BP-88779F
RESIDENTIAt
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2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Ag t:
2
Name (print)
Contact Addre7/4 Phone Number
3.1 Licensed Construction Supervisor/Speclalty License: License Number. �C((p(�2 �f
Company game/Contractor Name: 2Lti I O (l 16,e
Address:
Expiration Date:
Signature: Telephone: 0�qtf(y
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3.2 Homeowner 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 peerrsson(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 than
one home in c, two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature
05,54
Worker's Gompensation Insurance Affidavit must be completed and submitted with this application. Failure to rovide this
affidavit wi-I result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes ❑ No
x � �y
_w�TICI S 13€S£f�tl f�s3ptica6 y z�
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding ❑ Replacement window/door
(Energ;rreport
required) (Shed/Garage) (Energy report required) No. of windows Doors
b-DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): &umpster on site ❑ Dumpster On Street
Facility ' Name: �� ��� � WLocation:_ ` � � -` (' �
�f
*If new construction, please complete the following:
Single Farrgly: 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):
11 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the e above to be provided
13 Hot Water: Gas Electric Fuel Oil Other
Estimated Cost ($) to be completed by permit applicant,
L000
-
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) 0,
f
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'(Please Print)
G 4
I, Q �� ��'� as Owner of the subject property hereby authorize 04'vL ((o +euc:7jon
Eon
to act on my behalf, in all ma rs relative to work authorized by this building permit application.
n t A- COY, cc.+-
Signature of wner Date
QR(EEZ(,�ld�'!i><31�t[�E3>EP�T'Dt��Lr4t'I•Ir'3[�_:_
I, Cw ri�i 1`C �c
4Yi as Owner/Authorized Agent hereby declare that the statements and infdtrmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
/� Ot, A 7 - -aa-
-
Sigpfure of Owner/Authorized Agent Date
117!�
Less Application Fee$
Remaining Balance:
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration to al sq. ft.
Permit Issued to: a —1za
— �!� ----
I
RESIDENTIA1 ❑ Phased Approval (R106.3.3)
�.n M Imes I lompff yr Aqrnm WEV IQ NON HE -FUNDABLE NON -TRANSFERABLE
LE
_ DATE RECEI ,U` p
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9 ®ARTM®UTH BUILDING DEPARTMENT
r ° 400 Slocum Road G
f
i Z Dartmouth, MA 02747 4
Phone: 508-910-1820 Fax: 508-910-1838
1664
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELILING
Board of Health: Signature: Date:
Conservation Commission: Signature: • Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: i Date:
Brief description of work being performed; c� s-T
1.1 Property Address: Ll yLan C 1.2 Assessors Map & Lot Number:
-1v Ma
Contact Person. �r1 .� � a C�(1 p Lot
Phone Number: _ �Q 5(_-4 1�549
1.3 Historical District ❑ Yes M No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of1building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Histtoric Commission?
❑ Yes ❑ No Date:
r.
S&,J`Revised 5 /13
S `1• r 1: 'ram r`. "�� $ �' i\.�^- �' �)50.7 0-
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