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BP-91932RESIDENTIAL ryr ,� , SEQTION2 PRffPERTY'tOWNER$''Hlfft?%AUTfORtZED yOwner AGENT, = ' ; 2.1 Record: cr V I Cor�s�;ne ��curn _ � 1� 4 � 7�-� Name (print) Contact Address Phone Number 2. Authori d ent: YYI��d�Srl'�b Name (print) . Contact Address 0 421? 7�w Phone Number `.�.: 1 SECTION 3 CQNSTRl1GTtON`SR1t10EBV _ =Ri 3.1 Licensed Construction Supervisor/Specialty License: (` cic- License Number. 0 Company Name/Contractor Nam • I Buse A 6 03195 Addres Expiration Date: Signatu e Telephon _w 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. Forthe 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: YVkQkKER'Qllg)~NSATOI jlNtfEF.I`1DAFl1T' (A1tGL c i 52.25 ;. r 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: Q Yes ❑ No ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required t No. of windows_ Doors_ r ❑ 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 ❑ Fumace (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 urit) ❑ Norre of the abo+w- V*hd 0 Hot Water: G$9,► _ Electric Fuel Oil Other ' _ ti :: -, _ SECTION 6, IIiAATEl CONSTRiJCTIONCOST... Item Estimated Cost ($) to be completed by permit applicaint 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4) - � 4: Y SBCTIQ�I �A OIAINERA,UTFtQ�TZJ�Tt�N } �,` c �j f ♦ t r' .. '. '` i } i { t c' 1"M71 �.y.n..�. 'ram -. Y � : � ' •�9 •� i ' :`- 1 k�3 '� r � � ..„�to be-�omjifetec� yuher o�v��r's agerif or Cori_fracfol'�ppti`es'�ot�butdtngpermrf) �: _ , (PI se Print) � � ����,�, m N �`(�\ U� Owner of the subject hereby authorize { V� 4 h I, o -,as property to act on my behalf, in all matters relative to work authorized by this building permit application. f '. Signature of Owner Date ;. , ::SECTION 7B-_OWNER/AUT-,FtOIZEDAGENT max IRATIOh) _ . ':77 as Owner/Authorized Agent hereby declare that the statements and ihformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Si d under the pains and penalties of perjury. �1 Signature of Owner/Authorized AqerV Date �ECTtoN s ° o�FlrrT s�cTVI� xoTs Less Application Fee $2�0 ReM Balance: $ Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration t I sq. ft. A > Permit Issued to: " Z Ila AA&-Z . t� L z. r� Ak SI4CTfQ1 r CFES(BIF� O ,?FA/O BIIGyPE R1�1137 . _ r: ,. - p`1 I n / �• 1 - l l °�tt 1 �l ? C lm C� c ,�1 �� � r \S c_aXX� i� T1 1 C� Y1 �' >r8 4n c9 � 3 =,t l 1, ��e l t , �tJ� 1p qo'� RESIDENTIAL ❑ Phased Approval (R106.3.3) wires,"nN www lf,4Q NON BE -FUNDABLE & NON -TRANSFERABLE - DATE RECEIVED ." pUTH: •,,LP , DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road ° z Dartmouth, MA 02747 5, ` Phone: 508-910-1820 Fax: 508-910-1838 66 `www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIdN FOFZ QFFICIALtSE Zanita Qrstrst.. : Proposed Use �. Zone X {3 B ©A ©V Aquifer�on SkfOULlOE i�IOTfFIED THE PbLLOWINGAGENCIES Board of E7 :Cons D Planning ❑Address ❑ Engrneenng- Q Gross a APPt als Eicalth Cotnmrssron Card Connr�cfion Q Erre _ M Gas ❑,Electric '. Gi Other ❑ U�later card: ❑ 5eiererCard L��' chefi Cr+tflff r Cut Off Cirt Off v DE�'1RTMENI'AL APPff�Vi�tES - _ 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. - SEC� N _. t ' 1.1, Property Address: 1.2 Assessors Map & Lot Number: Contact Person: Map_ PhoneNumber: ^� 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 Corrnmission? ❑ Yes ❑ No Date: Re%vi M 5 1t ElCONSTRUCTION PLANS El SITE PLAN ❑ ENERGY REPOR