BP-71777a
M1 1 IAT1®1
Owner Record:'
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lame (punt)
Contact Address Phone Number
2.2 Auttorized Agent:
Name (print) Contact Address Phone Number
7,111
7-
3.1 Licensed Construction Supervisor/Specialty License: License Number: Ad i2 j5
Company Name/Contractor Name::t�� 1�` aL I
Address: (� 7 � ? r U(— . L,`(�G,3�joz- , d��$
Expiration Dater
27
Signature:-ete-phone:a1 .>
3.2 Horneo er 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
engages 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
there is, oT'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 apse applying under this section sign below:
Signature:
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Liu
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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
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XA Inndsto Stove
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace LPellet
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
11 DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facflity 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
❑ 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
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Item Estimated Cost ($) to be completed by permit applicgant
1. Building
2. Electrical
3. Plumbing
4 Mechanical (HVAC)
5 Total (1 +2+3+4) Z'
r -i _ &®�I_I p� 7210
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(Please Print)
as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
t ii I � , R � � �"
? 7 2 i1V � , �. � 011"A'
as Owner/ uthorized t hereby declare that the statements anc information
the foregoing application are true and accurate, to the best of my nowledge and belief.
Signed under Op ' a, penalties of perjury.
Sign e f O ner/Authorized Agent Date
i.,, J..
fi+1,81FF,IaSINP
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r� �Y Less Application Fee: $25.00 Remaining Balance: $3.
Total Permit Fee: $ /
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration t al sq. ft.
F 'p
Permit Issued to:
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RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NOSY BE -FUNDABLE s& NON T SftMc LE
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To DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road 26D NOV —6 PTI 33
Dartmouth, MA 02747
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 DWELLIING
Board of Health:
Signature:
Conservation Commission:
Signature:
D.P.W.:
Signature:
Fire Chief:
Signature:
Other:
Signature:
Brief description of work being performed. _
Date:
Date:
Date:
Date:
Date:
1 Property Address: 7V k, 1.2 Assessors Map & Lot Number:
j
Contact Person: ����--c Map Lot
Phone Number: A 44 St -7/
` 1.3 Historical District ❑ Yes 10 No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side off building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the His•;toric Commission?
❑ Yes 11 No Date:
Revised 5 /13
EJ CONST UCTION PLAINS � SITE PLAN E ERGY xREPORT
t-777