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2.1 Owner Record:
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Contact Address Phone Number
Name (print)
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
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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
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: J
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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
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❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* - ❑ Accessory Bldg. ❑ Addition 121 Roofing/Siding ❑Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows— Doors_
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❑ 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:
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):
❑ Bmiler (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)
❑ Ntone of the above to be provided
❑ Hot Water: Gas = Electric Fuel Oil Other
RESIDENTIAL ❑ Phased Approval (R106.3.3)
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.•'�-, DATE -EtRECEIVED
�Ty:. pARTM®UTH BUILDING DEPARTMENTNX
400 Slocum Road = , Af ,
Z Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 L'{t
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health: Signature:
Dater
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief. Signature:
Date:
Other. Signature:
Date:
Brief description of work being perfonned:
❑ Private Well - On Site Disposal System Has application been submitted to the Historic Cormmission?
0 Yes KNo Date:
Rrvi ed 5 13
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