BP-69630SECTION 2 - PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner Record:
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Na,115
rr&(punt) - '' J Contact Address
Phone Number
2.2 Authorized Agent:
Name (print} Contact Address
Phone Number
fi SECTION 3 - CONSTRUCTION SERVICES
3.1 licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: /�� A t
Addfess. J Z ) r � i
Expiration Date;
Si nature; Telephone: r%-%K-Z'Ty'(ti(ti� 1
3.2 Homeowner Exemption - One & Two Family Only Section 11 O.R5.1.3 1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Except"on: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides (hat if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of lhisseciion 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 ramify 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)
Worker"s Compensation Insurance Affidavit must be completed and submitted with this application. Failure t 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)
Ct Deck ❑ Pool ❑ Repairs O.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
0 New Construction* ❑ Accessory Bldg. Roofing/Siding ❑ Other
('Energy report required) (Shed/Garage) /` (Specify below)
17 Addition J%Ir
❑ Replacement window/do t El Demolition
('Energy report required) No. of windows Doors tF= y 'Fir, r� 00
% Ci�tr Specify below)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Fam11y: 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):
0 Air cond' •coning - (separate unit)
O None of the above to be provided
❑ Hot Water: Gas Electric- Fuel Oil Other
ivn a - r-0 r IIVIH I tU koUNS /RUCTION COST
Item Estimated Cost ($) to be completed by permit applicant,
1. Building a�--
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4) +o6
SECTION 7A - OWNER AUTHORIZATION
(#o be completed when owner's agent or contractor applies for building permit)
(Please r(nt}
1, M Ir- & 0 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.
Z2.• 1
Signa riof Owner Date
ron
SECTION 7B-OWNERIAUTHORIZED AGENT DECLARATION
�1 as Owner/Authorized Agent hereby declare that the statements and inforrmationplication are true and accurate, to the best of my knowledge and belief,
ains and Pena ' r'ury.
13
Autho ' ent Date
SECTION 8 - OFFICEIINSPECTOTS NOTES
Less Application Fe�-2�,5.qQ/rRemaining Balance: $
Total Permit Fee: $
Other $ Amount $ J
Gross Area - New Construction total sq. ft.
Gross Area- Alteration total nsft.,,, J
Permit Issued to.
SECTION g - ADDITIONAL COMMENTSISKETCHES
/ I // - - ') 12f
RESIDENTIAL
❑ Phased Approval (R106.3.3)
$25.00 APPLI[CAT10TV FEE IS NON BE-F>U"ARLE dtc NON -TRANSFERABLE
---.
DATE RE CEIVED
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DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
..
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www. town. d a rtm o u th . m a. u s
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A
ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBER:
DATE ISSUED: .
SIGNATURE:
DATE:
Building Commissioner/1 p ctor f Buildings
Zoning District:
Proposed Use: Zone: B ❑ A ❑ V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of
0 Board of ❑ Cons. ❑ Demo ❑ DPW ❑ Elec. ❑ Enerrgy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off Follow-up`
• Fire
❑ Gas ❑ Planning ❑ 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; l -F, t-e okcp r�
SECTION 1 SITE INFORMATION
1.1 Property Address: 1�q 3 q v'C k 4I i,5 1.2 Assessors map & Lot Number:
Lot Area (sf.) Frontage Map Lot /
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Year Built
Rear Yard
0 Altering more than 25% per side of buildinrg
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Co-mmission?
IJ Municipal 0 Private Well ❑ Municipal 0 On Site Disposal System 0 Yes ❑ No Date:
Remised 10111
CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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