BP-80115RESIDENTIAL
2.1 Owner Record:
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Name (print)
2 Authorized Agent: /
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Name (print) Contact Address
Phone Num
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Phone Number
SECTlON3 CONSTRUCTION
SERVICES. _.
3.1 Licensed Construction Supervisor/Specialty License:
License Numbers d S
Company Name/Contractor Name: P(c u
Address: Z3q_ �/ D,�-Vq
Expiration Date:
Signatur Telephone:
3.2 Homeowner ExemptOne & Two Family Only Section 110.R5.1.3.1 Exception: %�! �' ` (� sa3 (�//�
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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 Rome in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature: ��� aZ-iti—
SECTION 4 -WORKER'S COMP_ENSAT(ON .INSURANCE rAFF1DAVIT:(MGL b A52
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
SEtT10N 5'-:DESCRCPTION OP PROPOSED WORK" Check all applicable) ", ""
0
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofin iding ❑ 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 ❑ 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):
❑ Boiler (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)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
,,SECTION 6 r ESTIMATEO"CONSTRUGTIOWCOSTr;
1. Building Item Estimated Cost ($) to be completed by permit apiplicant
a
2. Electrical r
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4)
SECTIONS A - OWNER AUTHORIZATION
{to be completed when'owner`sagent or corffractor appi 6 foi 3iuildirtg permit)
(Please Print)
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relativ to
work authorized by this building permit application.
Signature of Owner Date
SECTION 7B = OWNER/AUTHORIZED AGENT DECLARATION:
as Owner/Authorized Agent hereby declare that the statements atnd information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Sign ure of Owner/Authori64d Agent Date
SECTION $ OFFIC'E/INSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balancer .$
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
} }S,ECTIN 9 ~ DESCRtPT10N flF1NORK BEING PERFORIIAED
RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON ICE.-fUNIDABLE & NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT
t4 400 Slocum Road P6
iz Dartmouth, MA 02747
J N072t
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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L. DAi E ISSUEQ: `
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date: e
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
Date:
Brief description of work being performed.
11.1 Property Address: !'-/ Qi('7� Uhl f 1.2 Assessors Ma Lot Number:
,�
Contact Person: s, 1 c Let Map Lot f � -61" r
Phone Number: 57.,V qq7
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 Comrmission?
❑ Yes ❑ No Date:
�C P� .5 /13
El CONSTRUCTION PLANS ® SITE PLAN ® ENERGY REPORT