BP-79567RESIDENTIM
®.Phased Approval (R106.3.3)
$25.00 PLICA'"ON FEE IS NON BE -FUNDABLE NON-1 SFEREIBLE
nourH: DATE : ECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road
8o zs
Dartmouth, MA 02747 r r
Phone: 508-910-1820 Fax: 508-910-1838 R
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:
Fire Chief: Signature: Dater
i
I
Other: Signature: Date:
P g P7
Brief description of work being eaformed: C �
i
11.1 Property Address:,,/-LJ-� ytg' r, .2,Assessors Map & Lot Number:
Contact Person: Map Lot T
Phone Number:
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 building
❑ Private Well ❑ On Site Disposal System Has application been submitted to'the, Historic Commission?
❑ Yes ❑ No Datre:
Revised
0 CONSTRUCTION PLANS 0 SITE PLANElENERGY