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BP-69239RESIDENTIAL ❑ Phased Approval (R106.3.3) a"LS.VV AYYI.IUXTIUN FILL IN NUN AgE- 'UNLABLE & NUN=1'11ANN1;EHAB1X DATE'RECEIVED, 7-PT. . DARTMOUTH BUILDING DEPARTMENT r 400 Slocum Road, P.O. Box 79399 „E -' { : `'' 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 Revised 10/11 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: �(�S�Y'i �i► D� r�iG'C'_ Q I CD/I.<PEZ-1- /f e2 '� S/t-i % /0(y� zk CI,l 5-6 Name (print) Contact Address Phone Number 2 Authorize Agent: enn e711 X, F— nv cP tZ C-Av '7,F r? Coal//;�S La 1z . h1 c�, &i��©rif�,1 `j�� Name (print) Contact Address — Ph -one Number �5 6`519-51 ra2O I SECTION-3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor/Specialty Licen e: 7W- 0 License Number: l y Company Name/Contractor Name: RiV C G f SdV-T7klV-' Address: 09 -12A 4% (J Y Expiration Date: 1` 7 Signature: �► — Telephone: \ ^G��/y3' 9a0I 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 struc es ac ory t uch 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: SECTION 4 -WORKERS COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 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: ❑ Yes ❑ No :.SECTION S - DESCRIPTION OF PROPOSED WORK (Chuck all applicable) ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction" ❑ Accessory Bldg. g/Siding w0lher4-PP'u/d ' (Energy report required) (Shed/Garage) (Specify below) ❑ Addition ❑ Replacement window/door ❑ Demolition (Energy report required) No. of windows Doors (Specify below) *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 �At/