BP-80981RESIDENTIAL ❑ Phased Approval (R106.3.3)
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DARTMOUTH BUILDING DEPARTMENT D Q- 9
=O� J 400 Slocum Road PT R 1 .1
Dartmouth, MA 02747
°� Sy Phone: 508-910-1820 Fax: 508-910-1838By
` tgfia�/ 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: Date:
Fire Chief: Signature: Date:
Other: Signature: l Date:
Brief description of work being performed:
1.1 Property Address: 117 f266,0- D,voM IQo.
Contact Person: 6X I aOJ- k
Phone Number: 'U508.7?7.95aq
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
XMunicipal )dMunicipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map — ac Lot
1.3 Historical District ❑ Yes ANo
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes XNo Date:
Revised 5 /13
❑ CONSTRUCTION PLANS El SITE PLAN El ENERGY REPORT
RESIDENTIAL
`SECTION 2-`PROPERTY:�WNERSFIIPIAUTHQRIZI [Q AGEN7 .
2A Owner Record:
C3pm,u W It I Roc!-&owoere k, � L1v,di��i. 0 .%S-6q 9
Name (print) Contact Address Phone Number
2.2 Authorized Agent: A's0
V,114 T24TAll, 10,4-0-1Dyu0u(_C %�D �So��s r?vtfiln
Name (print) Contact Address Phone Number
.rECTIQ[�.� =;CONSTRUGTIt?N Si=R1fICES
3.1 Licensed Construction Supervisor/Specialty License: License Number: GS f5 bBGf 5
Company Name/Contractor Name: f41_ �a3;0
Address: 3')4 Roc(-0_ajv,6C' �D 1. t h Expiration Date: CS -
Signature: Telephone: 505-rf ';'(-i sod 9 141 _ 10-1a-16
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 PROJ
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section* es 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 ich 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 s e 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 sign below:
Signature:
x >r EG CIQN 4 »DV{iQ11083,"1C[1NIP $AV0N `INSURAN(E 0000#1MGL c, 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
SECrIto S .'I?ESGRIR}'lO1V QF PROPCISED'>WORK Gttec[ all appllca,IileJ „. Y _ ,ti:
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding XN'o.
Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: AJ6W 86,0/b1D 7/n Location: -A4w�
*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 U�iL2�❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, oth ecify
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, ele other (specify):
❑ HVAC (combined unit) - primary fuel, natural ropane, electricity, other (specify):
❑ Air conditioning - (separate uni
❑ None of the above provided
❑ Hot Gas Electric Fuel Oil Other