The URL can be used to link to this page

BP-88968RESIDEKTa - ❑ Phased Approval (R 106.3.3) S2i.00 LE JPPL,[CA ION FEE" IS NON RE-FtLNUABLE &I NON-TRAL DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT • 400 Slocum Road _' Dartmouth, MA 02747 ' c Sys, Phone: 508-910-1820 Fax: 508-910-1338 ' 'fs64 www.town.dartmouth.ma.us :_APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY 4WELLING _n DATEE ISSt1E DAI Sultdfnq EIoFl@I' IS f)f lit SF " _ a - use.: Z`da r3i�JC �tl t AQkllf@rZOne i - wOULM cjf 4 f 13Cons 0fPlanning: �P_tdcesa I3Engineenng f�C�+es _ - ( S He�ttlt- �atiss<cn Eerd Go .mnection fl offs Q Gas G Electric O Other ❑ dater Card Q S's Gard .Gatoff Cut -Off Cut-off cut off Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: fit/ S Brief description of work being performed: , QW 1.1 Property Address: ,�j �'1 _?5"y {.�Prr)l 1-'� r. 1.2 Assessors Map & Lot Number —_4 M c S O ✓1 Map T Lot �`*? Contact Person: �' <' Phone Number: qC 1- 2— Z 1— 9,f �,' G 1.3 Historical District ❑Yes ❑ Nc 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of buik-fing ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic 3ommission? ❑ Yes ❑ No Date: Revised 5 113 El -CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT oreinluTlA1 ••�•••••�•• • ••�• SECTION 2 - PROPERTY OWNERSHIP/AtJ-THORIZED AGE14T 2.11� -Jwrer Record: �arY >al?e ��ie�tyKG` /`� /v. ! `fnJL UT, A ,ortact Address T Phone Number dame rr;rt) I Z-G (�j;1 iZGi 2.2 Authorized Agent: �� it an �n�tiS�nt� r.��10 i Name iPrinf) Contact Add ess Phone Number S0't'COE3 CEQINST[E1�11f1fE- . 3.1 Licens to rf- rvisor/Specialty License: �; C p License Number: p Company Name/Cant actX me: 1 1-MA r ' �✓ Jd ' Address: Lip- , /► - L 1 Expiration Date: - 'r.-� Sig ature•,.L Telephone: -2- - 3.2 Homeowner Exemption - One & Two Family Only Section 11Q.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: ;any I-iorneowner performing work for which a 3uilding Permits required shall be exempt from he provisions of this section; provides that if a Homeowner engages a person(s) `or hire to do such work, that such Homeowner shall act as supervisor. For the purposes 3f :his section only, a 'Homeowner" is iefined as follows: Person(s) who owns a parcel of !and on which a/she resides or intends to reside, on which there s, or .s ntended 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 iome n a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: i _ - =S��.cQ1�E�+1�►QFz�lElt�'�`ar -_ S/�i�C��,��!>E�/fE�EE�" lfA�� F�'t �.Z� -- _ . _ - Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this No affidavit will resi.it in the denial of the issuance of the building permit. Signed Affidavit Attached: ?�Yes ❑ SE ON E , fliES on-, Pico IlK i tiscCl a�F�p�fcahro ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Constrjction' ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding EYReplacement window/door No. of windows Doors— (Energy report required) (Shed/Garage) (Energy report required) ❑ 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): ❑ 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 abcve to be provided ❑ Hot `dater. Gas Electric Fuel oil Other �-- 3EG1-10ft t► - tea 1, anti =u 46,U110 Frguc, r rum. vw f Item stimatedd most '3t :o he :amp/ 1 Building I Z, Electrical j 3. Plumbing 41 Mechanical (HVAC) �O 5, Total =(1+2+3+41 - - sECTCON 7A O EEC iEJtTCi [O ( cs be compieted whe�-o�nf - oes ageing o c6 - doe appCie fvr baits by permit a %Please rnm� as Owner of the subject property aereby authorize °o act on my behalf, in all matters relative to Nork authorized by this building permit application- D ate Signature of Owner SECT100B - GWFtEE tUTMK0idLZ- AGENT DECLAIM TIOr as Owner/Authorized Agent hereby declare that the statements and infarmatiton on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain and penalties of perjury. Date Signatu Own uth 'zed Agent S ET10[ ©FFiCE11I PEE- 001YOITES Less Application tee: $25.00 Remaining Balance: v Total Permit Fee: $ _ Other 3 Amount 3 Gross .Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: -- f ,- -- - - -- - - + re e