
1,772
7A--OWNER-AVTRORI J'ZATIQ
ract r.A0[eisiforbQ'1W n16" Q a 6
to be r1t; pe rniflit')
(Please Print)
I Robert Powell
as Owner of the subject property hereby authorize Superior Energy Solutions, Inc.
to act on my behalf, in an matters relative to work authorized by this building permit application.
See attached
Signature of Owner
Date
SECTIO?47B.OWNEPiAUTHOrIZEDAC;ENTDPCLARAtION
1, Carl Rebbllo , 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.
4d04— 02/21/2019
Signature of Owner/Authorized Agent Date
SECTION z'
71014 8 -WICIERN912ECTOWS NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other$ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteratio total sq. ft.
Permit Issued
Q;OIEJA , OP _M