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2.1 Owner Record:
Name (print)
Contact Address hone Number
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2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
3 1' ,Licensed:,Construction Supervisor/Specialty License: License Number:
0
Company Nme/Contractor Name: l 0
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.
If yeu are applying e this section si be
Sign; .,ture:
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
E�f3�1 _ C3 PI$i�1fctl appcabf�)= -
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❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding Replacement window/door
Al
(Energy report required) (Shed/Garage) (Energy report required) ofwindows.2f Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54):' ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No, of Baths Unit 2
• Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
X
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4)
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♦may ..i � '`�j���, q�.-s'^:�v; � g�" �" Tag -
(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
aEitE34� ®4CEil Q �6Et��Tt1lCiF�
I, o� ChYI L ii & 1 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.
140 -5 P
Si ature of Owner/Authorized Agent Date
Sr
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:
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RESIDENTIAL❑ Phased Approval (R106,3.3)
S25.00 APPLICATION FEE IS NON BE-FUNBABLE & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
Dartmouth, MA 02747
C2
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
Board of Health: a' Signature:
Conservation Commission: Signature:
D.P.W.: Signature:
Fire Chief: Signature:
Other: Signature:
Brief description of work being perfbn
1.1 Property Address: _ fi:2 KQ�K D ' !)cJld i
Contact Person:
Phone Number: 732 ` &"�
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
�Q Municipal ❑ Municipal
/❑ Private Well Y6n Site Disposal System
I'er. Zone'
Date:
Date:
Date:
Date:
1.2 Assessors Map & Lot Number:
Map Lot _-
1.3 Historical District iY s No
Year Built id�
❑ Altering more than 25% r si o ding
Has application been submitted to istoric Commission?
leYes ❑ No Date:
I- a J ��lRevised 5 /13
CONSTRUCTION PLAN ENERGY REPORT