BP-89350—M..P A T
2.1 Owner Record:
Name- (print
o;hta6t Address Phone Number
f2.2 Authorized Agent:
N, I I-)
Contact Addre�is Phone Number
3.1 Licensed Construction Supervisor/,Specialty License:
License Number:
Company Name/Contractor Name: na zI 575 CQ
Address:
Expiration Date:
Signature: 1--,-2 ------ �elephon e,
5.2 HomeoWner �Wption - 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
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 an 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 andlor 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:
RiR
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to ovide this
will result in the denial the issuance the building Signed Affidavit Attached: 0 No
affidavit of of permit.
0 Deck 0 Pool 0 Repairs 0 Alteration El Chimney/Fireplace 0 WoodstovelPellet Stove
11 New Construction* 11 Accessory Bldg. El Addition 2��f g/Siding 1:1 Replacement window/door
(Energy r-aport required) (Shed/Garage) (Energy report required) No. of windows Doors
A,QEMDLITION
(specify): ----------
Location of debris removal (per MGL C.40 Sec 54): 0��ster on site 13 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 I
No of Bedrooms Unit 2 No. of Baths Unit 2
13 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
El Boller (heating) -fuel fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
13 Air conditioning - (separate unit)
0 None of the above to be provided
13 Hot Water: Gas Electric Fuel Oil Other
11-
11(4
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_3
Item
Estimated Cost to be completed by permit applicant
1 Building
I O00
2. Electrical
3. Plumbing
4. Mechanical (HVAG)
5. Total = (1+2+3+4)
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-(PI
I LA CL NY% �0\6 kc-C. as Owner of the subject property hereby authorize. 6to
act on my b all, in al atte relative to work authorized by this building permit application.
V) e-0 -7-1 Iq -
SignaturOwner Date
ftA fo 7
I, on as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under and pe es jury.
Signature o er/AuthorizedA6ent Date
T,
Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $ s�
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: ot�kooz>
NOT PEE
t
RESIDENTIAt ❑ Phased Approval (R106,3.3)
�,�a tee, m.■.a�a�r WW1V iC 7AT"M UW_WTrWnAmw.W mam-'i'n AM..QW1F. 11alf'IF
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
sz Dartmouth, MA 02747
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,� Phone: 508-910-1820 Fax: 508-910-1838
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1664f'' www.town.dartmouth.ma.us
4
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR O FAhAILV DWELLING
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❑ }address ❑�I;ng�r<eering Q Gra�js
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❑Gas ❑ Etecfr3c d Qttrer
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Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of worst being performed. o-
1.1 Property Address: t _ } . , 1.2 Assessors Map & Lot Number:
Contact Person: Y,�� .� Map Lot -
J
Phone Number: `z) - i
1.3 Historical District ❑ Yes ❑ No
1 Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of buildinfg
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
j,,,j H F S 'tbo, -r,aevised 5 /13
El CONSTRUCTION PLANS El SITE PLAN ENERGYREPO