BP-88434i
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RESICINTIAL ®Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IN NON RF.F1 r1%Tn,1Ny w Az, a mTwww
DATE RECEIVED
fQ 1 9'• DART OUT H BUILDING DEPARTMENT'
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cl 400 Slocum Road
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=;2 Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
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APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE dk TW0 FAMILY DWELLING
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
17 Date:
Brief description of work being performed,
vECIQI 1 StTE EIdCi3M'Ti}N �.f ..: .k.e..;
1.1 Property Address: 7_ 11 l £ is . 1.2 Assessors Map & Lot Number:
�?
Contact Person: JaeCbt,� `h) Map Lot
Phone Number:
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 Has
Disposal System
p Y application been submitted to the Historic Comrmission?
❑ Yes ❑ No Date:
5 eviised 5 /13
CONSTRUCTION SITE Y REPORT
RESIDENTIAt
2.1 0 ner Record: M
Rd
Nam rent)
Contact Address - Phone Number
2,R Authorize Agent:
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(s a� V /�((,/(�]f,\�J,�({�/f/fps � //{(.,./jJ� `�
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Namebt
(print) Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License:
_
License Number: a
Company Name/Contractor Name: kAdv L6, Ilk 6 "S q
Address: ' t7 ' J�jf 1%'l� Expiration Dater HAG
P
Si nature: s Telephone:
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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:
_•_• C-... .-_ .._. .. ,_..t4,..ft... ,.,.+ .. .v::-._. �� _..-.{.IT��t�_��$33��✓�yi�a��(�_7�p�� i��:�1� � - 4 ..
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
❑ Deck ❑ Pool ❑ Repairs
Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ bumpster On Street
Facility Na
me: ame: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fueloil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
- _ _ r_.... __ __ _ ;. § _4
Item Estimated Cost ($) to be completed b�
�permit applicant
y
1. Building ,,
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4}
sx $LUT1/�A[�Y�GIIte�C7��l0� Y
(Please Print) -
11 __ as Owner of the subject _ ! property
petty hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
H-1 #
1 L �"/G' �9 t�J //IX Owner/Authorized
• as Agent hereby declare that the sttatements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signy under the pains' d penalties of perjury.
Sigrfaturd of Owner/Authorized Agent Date;
CTld? ®>`tG�illSPCCi` tT�S
Less Application Fee: $25.00 Remaininrg Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area- New Construction total sq. ft.
Gross Area - Alteration total sq, ft.
Permit Issued to: