BP-91977TT- I 1
2. Owner Record: 1 it % /�, i
Name (print) Phon Number
Contact Address
2. Aut"ized A . t.elz
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Narp 'r n C ntact Address
Z Phone Number
3.1 Licensed Construction Supervisor/Specialty License: ~License Number:
Company Name/Contractor Name's ; ft) _ )IN
Address: f ,/
!� Expiration Date:
Signature:
Telephone: .
3.2 Hom4/ne'r Exemption- One & Two Family Only Section 11 O.R5.1.3.1 Exception:
�y FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exceptiorrr 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 ush"work,-4hat.spch Homeowner shall act as supervisor.
For the purposes of this section only, a "Homeowner" is e ned.3s 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 de a hed..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_
IfYou are applyingu nder this'
section.. sign below.
Signature:
Worker's {Compensation Insurance Affidavit must be completed and submitted with this application. Failure to ovide this
affidavit will result in the denial of the issuance of the building permit, Signed Affidavit Attached: es ❑ No
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition l�ofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMDLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): Dumpster on site ❑ Dumpster O feet
Facility Name:._ �
�� Location: ,
a
*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 (Bating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air cond'tioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas ' Electric Fuel Oil Other
J
1. Building
Item Estimated Cost ($} to be completed by permit applicant
�
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
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as Owner of the subject property hereby authorize
to act on my behalf, in all matter relative to work authorized bythis building permit application. ,`F
Sign at re of Owner Date
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i, as Owner/Authorized Agent hereby declare that the statements and inforrmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signe under the pains a d penalti s of perjury.
Sign ure of Ow
ed Agent Date
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% Total Permit Fee: $ Less Application Fee: $25-,M- Remaining Balance
Other $ Amount $
Gross Area - New Construction total sq. ,,ft.
Gross Area - Alteration total sq. ft.t
Permit Issued to:
NO
'3l
TI❑ Phased Approval (R106.3.3)
$25,0® PLICATI®1V' SEE IS NON ][6Em�' l[.E a� 1®T®1��7C5FER��LE
s�
DATE RECEIVED t
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DARTMOUTH BUILDING DEPARTMENT
[� 400 Slocum Road
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838 , a
7-1
wwvv.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR T AM1LY �WEtLING
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TOLt QIkNGAGENi✓lS:HQtJLb BEIfaT1FE
„y Q Cross..
<.:; [! Address :Ci Bngrneer ing
Ci6Qard of; t7 Board of Q Cnns Planning _
Card Connec@ion.
OR
Health . Con?m[ss�orr
Seiner:G�rd
4 Li Ftre Gas ❑ Eiectnc Ed Ofkter CI W -
i = Cut Off, Guf Off
., Ghiet :Cut If _ -
Cut:Off
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��I�ARTIN7•AL ,�PPRa�iA�(��
{ Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature:
Date:
Signature:
Date:
Fire Chief: g
t Other: Signature:
Date:
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Brief description of work being performed:
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1.1 Property Address:
j '7 yj � GL jtt✓ 1.2 Assessors Map & Lot Number..:
Contact Person: ��
�f Map Lot ---
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Phone Number: J C) q— 6-7
t 1.3 Historical District ❑ Yes ❑ No
1 Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted teethe Historic Commission`
❑ Yes ❑ No iDate:
• 5 °�p�evised 5 /1
C ST UCTI PL SITS PL. P� EI� Y REPORT
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