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RESIDENTIAL
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
!_ cn >,V � is
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this; affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
-_ _ .. _.._ _ _ ' ! _ 7 _!; _ . t � • ... � 1 .'.:.:..,,...�� � r. mil-. � �� •. ;: ...
❑ new construction*
(energy report required)
❑ deck
❑ pool
❑ addition
(energy report required)
cessory bldg.
(shed/garage)
If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs
❑ replacement window/door
no. of windows doors
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):
❑ - 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
Brief Description of Proposed Work:
Item
1 Ruildina
Fle..r.trirnl
I Plnmhi
A MPrhnniral (TJVAC )
5. Total = (1 + 2 + 3 + 4)
�l
❑ chimney/
fireplace
❑ other
(specify below) :
❑ woordstove
❑ demiolition
(specify below):
Estimated Cost M to be completed by permit applicant
* Estimated Total
(please print)
, as Owner of the subject property hereby authorize
19
to act on my behalf, in all matters relaAve o clrkjuthorized by this building permit application.
Signature of Owner
Date
v I t, s , Lon-x iIV 6 ()� , as Owner/Authorized Agent hereby declare that the statements and iniformation
I k
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pair s and penalties of perjury.
ate
Signature of Owner/Authorized Agent
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CAbldg.forms\Bldgapp.res.wpd
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Re;v. January 1, 2003
RESIDENTIAL
1:1 FOUNDATION ONLY
RESIDENTIAL 2004
El FOUNDATION ONLY
$25.00 APPLICATION FEE IS NONmREFUNDADLE & NONwTHANSFERABLE
1. Date plan reviewed:
2. 30.days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:-
7. HOLD subject to Zoning Board of Appeals action: Date:
S. Comments:
TOTAL FEE: oo Gross Area - New Construction total sq. ft.
Gross Area - Alteration total'sq. ft.
Permit Issued To: � 4.7 Y,- / rl /0 -Ox Eee:�J- / C"Oot /I
I
$25.00 APPLICATION FEE IS ZVONwRFTUNDABLE & NOMmTRANSFE N'RiABLE
DARTMOUTH BUILDING DEPARTMENT DATE RE WED
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
C. ;4
oning Distric Proposed: t .0/0
Z t ' - lus d Zone�,� u sideYloo '& r ft:
Ulfe Zo
THE FOLLOWING AGENCIES SHOULD'BKNOTIF IE D
-11 Board:of oafd: of
OC Con: ..... 1:
on C �4, �* elmo
Cam: IJ �D 0 DPW
13 El c i��:
e
V-� t
rgy:11( epor
Appeals: ealth':5
-"�AffidW; it Card%Sent:
V1
C U wff
TolloNN, ul?7:;�:x-:
W V :Pk
0 F 0 G-a's
0 Planning BoardOSeweu'Card Water Card
Zoning
O OtherJ,1P.,: 1,
Chi Cu
Chef
U .Off,.
re t 1 Cut Off w
Review
QUIRES'I'N"SP'E"C"TO'R":S'RE�VIEWBEFORF,THE ;,ISSUANCE OF
... . ...... .
EPARTMEN
TALAP PROVAL�d��,-
W Z.Aft
Zoning Review: Signature: Date:
ffid--I
Energy Report: Signature: Date:
Fire . el: Signature: /110) Date':
o 0ard f of HoI 'Alp
ealth: Signature:- Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:—j
NUMBER OF PLANS SUBMITTED:
1.1 Property Address: ;K ver13 67-41Llv Z^�
Nearest Cross Street: /?fF7&-b
Subdivision Name:
31 -
Total Land Area Sq. Ft.:z3 -
1.3 Historical District Dyes Ono -
Has application been submitted to the Hiistoric Commission?
11 yes El no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
Private V, n 0 Municipal Private Well El Municipal VIO
I Siite Disposal System
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t ��
Rev. January 1, 2003