BP-75337RESIDENTIAL ❑ Phased Appr val (R906.3.3)
$25.00 APPLICATION FEE I5 NON BEV ,FUNIIABLE A NON-THANSFEBABLE
Contact Person:
❑ CONSTRUCTION PLANS
Revised 5 /13
0 Si E PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION-"Pf�OPE1TYOWNERSHIP/AUTHORfZED
AGI=NT,
2.1 Owner Record:
D6Vib LiNt o
Z WD01-Cytl< Pam' ,. 5-vB50537W
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
ypect r�fl
�3 1� (� S r 7 71/ z 3 410 `/"-/
Name (print)
Contact Address Phone Number
SECTION 3', CONSTRUCTION"SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
LCompany NamelQbntractor Name:
Address:y
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 Vitended 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:
V
Signature: X_lT aa4 E, ,
SECTION I = lt{iORKER.'S;GOMPENSATION JNSS AANCE AF
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
=SECTION 5„ilf3ESCt2tPTION L?P.PROPOSED'W0RK(Ch' all" pplicabls} "
❑ 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) 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:
1
Single Family: No. of Bedrooms Z No. of Baths 2—
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): i L
HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
Hot Water. Gas Electric Fuel Oil Other
SECTION 6-'ESTIMA ED.CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0 +2+3+4) Q 00Z) O /✓ / /9 D
SECTION 7A; O NER AUTHORIZATION
(loKambe �amplet — when'owher's ages or contractor applies fof tiutld rig pe"rm[tj
(Please Print) 1 /
I, q V � �� i , as Owner of t e subject property hereby authorize Ta5 e
to act on my behalf, in all matters relative to work authorized by this building permit application.
13"J
4/7
Signature of Owner Date
/ SECTION 7B _ bwN-
'IEWAUT HORIZEb AGENT. DECLARATION
I, O OS ey�L i ,� j A4 as Owner/Au orized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
I--- \L1--l-�) /0 -) 7
Signature of O er/Authorized Agent Date
x ; .SECT[ON 8="OFF14E/INSPEOWS NOTES.;
1.
/ Less Application F . 5.00� Remaining Balance:
Total Permit Fee: $ 1
3.5
Other $ Amount $ J
Gross Area - New Construction total sq. ft.
Gross Area - Alteration PWI sq. ft.
Permit Issued to:
00
N
EXISTING
FOUNDATION
T.O.F.=112.20
320.2'
0
3
EXISTING
o d- WELL
L
►� `0
0
Z
00
L
ESTATE LOT 3
478547 SF
10.99 ACRES
N 00'48'23" E
491.78'
N 00'48'23" E
999.76'
104.0'
IC111
vN
00
Z
2015 J! 1 2-3 Al'1 11: 17
511.43'
N 00.48'23" E
I HEREBY CERTIFY THAT THE FOUNDATION AS SHOWN
COMPLIES WITH THE ZONING REQUIREMENTS AS SET
FORTH BY THE'.TOWPJ OF DARTMOUTH ZONING BY—LAW.
ATE/2.29. �¢
l f
4ur_ COPY
(zV �/a 4 ez t RCX,
sco% 1 ~ =100�
SITEC
449 Founce Comer Road
dote: 12-29-14
Dartmouth, MA 02747
(508) 998-2125
drown: DSG
Civil and Environmental Engineering
FAX (508) 998-7554
chocked' SML
Land Use Planning
I
approved. SDG
MAP 33, LOT 118-5
WOODCOCK ROAD
DARTMOUTH, �ASSACHUSETTS
t. DAVI D LIMA
FOUNDATION
AS, BUILT
sheet 1 of 1
drawing number.
13-5497—FAB
11 33-4-