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BP-71767RESIDENTIAL ❑ Phased Approval (R106.3.3) i i—..—... T TTT rC -Tnw "w-wiTlvnsng,w, x NoN.TBANSFERABLE ,�� DATE RECEIVED DARTMOUTH BUILDING DEPARTME to P. 400 Slocum Road -" Dartmouth, MA 02747�� h0 - 6 Phone: 508-910-1820 Fax: 508-910-1838 Efi =' www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work being performed. 1.1 Property Address: I Rat- O- Qw✓ cc Ragn Contact Person: I3 I 1 RO-TA �iC Phone Number: 508- Ig2-7aSLJ 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: 'Municipal ❑ Municipal ❑ Private Well On Site Disposal System Date: Date: Date: 1.2 Assessors Map & Lot Number: / Map_ Lot 1.3 Historical District ❑ Yes X"No Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: o....:....A C /4'� ❑ CONSTRUCTION PLANS 0SITE PLAN El ENERGY REPORT RESIDENTIAL 2.1 Owner Record: (3ai�ti l�/"JJ Name (print) 2.2 Authorized Agent: Q,,n Tcc74k Name (print) 3.1 Licensed Construction License: I I r? ROCS -©- CC R0A1) i-sc61.765-0`f, Contact Address Phone Number Contact Address Phone Number License Number: 14 1- Company Name/Contractor Name: 'tt2G�jAkSCCa4Ri d;{t2, A/,JfvT2r?nlL� Address: 31)7 Rpc.-O-i0v&Vcc 6 -5;, 0-4Ztna-A 14A Expiration Date: CS fi•aa-IS Signature _ 14 _. Telephone: j-S��'-%�q 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 parcland 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 structuresccessory 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. ' Y If you are applying under this 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: PCYes ❑ No S CTIONr5.015SCRIPTION.OF PROPOSED WORK Check all applicable} s ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove CY New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. ofwindows S Doors ❑ DEMOLITION (specify): 'T�i►tf o T t✓�s fb+S'�- - Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: Al,g WAy& WLocation: *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 ❑ Furnace (hot air) -fuel gas (natural or propane), fuel oil, electricity, other I ): ❑ Boiler (heating) -fuel gas (natural or propane), fuel oil, elect' ' er (specify): ❑ HVAC (combined unit) - primary fuel, natural opane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above t ovided ❑ Hot Wate as Electric Fuel Oil Other