BP-78363RESIDENTIAL ❑ Phased Approval (R106.3.3)
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DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road +t,
of 20t5 1I �a3 —7 Pr1 3: 54
i C Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
.166
www.town.dartmouth.ma.us
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: /
s
11.1 k perty Address-399't aOCk b` OUP Jee.'-�14 1.2 Assessors Map & Lot Number:
act P r '_
cl
e son.e,C�S�. F w Map Lot -
Phone Number: SO 4 19
1.3 Historical District ❑ Yes ❑ No
1.4 Water Supply (MGL c40 s54): 1.5 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:
_ I
RPvisPrl S 113
❑ CONSTRUCTION PLANS 0SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
' - _ !SECTI.ON 2-.P.ROPEI2TYQWNERSFItPJi4UT�-tORIZET�
AGENT - -
.1 Record:
Owner
Name (print)
Contact Address Pon Num er
9 40T - o
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTfON 3=,CONSTRUGTIOM SEKVICES - -
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Signature: Telephone:
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:
SEGTION WORKER`&,lilIPE1VSATlO(V I[dSURAGEAFF1DAt/IT<�MGL
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
'::SECT!(3N 5 = DESCRtPTI{31V tA—O FY.
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
iReplacement
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors_
f
❑ DEMOLITION W,' ecilby):
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):
0 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
-' - SItCTfON ESI_IfAAATED_CtJt�SIRUCTr?IdGOST
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
SECTION 7A - 0W ER AtiTF#ORI -ATION
- it tie ca�iij (etet when ovtrtter's agentvi cohfractor applfb forbu11d'ing permit]
_ _
(Please Print)
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
'SEGTION`78.= QINNERiAUTHQRIZEQ AGENT DECLARATION
I Q.iL�Sss— PIC> as Owner/Authorized Agent hereby declare that the statements and information
r(the oregoing application are true and)accurate, to the best of my knowledge and belief.
Si ed under he pains and penalties of perjury.
an
a t�
ignature of Owner/Authorized Agent
Date
77
SEC?IONt3.,;OFFiCElihiaPEGTQR'S10TES
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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: - J rn
- , . SEGTIOIcC�, ,,QESG�tPTjO�I QF�WORK,IBEING:1?E�ti=ORMED ..
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