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BP-93302,ttIAL _ ,_ 5ECTIOtV 2 ;E�REiPfrR3XI,d1NNERSHIPIAI](THOfZtZER ADtVT, ?.1 wner Record: 9 ®(a44� Jame (print) Contact Address Phone Number >_.2 )kuthorize gent: l'q?l oo ,Ia (print) Contact Address Phone Number 1.1 Licensed Construction Supervisor/Specialty License: License Number: ;ompany Name/Contractor Name: sakpwk�1 0 l v lddress: Expiration Date: r(J%a5__1lq signature: Telephone: IzFr7 91 ,(00 l.2 Homeo r Exemption tne & 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 igacges 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 ere irs, 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 ie home in a two-year period shall not be considered a Homeowner. ' you are applying under this section sign below: 1gnature: $,. SEGt(3N,,{1VORRY$rG3V1Et�SAT�DN[SUftAfiICFF1DA�l1it(MG�„c1j2vj.A: Yorker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this ffidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No Lt 1 51* Flb f 5 t? $GRIt IO81 Q `PRQPOSED WORK" heck all ai5p('[cabl�j f __,: h 7 Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove 7 New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors r' I DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: Location: f new construction, please complete the following: 'ngte Family: No. of Bedrooms No. of Baths vvo 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): BoJ1er (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): Air conditioning - (separate unit) None of the above to be provided Hot Water: Gas Electric Fuel Oil Other 5^7 .• x .. = yr . `<__ - SEG�[V 6 ESIIiACFED=GE1ST,1f TtDN=COST Item Estimated ed Cost $) to be completed by permit applicant 1. Building (� l 2. Electrical 3. Plumbing 4. Mechanical (HVAC) �---- 5. Total=0 +2+3+4) Q s x � k N TA O�1NER�liTt{O IZI�$taf� , _ . �,'��o,be_�aFmpA�ef�d`yuhtrt�.owrter`s�gertf �r:contractorappii�;sf�r�tt€Cdtn�'pefml��, � �. , ...crin , - �= (Pleas as Owner of the subject property hereby authorize to act on my beh f, in all matters re tive o work authorized by this building permit application. ~491 �jV re o Own Date .° . �.�4- =� t .. .=' ...` SEG?(DN 7B �IAINERiA�11?I�QRt�Epl.�►��f�T t7liGtr4R�4'�10(�..:�=� ...:'. " as Owner/Authorized Agent hereby declare that the statements and] information on the foregoing applicab'o are true and accurate, to the best of my knowledge and belief. Signed der the pains and penalties of perjury.Zovr/ ^^'' i Y Si re of Own r/Au orized Agent D datete Total Permit Fee: $ Less Application Fee:42t"U �Other Remaining Balance: 6 _/ $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: v y 1 ajklvu ek� ti 1 lwe( L, 't 6"i7L worl 11 DESIDEDiIAl ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON RE -FUNDABLE & NON-'HANSY,ERABLE - -, Dkt RECEIVE °UT° .�`- DARTMOUTH BUILDING DEPARTMENT Cz 400 Slocum Road v 'O Dartmouth MA 02747 ioard of Health: ;onservation Commission: ).P.W.: 'ire Chief: 1.1 Property Address: Contact Person: / / Phone Number: 5� g9 / 66©d 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well ❑ On Site Disposal System r04 Date: Date: Date:: Date:; 1.2 Assessors Map & Lot Nurmber: Map 4(0-- [Lot 1.3 Historical District U Yes ❑ Year Built ❑ Altering more than Z5 % per side of b Has application been submitted to the Histo ❑ Yes ❑ No Date: :J I v r i� H ,iz- A 5 aft CONSTRUCTION PLANS SITE PLAN ENERGY F