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BP-69460i i shy � I i NY- ry, el I i� <-e E F k �� 0 �« a-: a y Ar g .4 Nl 1-. n r :�— I t y egg+w,aad421 -+ayy. cEf of n; r ypa.,�. �$ p�":�`'S>,. � yip•. ,�.Cis y t -Virep s 7 7 y 4 t tl a .g Y i 3 k MOVED )ARTMOM OMIT. 7013 APR I 2n $ f y q 'f C C f RESIDENTIM SECTION 2 -PROPERTY OWNERSHIP/AUTHORiZED AGENT 2-1 Yner Record: s e dm ,�j �/ (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: Company 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 engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. For the purposes of this'seclion 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 H o her. If you are applying nde is sect' sig elow: ignature: 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 b;Al result in the denial of the issuance of the building permit. - Signed Affidavit Attached: O Yes ❑ No SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable) ❑ Deck ❑ Pool ❑ Repairs ❑.Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other (Energy report required) (Shed/Garage) �(� (Specify below) uninn y ❑Addition ❑ Replacementwindowldoor =� z ❑ Demolition n., (Energy report required) No. of windows Doors }• 1 (Specify below) *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 • Fumace (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 condi5oning - (separate unit) ❑ None of Oe above to be provided Hot Water: Gas Electric Fuel Oil Other SECTION 6 - ESTIMATED CONSTRUCTION COST Item E timated Cost ($) to be completed by permit applicant 1. Building L 2, Electrical 3. Plumbin G 4. Mechanical (HVAC) Uu.' 5. Total=0+2+3+4) ®p M SECTION 7A - dWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (Ple s Print I; t I as Owner of the subject property hereby authorize to a ton my beh in ma rs relative to work authorized by this building permit application. . I JK 41143 Signatur of owner Date SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION ` �_, as Owner/Authorized Agent hereby declare that the statements and informmlion on the foregoin pplication ar rue and accurate, to the best of my knowledge and belief. " Signe and the pains penalties of perjury. 60 4110113 ature wnerl th ' Agent Date f SECTION S - OFFICEIINSPECTOR'S NOTES - Total Permit Fee: $ _e�l� Less Application Fee: $25,00 Other $ Amount $ Remaining Balance: $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq, ft. t Permit Issued to: SECTION 9 - ADDITIONAL COMM ENT%SISKETCHES _ f/ RESIDENTIAL - ❑ Phased Approval (l?106.3.3) $25.00 APPLICATIQN FEE IS NON BE-FUNDABL 6 a'±ic NON -TRANSFERABLE ou—Tk f ," "0 DATE RECEi p ,o _, DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road r Dartmouth MA 02747- 1 g = r') _ .;. � 4 .E 6 F�o PM` �u� 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 DWELL-ING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT NUMBER;' DATE ISSUED: SIGNATURE: DATE: Building Commis one r/ nspe for of Buildings C Zoning District: Proposed Use: Zone: ❑ X O B ❑ A ❑ V Aquifer Zone: THE FOLLOWING AGENCIES S - , LD BE NOTIFIED: • Board of Boa ❑ Cons. Q Demo ❑ DPW ❑ Elec. Q Energy Report Appeals Health Commission Affidavit Card Sent: Cut Follow-up* ❑ Fire 0 Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑ Zoning her Chief Cut Off Board Cut Oft Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT, DEPARTME TAIL APPROVAL �- VX Q F�F.�.� Board of Health: Signature: �rdQ nafjA v,-& bate:.r-- Conservation Commission: Signature: Date: Other: Signature: Date: Signature: Date: Signature: D te: 7� � Brief description of work being performed; l o� /�, SECTION 1'- SITE INFORMATION 1.1 Property Address: A/ C�'�? & 1.2 Assessors Map & Lot Number. Lot Area (sf.) Frontage Map Lot I Required Provided Front Yard 1.3 Historical District 0 Yes ❑ tNo Side Yard Year Built Rear Yard U Altering more than 25% per side of bujilding 1.4 Water Suppl (MGL cot) s54): 1.5 Sewage DV�e System: Has application been submitted to the Histork Commission? El Municipal Private Well CI Municipal Disposal System © Yes ❑ No Date: Revised 10111 ❑ CONSTRUCTION PLANS ❑ SITE PLAN '' NERCO` REPORT 7� USG