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.PL.IFATI®NFEE IS "N RE=EEN .ARLE
SZ�DATE RECEIVED
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DARTMOUTH BUILDING DEPARTMENT
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400 Slocum Road
Dartmouth, MA 02747
Phone: 508-910-1`820 Fax:-508-910-1838
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www.town.dartmouth.ma.us
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REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
4 TO CONSTRUCT,
tAPPLCCATION
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t tLDfI4:PERHui V*%AIVtl3 v+
DATE ISSUED-
DATE.--
Burtdb! Commrssioner r sp irtarot Yurldings -
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ni osed EJse done = Irt 9 13 A ❑ V Aquifer -Zone'
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:3fErfl�t(7I€S $HOIBI�C�ITtGT. ;
Bc;ard of
Q Bo�rt of a Eons 0. Planrring:
Q Address Q ERgineenng Er Cross
Conneetiorr
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"SAPels
Iiealti Cvtrmissiari
Card _
_- _e.
fI Fita .
ElGas-❑ Electric 0 Other
❑ Water Card:, Q Suer Card
cuf off
__.runoff _ Gut OffCif
Ofi
Board of Health:
Signature,
Date:
Conservation Commission:
Signature:.
Date:
D.P.W.:
Signature:
Date:
Fire Chief:
Signature:
Date:
Other. _
Signature:
Date:
l
Brief description of work being performed.W.
- -
1.1 Property Address:
4 Sniff,
N2c
1.2 Assessors Map & Lot Number.
Contact Person:
,1 l2°f�
QP/
Map _1�/_ Lot
Phone Number:
❑ Yes ❑ No
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.3 Historical Distract
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
O-CONSTRUCTION PLANS ❑ SITE PLAN ❑ENERGY REPORT
RESIDENTIAL ' Item Estimated most ! 5} to be completed by permit applicant
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SECTION Z- PROPERTY- OWNERSHIP/AU-THORIZED
AGEN I
;;2.1 Owner Record::
�Y f e�nE Y
S. oz7i/k Sa��`�4(0- S�bY S
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Contact Address Phone Number
�1k1 ,;2 �GXtla
Name "print}
2.2 Authorized Agent:
I
t
a n �nrtisa S Al r
l Name iprint)
Contact Add ess Phone Number
3.1 Licensed Construction Supervisor/Specialty License: �; ' So
License Number. p
Company Name/Contractor Name: vvTFt �C/a '
Address: 2— dE .- , n , L Expiration Date:
` Tele hone: Z.
Signature- p
3.2 Homeowner Exemption - One & Two Family Only Section I IG.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 s 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 definedas follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there :s, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use andfor 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:
-"_ST[OEE+itVORfXS%EC3fti2/1Clrll�lft
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
Pfyes No
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑
- CTId[ ` _fiESCRIPf[0[iE O Pk�o"EU—WORK
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
Replacement window/door
❑ New Construction" ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding
e
required) No. of windows Doors
(Energy report required) (Shed/Garage) (Energy report
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster 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
13 Hot Water: Gas Electric Fuel Oil
Other
1. Building
Z. Electrical
3, Plumbing
4. Mechanical (HVAC) / O
5, Total=0+2+3+4)
SECTION TA OWER,E�UTi{O�I?�tTIC N
f (cr be 4xiipleied when oH►naes sae- for don-
lX -dot appii fog buildfo�permitj
(P!ease Print)
! , as Owner of the subject property/ hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application,
Date
Signature of Owner
- SEGTIQ[ B-fIt!{IFtER/i4tkT140- iREd.AQERT-DECLAEL4TI0
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4V-:✓1 , 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 painsiand penalties of perjury.
Less Application Fee: $25.00
Other $ Amount S
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: 1
m Seal/ O-z ��
v
Date
Remaining Balance: