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BP-87002❑ Phased Approval (R106.3.3) RESIDENTIAL FEE IS NON ICE-FCNDAVLE & NON-sTRANSFEBABLE $25.00 ApPLI[CATION DATE RECEIVED DARi11 OUTH BUILDING DEPARTMENT /} .a y 400 Slocum Road / r4 �: i° Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838- t; !6`= 5' www.town.dartmouth.ma.us TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING APPLICATION TIiIS SECTCON,FR OFFICIAL USE ONLY - BUILDING PERMIT NUMBER: REGEIVED;BY. .. DRTEISSUED;;_ ,. J DATE: SIGit1ATtJR� _ _ _ • Building Carnmi n /I " pector of Buitdirigs Zoning Distrrct Praposd Use '. Zone LI X. ❑ B CIA ❑ V AgiiiferZoni~ AGEIJt IES SHOULD BE NOTIFfED. D}'W T1' E FdLLaWING ❑ Soart of ❑Board of ❑nhs El Plan ' ❑ Address ❑ Engineenng ❑Cross Cartl _tlonnection Appeals Health - :Commission ❑ Ftre ©Gas - ❑Electric ❑ aiher' ❑ water Card [].SewerCar , Gut Off • , Cuf Off , . _Cut Off cut off - tit =DPRR�VAt (51 - 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: �G % L✓r„�f) °�✓ I A / } 1.1 Property Address: Contact Person: Sid L i C Phone Number: 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well ❑ On Site Disposal System 1.2 Assessors Map &Lot Number: Map --��— Lot —3 1.3 Historical District ❑ Yes lVo Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: 5 /13 ❑ CONSTRUCTION PLANS 0SITE PLAN ❑ENERGY REPORT RESIDENTIAL ON-2:PROFEFtTYOWNERSHIP/AUTHORIZED AGENT _ 2.1 Owner Record: .� LG N RD Name (print) Contact Address Phone Number " 2.2 Authorized Agent: 4GL1 Name (print) Contact Address Phone Number ,SECTION 3° COIVSTRCIGTIOIV SE. RYICES - = 3.1 Licensed Construction Supervisor/Specialty License: LiceS N mt e Ud% 26 v Company Name/Contractor Name: ° 6��� 'Gal s R7 ` r ' Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption ne & 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: ION-4 WQBltER'S GaMPE1AT�tiV INSIlIANG4F0IDll1(1T,€NiGL;c"t5 § 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 - _ - �, ,�4.SE�TION 5 :�}ESGBtPF[ON'OF PROF'CASED`lNORK(Ghecr��Ifappjica6le} .. _ _ ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): V Dumpster on site ❑ Dumpster On Street 3 � / Facility Name: A�G �y �t��.j`V Location: �{/��'(JJ Pj � PAD *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 v SECTIOfV6 , ESTI6AATED CONSTRUCTION COST Item Estimated Cost ($) to be completed by permit applicant 1. Building 1611-0 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) St~CT14 1 T ► - all11NER AUT GRIZAkFION :(to 6e comple#ecf wfit en ornrneNs agent or iron racEorpp[res fiir buildtrg permit) (Please Print) L �j,�GG/{�i J� I, A}L , as Owner of the subject property hereby authorize to act on my bet lf, in all matters relative to work authorized by this building permit application. Slg rp of Owner Date SEGT[OIV`TB NER/iS OWUTHORIZED.AGENTPIECARATIOhJ, I, }/1,A Z, /ji S,4/ f-S 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. Signature of Owner/AuthodzQogent 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: _