BP-94642RESIDENTIAL ❑ Phased Approval (R106.3.3)
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DATE RECEIVED
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�. DARTMOUTH BUILDING DEPARTMENT
55
400 Slocum Road
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u Dartmouth, MA 02747
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— Phone: 508-910-1820 Fax: 508-910-1838
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1664 www.town.dartmouth.ma.us
APPLICATION TO ONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Board of Health: Signature:. Date:
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Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: s Date:
Other: Signature: Date:
Brief description of work being performed r 1^
1.1 Property Address3g2 51��p �ern¢t` d7o�tl 1.2 Assessors Map & Lot Number:
Contact Person: Map 4"'OA— Lot_
Phone Number:
1.3 Historical District ❑Yes " ❑ No
�. Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑
❑ 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:
� S b mevised 5 /13
2.1 Owner Record: -•
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Name (print) t+ r ; .
2.2 Authorized Agent:
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Name (print)
3.1 Licensed Construction Supervisor/Specialty License:
Company Name/Contractor Name
Address: /%,`7
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Contact Address Phone Number
Contact Address Phone Number
License Number. 69 N�zG
Expiration Date:
Signature:
Telephone: 7% 0' Z 3
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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'rf 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.
you are applying under this section sign below:
Signature:
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction*
(Energy report required)
❑ Accessory Bldg.
(Shed/Gars e
9)
❑ Addition ❑ Roofing/Siding
(Energy report required)
❑ Replacement window/door
No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL CAA Sec 54): kbumpster on site ❑ Dumpster On Street
Facility Name,. � 110,'k 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): _
Cl 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