BP-65891RESIDENTIAL ❑ Phased approval (r 06.3:3)
$25.00 APPLICATION FEE IS NON RE-FUNDA TRANSFERABLE
,( PP, RECEIVED
,�U„• DARTMOUTH BUILDING DEPARPMNT
•r 9f
400 Slocum Road, P.O. Box 79399 2017 HA9: 27
x Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
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:
Other: Signature: Date:
Signature: Dater
Signature: Date:
Brief description of work being performed.
1.1 Property Address: �' %% .j 4/MO--klee-k J
Lot Area (sf.) Frontage
Required
Front Yard
Side Yard
Rear Yard
Provided
owater SupPriGL c40 s54): 1.5 Sewage Dis sal System:
Municipal Private Well ❑ Municipal tZOn Site Disposal System
1.2 Assessors Map & Lot Number:
Map Lot 2e -
1.3 Historical District ❑ Yes ❑ No
Yeas Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
-; 'SECTION 2 --'PROPERTY OWNERSHIPLAUTHORIZED
AGENT . ,,,
2.1 Owner Record:
Mc 601rt'
xle,� ;eV 774%taba--?S65--
Name (print)
Contact Address Phone Number
2.2 Authorized
rAgent: �//��
�.4-v ! Cher •� L �/
Q P .t't sr, 1,9«i/ w.�d86 jY-
Name (print)
Contact Address Phone Number
SECTION 3 = CONSTRUCTION SERVICES , W .
3.1 Licensed Construction Supervisor/Specialty License: C'
License Number:
Company Name/Contractor Name: % Oer „aev 1,9�G ��P-
Address: d , 0 4Yaf 5't
Expiration Date:
7 v�G Z z-
Signatu Telephone: (07 E/y/S�
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:
:.SECTION 4 - WORKER`SCOMPENSATION INSURANCE AFFIDAVIT (MGL c'152 § 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: [T es ❑ No
SECTION 3-DESCj2tPT10N OF PROPOSED"WORK (Check all ajsplicable).-, .
❑ Deck ❑ Pool ❑ Repairs n-A- lteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
'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
7 � Less Application Fee: $25.00
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
A.1/5--_'
Remaining Balance: $
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