The URL can be used to link to this page

BP-87668RESIDENTIAL ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON RE-FUNBARLE NON -TRANSFERABLE DATE RECEIVED UN DARTMOUTH BUILDING DEPARTMENT ` Q Ni ° 400 Slocum Road Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 4 ` `6_6 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR. -TWO fAMIL'Y,DWELLING F�EGEIVEDBY : �7VIUJtIYl3-�CIllYlli IYVIYIULf1 /fllf/mil t SIGNATURE DATE Budding Commissionefflnspect0 o fdin Zofltrrg Qrsfrrcf "� - .Proposed U.se Zone DX E[8 ©A p V AqutferZone ee THE fOLtOVUING AGENCIES SHOULD BE 1VOTIF[ED = Q Board of : [] Board of - ❑ Cotrs 17 PlarOng p Address ❑Engineering ❑Cross Repeals,. - Heatttt Corrimrssrori Card = Cannech�{t ❑ Elte Gas ❑ Efea_trrc L Other '' Water t;ard C7 Sewer Card thief Cat Off Cut"OfF Cut Oft Cui Off Board of Health: Signature: Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work being performed: 1Property Address: ""I J HA (T I, /U UL ( Contact Person:��f //✓�'� - Phone Number: � 1.4 WT;er Supply (MGL c40 s54): 1.5 Sewage Disposal System: Municipal ❑ Municipal ❑ Private Well ,.E On Site Disposal System Date: Date: Date: Date: Date: C 1.2 Assessors Map & Lot Number: Map Lot 1.3 Historical District ❑ Yes [Il'QVo Year Built y ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yeso Date: ■ CONSTRUCTION ■.SITE PLAN ■ENERGY REPORT 2.1 Owner ecord: - Nam (r' t) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address tj Phone Number c. - ---._ _..-. ._ ,:�-_-:= T—�• .,.-:.� _... .a�:.,, amour-wLv - 3.1 Licensed Construction Supervisor/Specialty License: License Number.S'�02 Company Name/Contractor Name: Lc , &VX %f A� �,# , ddress: � ✓. iti'�, _ Expiration Date: fi j ature ph& Tele one: mption - 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 `$ Fitill S 'DESERtf3Tltt L7F PRC317t3EE iMORK. check a�IWOtcattle ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* (Energy report required) ❑ Accessory Bldg. (Shed/Garage) ❑ Addition ❑ Roofing/Siding (Energy report required) ❑ Replacement window/door No. of windows Doors QEMOLITION (specify): Location of debris removal per MGL C.40 Sec 54): �Dumpster on site ElDumpster On Street � Facility Name: ��G` Location: ,��sy��yi ,�''i �'✓ - *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 0 Hot Water: Gas Electric Fuel Oil Other -.:.< .., :. �. . z-. :;;r... �:`- .,... -:,R_ . s:. _.� � � _ - ♦. r� cv'v � � V LSV V V It. - .S' - _ Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4) _ c�t�N zA OWNER atiTH©RI�iTIt3tV (fo beompleteci�ifher ouvnets agerff or catff�ct applies fotuldtng permit) - - (Please Print) 1, e<naS & , as Owner of the subject property hereby authorize_ to act on my behalf, in all mattrs rel ti work authorized by this building permit application. Signat e o Owner` Date EGlltitV�B-f►WERI�4llT1iC3RlZEDAGENTaELARATIt�hl _ = � ner/Authorized Agent hereby declare that the statements and information on the foregoing applicatio a true and accurate, to the best of my knowledge and belief. Signed under the pains an penal ' perjury. Signature of Ow horize ent Date 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: `� �'� £' � �- 'SEGT-IQI�i•9 �ESGt3fPT�O�V�F 1�iQRKK`BEi[�G1aER[=�1�}�_ EI3 k ��; ,�