BP-82563RESIDENTIAL 0 Phased Approval (R 106.3.3)
$25.00 APPLICATION FIFF lFQ lvnv nir-vvTiww% our iv -a- wTA%, T
DATE RECEIVED
MiP �s,DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
Dartmouth, MA 02747
-910-1820 Fax: 508-910-1838
Phone: 508
. ..... 64 www.town.dartmouth.ma.us SEP 0 6 2016
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A -ONE R'TWO FAMILY DYVEWNG
li H S SECTION FOR OFFICIAL USE ONLY,�
RECEIVED BY
BUILDING PERMIT NUMBER:
A.
DATE ISSUED:
SIGNATURE:
77,
J,
. . .... .... .
DATE:
Building Commissi e spe
r of Building-
Zoning District: ,,,""Proposed Use:
Zone: 0 X'O B 13 A 0 V Aquifer Zone.
THE FOLLOWING AGENCIES sHOL)Lb"BE NOTIFIED:
DPW
ho
r-1 Board of 16 B,o,ard of OC 0 Planning'
J:1 ons,
Y,
0 Address �,E
I I n Ine'
9 enIng 6'ro'ss
Appeals, Health,","' ornmission
:14,
Card'
Connection
11 Fire ec ric,,
t
0 �'El Other
''c 11 11 sew'4C�rd"l
d Water Card
Cut fit Off m�! C
Cut off
Cut 0 "','Cut" Off
hl:
DEPARTMENTAL APPROVAL(S)
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. Agn),Io�
-rw P<X)4 fl)"I)Aw &�'-41
1.1 Property Address: 1-// <4,mer Lau
Contact Person: 141LA Xk-Act4
Phone Number: Sll 63 C- W-C
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
0 Municipal 11 Municipal
0 Private Well 0 On Site Disposal System
1.2 Assessors Map & Lot Number:
10 �/
Map Lot
�-
1.3 Historical District 11 Yes 0 No
Year Built
0 Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
13 Yes 11 No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
Name (print)
2.2 Authorized Agent:/�,(Llrr 3e�rS
Name (print) ��tt11
Contact Address Phone Number
(yp` AI;) 5�� �.p. ! orr_T_Oro
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name: � l L� QN y n
Address:______j4'��� S� %1/Gv Expiration Date: U
Signature: r� Telephone: �j�/- (Y '
3.2 Homeowner Exemption - ne & 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:
a
Signature:
❑ DEMOLITION (specify):
Location of debris removal (per MGLC.40 Sec 54): Dumpster on site ❑ Dumpster On Street
Facility Name: 7C 06 /rt1 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