BP-52051COMMERCIAL'
COMMERCIAL
COMMERCIAL
Item Estimated Cost ($) to nearest dollar. To be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
[5. Total = (l + 2 + 3,+ 4) Estimated Total Cost Including Labor: $
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I, l U-/ P, Co S ty as Owner orized Age t hereby declare that the statements and information
on the foregoing application are true and accurate, to the best o edge and belief.
Signed ; e th pains nalties of perjury.
t
Si re of Owner/Agenf Date
I. Dale plan reviewed: 5. DENIED (see project review worksheet):
2. 30 days to review period expires: Date:
3. OK to issue date: 6. HOLD reason:
4. OK to issue subject to requested submittals (see project Date:
review worksheet): Date: 7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature: DateJAN 19 ,nnR
Applicant informed of abo Clerk
Comments:—#�E '
. ....... .......
Total Permit Fee: �� Less Application Fee: $ 25.00 Remaining Balance:
Gross Area - New Construction
Gross Area Alteration
Permit Issued To:
c:\bldg. fo-ms\bldgapp.com Page 4 _ rev. March 12, 2004
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
DATE RECEI`VED
" DARTMOUTH BUILDING DEPARTMENT ., . -a
o z's 400 Slocum Road, P.O. Box 79399 1 ' t:,: .
" Dartmouth, MA 02747 ,
508-910-1820 FAX 508-910-1838 ` 4 � '�2 9a `. t19
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING (includes 3 or mr)re family dwellings)
Zoning Review: Signature: 0A Date:
Energy Report: Signature: Date:
Fire Chief Signature: Dater
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Descrintion of Work Being Performed:
1.1 NUMBER OF PLANS SUBMITTED: ` 1.2 SITE PLAN SUBMITTED: ❑ yes 01no
1.3 Property Address: % 1.4 Assessors Plat & Lot Number:
Nearest Cross Str et: `
�us. Na �i �- Phone#, Plat Lot
J.
Total Land Area ht a , � �'-
1.5 Water Supply (MGL c 40 § 54): 1.6 Sewage Disposal System:
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site, -'Disposal System
2.1 Owner of Record:
ye/� / alel-� Az/<- L L AS- Vel?
Name (print) Contact Address p
Tele hone
2.2 A thorized Agent:
ame (print) Contact Address 4 Telephone
ro c•\hlda fnnnc\hl�loann cm hPaaa 1 �r,r.,.-,." 11 nnn I