BP-71387RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON-TBANSFE ABLE
aP��'�ourH T. DARTMOUTH BUILDING DEPARTMENT DAITi F a!_�,DEPT.
to _ _ 400 Slocum Road�� a�j
z Dartmouth, MA 02747 ��: 25
Phone: 508-910-1820 Fax: 508-910-1838
(664 rr
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health:
Signature:
Conservation Commission: Signature:
Date:
Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: ler-leOdf/✓le— of .;",oVs6---
11.1 Property Address: L/y.
Contact Person:
Phone Number:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map Lot ' / -�
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
Name (print)
2.2 Authorized Agent:
Name (print)
�, 4ull p"nr /-,v. 1548 5� 9 d -_j;�30I
Contact Address Phone Number
�-_,Vla,vep 4 re 5-dy 9? 2 3(G'Z.
Contact Address Phone Number
13.1 Licensed Construction Supervisor/Specialty License: I License Number: I
Address
nature:
7 X�A1 y%yd
1` Me -
Telephone: 5-05 9 239
Expiration Date: A/*
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 section sign below:
Signature:
d
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: Q'i'es ❑ No
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace
❑ New Construction* ❑ Accessory Bldg. ❑ Addition LPORoofing/Siding
(Energy report required) (Shed/Garage) (Energy report required)
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54)
Facility Name:
"If new construction, please complete the following:
Single Family: No. of Bedrooms
❑ Wood stove/Pel let Stove
E Dumpster on site ❑ Dumpster On Street
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
❑ Replacement window/door
No. of windows Doors
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 +2+3+4) //, L4bo, —
(P:nEPrint)I,AM44P �rYSfiDE� 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.
Signatur�of
Date
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/Authorized Agent
Total Permit Fee: $ 7-�
Gross Area New Construction total sa. ft.
Gross Area - Altere
Permit Issued to:
Less Application Fe 5.00�
Other $ Amount $
Date
Remaining Balance: $