BP-73664RESIDENTIAL ❑ Phased Approval (R1063.3)
rS25.00%PPLICATION FEE IS NON RE-FUNDADLE & NpaZOANgERABLE
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£tTFTCEIVED
RTMOUTH BUILDING DEPARTMENT
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°P Nam, 400 Slocum Road �' �.
Dartmouth, MA 02747
14
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Phone: 508-910-1820 Fax: 508-910-1838
lfifi4�r www.town.dartmouth.ma.us
APPLICATIQU TO,CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health: Signature:
Conservation Commission: Signature:
D.P.W.: Signature:
Fire Chief: Signature:
Other: Signature:
Brief description of work being performed:
1.1 Property Address:
Contact Person:
Phone Number:
�-,--cLA \Ak
1.4 Water Supply (MGL c40 s54): 1.5 Sewa Disposal System:
❑ M�rficipal ❑ nicipal
q�/Private Well Von Site Disposal System
Date:
Date:
Date:
Date:
Date:
V
1.2 Assessors Map & Lot Number:
Map Ir Lot �5 -
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes 0 No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN El ENERGY REPORT
RESIDENTIAL
° SECTION 2 * PRtOPERTY OWNERSHIPiAUTI ORIZED AGENT
X Owner Rt� ord: 644
Name (print) Contact Address Phone Number
2.2 Autho -zed Agent: n /�
ame (print) tontact Address Phone Number
SECTION 3 - CONSTRU TION SERVICES
` 3.1 Licensed Construction Supervisor/Specialty License: License Number: (9( 0
Company Name/Contractor Name: kvVuL�Wfc�-P_v
Address: To bn�� c' Expiration Date: 2a (`ZQ ( r
Signature: Te ephone: I
3.2 Homeowner Exemption - Ord UwoFamily 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:
m °m SECTION 4 WORKER`S COMPEh15AT1ON INSURANCE AF I0AVIT(MGL c 152 § 25)'
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affrdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
SECTION 5 =ZESCR1PTI0 0F.PP.0P0. SED WORK (Check all applicable) r k r
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/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): AID (AK
Location of debris removal (per MGL C.40 Sec 54): aDumpster on site ❑ Dumpster On (Street
Facility Name: [� J t �(L Location: , ���� 114 (i t
'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