BP-70462RESIDENTIAL ❑ Phased Approval (R106.3.3) *
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DARTMOUTH BUILDING DEPARTMENT I;A
400 Slocum Road
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Dartmouth, MA 02747
2013
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Phone: 508-910-1820 Fax: 508-910-1838
www_town. da rtmouth. ma. u s
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
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RECEIVED BY:
BUILDING PERMIT NUM14ER:
DATE ISSUED:
DATE:
SIGNATURE:
Building Commissioner/Inspector of Buildings
Zoning District:
�_ Proposed Use: Zone: 6- ❑ B ❑ A ❑ V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of
❑ Board of ❑ Cons. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off Follow-up`
❑ Fire
❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW'BEFORE THE ISSUANCE OF A PERMIT,
DEPARTMENTAL APPROVAL
Board of Health:
Signature: Date:
Conservation Commission: Signature: Date:
Other:
Signature: Date:
Signature: Date:
Signature: Date -
Brief description of work being performed:
l'SECTION .I - SITE (INFORMATION
14 Property Address: �/ s%`�i`*�' %✓►'�� 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District El Yes (I'No
Side Yard Year Built
Rear Yard I
13 Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?)
rl Mimicinal ❑ Private Well 1 ❑ Municinal ❑ On Site Disposal System ❑ Yes • ❑ No Date:
_J
10/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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RFSIIIFNTIAI
SECTIO-N - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
)2- Owner Record:
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1-5Z5-15m/rA /,,�Cdr
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor/Specialty License:
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License Number: d
ompany Name/Contractor Name: LL'% l ry Jsl
Address: , p �,j
Expiration Date:
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Signature: Telephone: d �� �/����
3.2 Homeowner Exempti2010ne & Two Family Only Section 110.135.1.3.1 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 helshe 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 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:
SECTION 4 - WORKER'S 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 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑-Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* [],Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) hed/Garage) bc (Specify below)
❑ Addition Replacement i dow/door ❑ Demolition
report required) No. of windows Doors �' 4 `''`' (Specify below)
(Energy
*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
r-umace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
13 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
• Air conditioning - (separate unit)
❑ None of the above to be provided
11 Hot Water: Gas Electric Fuel Oil Other
00
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be com leted by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total +2+3+4)
SECTION 7A - -OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
Li�gljLz �I��I Owner of the subject hereby authorize hf ► lf�l ��
} as property v
to act on. my behalf, in all matters relative to work authorized by this building permit application.'9Z
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Signature f Owner Da
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
11-11411111m— as Owner/Authorized Agent hereby declare that the statements and information
a foregoing application are true and accurate, to the best of my knowledge and belief.
7Igned under a pains To penalties of perjury.
Signature of Own thorized Agent Date
SECTION 8 - OFFICE/INSPECTOR'S NOTES
Total Permit Fee: $ �L5
Less Application Fee: $25.00
Remaining Balance: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. r
Permit Issued to:
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SECTION 9 - ADDITIONAL COMMENTSISKETCHES
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