BP-78467i -
RESIDENTIAL ❑ Phased Approval (RI 06.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TBANSFEBAB?L le,
—�
DATEREC'E[V'ED
DARTMOUTH BUILDING DEPARTMENT¢
400 Slocum Road
n
2'�lu
;Z
Dartmouth, MA 02747
l `t �2 30
4 yyr
Phone: 508-910-1820 Fax: 508-910-1838
www.town. da rtmouth. m a. us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWfELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMEIE (�
DATE ISSUED:
SIGNATURE:
DATE:
Building Commissioner/Inspector of Buildings
p U , Zone: MX 0 B ❑ A ❑ V Aquifer Zone:~
Zoning District:
Proposed
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
0 Board of
0 Board of ❑ Cons. ❑ Demo ❑ DPW ❑ Elec.
❑ Energy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off
Follow-up'
❑ Fire
❑ Gas ❑ Planning O Sewer Card ❑ Water Card ❑ Zoning
❑ Other
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health:
Signature: Date:
Conservation Commission: Signature: Date:
Other:
Signature: Date:
Signature: Date:
Signature: Date:
Brief description of work being performed.
SECTION 1 - SITE INF MATION
1.1 Property Address: 6— f� C , I rF J ,�J/ 1.2 Assessors ap & Lot Number:
Lot Area (sf.) Frontage Map � Lc tt �
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
Altering more than 25% per side rnf building
1.4 Water Supply (MGL c40 s54): 1.6 Sewage Disposal System: Has application been submitted to the Hltstoric Commission?
O Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System 0 Yes , ❑ No Dater
Revised 10/1
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY" REPORT
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner R c d:
Narne (po t) „ / J „ }
Co a ddres Pon ber
2.2 Authorized Agent:
S c USA � fT c
5-5�io
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License: ` 1 I"L SL U �,il
License Number: p G `j L
Company Name/Contractor Name:
Address: l - W92L N cui - ' QasiL"p
Axpiration Date: /
-/
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Si nature:, `� 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 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:
Signature:
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
WoAer'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 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. I-Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition eplacement window/doom F El Demolition.
(Energy report required) No. of windows :s� Doors` "�� (Specify below)
*If r,ew 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
❑ 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. Total=(1+2+3+4)
To v o
SECTION 7A - OW ER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
1, G,1_.,,_ A C 8 F G ,R R E 19 as Owner of the subject property hereby authorize S 11(/ S A rA R
to act on. my behalf, in all matters relative to work authorized by this building permit application.
9 ` L
SignatIreAf Owner Date
SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION
I, ) U S (� l l !7� J19 as Owner/Authorized 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.
Si nature of Owner/Authorized Agent Date
SECTION 8 - OFFICEIINSPECTOR'S NOTES
/
Total Permit Fee: $
Less Application Fee: $2*'01-
Remaining Balance: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total q. ft.
Permit Issued to:`�'��
SECTION 9 - ADDITIONAL COMMENTSISKETCHES