BP-71453REs1DENTE
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2-1 Own r Record:
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Name (pnnt)
Contact —���
tact Address Phone Number
2.2 Aythorized j�ge :
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31
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty License; ece9
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License Number.
Company Name/Contractor Name:
Address: Fk)n
Expiration Date:
Signature: Telephone.
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3.2 Ho eowner 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 persons) 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 heishe 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:
SECTION 4 - WORKER'S COMPENSATION INSURANCE 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: 121,14 es ❑ No
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
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L9'Deck ❑ pool ❑ Repairs ❑.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
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❑ Addition ❑ Replacement window/door ❑ ) �� Demolition
(Energy report required) No. of windows Doors - Specify below)
*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):
11 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
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)
0 ','.c.�
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please eri t)
as Owner of the subject property hereby authorize 0 SS L'i
to act on my behalf, in all matters relative to work authorized by this building permit application.
XILN�, ", J ch ?-- —
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I, &n, 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 and pains a enal ies of perjury.
� 1?X 3
Sign' re of Owner/Authorized Agent Date
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SECTION 8 - OFFICE/INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ .00 ,
Other $ Amount $
Remaining Balance: $ _
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: Z (>0-X
SECTION 9 - ADDITIONAL COMMENTS/SKETCHES
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Y
RESIDENTIAL ❑ Phased Aoprovat (R10b.3.3)
$25.00 APPLICATION FEE IS NON BE-tF17"AB E�RECEIVEI7
° DARTMOUTH BUILDING DEPARTNOW
400 Slocum Road 2013 OCT -g PM 2 34
i Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
BUILDING PERMIT NUMBER:
RECEIVED BY:
DATE ISSUED:
0413
DATE: &,
SIGNATURE:
Building
of Buildings
Proposed Use; ' Zone: EK 1D B ❑ A ❑ V
Aquifer Zone: J
Zoning District:
�L —
THE FOLLOWING AG
I SH ULD BE NOTIFIED:
❑ Board of
o rd ❑ Cons. ❑ Demo ❑ DPW
❑ Elec. ❑ Energy Report
Cut Off Follow-up`
Appeals
e t Commission Affidavit Card Sent:
E Planning ❑ Sewer Card ❑ Water Card
❑ Zoning ❑ Other
❑ Fire
Chief
as
Cut Off Board Cut Off Cut Off
REVIEW BEFORE THE ISSUANCE OF A PERMIT,
*REQUIRES INSPECTOR'S
DEPARTMENTAL APPROVAL
Board of Health:
Signature:
Date:
Conservation Commission:
Signature: '
Date:
Other:
Signature:
Date:
Signature:
Date:
Signature:
Date: —
Brief description of work being performed:
SECTION 1 - SITE INFORMATION
1.1 Property Address: ` 6 3 1.2 Assessors Map & Lot Number:
Lot Area (sf.}
Frontage Map Lot"
Required Provided
' 1 3 H` t al District ❑Yes �o
Front Yard
Side Yard
Rear Yard
1.4 Water Supply (MGL c40 s54): 11.5 Sewage Disposal System:
[ r
❑ Municipal ivate Well ® Municipal or6n Site Disposal
is anc
Year Built
D Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes • ❑ No Date:
❑ CONSTRUCTION PLANS ❑ SITE PLAN
i
Revised 10/11
❑ ENERGY REPORT