BP-88426IIESIETIL ❑ Phased Approval (R106.3.3)
R21_80 APPLICATION FEE IS NON BE-FITN'DABLE a& NON -TRANSFERABLE
i
_ DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
Dartmouth, MA 02747
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
DATE ISSUED
VA
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: i
SITE Iiar;ORMATIQN x...�v: .
1.1 Property Address: �7' AVwley 1.2 Assessors Map & Lot Number:
Contact Person: f,la Map
Phone Number: gy71#1
1.3 Historical District ❑ Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ 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:
5 &100KlRevised 5 /13
■ CONSTRUCTION
,.O PLANS■ SITE PLAN
It ENERGY REPOR-1
RESIDENTIAL
ESWN)=RSNIPJAUTHORtZED AGENT _
2.1 Owner Record:
Name (pant) Contact Address
Phone Number
2.2 Authorized A t:
JIV
Name (print) Contact Address Phone Number
SECTIOP)=MCpN8FRl1GT10NEtYI
3.1 Licensed Construction Supervisor/Special License: icense Number:
Company Name/Contractor Name: Q.Q S 1��c5 03
Address: c, 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:
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to pf°vide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ®'Yes ❑ No
4_ y ys'CTK3 5 _ C)ESGEtPl tON QF F?RQ>a+vISE>ti 1NORKGheck71 appCeable)
LT
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ofing/Siding 7 eplacemen indow/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows 11 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):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
O None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
SEGTtQN 7A ONtNER AtfTtiQ�21ZA►Tit"�N
_ fo be,c�tiplefe�wt en owner`s gent ar cb_ ttfracfar ape s foi - uildirttIpeTMJ
_
(Please Print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to wor authorized by this building permit application.
Signature of Owner Date
SEGTtQIV'7B, :E�WNER/AIIT14 RIZED AGENT DECLARATIQPt
.....
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application ar true and accurate, to the best of my knowledge and belief.
Signe n r the pains and penalties of
2� /I;;—
ture of Owner/ t orize Datdd
=ECT[�N 8 QFF'1i+rE/l1SPECTt3R`S,1�t0`�ES. _;-_
Total Permit Fee: $ ��
Less Application Fee: $25.00
Remaining Balance: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: ,
i
SETIQT�- DESCtRT[OI flF�WC?�RC,BEI[dGt i?E�f�2MED �: �_ _
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