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BP-94677RESIDENTIAL - Item Estimated Cost $ to be com leted b 1. Building;c� 2.1 Owner Record: ,/�' o j°11 C° I-s .- _ `tea m 2 Electrical V13 Name. (print) _> G 3. Plumbing Contact Address Phone Number .. 4. Mechanical (HVAC) ' 2.2 Authorized Agent: 5 Total (1 +2+3+4)Q > Name (print) (P ) Contact Address Phone Number -A Z;E TJ a� = AS%E3 t r 3:_::_ r _ ... _.... .3 _.. ...._ Q It fE w., as Owner of the s ubject property hereby authorize _ 3.1 Licensed Construction Supervisor/Specialty License: to act on my behalf, in all matters relative to work authorized b this building permit Y 9 P t application. License Number; i Company Name/Contractor Name: . 1 � Signature of Owner ' Date Address: Expiration Date: Signature: SECTt i' £� Ett�ilt,IIfh� Telephone. 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: I' C� as Owner/Authorized Agent hereby declare that the FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE statements and mfotrrmation on the foregoing application are true and accurate, to the best of my knowledge and belief. 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 engages for Signed under the pains and penalties of perjury. a person(s) a Homeowner 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 i reside,. on which there is, air is intended to be, a one or two family dwelling, attached or detached structures accessoryto 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. - Signature of Owner uthorized Agent f� 2 D Date If you are applying under this section below: sign b � ._ Signature: �---c �- Less Application Fee; $25.00 Total Permit Fee: $ `�� Remarning Balance. $ ��:� --- her $ Amount $ Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this Gross Area - New Construction total sq. ft. . affidavitwill result in the denial of the issuance of the building permit. Signed Affidavit Gross Area - Alteration total sq, ft., Attached: ❑ Yes ❑ No e Permit Issued to: j ®� ❑ Deck - ❑Poo{ " 0 Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition �RoSiding ❑ (Ener-gyreport required) (Shed/Garage) Replacement window/door(EnergY re ort re required) No, ofwindows ndo ws Doors ❑ DEMOLITION (specify): le- rncpL,-,- Location of debris removal (per MGL C,40 Sec 54):umpster on site ❑ Dumpster On Street ✓ � Scx-� 1 �i �. . p j 17�,' j _ Facility Name: Location:t �< _ *If new construction, please complete the following: SingleFamily: 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, 1r'R j if (hot air) -,fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ Boiler (teating) - fuel gas (natural or propane), fuel oil, electricity, other (specify); 11 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) Cl None ofthe above to be provided El Hot Water: Gas Electric Fuel Oil Other RESIDENTM ❑ Phased Approval (R106..3) 4 �.�a nn ,axexoa.irA'"am E'ww 7e wnm uw.. AR1.F _ P niv. &Vq R I,E - DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road 0 C; Dartmouth, MA 02747 ;o� •=5y�:-, Phone: 508-910-1820 Fax: 508-910-1838 1664 ° www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY ®WELLING f --------------- f D Sutld�ng CciimassronsIpetarcut[ngE� _ ..mJF h. s'Y �;£�j : �� �lJ�rt ���� � i �G©Q�eFiS��� .i'�"'' a"2•�Y..iG4 I�� �� - i t 2 j t �r DPYL F TF FfLIi\7 CSEiCIEGxl-t4€3� EE kVaTIF C Z Baslyd of - i Bi and of Lt Cn�is -T Pfartn€bcI Lt ggsa ❑ Eng�neec[r<g L Goss ' t�ac�nec€pan ...........f;artl Frre' is Cas ❑ Eiectre ❑ �}CiiOC` ❑ WateF4a�C} ❑��weLCactt p Eattif€ Cut C�fF' Cat"C7tf _ Cu�C)ff - _ - Chtef � s r PRa�7A1. f 7. _ -EPc� 0 iT ; . Board of Health: Signature:, Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief- Signature: 4 Date: _ Other: Signature: Date: Brief description of work being performed: C / 1.1 Property Address: 1.2 Assessors Map & Lot Number: ,,� E Contact Person: /f, / C-z S 0/� �.✓ C'G-%� r� Map Lot Phone Number: � �� S78 z- % zf/- 1.3 Historical District ❑ Yes Ifd'No Year Built 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: [Municipal ❑ Municipal ❑ Altering more than 25% per side of buiilding ❑ Private Well P'On Site Disposal System Has application been submitted to the, Historiic Commission? ❑ Yes d o Date: d 5 ! 3 r mQTP11r_TInN Ply AKIR rl gITF PLAN LJ ENERGY R, R