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BP-75250RESIDENTIAL ❑ Phased Approval (R166.3.3) $25.00 APPLICATION FEE IS NON RE -FUNDABLE & NON -TRANSFERABLE l'C"M1vUTN ., - _ _ -- DATE RECEIVED - .e sz DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road Dartmouth, MA 02747Uj Phone: 508-910-1820 Fax: 508-910-1838 1664 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIN$, e<n /lord of Health: Signature: ` //Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work Oeft perfonned. 1.1 Property Addre kr- r r m-,P-r kh t) JE Contact Person: 0r0- �d�l I Phone Number: 5-03, - 7 J _ 9C,70 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ur Private Well{ On Site Disposal System 1.2 Assessors Map & Lot Number: Map _ Lot 1.3_ Historical District ❑ Yes llo Year Built a'o l � ll ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes No Date: Revised 5 /13 E[CONSTRUCTION PLANS Ef SITE PLAN 3 ENERGY REPORT IILOIULM I IfiL 2.1 Owner Record: vaaf�-rn� r, CORP Name (print) 2.2 Authorized Agent: o Name (print) 11h1 5T Contact Address Phone Number IL imp, V-tbr-) 57' Contact Address J Phone Number R1ClCES 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 sectio sign below: \\ ` Signature: C, n-ti1i� l E�1�Irt_ lifiQ12KER` CfMBENSdT#thINSftANEFFJ[AV► �MGc �52 § 25,.. _ �` ._, _ _. 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 . -_ _ ;:T10N_ t1£Et1pTCQtV fl �C� OSEDIUORKrCtaecK alt ;��p#tcabfe} Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/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): j"Dumpster on site ❑ Dumpster On Street FacilityName: i�fl �� ( `jL/; Location: *If new construction, please complete the following: Single Family: No. of Bedrooms Pi No. of Baths 3- 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, ectt t $other (specify): Boiler (heating) uel " s (�attral or propane), fuel oil, electricity, other (specify): iVAC (combined unit) -primary fuel, natural gas, pane,. electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided Hot Water: Gas Electric Fuel Oil Other - Item Estimated Cost ($) to be completed by permit applicant 1. Building C 2. Electrical 0t` 3. Plumbing C�oo + i 4. Mechanical (HVAC) - c 00C , 5. Total=0+2+3+4) ( , I ECT1t 7y 7A Q1tVNE A kf��tl fi3N X -_ - �' - to �iQ � lete� vihe6 cit)�ti�r'�a e t or'�tii►�#ras�o { ids fo��u'itdfri-� �rrti%_ _ - � _��," (Please Print) I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date +. ,1.;� .. _ � -;;- s ,SEC7fON 7B = ©lAlNEft/At1TFiORIZEb AGENT DE�LARATIt3N - - _ I, 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 pal s and enaltie of perjury. ) Signature Kf Owner/Authorized Agent Date / _. NEerfaly 8 oIF�CEf1NPEG7(7f2"SNt?TES 4 = _ 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: 4.0 / -- —S �--8 81 MAP 25 LOT 1-11 PURDY BARBARA 80*02'582) 74.3 80*02'58- 7Z�,"Cllv Is, S19- Spa 9- MAP 49 LOT 3 BOGUSKY RONALD T & tl: 26 OCT 14 2014 r - '16a -u J) fl-