BP-89893RESIDENTIAL
❑ Phased Approval (F 106.3.3) _.... _.,..
$25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON-` RANSFERAMLE
DATE RECEIVED i
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
e -
Dartmouth, MA 02747 Y
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRI,ICT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
RECEIVED;:BY; :
!/
Rt-(a-:
BUILDING .PERMIT NUMBE.
DATE ISSUED:
SIGNkTURE:
:F
DATE:
Buildfng Commissioner/inspector o
sidings
Zoning QistiictY
Proposed Use,, Zone..
X ❑ B -
q A ❑ V Aquifer Zone
THE FOLLOWINGAGr=NCIES SHOULD BE NOTIFIED. ' =
DPW
❑ Board of
❑ Board of, ❑ Cons.,; >] Planning
❑Address
❑ Erigirteering Q Cross .
Appeals
Health Commission '
Card ,
Connection
❑ Fire.
❑ Gas ❑ Etectric 11Other
❑'Water Card ❑Sewer Card %�. PDF
Chief:
Cut Off Cut Off
Cut Off
Cut Off
-
- —
-DEPARTMENTAL APPROVAL(S)
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 i . rope Address:
zontact Person: ��✓f u/ 1TY-
�eNurnber: 3 3 17' gK-7 ��VX
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 / f Lot
-
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:
j1�evised 5 /13
0 CONSTRUCTION PLANS 1:1 SITE PLAN 06NERGY REPORT
SECTION Z - PRaI'ERTY OWNERSHIPIAUTHOR(ZED
AGENT =;
2.1 caner Record:
Name (print) �/
/
Cot A ress Phone Numb r
L , sZti.Cc
2.2 Authorized Agent:
c
Name tint
(P )
Contact Address Phone Number
SECTION 3 ,CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name: 0
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.
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 andlor farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If yo re applying under this section sign below:
ignature:
Je
SECTION 4,= UVO[KER'.�sGOI�iIpEI�iSATIOId:INStiRMGE.APFI.RF!!T.(AGL,c52 § 25
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
S`EC:TIOI�I 5 = DESCRIPT[OIV QF ,PROPQ 9EEi..V�ORK (Check all applica[i!�)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pel let 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 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
Item Estimated Cost ($) to be completed by permit
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total (1 +2+3+4) 605/ i 1
—SECTION-1 OWNER AUTHO IZATION t
{foeeownersbagenoconfractora_pe cam phss foriaal}tl ng permit}
(Please Print)
I, , 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.
Signature of Owner Date
SECT(6 7S - OWN EIVAU HRIZED; �(�EPdT DELL A�TICN
v�Gt/ S411/T?�
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.
Z2__
/6
Si ature of Owner/Autho Date
Less Application Fet_. 00
Total Permit Fee: $ .J
Other $Amount $ _T
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
Remaining Balance: $