BP-69959RESIDENTIAL
❑ Phased Approval (R106.3.3) ,
Si25.00 APP11CATION FEE 15 NdIN IIF.FI7NDABLE & NON -TRANSFERABLE,
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DARTMOUTH BUILDING
400 Slocum Road
EPARTMENTt
WIT
b `
Dartmouth, MA 02
Phone: 508-910-1820 Fax:
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508-910-1838
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www.town.dartmouth.
a.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE
OR DEMOLISH A ONE OR TWO FAMILY DWELLIING
THIS SECTION
FOR OFFICIAL USE ONLY
RECEIVED BY:
s_
L,
BUILDING PERMIT NUMBERL)4
DATE ISSUED:
SIGNATURE:
DATE: .-A L 0 7 2013
Building Commission
r/Inspector of Buildings
Zoning District:
Proposed Use:
Zone: C X ❑ B ❑ A ❑ V Aquifer Zone:
THE FOLLOWING AGENCIE SHOULD BE 1�TiFIED:
❑ Board of
Appeals
oard of CCons. ❑
Health Commission Affidavit
emo ❑ DPW ❑ Elec. ❑ Energy Report
Card Sent: Cut Off (Follow-up'
❑ Fire
❑ Gas ❑ Planning ❑ Sewer
Card ❑ Water Card ❑ Zoning ❑ (Zither
Chief
Cut Off Board
ut Off Cut Off
"REQUIRES INSPECTOR'S REVI
W BEFORE THE ISSUANCE OF A PERMIT. -
DEPART
NTAL APPROVAL
Board of Health:
Signature:
Date:
Conservation Commission: Signature: G' 1
` Date:
Other:
Signature:
Date:
Signature:
Date:
Signature:
Date:
Brief description of work being performed:go
�0n�
SECTION I
-SITE INFORMATION
��L%
Number:
1 Property Address:
I
1.2 Assessors Map & Lot
Lot Area (sf.) �Frontage s
Map Lot �.
Required Provid
d
Front Yard
1.3 Historical District ❑ Yes mo
Side Yard
Year Built /` �P�
Rear Yard
Altering more than 25% per side of b0ilding
Has application been submitted to the Historito Commission?
1.4 Water Supply (MGL c40 s54):.75
Sewage Disposal Syst
m:
El Municipal ❑ Private Well
❑ Municipal ❑ On Site Di
posal System
❑ Yes • 9? o Date:
I/_ /y/8 t t,evisea i un i
CONSTRUCTION PLANS SITE PLAN ❑ ENERGY RIEPORT
1k,
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2 Owner Record:
-.��
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address /��0 ��� 7d one Number
SECTION 3 - CONSTRUCTION
SERVICES
.1 Licensed Construction Supervisor/Specialty License:
License Number: 4 S' 319
Company Name/Contractor Name:
Address: o4v , ec �—
Expiration Date -
Signature: Telephone
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.
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which helshe 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 andlor farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are app`ying under this section sign below:
Signature:
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to vide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: O es ❑ No
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
t Deck ❑ Pool ❑ Repairs kAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
:.;�::
❑ Addition ❑ Replacement window/door .�,, , x _.! ❑ Demolition
(Enercy report required) No. of windows Doors`'` ° `' "+ (Specify below)
*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 a,r) - 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):
0 Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
SECTION 6 - ESTIMATED
CONSTRUCTION COST
Item
Es
imated Cost ($) to be completed by permit applicant
1. Building-Db
2. Electrical
3. Plumbing_
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
e>O
SECTION 7A - OWNER,
AUTHORIZATION
(to be completed when owner`s agent or gontractor
applies for building permit)
(Please Print)
I, � ON 7-4007 AS as Owner of the SL
bject property here authori .e r ��l
o act on my behalf, in all matters relative to work authorized by this building
permit application.
Date
ature of 0 er
SECTION 7B - OWNERIAUTHORI
ED AGENT DECLARATION
I, A� ef� (��1 �ta as wnerlAuthoriz
d hereby declare that the statements and information
on the foregoing application are true and accurate, to the best o my kn
DwIedge and belief.
Signed and the p ins and nalties f perjury.
cle
Lcj�hatu—re of Owner/Authorized Agent
SECTION 8 - OFFICEIIN
PECTOR'S NOTES
�J
Less Application Fee: $
5.00
Remaining Balance: $
Total Permit Fee: $ J
i
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. U'L�
J
Permit Issued to
e-
021 ,.s► L
+ ..
SECTION 9 - ADDITIONAL C
MMENTSISKETCHES
AAA 3' To C- i Sti,j
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new q'x (o' P� Po-rc�v-' I-
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