BP-680091111:51U IAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE- L'NDABLE & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT §'"VED
s? 400 Slocum Road, P.O. Box 79399 w ' GDEPT.
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 " OU 2 3 A ' 4
www.town.dartmouth.ma.us
o APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other; Signature: Date:
Signature: Dater
Signature: Date:
Brief description of work being performed.
1.1 Property Address:)1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot _1-
Required Provided
Front Yard 1.3 Historical District ❑ Yes Alo
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been sub i ed to the Historic Commitssion?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes No Date:
Revisedi 10/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPOPIT
j RESIDENTIAL
2.1 Owner Record:
Name (pn t) � Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
"` SECTION.3! °CONSTR GT1flN"SERVECES , :r
3.1 Licensed Construction Supervisor/Specialty License: License Number: ® L.}g a 9-5--
Company Name/Contractor Name: A' i ,Z_-o p u
Address: Expiration Date:
Signature: , n.�`Z .- Telephone: d
3.2 Homeowner Exemption - On & 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.
Fcr 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 below:
Signature:
. EGTION'4;=.WORKER'S:"COMPENSATION INSURANCE'AFFI ly
AVITJMGL
WorRer'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
:. ,.,;° "SECTIOTI S=°DESCRIPT[ON';OF ;PRQPOSEI3 WORFC "{Check;all "applicable}
0 Deck ❑ Pool ❑ Repairs teration ❑ Chimney/Fireplace ❑ Woodstove/PelletwStove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
0 Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
*If new construction, please complete the following:
Sinoe 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):
❑ Bdiler (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
❑ Hot Water: Gas ' Electric Fuel Oil Other
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
Estimated Cost ($) to be
(Please Print)
I,l as Owner of the subject property hereby authorize
to act on my ehalf, in all matters relative to work authorized by this building permit application.
�I
12,
Signature, f Oner Date
I, Tk ta- 9-1 `t V-0 P_ L1 er as Owner/Authorized Agent hereby declare that the statements and ihfformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under tqe pains and penalties f perjury.
41-
Signature wner/Authorized A n Date
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. 1.2 -7 61
Permit Issue to: (",:—�t> j, yt t� i-►pro• z1 C<,,., r�, r�'� 11irrw�
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pe, EAU C.40 SBC.
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