BP-95885RESIDENTIA1. ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE-FUND.'iBLE & NON-TrIANSFER LE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
ro z' 400 Slocum Road 2
':2 C Dartmouth, MA 02747 2020 18 PHI 3
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
:APPLICATION'TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SIGNATURE:.': �✓
DATE: �
� ��
Building Commissionerllnspector of Buildings
Distnct Proposed tJse
_Zoning Zone ,, LDIX 13 Q A ❑ \f
: ;. Aquifer Zone:'��"
THE FOLt_t?WING,4GENCIES SHOUL6 BE'NOTIFi5b
DPW . .
❑ Board of ❑Boardof ❑Cons ❑ Planrnng _
C} Address
❑ Engineering .
' . ❑Cross
Appeals Health =Commission
..
Garzf
jo
Connection
L7 Fire ❑Gas ❑ Etectnc ❑Other
❑Water Card ,
C7 Sewer Card
Chief �� : -Cut Off ,Gut Off
a Cut�Off
w Cut Off
DEPARTMENTAL APPROVAL(5)
Board of Health: + Signature:
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
Date:
Brief description of work being perfonned:
11.1 Property Address: 6 .&L M.:F T !rt 1.2 Assessors Map & Lot Number:
Contact Person: bouIxC�s S -7�„ ,, Map _ Lot_�-
T
Phone Number: __ S o$ 3 a W 3qS)
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.3 Historical District ❑ Yes ❑ 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
0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2 • PROPERTY OWNERSHIPIAUTHORIZED
AGENT
2.1 Owner Record:
ouli va sm
1
�4f-;
Name (p rit)
Contact A dress Phone Number
2.2 u,)horiz d Age t:
her
Jr- Y97
r�ti
.Joy .1c2o
Name (print)
Contact Address Phone Number
SECTIO( 3 = CONSTRUCTION SERVECES _
3.1 Licensed Construction Supervisor/Specialty License: Mod 0 n
I License Number: .
Company N me/G%ritraetar Name: 9' 6aij .L r
Address: 31 B 1 A:I "4A A
Expiration Date:
Signature: Telephone: p $ o10 7 O
_SAZ)�
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 applyin er this sectio�sig elow:
Signature:
SEGT(ON*�,rIV6kkt*st6MPENSATii)WINSURANCE AFFI001T:{MGL c 952
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure t_oprovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: @'1'es ❑ No
SECTION 5-DESCRtPFION pF PRGIPOSED;WORK (Check ail'�pplicabl�j .. r ,�
❑ Deck ❑ Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition E�-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): 0 Dumpster on site Dumpster On Street
pp❑
Facility Name: �� Q9t2- Location: 91XfQ�
*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
(Please Print
I, DO
to ct o my behalf, in all matters
C�u� GCS
Signature of O er
as Owner of the subject property hereby authorize
e to work authorized by this building permit application.
130
Date
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 under the pains and penalties of perjury.
Signature of O ner Authorized Agent Date
Total Permit Fee: $ 7,f,ey
Gross Area - New Construction total sq. ft. _
Gross Area - Alteration total sq. ft.
Permit Issued to: r
Less Application Fee: $25.00 Remaining Balance: $
Other $ Amount $
e