BP-79699Item
Estimated Cost ($) to be
"=
■■®varrae ■ 00os,
2.1 Owner Record:
Name (print)
M
2.2 Authortzea H C� �
-Name print)
Phone Number
Contact Address
1
Contact)
ed Construction Supervisor/Specialty Licensek�i-AE) _IVA
2 Phone Number
License Number: o L � ' �
3 1 Llcens =Exppliration�
Company Name/Contractor Name: �
o6S Address:
Signature:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BEl be
RECT
SPONSIBLE
the provE ions of thFOR issection;IR ,prov des that if a Homeowner
Exception: Any Homeowner performing work for which omeoding wner shall fact as supervisor. sides or intends to reside, on which
a person(s) s) for hire to do such work, that such Ho s who owns a parcel of land on which he/she re is more than
engages p
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) )
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 construe
one home in a two-year period shall not be considered a Homeowner. €
If you are applying under this section sign below:
Signature:
be completed and sub
is
Worker's Compensation Insurance Affidavit must submitted
Signed th tapplication.his Failure
edAffid Affidavit Attachedn C3 Yes �d No
affidavit will result in the denial of the issuance of the building permit.g
❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ Deck ❑Pool
❑ Roofing/Siding X Replaceme w/door
El New Construction* ❑ Accessory Bldg. ❑ Addition No. of window ' ors___
(Energy report required) (Shed/Garage) (Energy report required)
[3 DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑Dumpster On Street
Location:
Facility Name:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
No. of Baths '
No. of Baths Unit 1
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 2
No of Bedrooms 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):
O HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided Fuel Oil :— Other
❑ Hot Water: Gas Electric
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2+3+4
(Plea— se Print) as Owner of the subject property hereby authorize
I,
to act on my behalf, in all matters relative to work authorized by this building permit application.
r Date
Signature of owner
ff _, as Owner/Authorized Agent hereby declare that the statements and information
I,
application are true and accurate, to the best of my knowledge and belief.
an the foregoing
Signed under the pains an penalties of perjury.
L l Z3 !
® Date
Signature dt-OwneriHuu lu, 7777777
�a
A fE/li+F'E�t3R `llE -
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Altere
Permit Issued to'
/vlJST/kc� �7 ) 12e�46eirt"O' Gil/�G`vs
0c)
s-71_etCC1_y tf-
ss -
RESICENTIAL ® Phased Approval (R106.3.3) N
- �tr G C
,
DEPT
r,UTH. •.
-DARTMOUTH BUILDING DEPARTMENT
A #
Q ^, 400 Slocum Road
2015 NOV 24 AN 9: 16
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 DWELLIN-G
r
�
777 *
07
IIL[Ik'I�t(T Cf11BEP
t
fi S }.2c-. i`:s Yc f' sx �i-\���VS•C�
'�IBICIIng �`,f}TtrktBttile#lse( tofCitIfu
y
P--er #—• fix'
'=V'i%' -
3,4'
F
E1N (ES HOUL,E E O I (t 13P €
z,
}ng�neer�rtg Q Cfoss
5, ❑ifkes '
--Baafrf i, ❑' �i?E� Qf ,rt_Iio�1.51fl'ITltnF� .:.,? a
,jL3nn8C[on
.; '
CI Oaf C1 lectac i Other C7 WWaterCafd tl Sver�aro
E1rre 7
' did off Gtt Offer
Crreu ti7t€
' �
� is ^tG ..<• .{ }��+}�g�y ®ry �_p� �[ pB y�(� �n _ _
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
2&mm��
Brief description of work being performed.
1.1 Property Address: 11 a 5 RU l (LLS . 1.2 Assessors Map & Lot Number:
1) ,
Contact Person: �/ Sd Map Lot -
Phone Number:_%� g %� 0-
1.3 Historical District ❑ Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
CONSTRUCTION PLANS