BP-93470I
RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE NON-TBANSFE ABLE
RECEIVED
"""°"T"'�� DA+RTMOUTH BUILDING DEPARTMENT
io A' 400 Slocum Roads Dartmouth, MA 02747
.Z H Da ,
- yy Phone: 508-910-1820 Fax: 508-910-1838
S .1664.-^' www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY 777777777777
DWELLING
THIS SEGTION FO€IrOFFICIi4L USE ONLY
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M CrOss
Connecfion
Signature.
Board of Health: 9
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Signature:
Si
Fire Chief: 9
Date:
Other: Signature:
Date:
Brief description of work being performed.
SECTION„':SITE ENE�RMATJ4_N 77-
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1.2 Assessors Map & Lot Number:
1. roperty Address: 4z z .���
�
ntact.�erson:
P
Map Lot —
P one Number:
1.3 Historical District ❑Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal System:
❑ Altering more than 25% per side of building
❑ Municipal
❑ Municipal
❑ Private Well
❑ On Site Disposal System
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
C' evised 5 /13
CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT
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RESIDENTIAL
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2.1 Fe'&c .
�as4&j4 s c.na or RQ ,
ame ( rint)
Contact Address %one Numbe
U
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
-
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: �
Address: '
Expiration Date:
Signature: Telephone:
,, omeowner Exemption -One T amily Only Section 11.0.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:
Ignature:
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
_ _. � ,:,-���'f•fDN 5'` bESG�tF�'�QIV Q� jPRDPaSED U$'�RK�Check a11;ay�pltcaCf��
. �= �.; F �, .�_ �.. t...s
❑ Deck ❑ Pool ❑ 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
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
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Item
Estimated Cost to b ($) a completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Tota1=0 +2+3+4) {Q
'`{__., _. ����q=b� ec�t��efeclt=uvhett°a�rtner�s�agenf � h
..,g _� 4 .:r, �rt con�r�ctorappttesfor�taiFd�n�peFnit� .. ; �
(Please Print)
1, � �t'� ��� Owner 1 the subject property hereb horize
o my be alft in all matters relative to work by this building
oo Rgt Lo autho a permit application.
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ignature of vtfner Date
SEGItE3N7B,_ QINNEPJ/UTHOk21ZEl];`AGEIV QEELARATIDN,..,
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I, Jai V bg as Owner/Au Florized Agent ereby declare that the statements and information
on the foregoing application are true and accurate, to the best of m vt�dge and belief.
Signed under pains and penalties of perjury.
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Signature of Owner/A zed Age t Date
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_ wk=. _ ,oFl:t�E�rtsP`rEe-rvi�ws�ra�Es
Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
C o-VI