BP-85368RESIDE Ti 1. ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE NON -TRANSFERABLE
- - -DATE RECEIVED
.� out DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
rO S Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
/6G4 ,,. www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zan�r[q" irstncf.. Proposed Use Zone ❑ B ❑ A "❑ V ., Aquifer Zoney
Board of Health:
Signature:
Conservation Commission:
Signature:
D.P.W.:
Signature:
Fire Chief:
Signature:
Other:
Signature:
Brief description of work being performed:
1.it ro erty Address: 1�1Xj—, Ui-W
ontact Person:
/Pone Number: to
Vu1c
rSuppy(MGL c40 s54): 1%� Sewage Disposal System:
nipal ❑ Municipal
ivate Well WOn Site Disposal System
ross
Connection .•�
Date: Cam/
Date:
Date:
Date:
Date:
1.2 AssessorsMap& Lot Number:
✓1�_ �S
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
:sECrloN = PROPERTY,011VNERSI
IIPIA[13HOENT_
2.1 Owner Record:
Name (print)
Contact Address hone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
= SECT1i3N,=:CONSTRUCTION SERVICES ; . ,,.
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: Zewx
Address:
Expiration Date:
Signature: Telephone:
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.
are applying under: is section s n low:
Vignature:
f.^ SE�TIO . � ;yVORKER'� Gt?l1APErISgT10N<1NSURANCE�CFFIQ�CVIT (MGL c �52 25) y r ' -
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
_a SE TI( DESCR- '-,T- ?N. t2F PFtQPDSED, NORK � heck all appl cattle) . t ,'"
❑ Deck ❑,fool ❑ 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: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
nTwo Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
G Fumace (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
0 Hot Water: Gas Electric Fuel Oil Other