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1Building J
2.1 Owner Record: 2. Electrical
K 60 R
14""` r 3. Plumbing N TO t4 I-0- Ruco--GLEO. Is; MuIWGBIRL)
Name (print) Contact Address Phone Number 4. Mechanical (HVAC)
5. Total (I +2+3+4)
pi
2.2 Authonzed Agent:
. - •ram `. r !t � � - -t t•= -4'r � #
Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: _ : _ License Number: ---
Company Name/Contractor
i N Iqs
Address:LIA
f-,-"ot I- Expiration Date: MS W
Signature: Telephone: l 14-2 Lai- 21
3.2 Homeown r Exemption - One & 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
eigages 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
tt, ere 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.
(► you are appying_under thissection-sign-below:
Sgnature:
Worker'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
❑ Deck ❑ Pool
❑ New Construction*
(Energy report required)
❑ Repairs ❑ Alteration ❑ Chimney/Fireplace . ❑ Wood stove/Pe llet Stove
❑ Accessory Bldg.
❑ Addition
❑ Roof ng/Siding
❑ Replacement window/door
(Shed/Garage)
(Energy report required)
.5ellt,14 v
No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*If 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
❑ Fu-nace ('hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Bo"er (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
O Air conditioning - (separate unit)
❑ None of the above to be provided
13 Hot 'Water: Gas Electric Fuel Oil Other
-
Estimated Cost ($) to be completed
ermit applicant`
M
(Please Print)„
as Owner of the subject -property hereby authorize
to act on my behalf, in all 6tters relative to work authorized by this building permit application.
ald
Signa ure o Owner Date —T
SECTI_�hI _7B.__� tE�/ 7 IZED-GBNT,:DE�GLRATIat:.
...... . -
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pp' s nd penalties of perjury. j t
/Y
Signaf�� Owner/Authorized Agent Date
sp- _
- - t
- rd
_ Less Application Fee: $25.00 Remaining Balance: $--�
Total Permit Fee: $ _
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
712-5
9Permit Issued to: -, Perm /�
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01
149.s-1
11
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RESIDENTIA1 ❑ Phased Approval (R106.3t3)
DATE RECEzTVED
��" o�'' "��: ,j� T OUTH BUILDING DEPARTMENT
�_ 1�t .
'��_- DAR A Mid •
to ' 400 Slocum Road
n� _. _.... _..
'� C. Dartmouth, MA 02747 ,4
2 _ c, "
:.o �y ,:r Phone: 508-9� 0�1 820 Fax: 508-9 0-� 838
`Z` • .. .— ^ WWW.town.dartmouth.ma.us `:
N TO CON TRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR Two FAMILY DVW LLING
APPLICATION -- _ _� _ _ _
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Board of Health:
• . - Conservation Commission:
D.P.W.:
Fire Chief:
Other:
Signature: Date:
Signature: Date:
Signature: Date:
Signature: Date:
Signature:
Brief description of work being performed.
A
1.1 Property Address: t
Contact Person: -R
Phone Number
O', (11013 e^
k
1.4 Water Supply (MGL c4o s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private well ❑ on Site Disposal System
Date:
1.2 Assessors ap & Lot Number: ,�-
- 0s
Map Lot
I
0
1.3 Historical District ❑ Yes I❑ No
Year Built
❑ Altering more than 25% per side of ` building
Has application been submitted to the Hisitoric Commission?
❑ Yes ❑ No Date:
_ _. /^J P��� ��.� d5/13
❑ CONSTRUCTION.PLANS'
❑SITE PLAN ❑ENERGY [REPORT^,-5��1`