BP-68829-1311b01UCF1IIHL
SECTtON'2: - PRt]PERTY OWhIERSHIPIA[JTHQRIZEO
2.1 Owner Record:
Name (print)
aGt ddress Phone Number
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2.2 Author'zed Agent
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Name (print)
Contact Phone r
- - SEGTfI': _ Cf3h1STRUTIQ[V
SERVICES _$
3A Licensed Construction Supervisor/Specialty License:
t
License Number:
Company Name(Contractor Name: N
Address:
Expiration Date:
.Telephone:510f,�'"3//�
Signature:
AV-
3.2 Homeowner mpti n - One & Two Family Only Section 110.Rb.1:3.1 Exception:
FOR HQMEOWNERS 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 hireto do such work, that such Homeownershall act as supervisor,
For the purposes of this section only, a "Homeowner" is defined as follows: Perron(s) who owns a parcel of land on which he/she resides or intends to reside, an 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:
SECTIQN4 WQfKERS't10MPENSAIN,INSURANCE:AFFIDAVIT.{MGLc_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: ❑ Yes ❑ No
' _ SE__C_]'it]N �''CJESCEt1P�'!ON DEPFtGPQSEt1 WQRK{Check all aRpltcai7[e� _
❑ Deck ❑ Pool ❑ Repairs 0,Ateration ❑ Chim n ey/Fi rep lace ❑ oodstove/Pellet Stove
❑ New Construction* ❑ Accessary Bldg. ❑ Roofing/Siding ❑Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑Demolition
(Energy report required) No. of windows Doors (Specify below)
*If new construction, please complete the following:
J
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
0 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
SECTION:6 ST
RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE I5 NON RE-F[TNDABLE & NON -TRANSFERABLE
DATE RECEi11ED
DARTMOUTFI BUILDING ❑EPARTMFNT
1.1 Property Address: "1 1 1Z%A% ELF KkILI.S RP, 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District V"7 es ❑ No
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of building 4V'
1.4 Water Supply�rivate
GL c40 s54): 1.5 Sewage D7ispal System: Has application been submitted to the Historic Commission?
❑ Municipal Well 0 Municipal Site Disposal System El Yes "o Date:
Revised 10111
El CONSTRUCTION PLANS SITE PLAN ❑ENERGY REPORT