BP-81812RESIDENTIAL
❑ Phased Approval (R106.3.3)
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foz~ qs;. DARTMOUTH BUILDING DEPARTMENT U `, r
(� z`i 400 Slocum Road �J W4
Dartmouth, MA 02747
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
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
Date:
Brief description of work being performed:
SEt;TIbN _SITE IN�OFtMATFaN
1.1 Property Address:
1.2 Assessors Map & Lot Number:
Contact Person:
Map C Lot
Phone Number:CJ��S�.
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 Commissions?
❑ Yes ❑ No Date:
Revised 5 /I13
CONSTRUCTION PLANS SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
2.2 Autho
Name (print)
Cona�dress Phone Number
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3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name�Contractor Name: n
Address: ;
Expiration Date:
Signature Tele hone:
3.2 Homebwne, E e - ne & wo Family Only Section 110.R5.1.3.1 Exception:
FOR HO NERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Except • n Horn orming 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 elow:
Signature:
�rftc?RKE _ QMPENSATIaKO. S
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
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❑ Deck ❑ Pool epairs ❑ Alteration ❑ ChimneUppla ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition iding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DLNIOLITION (specify): IM C
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Aon to 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
11 Hot Water: Gas Electric Fuel Oil Other