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BP-79629RESIDENTIAL ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE .& NON -TRANSFERABLE DATE RECEIVED ti DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road I° Dartmouth, MA 02747 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 Board of Health: � Signature: Conservation Commission: D.P.W.: Fire Chief: Other: Date: Signature: Date: Signature: Date: Signature: Signature: Brief description of work being performed. 1.1 Property Address: 117 Roe- -n Ai✓, r �Pfl, Contact Person: 811 ) TROJyk Phone Number: 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: fed Municipal ❑ Municipal ❑ Private Well 6if On Site Disposal System Date: Date: r>'© 'vfa 1.2 Assessors Map & Lot Number: Map --�= Lot 1.3 Historical District ❑ Yes KNo Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: 5 /13 ❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT RESIDENTIAL ':SECTION 2 PROPE>:'tTY:GWl ERSH1PIAUTHORIZED AGENT 2.1 Owner Record: aArAy 117 Roca-O-Almocr, go, 5.DAQ4n,vf J_1A Name (print) Contact Address Phone Number ,-SoB- t- � 2.2 Authorized Agent:. Art/ raoT� / 3?q &•o- A�Na66 AD, SO. 10.�/,r1Mal h Name (print) Contact Address hpome Nu ber .:SECTION 3 =.CON1FtUGTION SERVICES= 3.1 Licensed Construction Supervisor/Specialty License: C S -114iC License Number: - (� Company Name/Contractor Name: TRoT45 cmR f,' Address: 31 Q - a., � ,,,Qy�r j, D ? v Expiration Date Signature: Telephone: /-5OR-91PY7� Cl 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 PROJE Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this secho - i as 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 o n 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 acces 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 si in Signature: '._:. �.. ,;;=SEGTION��-W©RICER`S �OIVIPENSATION iNS��4t+iGE:vi4F.F'IDAVI7(MIOC. c;152 § 251:.�_, .. :" ., . ., 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: L(Yes ❑ No .. �� '`:EEGTiON sw�ESCRfPTi{fliV OF-PROPOS.EQ�WORK,�Giieck.all applicable) `�� ,=M. ❑ 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): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: &WO/w uns?46 Location: tiEw 6CV1?),e 0 *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 ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, elec ' i , other (specify): ❑ HVAC (combined unit) - primary fuel, natural opane, electricity, other (specify): ❑ Air conditioning - (separate unit)) ❑ None of the above to b ided 0 Hot Water- s Electric Fuel Oil Other' X X C' SEOTI4N 6 ;.ESTIMATIWCONSTRCFCTION COST ,. . , �M n�L� Li�L" Item I Estimated Cost ($) to be completed by permit applicant 1. Building _ 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4 (Please Print) 11 E ri. �. In/ j % as Owner of the subject property hereby authorize �;a r %RDTi4 to act on my behalf, in all matters relative to work authorized by this building permit application. 4 Signature of Owner Date 1, (,t�L 7izTA�_ , 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 Owner uthorized Agent Date Less Application Fee: $25.00 Total Permit Fee: $ •�S Other $Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: .G.(-I- A��f Remaining Balance: $