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BP-75173MIUMIA! r _ - - � r5ECT10N �=PROP�t�'YOVII�IEFtSFIPiAUT1OR(�EDA�ENT, °" _ - 2.1 Owner Record: Name (pr'jnt7 Contact Addre 5PIrPhone Number 2.2 Au horized Agent: / y� r l�ij � Contact Addre qo umbe Name (print) - SECTION 3,, CO�iSTRUGTION SERVICES51- 3.1 Licensed Construction Supervisor/Specialty Licen 4-14 License Number: j Company Name/Contractor Name: Addres Expiration Dat : Signature:9 1Z�?�Z����TelephonP 3.2 Ho caner 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. 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 ra two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: s . 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 _ .,.s S��TIC3ht 5 � bESCFtPTION ILIF,PROPOSEF1,atVOR1{ �Gheck-all applicable} �- " "' :� =; ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding 'Replacement window/dogr (Energy report required) (Shed/Garage) (Energy report required) / No. of windows _ Doors ❑ 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 ❑ 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 condtioning - (separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other RESIDENTIAL ❑ Phased A proval (R106.3.3) $25.00 APPLICATION FEE IS NON I I&FUNDABLE a& NON -TRANSFERABLE ; DATE E ECEIVED DARTMOUTH BUILDING DEP RTMENT ; t ra , r� 400 Slocum Road Dartmouth, MA 02747 r ,r ° .� Svy' Phone: 508-910-1820 Fax: 508 910-1838 r a f i 19 www.town.dartmouth.ma. APPLICATION TO CONSTRUCT, REPAIR, RENOVA TE OR DEMOLISH A ONE OR TWO FAMILY DWELLING GtAL USE OhILY "; ` ' }iECENED BY $UILDiNG_�P_ERMIT NUMBER 5iGNATUR DATE"': Bwlding Comrraisstonei7lns actor of Bdildtngs _ - z6nrtrg District Pro osed iJse - P � z ��ode ° j r ❑ � ©A d �" Aquifer Zane. . ,. WTi 3i-D[G ❑ 13oartl of 4ard of } O Cons t Planrn g , t7 Address D Engineenrrg C1 Cross Appeals Heayft; Coit?mrssron ; Cant '- Cottrttecfran i �tre ❑G d f? sewer.Card Chief Cut Off Cut Off t;ut off = } 'Cut, Off_ - r : DEPARTMENTAL APP'Rr3VAL(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. _SECTION 'l ,-;SIT iNEORIUTATION = , - 1.1 Property Address: 1.2 Assessors Map & Lot Number: Contact Person: �d Map �- Lot Phone Number: 3 3 l 1.3 Historical District ❑ Yes ❑ No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ 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: Rewised 5 /13 ® CONSTRUCTION PLANS ® " ITE PLAN ® ENERGY REPO RT