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BP-91675RESIDENTIAL ❑ Phased Approval (R106.3.3) S25.00 APPLICATION FEE IS NON RE-EIIINDARI.E l.@TON.TBANSFLE ERRAEECEIVED °"TH:-.` DARTMOUTH BUILDING DEPARTMENT o ,yam, r f4ry` 400 Slocum Road n� Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838. ''•-16" ' '� ` www.town.dartmouth.ma.us � ��. ' APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILYDWELLING 15'6'ard of Health: Signature: O'nservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other. Signature: Brief description of work being performed: 0 1.P Property Address: / S 1t A � M `, we ont�'t Person: 11 t c c r � 2 Phone Number: ti � 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well ❑ On Site Disposal System Date: Date: 1.2 Assessors Ma & Lot Number: Map % J Lot 1.3 Historical District ❑ Yes ❑ No Year Built 4 ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: 0 CONSTRUCTION Revised 5 /13 ❑ ENERGY REPORT RESIDENTIAL SECTION2 pRt3PE2TY t3uVt�fERSHIPA[t3NOFtI�ED AGEN7 , 2.1, Owner Record: i` U t,Clo r-' A wu & L Ctr viand e--c L16 6 S I a rcu-vim I CdA e Name (print) _ Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number sECT(o 4coNSTRcrolu sRviEs a 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: h, � 1 ewx -A 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. I�you are applying under this section sign below: Signature: ( 4� dQTIOf WOBK£RrQlIdENSATQ�f tlSiltLEF1QAblT�I11iQL c-S2 §;25j �., -v* , ,=wF._': 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 .,< SCTTON UESGRtf�T[0110F PROPQSEE3 WO.Rk,�heckaTl appltca4fe) © Deck ❑ Pool ❑ Repairs eration ❑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 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 urit) ❑ None of the abov^ mad ❑ Hot Water: GS3+= Electric Fuel Oil Other Item Esti o mated C st ($) to be completed by permit applicant 1. Building Q 2. Electrical C 3. Plumbing 4. Mechanical (HVAC) -- 5. Total =(1+2+3+4) SEGTtON zQ O�iIINER �IUTTtOtT2TTi�N x ` w 1 ; .. m _ - ,Ito'be_comTilete�wtien,owrtirr�s ageri�or corm"recE"ot'_applTes"�or�T�ulc�tng:p�tin�f} ,; (Please Print) I, , 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 =SEGTI:ON'iB <OWNET7/AUttiQE I t555E[!iTD0lAFiAT f I,: I h C k-01 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. ature of Owner/Authorized Agent I Less Application Fee: $25.00 Total Permit Fee: $ `�d Other $ Amount $ Gross Area - New Construction total sq. ft. , e Z) 3 o,? Gross Area - Alteration total sq. ft. . ;�, `f!J Permit Issued to: Remaining Balance: $ s i i- 19 X 24 PRINTED ON NO.100011 CLEARPMKrs luf2