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SECTION 6 - ESTIMATED CONSTRUCTION COST
Estimated Cost ($) to be comple#ed
-------------
ermit applicant
RESIDENTIAL
2 Owner Record:
-1L
Name (print)
2.2 Authorized Agent:
SECTION 2 - PROPERTY OWNERS HIPIAUT14ORiZED AGENT
Contact Address
1, Building
2. Electrical
3. Plumbin
/� l S� ��� �° �✓? 4. Mechanical (HVAC)
Phone Number '
5. Total = (1 + 2 +_3 + 4)
Name (print)
Contact Address Phone Number
.
SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
Signature: Telephone:
3.2 Llomeowner Exemption - One & Two Family Only Section 11 o.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
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For �e, purposes of this7section only, a "Homeowner" is defined as follows, Persons) 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
one home in a two-year period shall not be considered a Homeowner.
if you are applying under this section sign below:
Signature: �L
y
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Work-er's 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
IA
SECTION 7A - OWNER AUTHORIZATION
to be completed when ownees agent or contractor applies for build!
rml
(Please Print)
1,
as Owner of the subject property hereby authorize
i to act on.my behalf, in all matters relative to work authorized by this building permit application.
Date
Signature of Owner
SECTION 713 - OWNERIAUTHORIZED AGENT DECLARATION
I,
as Owner/Authorized Agent hereby declare that the statements and infcormation
the foregoing application are #rue and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
�►J�VAvl
Date
Signature of Owner/Auth rized Agent
I Total Permit Fee: $
SECTION 5 - DESCRIPTiON OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool
❑ Repairs d _Alteration
❑ Chimney/Fireplace
❑ Woodstove/Pellet Stove
❑ New Construction*
❑ Accessory. Bldg.
❑ Roofing/Siding
Ei Other
(Energy report required)
(Shed/Garage)
(Specify below)
❑ Addition
D Replacement window/door
❑ Demolition
(Energy report required)
No. of windows Doors ,
(Specify below)
V 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
D Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Bailer (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
D A17- conditioning - (separate unit)
❑ Ncme of the above to be provided
Hc)t Water: Gas Electric Fuel Oil Other
M10
SECTION 8 - OFF(CEIINSPECTOR'S NOTES
Less Application Fee: $25.00
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
O
Remaining Balance: $
ECTION 9 -ADDITIONAL COMM ENTSISKETCH ES
/1")
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RESIDENTIAL
❑ Phased Approval (R106.3.3)
S25.00 APPLICA►.TIQ1T FEE IS NON ItE-FUNDABLE & NON-Thf4ANSFEItABL1C
DATE RECEIVED
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DARTMOUTH BUILDING DEPARTMENT/7-
q
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400 Slocum Road
,.
Dartmouth, MA 02747
J664
Phone: 508-910-1820 Fax: 508-910-1838
-: -
wm.town. dartmouth. ma. us
_ .. _ ....
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR ;;QUO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDII\k"G
PERMIT NUMBER (e099,672
' -
r
DATE ISSUED:
MAY 1,0 2013
SIGNATURE:-"'
.
DATE.
Building Commissioner/Inspector of Buildings.
❑ B ❑ A ❑ V'
Aquifer Zone:
Zoning District:
.
Proposed Use: - Zone:
P
THE FOLLOWING AGENCIE SH U NOTIFIED:
❑ Board of
❑ oard of ❑ Cons. ❑ Demo ❑ DPW
❑ Elec. ❑Energy Report
Appeals
Health Commission Affidavit Card Sent:
Cut Off Follow-up*
❑ Fire
❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card
❑ Zoning ❑ Other
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OFF A PERMIT.
DEPARTMENTAL APPROVAL
Board of Health:
Signature:
Date;
Conservation Commission: Signature:
Date:
Other:
Signature:
Date:
Signature:
Date:
Signature:
Date:
Brief description
of work being performed: _ey
41
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SECTION 1 - SITE INFORMATION
1 1 roperty Address: 1 ULk 111I &r-J Pcfa:) 1.2 Assessors Map &: ' Lot Number:
Lot Area sf. '/ 5 Frontage Map Lot 2—
- U
Required Provided
Front Yard 1.3 Historical Districts ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
0 Altering more tlhan 25% per side of building
/4. Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been ',submitted to the Historic Commission?
❑ Municipal YIPrivate Well ❑ Municipal X
On Site Disposal System ❑ Yes - ❑ No Date:
Revised 10111
CONSTRUCTION PLANS _ SITE PLAN ' ENERGY REPORT