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RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE I5 NON RE -FUN DARI N d& l®ftN.TRAN,1WFFiRA Ri.W
DATE RECEIVED
�;��TH.�, DARTOUTH BUILDING DEPARTMENT
�400 Slocum Road
Dartmouth, MA 02747 U
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Phone: 508-910-1820 Fax: 508-910-1838 APR
www.town.dartmouth.ma.us
APPLI . TIO O CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR �W FA LY 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:
11.1VPPrroperty Address: _3cv-ijdc_kc_ O t�I2d 1.2 Assessors Map & Lot Number:
i:(One
tact Person: Ca4/� �1-,/� Map Lot -
Number: C1 t 'Z -7 q LA� -
1.3 Historical District ❑ Yes ❑ No
}
1.4 ter Supply (MGL c40 s54): 1 Sewage Disposal System: Year Built
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:
Revised 5 /13
® CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
` SECTION 2 = PROPERTY OWNERSHIPIAUTHORIZED
AGENT-
2. Owner Record:
o
545 16U2i R D a PA3q 5-Z- -cf
Name (print)
Contact Address
Phone Number
2.2 Authorized Ag
A
Name (print)
Contact Address Phone Number
". SECTION 3.=;CONSTRUCTION SERVICES- "
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Signature: Telephoner
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 re applying under this section sign below:
i nature:
SECTIOi�I �"WORKER'S;COlU1PENSATIOIV 1NSUAANCE AFFIi?AVIT,(MG L
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 :`DESCRtPTlON OF PROPOSED: WORK (Check'aq oppllcable, ; >_
❑ Deck ❑ Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
* (Energy report required) hed/Garage) (Energy report required) No. of windows_ Doors
❑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
❑ Hot Water: Gas Electric fuel Oil Other
=_ ; SECTION G-ESTI.MATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4) n- Ono
SECTION 7A ;OWNER AUTHORIZATION"
(fo be' 'completed.when owneYs agent or cottf�actor_applies for building perrott�
(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.
I, a t� as Owner/Authorized Agent hereby declare that the statements and information
the for application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
�a v Q ft,�_ 141-201 ho
Signature of Owner/Authorized Agent Date
ECT(ON $ - OFFICE/INSPECTOR.S ROTES
t.
J i Less Application Fee: $25.00 Remaining Balancer$
Total Permit Fee: $ )
�s^ Other $ Amount $
Gross Area - New Constructioh total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
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