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2,1 �vner Record: 1. Building
Item Estimated Cost ($) to be completed by permit applicant
2,;kner Record: 1. Building
2. Electrical
Y\G
i wc,J6 3. Plumbing
Name (Print) Contact Address Ph4'
Phone Number . Mechanical (HVAC}
5 Total (1 +2+3+4)
2.2 rthorized Agent g {
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7 to be cc tetecinr _.v __ t;;-:
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Contact .. , , /° _,�: � .. _. bier[`_tner'�.��ert�nxcc�ra%acti�� t a�•for,-#'�i�cli� `* ; �� ,x
PR. ng prmti . r:-
Address
Please Print �� Phone Numbe
as Owner of the subject property I,
J P P dY hereby authorize
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to act on my behalf, in all matters r I tive t work a orized b this building _ Y g permit application.
13.1 Licensed Construction Supervisor/Specialty License: � � License Number. SS � i
Company Name/Contractor Name: � ;; � Signature of Owner �
Date '
Address: � i I
c Expiration Date:,,E
Signature.
/a Telephone: �. ---
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3.2 Hom owner Exemption - One Two Family Only Section 110.R5.1.3.1 Exception: !' e
as Owner/Authorized Agent hereby declare that the statements and information
on the fore ping application are a and accurate, to the best of my knowledge and belief:
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 S ed der t an e al O erjUry.
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 t
one home in a two-year period shall not be considered a Homeowner. than attire Of Own i�UthorlZe Agent Data
Ifyou are .? vtiz .. r i
Y e applying under this section sign below. a 6CTI��d $ bFF�GE/IS�'C`CR 5.JKOTES
g 3
Signature: Total Permit Fee: $ Less Application Fee: _ .00/ Remaining Balance: "
Other $ Amount $ —
$EG 10 KER CQ1UIR NSAT
[flN;INSURANGE AFt=1bAtTMGL c52
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to Arovi thi Gross Area - New Construction Val sq. ft.
s Gross Area -Alteration total sq
affidavit Will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 1?1es ❑ No
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SFE?;ll fi)F2K,.(Citeck l cahte ..:; Permit Issued to:
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition oafing/Siding ❑Replacement window/door
(Energy report required) (Shed/Garage) (Energyre
report P required) ) No. of windows _ Doors
❑ DEMOLITION (specify):
4 �
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpste On S et
FacilityN► f;
Name: 56 7 -% r i. ... = 1it5f pEG N i31RNI1Efi
Location: .. ... g ��1 �....�
*If new construction, please complete the following: �l
Single Family: No. of Bedrooms No. of Baths
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Two Familyf No of Bedrooms Unit 1 No. of Baths Unit 1
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No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
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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 tl-e above to be provided
❑ Hot Water. Gas
Electric Fuel Oil Other
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RESIMENTIAL
® Phased Approval (R106.3,3)
ATE.R�CEIVED>
DARTMOUTH BUILDING DEPARTMENTT.
f 400 Slocum Road
a C Dartmouth, MA 02747 loll!AUG18 AM I k 03
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 DWELLIN
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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 work being performed.
11.1 Property Address: Set —21 14- 01.2 Assessors M & Lot Number:
Contact Person: G Map --9 Lot
Phone Number:
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 Commission?
❑ Yes ❑ No Date:
■CONSTRUCTION
eSITE PLAN ■ ENERGY . ,, ,