BP-70232RESIDENTIAL ❑ Phased Approval (RI t06.3.3)
$25.00 APPLICATIO\T FEE IS NON BE -FUNDABLE 1Ic NON-TBANSTEItABLE
DAYE RECEIVED
DARTMOUTH BUILDING DEPARTMENT�Zl l r3
.4 400 Slocum Road
z S Dartmouth, MA 02747
��'�✓ . " yy 'r 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
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT NUMBER: Y
DATE ISSUED:
(2
SIGNATURE: 1 - DATE:%
C misinner/ins ector of ildings
ui Ing oms p
Zoning District: r Proposed Use: Zone: 0<110 B ❑ A ❑ V Aquifer Zone:
M
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`
O 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:
SECTION 1 - SITE INFORMATION
1.1 Property Address: �`� ¢�
1.2 Assessors Map & Lot Number.
Map_ Lot �-
Lot Area (sf.) Frontage
Required Provided
Front Yard
1.3 Historical District ❑ Yes �u No
Side Yard
Year Built
Rear Yard
Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposa! System:
0 Municipal Y?rivate Well
CI Municipal ❑ On Site Disposal System
13 Yes • ❑ No Date:
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
)Tz4,erI T, /C�
/�tYAA01% 4��
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
�i��.rC..,� ,�,�;,�
3 (,fr�� 5���,�SGI•pc�?�� O�L'8`�f`t?fJ �
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
(' p
License Number: J D �l
Company Name/Contractor Name: 4l ec" ��� r',('Cot ft,
Address: S' ,c c (r , f b 4 rA-- -A
Expiration Date:
Signature: Telephone:.To-
3.2 Homeowner Ex tion - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEO S WHO INTEND TO PERFORM AND BE RESPONSI OR THEIR OWN PROJECT
Exception: Any Homeowner performing work for whi ' ing Permit is required shall be exempt fro provisions of this section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner s s supervisor.
For the purposes of this seclion only, a "Homeowner" Is defined as follows: Perso wns 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 s res accesso ch 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 elow. _
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) (Shed/Garage) (yyFj rim¢ (Specify below)
- -- rn Add!ti ,7 ❑ Replacement i dowldoor ❑ Demolition
,1
x 4"c
(Energy repc.'t required) No. of windows Doors : ' n ='x* (Specify below)
*if new construction, please com'.'te the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 —NO. D s Unit 1
No of Bedrooms Unit 2 ,,a. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane oil, electricit , he; (specify):
❑ Boiler (heating) - fuel gas (natural or pro e), fuel oil, electricity, other city;: i
natural gas, propane, electricity, other (sp
❑ HVAC (combined unit) -pri�nit)
D Air conditioning - (separa
❑ None of the above a provided
❑ Hot Water: as Electric Fuel Oil Othe
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1 +2+3+4)
60� . a it
SECTION 7 - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print) E
_1
I as Owner of the subject property hereby authorize IVA C"
to act on.my behalf, in all matters relative to i4ork authorized b this b Iding permit application.
YL?
Signature of Owner Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
,) /
` r 'h
I. (l 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 pai penalties of perjury.
Signature of Owner/Authorized ent Date
SECTION 8 - OFFICEIINSPEC OR'S NOTES
q
Less Application Fee• 5.00/
Remaining Balance: $--dL�
Total Pert Fee: $
Other $ Amount $ S
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: Lti' 1���
f� `e, -�, (7 /
SECTION 9 - ADDITIONAL COMMENTS/SKETCHES