BP-90381RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE NON-THANSFEII MLE
OUTN y=, --DATE RECEIVED -
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DARTMOUTH BUILDING DEPARTMENT -
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�? 400 Slocum Road
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 01i s
www,town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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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:
Date:
Date:
Date:
Date:
Date:
I /L/ �Gl�C . t.2 Assessors Map & Lot Number:
/�- Map � Loth vx
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?
"7"" ❑ Yes ❑ No Date:
' v Revised 5 /13
CO�ISTRUCTI0"N PLANS rl AITR LEI AKI r1 V7 r1.r-M„%r,IF"
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RESIDENTIAL
2.1 -Owne . r Record:
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ame (print)
Contact res*v-6"--0e, /"0 Phone Number
f2.2 Authorized
�me rprint�0 Untact
Address _Rh9ne Number
31 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name[Contractor Name:
Expiration Date:
-Address:
Telephone: -
-Signature:
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 t; 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:
If
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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 denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes 0 No
GR _-t � W.
M 0
4-
1 0 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace ellet Stove
Vew Construction* 0 Accessory Bidg. 0 Addition 0 Roofing/Siding 0 Replacement window/door
riergy report required) (Shed/Garage) (Energy report required) No. of windows Doors
M DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street
Facility Name: 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
[I Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
D Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
[I HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
G Air conditioning - (separate unit)
[I None of the abow- *_-hft%*d
0 Hot Water: Ga%l Electric Fuel Oil Other
W4,$-r A-S MV
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
I
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
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5. Total= (1 +2+ 3+4)
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(Please Print)
1, is - as Owner of the subject property hereby authorizEk/5�___
to act on my behalf, all matters relative to work authorized by this building permit application.
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Signature o`bv�fjr
1
Date_
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1, i7 as Owner/AfAhbrized Agent hereby declare that the statements and information
on the foregoing application are true and 151ate, to the best of my knowledge and belief.
Signed u er I and penaltle p dury.
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Si gfi of er/Aut ed AdeKt
Date
Total Permit Fee:
Less Application Fee: $25.0
Remaining Balance.
Other$ Amount 1;
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
t.