BP-82749RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE A NON -TRANSFERABLE
DARTMOUTH BUILDING -DE
400 SI8 u n Ro9d LG
Dartmouth A.OV47
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16 Phone: 508-910-18s 0i:� Fa�d 5b8-
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64
` www.town.�ailmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR -RENOVATE -OF
DATE RECEIVED
Uai`E
S'P 01 C I
A ONE`OR TWO FAMILY DWELLING
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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:
D �l--D—
Brief description .of work being perfonned.
y
Rewised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
;i'SECTION 2-PROPERTIF.OWNERSHIP/AUTHORIZED
AGENT -
Owner 5cord:v�
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hQATYX)CA�L ' 03
Name (print)
Contact Address Phone Number
Authorized Age( :
Cope `CUi�
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Name ( rint)
Contact Address Phone Number
= _ , „ '� � ... � SECTION 3=.CONSTRUGTION SER1fiCES
3.1 Licensed Construction Supervisor/Specialty License:
License Number.
Company Name/Contractor Name:
( p
Expiration Date:
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Signature: Telephone: -
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3.2 Homeowne 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 Rs, 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
on6 home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
'.'51=GTlON 4-111tOFti{ER`S GOMPENSATfON INSURAiVCEAFFIDAVIT (MGC c. f52 9'25}
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
. un.,.,°SEGT(ON 5=1:3ESGRlPTION"(),P PROP�$ERWORK,(Check all appltcabin) � � .;
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace 5Wo dstove/ ellet 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 ❑ 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):
❑ B0er (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)
❑ Norge of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Item
D;CONSTRUCTION CO
Estimated Cost W to be
it a
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2+3+4)
"SECTION 7A= 'OWNER AtiT IiORI2:A
tto'be'�orrtipleted when ovrrner's agent orcon ractor"aj pGes+for building permit)
(P e P inerat)
I,MC� es as Owner of the subject property hereby authorize
to act on my/�ehalf, i all matters relative to work authorized by this building permit application.
Jv�&aAi
u
Sianature of er Date
I, a� LNvs , as Owner/Authorized Agent hereby declare that the statements am, d information
on the fo going application are true and accurate, to the best of my knowledge and belief.
Signed under thp pains and penalties of perjury.
_ l)I caSignature of O er/Authorized gent Date
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