BP-69304i
RESIDENTIAL
❑ Phased Approval (R106.8.3)
$25.00 APPLICATION FEE IS NOTv IMF FTjkDABLE & NON-TRANSIFEItABLE
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DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
t"y PT.
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Dartmouth, MA 02747
1111JR 25 PH5
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
Ttil,VSECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBER,
DATE ISSUED:
SIGNATURE:
DATE:.S
Building Commissioner/Inspector of Buildings .
Zoning District:
Proposed Use• Zone 0 X ❑ B
❑ A 0 V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of
❑ Board of ❑ Cons. ❑ Demo ❑ DPW
❑ Elec. ❑ Energy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off Follow-up'
O Fire
O Gas ❑ Planning ❑ Sewer Card ❑ Water Card
❑ Zoning ❑ Other
Chief
Cut Off Board Cut Off Cut Off
"REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health:
Signature:
Date:
Conservation Commission: Signature:
Date:
Other:
Signature:
Date:
Signature:
Date:
Signature:
Date:
Brief description of work being performed: AQ14,9-
SECTION 1 q1TE INFORMATION
1.1 Property Address: I&AW 1,2 Assessors Map & Lot Number:
Lot Area (sf.) - Frontage Map—�L--:� Lot(.
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
Altering more than 25% per side of building
1.4 Water Supply (MGL o40 s54): 1.5 Sewage Dis osal System: Has application been submitted to the Historic Commission?
Municipal ❑ Private Well ❑ Municipal n Site Disposal System ❑ Yes • ❑ No Date:
Revised 10/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
J
RESIDENTIAL
SECTION 2 - PROPERTi'OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
Name (print)
Contact Address to e Number v � �
2.2 Au t ized Agent:
Name (pnnt)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty Licens :
License Number:
Company Name/Contractor Name:
Address: U
Expiration Date:
Signature: T lephone:
3.2 Homeowner Exemption - One & Two Family 04 Section I I O.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'seclion 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 ortwo family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than
one home in a hvo-year period shalt not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
i
SECTION 4 - WORKER'S COMPENSATION 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: ❑ Yes ❑ No
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs RIteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door El Demolition
(Energy report required) No. of windows Doors (Specify below)
*if new construction, please complete the following: i
I
Single Family. No. of Bedrooms -No. of 4ths
Two Family: No of Bedrooms Unit 1 J, of!Baths` ni 1
' '
No of Bedrooms Unit 2 p. of1``Baths 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, ell cityother (speciy):
❑ Boller (heating) - fuel gas (natural or propane), fuel oil, electricity,other (�ecify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
O Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimat Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbin
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
SECTION 7A - OWNER AUTHORIZATION
(to be completed
when owner's agent or contractor applies for building 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
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true a
d accurate, to the best of my knowledge and belief,
Si ed r the pains and penalties of perjury.
/
ignature of Owner/Authorized ent
Date
SECTION 8 - OFFICEIINSPECTOR'S NOTES
Less Application Fee: $25,0�
Remaining Balance:
Total Permit Fee: $
Other $ Amount $ r�
Gross Area - New Construction total sq. ft.
Gross Area - Alteration to I sq. ft.
Permit Issued to:
�J
SECTIO/N�9 - ADDITIONAL COMM ENTSISKETCH ES