BP-76058RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON I1E-FUNIDA7JrX .& NON-TIIANSFERABLE
DATE RECEIVE
DARTMOUTH BUILDING DEPARTMENT + ��
Q =, 400 Slocum Road ^r
3nt ?
c LUi � a
Dartmouth, MA 02747
T: ��: 02
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
I
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P•W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: c Date:
Brief description of work being performed: �� J
1.1 Property Address: �13 R84AL d Nillbe QA.
Contact Person:v;rryd��l�
Phone Number: So $" q �'- G 15')
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
1
® Private Well M On Site Disposal System
1.2 Assessors p of Number:
Dn�C
Map Lot 5 (i' - 07
Parcel ID'. OOHS- t)DntA"
1.3 Historical District ❑ Yes 5/No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
1-3 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
:SECTION 2 = PROPEt�TY.O NE
914tPIAU'7HORIZED AGENT
2.1 Owner Record: i
1q Rock d 1 �� D¢famair�l� !�A 5(5g75
Name (print) T
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
. , r .. , ; .SECTION 3'=CONSTRUGTIt)N
`5ER1tICES-,
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: r�
Signature:
.. rSECT10N 4: YVQRft)=R`S :CCiNIPE(VSAI ION`IPISRANCE,4FI=1[?AV,iT.f MGL i5 § 25 .....Y ` ., . , 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 ❑ Yes ❑ No
.. _;,SECTION 5°�;bESERIPTIONQE`PRQPO.SED 11VORt{�Gheckfall�pplicable} _ � �v. , .,,
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace IdWoodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/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
r
t ry a :.....,SECTION 6 - ESTIIiAATEQ CONSTRUCTION CAST
Item Estimated Cost ($) to be completed by permit applicant
1. Building O
2. Electrical 0
3. Plumbing
4. Mechanical (HVAC) iD0
5. Total = (1 + 2 + 3 + 4) 700
(Please Print)
I, as Owner of the subject property hereby authorize
to act on my behal , in all m ers relative to work authorized by this building permit application.
Signature of Owner Date
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.
I' U � Permit Issued to.
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