BP-74826RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON -TRANSFERABLE
"DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
(o 400 Slocum Road Lu;[)
2 Dartmouth, MA 02747'
Phone: 508-910-1820 Fax: 508-910-1838
w 1664 I
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health:
Signature:
Conservation Commission: Signature:
D.P.W.:
Fire Chief:
Other:
Signature:
Signature:
Signature:
Brief description of work being performed.
Date:
Date:
Date:
Date:
Date:
1.1 Property Address: 4 ('(� (�- le(`L Q Cj 1.2 Assessors Map & Lot Number: (� `
Contact Person-?nu� Gm tss Map Lot 0 -
Phone Number:,'Q��-
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
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:
❑ CONSTRUCTION PLANS
Revised 5 /13
❑ SITE PLAN ❑ENERGY REPORT
RFsinFMTIAI
A
OwnFir Record:
Name (print) Contact Address Phone Number
Authorized �en (`�,��P �0J-go-qn1
Name nnt) Contact Address Phone NumberAddress Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number:t` I Or
Company Name/Contractor Name:
Address: ,-V V`1 A oa,?q? Expiration Date:
Signature: Telephonkl
3.2 Homeown 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.
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:
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding
(Energy report required) (Shed/Garage) (Energy report required)
❑ DEMOLITION (specify):
6X Wood stove/Pellet Stove
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
Location:
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
13 Hot Water: Gas Electric Fuel Oil
Other
❑ Replacement window/door
No. of windows Doors
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1 +2+3+4)
(Pie Aonm
I , as Owner of the subject property hereby authorize �
to abehalf, in all matters relative to work authorized by this building permit application.
of
-- -( ` f
Date
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,}Inder the pains an4 penalties of perjury.
of Owner/Authorized Agent
Total Permit Fee: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
Less Application Fee: $25.00
Other $ Amount $
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17 — �? ^/ /
Date
Remaining Balance: $