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Name (print)
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Contact Address Phone Number
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Name (print)
Contact Addt i ,hone Number
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3.1 Licensed Construction Supervisor/Specialty License; License Number:
Company Name/Contractor Name,
Address: ✓
Expiration Dater
Signature_ Telephone:
3.2 Home ner Exemption- One 8dwo 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 p5 ing work for which aBuilding 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 such wo such Homeowner shall act as supervisor.
For the purposes of this section only, a "Homeowner d as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
they e is, or is intended to be, a one or two family dwelling, attached or 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.
if you are applying under this section sign below:
Signature:
.,.EIISi.tCiit' GUiVfPlvtSTfLI(#1atFGt=FC[?AtLt (OGI52 §�1 ., ..w� a :
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
of davit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
❑ 'Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ ;New Construction* ❑ Accessory Bldg. ❑ Addition oofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows_ Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL CAA Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
1f'new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Tw,o 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):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ Done of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
Item
�Estimated Cost to be Completed by permit +ppli ant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
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GT1Q A -� E AI3T �17.1t► �� � ,
when,otivnet�s agent dr corttrat tctpPfi�r (3,raildrng p_rr ifj 4
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(Plea e tint %
1, as Owner °Wsubject property hereby authorize r
t this b 'I in r it lication. to a t y beh f, in all m e s r i e to work au y ul d g pe m app
Signature o er Date
2 2EGT(Q ' =QWi�Eit, . T€3Rlli A�GP f}ECtATIOF f, =
_713
Authorized Agent hereby declare that the
1 r statements,, rand information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Sig ne nder Jhe pains and penalties of perjury.
Signa re of Owner/Authorized nt Date
=.Ep �y
(Y P�C'i� Q' i:i a>r^''� T:y:;..- r' :: ' c ;
-� ` ,S? .a .t ..r
Less Application Fee: $25.00
Remaining Balanca3: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
�E..r..t.. �"�rt.,
ts9:..Y�e....:..s�a^wna�...:,..... .-€.et. ,. �..`�_.rc .+�,...-._ .a. .-.....: ... _,.._. ...uC'. .„ -+§- .Y'..'Z ...<5v.. '#:. ... :�` .ks. '.: �.,> °..'•'s. 42�. v.A
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RESIDENTIAL
❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON HE -FUNDABLE
pAiE P'EEIVED
DA T OUTH BUILDING DEPARTMENT �1� DEPT.
400 Slocum Road
° c Dartmouth, MA 02747 I'M S- P B #3 2: 02
Phone: 508-910-1820 Fax: 508-910-1838
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:
Date:
Other: Signature:
Date:
Brief description of work being performed. Ile, ej7W
1.1 Property Address: )
lamContact Person: K0.1
�J�7
Phone Number: J S
6 6 P /
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number::
Map Lot
1.3 Historical District ❑ Yeas ❑ No
Year Built
❑ Altering more than 25% perr side of building
Has application been submitted toy".the Historic Commission?
❑ Yes ❑ No `Date:
RavisPd 5 /13
I
El CONSTRUCTION PLANS 0 SITE PLAN 0ENERGY REPO TIC