BP-88449RESIDENTIAL ❑ Phasec. A proval (R106.3.3)
$25.00 APPLICATION FEE IS NON E-FUNDABLE NON -TRANSFERABLE .
DATE RECEIVED)
f� 9s; DARTMOUTH BUILDING DE ARTMEVT
P
400 Slocum Road r "
Z Dartmouth, MA 02747
4
Phone: 508-910-1820 Fax: 50-910-1838
64 ` www.town.dartmouth.ma. s µ -: y..._
APPLICATION TO CONSTRUCT, REPAIR, RENOVi TE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
DEPARTME
Board of Health: Signature:
Conservation Commission: Signature:
D.P.W.: Signature
Fire Chief: Signature:
Other: Signature:
Brief description of work being perfonned. _ G
Date:
Date:
Date:
Date:
'SECTIQN 1. SITEWORMATIQN
1.1 Property Address:
2 Assessors Maap�& Lot Number:
Contact Person:
Map Lot _-
Phone Number:
1.3 Historical District ❑ Yes ❑ Ng
Year Built
1.4 Water Supply (M'GL 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 (Commission?
❑ Yes ❑ No Date:
J—( H F— A S a�K IlRevised 5 /13
CONSTRUCTION PLANS SITE: PLAN ENERGY REPORT
RESIDENTIAL
SEGTIOtV 2 PFtC3PERT� E;WNERSHtP/AtiTNORtZED
AEIVT ,
2.1 Owl( Recor
1Y
Name(print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
_..SECTtOGT10N StiYIeES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
0
Company Name/Contractor Name: Q
Address:
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 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 ecti sign ow:
-
Signature: r
_ 4fOAI Qf Ry `'�W-At k?E(dSATf01 = (FfSU
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��Tff�Pf 5•_f)ESCRfPTIOP� LF PROPOSED:_WORM(£#tec(�,a�t,appl�cable�� _
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction*
❑ Accessory Bldg. A� ddition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
L
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 conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
I Item I Estimated Cost ($) to be completed by Dermit aDDlicant ---I
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total= (1 +2+3 +4)
SEC7fOP17A Qfn1t�IE lkL1T�{O 011
(#o`# b: 9Tnp.-0- q nrhen_, ner's genf at con#raetoraptSCtes Fort ulfd�n j pe
(Please Print)
1, , as Owner of the subject property hereby authorize _
to act on my behalf, in all matters relative to work authorized by this bui ding permit application.
Signature of Owner Date
as Owner/Authoriz d Agent hereby declare that the statements and information
on the foregoing applic ion are true and accurate h best of my kn wledge and belief.
Signed under th pains nd p na ies rju
/Z
S' nature r/Authorized Agent Date
Vq6 — Less Application Fee: $6.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: (-,If �W, )
WI