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SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Necord:
60 etas -602_g f -36°78
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)'
Contact Address Phone Number
SECTION 3 - CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Cornpany 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
eng2ges a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
Forte purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which hetshe 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 strictures. 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 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
0 New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding elmther
(Energy report required) (Shed/Garage) r _ _ ( (specify below)
r ;
,�4 _
4`1y
Y
Q Addition ❑Replacement window/door El Demolition
,�
� _
(Energy report required) No. of windows Doors - 1 (Specify below)
(Energy
*if new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 3 No. of Baths Unit 1
No of Bedrooms Unit 2 N No. of Baths Unit 2 1
❑ Famace"(hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Bo"ler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
I7 Hi�4C (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning -(separate unit)
❑ None of the above to be provided
0 Ho4"Water. Gas Electric Fuel Oil Other
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1, Building
2. Electricala
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
!:
SECTION 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 76 - OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent hereby declare that the statements and;itnformation
on the fo going 444ion are true and accurate, to the best of my knowledge and belief,
Signed under the pains and penalties of perjury. }y
�j t [
Sig at e of Own r/�uth rized Agent Date
SECTION 8 - OFFICE/iNSPECTOR'S NOTES
/'�
Total Permit Fee: $
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq, ft.
Permit Issued to:
SECTION 9 - ADDITIONAL COMMENTSISKETCHES
RESIDENTIAL
0 Phased Approval (t?106.3.3)
$25.00 APPLICATIONT FEE I5 NON RE-FUNBARLE . NON -TRANSFERABLE
DATE RECEIVED —
f���" DARTMOUTH BUILDING DEPARTMENT`S t
t4 �`400 Slocum Road,
Z s' Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-18��
64
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBER:
f
DATE ISSUED:
SIGNATURE:
'
DATE:
Building Commission _ nspe or of Buildings
_
`
Zoning District:
Proposed Use: Zone:
A 0iferZone:
THE FOLLOWING AGEN ES OU(D B NO IF
< t
O Board of
Board )f ❑ Cons. ❑ Demo ❑ DPW
❑ Elec. ❑ Energy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off FFollow-up`
O Fire
❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ C)ther'
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT,
DEPARTMENTAL APPROVAL
Board of Health:
Signature; -
r
Date:Al
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date.
Signature:
Date:
Signature:
Date:
Brief description of work being performed:�t�
�J SECTION 1 - SITE INFORMATION
1.1 Property Address: 7 u�a5 07 1u;5 ) _ 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map - Lot
Required Provided
i
Front Yard 1.3 Historical District 's ❑ Yes ta)
Side Yard Year Built 6 K7
Rear Yard
❑ Altering more than 25% per side of builOing
1.4 Water Supply (MGL 040 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic (Commission?
Municipal ❑ Private Well ❑ Municipal 11fOn Site Disposal System 17 Yes • ❑ No Dater
Revised 10111
CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY RE1PORT
7