BP-79272RESIDENTIAL
T. SECT N . I'R€iPEItTYE)WNERSH-
IPtAUTHOR(ZEp
Item
Estimated Cost ($) to be completed by permit applicant ..
2:1 Owner Record:
1. Building}}
2. Electrical
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Name ( rint)
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Coritac Address
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Phone Numb
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3. Plumbing
4. Mechanical (HVAC)
5. Tofal-{1+2+3+4) l` CIW �fJ-
4 � SE TIOI� ZA O'I�iNER AUTHORIZATION .: �
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2.2 Authorized Agent:
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Name (print) Con act Address
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Phone Number
(Please Print)
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Y .. SECTION 3=,GOMS7RlIGTI.ON SEFtYICES._
3.1 Licensed Construction Supervisor/Specialty License: License Number:
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I, �� F[9�,�'JL r✓ILc7 as Owner of the subject roe hereby ,/� �{
1 property dY y authorize //C e-o
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date.
Com any Na*me/Contfacfor Name: -
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Address:
Si nature:
g Tele hone:
Expiration' Date.
SEGTtO{�'ZB==QINNER/AIJT#�€7�R►�lED AC9ENT.DECLARATIOh 3 .:: U, �-
I, PA(�--� as Owner/Authorized Agent hereby declare that the statements and informatiion
on the foregoing application are true and accurate to the best of my knowledge e and belief.
3.2 Homeowrer 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
engages a personfs) 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 int
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
one home in a two-year period shall not be considered a Homeowner.
that if a Homeowner
nds to reside, on which
who. constructs more than
Signed under the pains and penalties of perjury.
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Slgnatur Authoriz Agent
g Date
If you are applying under this section sign below:
'
Signature:
Total Permit Fee: $
Less Application Fee. 5.00
Other $ Amount $
Remaining Balance: $
�: SE�T`ION ��'Wl?�KtRy�C41V1�E(VS`ATIf�N=FNSt7RANGEtktFlt?r ti „ `�, `_'
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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
..��,ECT10N 5., 13�SC,Rt�TIO(V �IF�FRi�PGSE13�1V'OR�'�Chec{c�lt �ppltcablej`�
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to. r/ F
❑ De6k ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
ruction* ❑ Accessory g Bldg. ❑(E Addition
❑ New Const gY P q 9 Replacement
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report required) *Roofin Siding Re ' lacement window/door
(Energy report required) (Shed/Gar) e - of windows Doors
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❑ DEMOLITION (specify): -
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
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clllty Narrfe. t 1 rr7 � i% 5 � Location: �:�� �� � _
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_.._,.. .. _..... . � ...v:.. ,,.r ,....� ,_ � .. __.,-,.�,_ . T[_ N 1= �1LOIiKSEtt�01' P _., �_;; . .
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-51
*If new construction, lease complete th"`�`"
p e following:
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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 a1-) - 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)
O None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
® PhasedA provaT-R106.3.3
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$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-T SEEIl ABLE
DATE RECEIVED
T" DARTMOUTH BUILDING DEPARTMENT
rt� 400 Slocum Road
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Dartmouth, MA 02747 _•:• �°r: �� �° �•
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: h
Fire Chief:
Signature:
Date:
Other: Signature: Dater
Brief description of work being performed;
1.1 Property Address: _J 6 F L. i -ZA. L A-A66 1.2 Assessors Map & Lot Number:
Contact Person: 1 I �F_%L �('cv Map `t Lot -�
Phone Number: �� 7 , C�� 2,Lf
1.3 Historical District ❑Yes EkNo
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
X Private Well A(On Site Disposal System
Year Built T g
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commissiorn?
❑ Yes ❑ No Date: