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BP-82789RESIDENTIAL ❑ Phased Approval (R106.3.3) ANSFERABLE $25.00 APPLICATION FEE IS NON RE-FUNIIABLI✓ NON-T� DATE REC WED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road Dartmouth, MA 02747 y " Phone: 508-910-1820 Fax: 508-910-1838 o y t664 www.town.dartmouth.ma.us IR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING APPLICATION TO CONSTRUCT, REPA Board of Health: Signature: Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work being performed. 1.1 Property Address:?��' Contact Person: IPhone Number: 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well ❑ On Site Disposal System Date: Date: Date: Date: Date: 1.2 Assessors Map & Lot Number: Map Lot - 1.3 Historical District ❑ Yes ❑ No Year Built __. ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: Revised 5 /13 0 CONSTRUCTION PLA NS ❑ SITE PLAN ❑ ENERGY REPORT RESIDENTIAL Item Estimated Cost ($) to be nt SECTION 2 PROPE1tTY;OWNERSHIPIAUTHOR1tu �►tnt 5C- Lo 3(' 2.1 Owner Record: D2 I t�trl �3 SIa�P� R o4 CL (A Nam (print) Contact Address Phone Number 2 Authorized A nt: •C •� Name (print) Contact Address Phone Number _.. SECTION 3°° CONSTRUCTI'Ofi� SERVICES 3.1 Licensed Construction Supervisor/Specialty License: / License Number: / Company Name/Contractor Name: J /\ Address: Expiration Date: f)00, I t' I f/ t Telephone: hone: Signature: 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: 77 „ SEGt101Y `4 , WORKCR'S COMPENSA'1 E?N-1NS 1RANGE'AFI` 601T (MGL c;'1! 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 SE TION 5,- bESCR►P7101d'QF PROPt38ED=1N0KK (Check 11'a�icable =_ ' 4 _ ,.; , ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace uuoodstove/Pellet Stove L' 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 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=0 +2+3+4 (Ple se Print) 1 as Owner of the subject property hereby authorize I al to act od my behalf, in all matters relative to work authorized by this building permit application. ZZ � 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. "Signedder ins an en 's rjury. of w er/Authorized Agent Date Total Permit Fee: $ 17 I Less Application Fee: $25.00 Gross Area - New Construction total sq. ft Gross Area - Alteration total sq. ft. Permit Issued to: Other $ Amount $ �w C `U Remaining Balance: $