BP-77396RESIDENTIAL ❑ Phased Approval (R106.3.3)
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DAUDRECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
Dartmouth, MA 02747 ' _ t : 24
Phone: 508-910-1820 Fax: 508-010-1838 W
64 www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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:
1.1 Property Address l��1 - ����� '�
Contact Person: k 13d b 13&,4y
Phone Number: a- Sot 3 Ac" ST 0�`02
1.4 Wat r Supply (MGL c40 s54): 1.5 Sewage Disposal System:
2Vunicipal ❑ Municipal
❑ Private Well On Site Disposal System
1.2 As`sessors Ma & Lot Numb
Map v Lot
1.3 Historical District ❑ Yes 2-ITo
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
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5 /13
El CONSTRUCTION PLANS El SITE PLAN El ENERGY REPOR i J
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- SECTION2;,
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AGENi.=
,PROPERTYWNERSHIP/AUr+iORIZED
w er Record:
! /,
[Contact
Name (print)
Address Phone Number
/
2.2 �orize
Name (print)
T
�lr S
Contact Address Phone Number
a �d
_ _ S�GTJDN 3 CAIVSTRUCTIONS�EEiVIGES
_ _ - _
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: ,
Address: ,� r axle /t'r Expiration Date:
�1
Telephon41ra'
Signature: I
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.
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: a
Signature:
x _ _ = SEGT,ION 3tti1t})tK£R'11ENSkTIZ2INS1lRI1VGE AEIDAl1I
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Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
- affidavit will result in the dental of the Issuance of the building permit. Signed Affidavit Attached ❑ Yes ❑ No
SETlaN ,E bESCRtPTCOtd s3F PRQPtEEDeORK (Ghecklpplica6ls}
,
❑ Deck ❑ Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pel let Stove
❑ New Construction* ❑ Accessory Bldg. _❑ Addition ❑ Roofing/Siding A 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): 5a'1umpster on site ❑ Dumpster On Street
Facility Name: Location: % 4qy 14 U of &P 144
*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
SEGTION 8, ESTtAATE[�E2KSTRUcT(D[v evsr
tem* Estimated Cost ($) to be completed by permit applicant
1. Building !O o
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total (1 + 2 + 3 + 4) ss
SECTION 7A OWNERAt1THt3RIZATlt3(V
#v bea�rnpfetetluher owned r agent or corraoor`appGes fot�burtdri�trmtt)
(Pleas nt)
I XW�— eas Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SEGTIGN7B OWHERIAUTH®ERIt60CLARA ION
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.
�SiggAatu�reowner/Authorize�Agent�
Date
_.
ECT'tON $:=,OFFiCE�INStEGTOR`S�fOTES _
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: a �J14
SCTIQT�i SGRPTIO1 OF]#t!?EE([+f3WRM1=D
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