BP-79258tt�
RESIDENTIA1 11 Phased Approval (R 106.3.3)
$25.00 APPLICATION FEE IS NON BE-FUiNDZ!,BLE`'&NON-THANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
A! Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 T 2z
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16fid
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
7
THIS. SECTION FOR :OFFICIAL USE ONLY
-BUILDING
RECEIVED BY:
PERMIT NUMBER.�
DATE ISSUEDf:.
SIGNATURE_'
DATE.
Building
I hg Comrni lone Ins of Buildings
Z061nd -DiiW66,
_.'Z6ne:
11)(13:13 0 AO V _-�,.Aquifer Zone
THE FOLLOWING dl-E--.SHOULD b:kt4bTIFitb.
:DPW
_JTBoard of. b soifr'a of
0 Cons -0 Planning
0 Addr es
13 E ngineering [3 Cr6st':,:
Appea s Health
Gornnlsslo�
-connection.
Fire 0 Gas-
b bictri
a
Water
d , -0 Sewer r d
_f
Chief Cut 0�
Cut Off
Cut Off
Cu
DEPARTMENTAAPPRIPVAL_(S)
Board of Health:
Signature;
Date:
Conservation Commission:
Signature:
Date:
D.P.W.:
Signature:
Date:
Fire Chief:
Signature:
Date:
Other:
Signature.
A
Date:
Brief description of work being perfortned. h) IaIIJ7
SAM
e nr-A I*v-
1.1 Property Address: 2/7 /"/// 1.2 Assessors Map & Lot Number:
Contact Person: _Zi�k Map /L Lot 97
Phone Number: 901' 9 e 7,22,704
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
[J Municipal 0 Municipal
0 Private Well 0 On Site Disposal System
1.3 Historical District 0 Yes 0 No
Year Built
El Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
0 Yes 13 No Date:
1-1 CONSTRUCTION PLANS ❑SITE PLAN
Revised 5113
ENERGY REPORT
RESIDENTIAL
SECTION 6 �.'ESTIMAT-t6` NSTRUCTION COST
t/
_SECTION 2 - PROPERTY OWNERSHIRIAUTHORIZED
AGENT
2.1 Owne Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:kG�
�
�b�
Name (print)
Contact Address Phone
SECTION 3-CONSTRUCTION
SERVICES."``
3.1 Licensed Construction Supervisor/Specialty License:
License Number: j Q 49% 0-1/
Company Name/Contractor Name: J iX
Address: 7677 V2—
Expiration Date:
Signature: Telephone:..(,l ��
1 16/17
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'S,COMp.EHSATION='INSURANCE AFFIDAVIT.(MGL c'152 § 251:;� '
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
;;SECTION 5- DESCRlRT10N'flF PROPOSED.WORK{Check ll.applicable)_ :'
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Stove
Zstove/Pellet
w/door
❑ New Construction* ❑ Accessory Bldg. ❑ Addition❑Roofing/Siding place enXD
(Energy report required) (Shed/Garage) (Energy report required) No. of win owsrs_
❑ 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 applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
°.,.,SECTION 7A , OWNER AUTHORIZATION
to be corripleted when owner's `agent or contractor applies foi buQdfnfg permit)
Spleas�e^iPrint) nn /
1, J 0-4— glot c_Gx as Owner of the subject property hereby authorize '
to act on m behalf, in all matters relative to work authorized b this building Y y g permit application.
49L,
re of Owner Date
SECTION.713 -OWN ERIAUTHoRiztDAGENT>DECLARATIOht
fe
z , 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.
Signatur wrier/Authorized Agent Date
f �SECT(ON 8=;OFFICE/INSPECTOR
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
4t0tll*S =;DESCRIPTION OF M(ORKBEING PERFORMED .=4';