BP-75358,, RESIDENTIAL El Phased Approval Rtt76.3_���
lc $25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TRANt!�TEBABLE
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c4 ATi�#gEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
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i Dartmouth, MA 02747
2
LC I OrT '20 Pik �: 42
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FJAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PEF;MIT NUMBER -
DATE ISSUED::
SIGNATURE:
DATE::, ( CT 2 4
Building Commissioner/Inspector of Buildings
Zoning District: O Proposed Use: Zone: D B ❑ A ❑ V Aquiifer Zone:
THE FOLLOWING AGENCI SHOULD BE TIFIED:
❑ Board of oard of ons. ❑ Demo El DPW
❑ Eltec. ❑ Energy Report
Appeals Health Commission Affidavit Card Sent: Cuit Off Follow-up'
❑ Fire 0 Gas ❑ Planning 0 Sewer Card ❑ Water Card ❑ Zofning ❑ Other
Chief Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
oard of Health: Signature: (g aA 9—o -,,49 G
Date:: I
'N
Conservation Commission: Signature: f;-
Date:'
Other: Signature:
1
Date:
Signature:
Date:
Signature:
Date:
Brief description of work being performed: (4)& 4�7
SECTIO 1 -SITE INFORMATION
1.1 Property Address: 1,2 Assessors Map & Lot Nurmber:
Lot Area (sf.) Frontage Map Lsot 4,-) T -C—
Required Provided
Front Yard 1.3 Historical District LJ Yes ❑ No
Side Yard
Year Built
Rear Yard
Altering more than 250//o per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submittead to the Historic Commission?
0 Municipal 0 Private Well CJ Municipal ❑ On Site Disposal System 0 Yes • ❑ No Date:
Revised 10/11
ONSTRUCTION PLANS Co SITE PLAN ❑ ENERGY REPORT
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SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Own Record:
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Na . print)
Contact Address Phone Numbe
_
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
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
Excepnon: 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'seclion 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 hone_- in a two-year period shall not be considered a Homeowner.
If you are appiyi under this secti 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 provide this
affidatilt will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
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SECTION 3 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
f
El Addition ❑ Replacement window/door - N rOR &fi ❑Demolition
6,14
(Energy 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
0 Fumace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boller (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
O Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbin
4. Mechanical (HVAC)
5. Tota! _ (1 + 2 + 3 + 4)
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SEC TION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
I, , as Owner of the subject property hereby authorize
to act on.my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
r as Owner/Authorized Agent hereby declare that the statements and inforrmation
o he foregoing application are true and accurate, to the best of my knowledge and belief. "
Signed rider the pains rid penalties of perjury.
Sig ature of wner/Authorized Agent Date
SECTION 8 - OFFICEIINSPECTOR'S NOTES
�
Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $ G
_
Other $ Amount $
Gross Area - New Construction total sq. ft. 3
Gross Area - Alteration total sq. ft.
Permit Issued to:
SECTION 9 - ADDITIONAL COMMENTSISKETCHES
No. 31, !,,Q
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