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BP-96344RESIDENTIAL ❑ Phased Approval (R106.3.3) S25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE I fl DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road r° S Dartmouth, MA 02747 5yy. Phone: 508-910-1820 Fax: 508-910-1838 � AUG"b PH a-1 7 166"' /� ` 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. i j 1.1 Property Address: `f' if 0' L& 1.2 Assessors Map & Lot Number: - Contact Person 0��adY Map iC2�--o Lot Phone Number: ��� W 1 - G 3 S 1.3 Historical District ❑ Yes ❑ No i 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built j ❑ Municipal ❑ Municipal ( ❑ Altering more than 25% per side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: evised 5/13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT t RESIDENTIAL TION2:t'RCtPERT�(i3WId>l=f2Sti1P3AUTitORQED�4�EIV.T _r 2.1 Owne 'a-cord: ,. -FA 1-10 Name (print) Contact Address Phone Number . �'"'" Authori19�4" COZ Name (Pr CoWtdress Phone Number „SECI'ON tirCONS UCTiON SERKfICES 3.1 Licensed Construction Supervi r/Specialty License lAA InY�LC License Number: Company Name/Contractor Name- �c I,il� % Address:k6 Ser Expiration Date: Signatur : Telephoned(• 3� (• 13� 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: Signature: - � ;t _ �.ti, ��ECTON-,1�►QE?, , RSA,��`Ef�Sii�T�©t�C�(�Si1R#NCE �P,FID,��%1�" �GL,�o�S���-�S)� „_ 1 , � ��..; _��3yr.. 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 �� �' _ SEi�TibN 5 _ti�SCE�tPE(�Id Q',F RR(J��tlSEf3 �4t6RtfChectt��ifi a�pt(ca6Ce .� _ _ ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding eplacemen indow/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 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 ❑ 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 0 Hot Water: Gas Electric Fuel Oil Other -- } = E 1vN �i I=STINIAT A=G6NS` - ��.__ Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total (1 + 2 + 3 + 4) 4-5 z : SECT oi7if)v1ElQ AiTio ITz' r - '' ��fo�e��t�i�eie��vFet�owrter'serge»f�-e�t�r�cfor�p�stes�o��aild(tig=p�2fsYtj - - (P>Ase Print) � � I, , as Owner of the subject property hereby authorize n �� to act on my all matters relative to work authorized by this building permit application. ,eh��alf,��in Signature of Owner Date EGTtt3NB..f]IATFtERiFT#O�tE13tAGENTDECLAj4TIEl1�_:= I, h Ias 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� Signature of dwner/Authorized Agent Date 4 COW"FFiCEliNSPEGT(3R`S NQTES i y Total Less Application Fee: $25.00 Remaining Balance: $ 4— Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: v FSr.-- �• P s w�