BP-94557RESIDENTIAL ❑ Phased Approval (R106.3.3)
C21_1196 rAPP11CATIION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
6
_ DATE RECEIVED
°U s, DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road �•
Ciy _4
C= Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 7,192�0 1 Z
1664 ° www.town.dartmouth.ma.us
APPLICATION TO C,pNSTRUCT, 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: X 4 Date:
Brief description of work being performed. Is
1.1 Property Address: 730 4CJ 0j>.j��� 2 `J 1.2 Assessors Map & Lot Number: /
/ -�-Contact Person: �G rl� � �r � � Map Lot
Phone Number: f29L- Ro In /
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:
0 CONSTRUCTION PLANS ■ SITE PLAN
P—E X J 8)4-mevised 5 /13
RESIDENTIAL
_ _.:s_ - SECTION,2 - PRQP RTY f IEF
SNtP1AtJT_ ElIkED A
2.1 Owner Record:
Name (ptf t qr, p.,�
C�dd6ss Phone Number
2.2 Au Agent:
L�, /
ely4f(print) r l
Name (P )
Contact Addres Phone Number
�ECTtO COAIST}�C�CTION SERY(EES
3.1 Licensed Construction Supervisor/Specialty License:
License Number: l G 77
Company Name//C/ontractor Name:
Address: `T %1'/Ctr > �,
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 der this section i ow:
Signature:
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: 13 e. ❑ No
r._: TIOi�t 5_ bESC�tPiti3lV Q P0RC3E� lMt3R,�>recltalTs�pttcabte}_
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pe llet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ' 7�i�iding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify): AA—LJAJyc��
Location of debris removal (per MGL C.40 Sec 54): der on site ❑ Dumpster On Street
Facility Name: n%.. 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
17 Hot Water: Gas Electric Fuel Oil Other
01
Item
Estimated Cost ($) to be completed by permit applicant
I. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0 +2+3 +4)
_ SECTIIJO O ]i`IERa� Tti®i�t Tlfi�N
#f®' fie ��cgratract��.aptSCr��for�yt€s�n�
_ _ _ , pp€rtpte��a��rkters-o�n�r's_agent perrrslt� __ _
(Please Print)
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by h' buildi g permit application.
Signature of Owner Date
EGTtCIV 7B, Ei`:A1�tEtl#t3TF10iIZEQ;:AE�M DEQLAR4T1E7ht,
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed and ain d penalties of perjury. -
2 Zo
Signature ner/Authorized Agent Dater
QFfCIiNSPC54R,S:Ata
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: ."IZ ,
C - SITt€ QEStt¢®i QF11QEIEtdCD