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BP-91261RESIDENTIAL ❑ Phased Approval (R106.3.3) L, b i i $25.00 APPLICATION FEE IS NON RE -FUNDABLE NON-TRANSIVERABLE e i ATE RECEIVED l JUT 4^ �;. DARTMOUTH BUILDING DEPARTMENT /` s rrJ 7 I` — ` ' : 400 Slocum Road Dartmouth, MA 02747 - Phone: 508-910-1820 Fax: 508-910-1838 •�. (664 ' Sy. www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Tlt$-SEfTtON FOR OFFICIAL SSE 013F�Y - - f;EEEI�/EDBU(LDING.PE. - NtJliriB R, - � DATE:ISSEJED~ - _ SIGlATk]E2 .1� v E DATE l Bui(dmg::orftntis�onerl}rrspector ©fBuifd'ings r ZatNrr� Q�stnsf �ropgsed Else - ne �Jf DCB CT A ❑ Aquifer Zone HE z6 ll�tG A CfESLS140UKE) BE ldf-I i -i i7 Board of _ oard o€ ❑ Cons D Ptannrng f f ftddre~�s ` ❑1=itgineenrig 0 Cross ,. AlPeais kteatttf Catnrrissron Gard _ _ tiConnecfion - El GA" _ Electric �t Qther h +:: ❑ Water Card tl Sewer Card p Erie Chiefi Cat OfE-.; Cut Off = - Gut Off GLt Off L / 3 c� oard of Health: Signature: �� l r?�'l dA r�MJr Date: f Conservation Commission: Signature: D.P.W.: Signature: I Fire Chief: Signature: Date: Date: Date: Other: Signature: / Date: Brief description of work being performed., le a�: LG�y 1.1 Property Address dQ� VU Contact Person:�6�22cc7 Phone Number: 5 V Q 05 / ::7 - 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 2-- -" 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 ❑ No Date: w ■yCONSTRUCTION PLANSFIRITF PI AM 9:K1=0t-Nz X re ruwsmi 16W 16110INS& _ � GPEiRTY4f3iNNERSHlI��A.(:�7'Hdi��ZED AG��Ii, 2.1 Owner Record: �' � rl � 7?4 24 3 q619:), Derf, 71 �� n 7� � Contact Address Phone Number Name (print) 2.2 Authorized Agent: Name (print) Gontact Address Phone Number 7-7 _ - - 3.1 ,Licensed Construction Supervisor/Specialty License: License Number: �— Qmpa' Name/Contractor Name: Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption - One & 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. "Homeowner" a of land she resides or intends to reside, on which which he/ructures: For the purposes of this section only, a is defined as follows: Persons) who owns parcel /or farm stA person who constructs more than n there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and one home in a two-year period shall not be considered a Homeowner. If you are ap I . under this sect* sign bel : Signature: s; ri� iOf� 1FQKR GQ1gEF�S?'ftQPs!{V5'U[ fFIt1N1T,(Mu1 c22j X _-- 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 r ❑ 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): ❑ Dumpster on site ❑ Dumpster_ Street iOn Facility Name: A- %' C 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 urit) n nt.,.,e r,f the nhrw4 9h d 0Hat Water: Ga= Y - Electric Fuel Oil Other r 5T�V�i+�;1 U�r-/ 13 G.,'.y�Ts ?, Estimated Cost ($) to be completed by permit applicant Item 1. Building 2. Electrical 3. Plumbing 4 Mechanical (HVAC) 5 Total 0 +2+3+4) s 3 S1=C I d L l EE2 11t R Z, TION� tp(ef itvWheR o5vfieis gec► t r rEtf is oT dpR99!-�ori�uttd+ru pdFini4 e _- . _. - 1viP 1 a .se Print ��j C(� �1 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. r Pe o Ow r Date -QWf?AGEN7tUHTaIZ QooA 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. c Pigna gthorized Agent Date "t SECTIO $ ;GFFt C Sl3JECTOFt'S O'UP - $ l 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. i to: Permit Issued 7� - 7�3� �...��. .A C� �� '� �r iJ � `- J ®�—dOEP 115"7—eFlkW-0— Vl_. %,5 a�