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BP-77810V O per° a w 6 G �} C m Gm i� w O _ m � CD CD to c �N p N; N S IJ �H O n 2 C N � S ti lb Q UV � Z3 1 i H �Vj I �p T v CID r RE IDENTIAL $EGTfON & ESIIVFATEIDC©NSTRllTfFtCOST SECTION 2 =PROFRTY_OWNf=RSHIPIA[iT10RtZED �401_NT tPPlicant Item Estimated Cost ($) to be completed by permi . 2.1 Owner Record: '"" 1Building2. Electrical 3. Plumbing Name (print) Contact Address Phone Number 4. Mechanical (HVAC) 5. Total= 0 +2+3+4) 2.2 Authorized Agent: �_ = ;SECTION ?A O�tYNEf �4liTHORI2ATION _< 5 {#o be_coirnplete>when bwl�er'S agentOr'cotitracfor applies forbrailding permitj Name (print) Contact Address Phone Number (PleaPnnt) ll/ as Owner of the subject property hereby authorizen;i" SECTION 3`= CONSTRt�CTION SERVICES _ _ _ K to act on my behalf, in all matters relative to work authorized by this building permit application. EMicensed Construction Supervisor/Specialty License: License Number. Company Name/Contractor Name:,lirins tt CG %U i0oa Signat of O er Date C� Addres : Expiration Datet: ' ECTION 7B=.0WNER/AUTHORIZEQ AGENT pECLARATION Sign at e: phone: / 4j as Owner/Authorized Agent hereby declare that the statements, and information 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: on the foregoing application are true and accurate, to the best of my knowledge and belief. FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Signed under the pains and penalties of erjury. 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 j engages a person(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 SigKtuf6 of O /Aut orize A ent Date 1. one home in a two-year period shall not be considered a Homeowner. - _ ,SECTION 8 =OFFICEflNSPEG`I'�R'S NOTES ;r- _ _ If you are applying under this section sign below: / Less Application Fee: $2 Remaining Balancea: Signature: Total Permit Fee: $ Other $ Amount $ SECTION WORtCER SuCO�IPI;NSATION �iV$URANCE AFFIDAVIT (MGL c 15 § 2Sj e Gross Area - New Construction total sq. ft. Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this Gross Area - Alteration total sq. ft. affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No / r SECTION 5__ DESCRIPTtF.:PROPOSED.;WORK,{Chellppl(cable) _ Permit Issued to: 1 -/ ION ❑ Deck Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove11 %— New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street _ - , �, SEGTIOtt�1 'R1r5GHfPT(ON OF �IIfO.�tK=BEINGPE��ORIV�PD, :U ,>p, _ Facility Name: Location: *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 (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): l El HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): SLai/v ❑ Air conditioning - (separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other RESIDENTIAL ❑ Phased Approval (R? $25.00 APPLICATION FEE IS NON BE-Fi]T`_—...__-A-,E & NON -TRANSFERABLE -- DATE RECEIVED rP f"9ts DARTMOUTH BUILDING DEPARTMENT rgN ; l 400 Slocum Road Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us 1015 JU14 26 +l 1: 47 APPLICATION TO,CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING k � 1 oard of Health: Signature:'_ ` Date: k Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief. Signature: Date: Other: Signature: Date: Brief description of work being performed: r 1.1 Property Address: ( `r UyrlU, 1.2 Assessors Map && Lot Number: 2 Contact Person: el?q 7-i)-)q Map % Lot Phone Number: � �� z�5 -- O 1.3 Historical District ❑ Yes ❑ No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of buildir,1g Vrivate Well Lgf-*On Site Disposal System Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: F�evised 5 /13 ® CONSTRUCTION PLANS ❑ SITE PLAN., DENERGY REPORT r