BP-72497RESIDENTIAL ❑ Phased Approval (R906.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TBANSVEBABLE
ECI-
DATE RECEIVED
DARTMOUTH BUILDING DEPARTI'f71NTI1"+:.1" fl,n.DEPT.
400 Slocum Road
C' Dartmouth, MA 02747 20Iq JAN 16 PSI sg
Sfv. Phone: 508-910-1820 Fax: 508-910-1838
•.,, l fi 64 ; f
www.town.dartmouth.ma.us
APPLICATIQN TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
Date:
Brief description of work being performed.
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
Gl t � g,vLrtr 1 S
Name (print) Contact Address Phone Number
2.2 0uthorized Agent-
Name (print) Contact Address' Phone Number
3.1 Licensed Construction Supervisor Specialty Licen : License Number:
Company Name/Contractor Name:
Address: 2? A - -1, Expiration Date: p
Signature: �,. Telephone: J/z-05///(-/
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:
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
❑ Deck ❑ Pool
❑ Repairs
❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction*
❑ Accessory Bldg.
❑ Addition
2-Koofing/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):
tJ Dumps/tamer on site
❑ Du�mpster On Street
Facility Name:_
*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
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
(Please Print)
I,
to act on my behalf, in all
Signature of
I, / 4
on the fgregoing appli
Si ed nder the pains and
ture of Owner/ uthori:
as Owner of the subject property hereby authorize
to work authorized by this building permit application.
Date
/ , as Owner/Authorized Agent hereby declare that the statements and information
true and accurate, to the best of my knowledge and belief.
perjury.
/ IIAI'AK
Agent Date'
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: efl-;"Ielp
F.F Slr:�
;�7e-ll S--
Less Application Fee: $25.00 Remaining Balance: $
Other $ Amount $
d