BP-92987RESIDENTIAL ❑ Phased Approval (R106.3.3)
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_._....:_._.DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
{°y 400 Slocum Road
Dartmouth, MA 02747
i'�d Syv: Phone:508-910-1820 Fax: 508-910-18381664
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www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REI}R, RENOVATE OR DEMOLISH A ONE Oil YV1�01�AMILY DWELLING
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: 6 Date:
Brief description of work being performed.
1.1 y Address: ,lr= K Dek 0 Vtjt ride �° /�Gf 1.2 Assessors Map & Lot Number:
:V-n/taPerson: C- a � 6q Mapne Number: !�—p Jj Gt 0-0
❑N
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
nnec�ton
�F.
1.3 Historical District ❑ Yes o
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
5113
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■ CONSTRUCTION PLANS LJ SITEPLAN ■ENERGY REPORT
RESIDENTIAL
item Estimated Cost ($) to be completed by permit applicant
2.1 Owner Record: //--
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'Name (print) 4tact Address Phone Number
( _ .01 7"; h„ _ f, *> -7 f. —7
2.2 Authorized Agent:
j dui qd-el -qe&, '*�e
Name (print) I Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
Signature:p
� � � Tele hone:
` •.
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 y6u are applying under this section sign below:
re:
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition 03 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:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
Location:
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
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4
(Please Print)
1 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
SC
Cat e (eit o as Owner/Authorized Agent hereby declare that the statements and information
n the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under t)I g pains and penalties of perjury.
orized Agent
Less Application
Total Permit Fee: $ f \
Other $ Amount $ J
Gross Area - New Construction total sq. ft.
Gross Area - Altere
Permit Issued to:
7'ra'<
Date
Remaining Balance: