BP-70574RESIDENTIAL o Phased Approval (RI06.3.3)
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DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
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Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
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www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMB R-:76 5
DATE ISSUED:
SIGNATURE:
DATE:
Building Commiss' nerllns ecto of Buildings
Zoning District:
Proposed Use: Zone: [1 X ❑ B ❑ A ❑ V Aquifer Zone:
THE FOLLOWING AGEN S SHOULD BE NOTIFIED:
❑ Board of
Board of ❑ Cons. ❑ Demo EIDPW ❑ Elec. ❑ Energy Report
Affidavit Card Sent: Cut Oft Follow-up`
Appeals
Health Commission
O Fire
❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health:
Signature: Date:
Date:
Conservation Commission: Signature:
Other:
Signature: Date:
Signature: Date:
Signature: Date:
—77
Brief description of work being performed.
SECTION /1 - SITE INFORMATION
1 Property Address: �7CS �� `'�"' 1.2 Assessors Map &. Lot Number:
Lot Area (sf.) Frontage Map Lot "
j Required Provided
Front Yard 1.3 Historical District [IYes ❑ No
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL o40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes , ❑ No Date:
Revised 10/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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RESIDENTIAL
SECTION 2 - PROPERTY OWNERS
HIPIAUTHORIZED AGENT
2.1 Owner Record:
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Name (p nt)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Si nature: 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 helshe resides or intends to reside, on which
there is, or is intended to be, a one.Qr two family dwelling, attached or detached structures accessory to such use andlor farm structures. A person who constructs more than
ixsl shall not be ide d a Homeowner.
one home in a tw(1ying
If you are apnder t 's sect' n si below:
Signature: ILI�,
SECTION 4 - WORKER'S C MPENSATION INQ1 IPA "ICA AFFIDAVIT (MGL c 152 § 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
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stave
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door , " ;� '{ ❑ Demolition
(Energy report required) No. of windows Doors " " - `r (Specify below)
I,
*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
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
"
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building pennit)
(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
SECTION 7B - OWNERIAUTHORIZED AGENT DECLARATION
S' - 1'114V�,J as Owner/Authorized Agent hereby declare that the statements and information
on the foreg ing application are true and accurate, to the best of my knowledge and belief.
Si d under th ains a penal • s of perjury.
Sig tur of Own ri orized Agent Date
SECTION 8 - OFFICE/INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to
SECTION 9 - ADDITIONAL COMMENTS/SKETCHES
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