BP-95122RESIDENTIAL 11 Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TRANSFEBABLE
DATE RECEl'
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
Dartmouth, MA 02747 20 FEB 26 PH 2!
Phone: 508-910-1820 Fax: 508-910-1838
f 664 It.
I www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEI
Contact Person: ;-XLLAe- r Lq�W
D 7:1,07— U H E X 5 &DUrevised 5 /13
El CONSTRUCTION PLANS SITE PLAN 1:1 ENERGY REPORT
RESIDENTIAL
2.1 Recor
1wner
e, �:,�
UJQA-
Name (print)
Contact Address Phone Number
2. Authorized A9 t: Y
G{.�JV
N print) Contact Addres Phone Number
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3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: aI'e Tee omes, Inc 1�3
HattlestonAve.
Address:
Expiration Date:
Signature•1&�� Telephone:
3.2 Homeowner Exempti - 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 pr de this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
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❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition L�oofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
b DEMOLITION (specify):
Location of debris removal (per MG�L Sec 54): umpster on site ❑ Dumpster On Street
®C.40
L Facility Name: �7 �'v�
c K 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
11 Hot Water: Gas Electric Fuel Oil Other
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Item..
Estimated Cost to be completed permit applicant ($) c mp by perm t app nt
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
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fx y., ,+ 7 � �'1h 'rc .1 i'? Y -£ � !` � ,s�s�+Y' �' � '-i 4 �"t .�^�•"��_w"*`.'s`-�5 .-Yfi` ,i� �.���`' �T = C � k Y i -
�- �_ 4 _� ,_ :. :,_Y���o b�-paintp�efecJ uir�iirn _owner}� . �enf'��co�;�r�cto�Ka (i�a�o�-�u!lcilrtg permit). _ --�_ {•, ;_�r _ ,� = � .ti
(Please Print)
as Owner of the subject property hereby authorize
to act on my behalf, in all matters relati a tow rk authorized by this building permit application.
Signature of Owner Date
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AI, XV, 1;10 as Owner/Authorized Agent hereby declare that the statements and information
on the fo oing a pllc io re true and accurate, to the best of my knowledge and belief.
Sig a rider the pains n ties ury.
Ignature of wner/Authoagent D to
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:
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