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BP-88607RESIDENTIAL ❑ Phased Approval (R906.3.3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road ,a xi ; tZ Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 /fiG www.town.dartmouth.ma.us I',sJ..._._._-_..,-�.� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: ## Date: � Brief description of work being performed; 1.1 Property Address: 30 R04-0-0vNoc4r, Rar�►o 1.2 Assessors Map & Lot Number: Contact Person: 8111 TR.OT'4 Mapr ( / Lot - IPhone Number: "(-Soq-4789-�Saq 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: 0 Municipal ❑ Municipal b$ Private Well On Site Disposal System 1.3 Historical District ❑ Yes WNo Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: ■CONSTRUCTION PLANS El SITE PLAN 1:1 ENERGY REPORT SEC7101J:2.P.Ri3PEITYWNERSHIf?1AUTHO.RIiEDOENT`- - 2.1 Owner Record: -TOAV 1144r,q 367 Rb�-ca->� t {��ao,D�. i �► S� �`1' �IbCd Name (print) Contact Address Phone Number 2.2 Authorized Agent: 4/r l 6 r? i&� 3') I Po c, -D- ""5 I Pa oa %J �'d t-S09 -989% Name (print) Contact Address Phone Number _ _,_SECTION 3 �CfJhlSTftUGTIQN'SERVICES, _.-.> _ 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: Tne7.4 ej f0vx 121327 Address: 3%R Qoc( C�_ �u,v� a�2�,o aalvg Expiration Date: CS i QD, —Io1 Signature: Telephone: /b=9 9a '%d S t© I I 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 TH PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provi ' 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 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 str s 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 sectio gn below: Signature: �,SEO�ION`jWQRtR`rQ�IIPEHSAttON 1NSURANGE AFFtt}�4V1T M�1�'52.§ 25� ,. r. 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: XYes ❑ No ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding Ao. Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) of windows Doors ❑ DEMOLITION (specify): 10[.0 W/, L A/S Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: Aigiaaarg... Location: Alg *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 U ' No of Bedrooms Unit 2 No aths Unit 2 ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil ncity, other (specify): . ❑ Boiler (heating) - fuel gas (natural or propa , el oil, electricity, other (specify): ❑ HVAC (combined unit) - prima natural gas, propane, electricity, other (specify): ❑ Air conditioning - s e unit) ❑ None o a ove to be provided D of Water. Gas Electric Fuel Oil Other Item EstimatedCost ($) to be completed by permit applicant 1. Building �,© 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=0+2+3+4) sJ `, LL S�CTIQN7.A OVl(N�RA,tiTFtOt?1Z�TlON = t (fo be coniplete�_tvhen owner`;y agenf or cQnffacfbrapplies_ Foruldtng permit) (Please Print)(� I, a ��Cd/1 , as Owner of the subject property hereby authorize L4%1iNh ` T?o7. .4L•� to act c y behalf, in all matters relative to work authorized by this building permit application. Signature f Owner p _ 5ECT.ION 1B-_OWNEt�/AUTl1QIZEDAGENTDECt�t3ATION,_ I, __ i AW T&j 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. Signature of Owner? thorized Agent Date ` 1;ECT[dN t3 OF FiCEAI�SPEC7Q12`SNoE Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ ! S Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. J Permit Issued to: v WC la"11 61 R,694.4ays W PJD40:0s eu S&OW0 96i02 wr4� u€0 A U00aC7rX/ or>!'E's� OPrrut' wrllaNe .�RI?��I�F ov1y A(/l