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BP-73494i _ : ®, �F _ 01D 1 tJ ((5 * %V t=1 k 2.1 Ow r Record: �a L I� I l 3� rob �4g �4 Name (print) Contact Address Phone Number L. 2.2 Authorized Agent: 3�1 rAkIS 112(—A.,3�Roo & a 3G Name (print) Conta�Address Phone Number -14 Pill 'A Yw— 3.1 Licensed Construction Supervisor/Specialty License: C - Q 4 License Number: —0cl Company Name/Contractor Name: , C> E L Address: C f3Z i+ZCJC�I'L Expiration Date: P Signature- Telephone: seJ 5 3i©tf lcol 3.2 Homeowner xemption - 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 this section sign below: Signature:: - M - - V 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: IP/Yes ❑ No �Ai_ —� —��_ hq G Deck ❑ Pool ❑ Repairs dAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Gonstruction* ❑ 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): 12�'Dumpster on site ❑ Dumpster On Street Facility Name: CA SloUe, [4 jam Location: 10��' ) 4 j'V C—(f *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 (h-ating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air condi"ioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Irk Item Estimated Cost ($) to be completed by permit applicari t 1. Building pC'� 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5 Total 0 +2+3+4) _ AMI�, J � �.� n _ J� e -AR ._r gyp. mJ�e :,�F .Y"— — —€�y::��.,w� '�J� erteim`:kt+ nt +r:tie�rn w �P� � r�°t .�11 �_ tP (Please Print) 1, , as Owner of the subject property hereby authorize II matters relative t ork authoriz this b 'ldin perm a . to act on my behalf, in a �y g p ,�- Signature of Owner Date j� y p� 07 'ire ����� � ,-r.���a�� �ua�i , ��r� `.a i�iim„ O � 1, C�d f S /d!/7 ��� � , as Owner/Authorized Agent hereby declare that the statements and infformation on the foregoi g ap lication are tr ie and accurate, to the best of my knowledge and belief. Sig d de a pains an s of perjury. e 6f bwn r/ thorized Agent Date Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ 7 Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft.//�� (� Permit Issued to: SIE TI L ❑ Phased Approval (R106`3:3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON TRANSFERABLE ;ATE RECEIVED DARTMOUTH BUILDING DEPARTMENT"' 400 Slocum Road Dartmouth, MA 02747 °£ =fPIK 12:12 a: Phone: 508-910-1820 Fax: 508-910-1838 16 64 www.town.dartmouth.ma.us APPLICATION TO CONSTRU(;T, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,� _ "��r�,fl � — ia; r EMR ain� €r. i��� �'i� _ RE�tEl � a `,`mow." �"' � s `,"�.", �,• _ "a' �, a1r�z"I�..�!::��_ �� ":��ti! r"� ®� �`"im�,��!�. i" b� �'— ��d� tl:""��'���, ,_.�� :,,",•�",s��.'���._. �q � v� _�''� �, _.�Iflng��d 9�'I „i is i� s�dr �.:r W -Y �r �r a &" W ��a�� � aIMP, „ - " p I,: � : W: i;J��i,W •_ i = • .:�nad„ .€ , tli . I��i!s ..: ,"i (: 9,. , �. "-,�r,�i:"a!!.... is � !'"ti�i�i�-. „fly ai . .:,; ii , ,!.,,air � ,! r.... � ., i i �! ifl W .-�..,.. 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Hai . .....::: :�'... un�.w ...",W�Iwi gip: NNE, a I. i i a .aa and iai � ,:.: dreg „did ia,a ..:. ® d a uiWa:ifi7 id i "0,011114 i ��, r "C�i) ggS (t3i1 awi inia:W�i��t€i N. a 7i ,.:; di .. , , a, u�,-, .,. `�u �..._ : ,. ,._� .: it ,nib "W!:,.� a,.. t �... � i� itl rri it ,=Nl._sr i i ., i.. � rI � id . _.I .i ir•Iflml i , i i � dd : :Ifii i �" ria�;,�rta .si t flies � .id�ie fr�i im rOI,!iiylr�iai a ii ri :. a' r,W�i��aism : ����P:":= � :fin x r �I "I W is �n.:ipi�� ��: Ifi ,uyiaai ir� �i i�_i�_ k� , ®ir! „ e id i ra ii Fdi ��r � iii �Ii nl �rai ima,�,a i a � �,y�naza � �a; R+, n6,....., .`��ia,: �.,.�,::"m��: o„ d �nr � �H "'� S�. � i � � ,,.:unit -: � . a �.-:s:;-n iiirtiiat rJ fir Board of Health: Signature: �` <> > Date: Conservation Commission: Signature: (/ ' Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: / ate: Brief description of work being performed.- -2 _ t r WWt� ri , i�i r`rrW:aair�- `'� a:, ire jfi�i r.-i® ,a�a �� a!ia�. �F niW.iWW�i i�im'L ivi a w� i!f rai i =r.ai r rl i� .., a f"� , =i01I i� , T .tNF i ION - 1.1 Property Address: ' 301 P L 1.2 Assessors Map & Lot Number: Contact Person: (T P� 1S i V I n Map qj Lot/ - Phone Number: K-OF)�- 1.3 Historical District ❑ Yes ❑ No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commiission? ❑ Yes 0 No Date: eves ed 5 /13 CONSTRUCTION PLAINS SITE PLAN ENERG T