BP-78188a
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2.1 Owner Record:
45 Y�ADOWOOd - 7�--�yy-3��
Name (print)
ContagAddress Phone Number
2.2 Authorized Agent:
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Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number: (�T
Company Name/Contractor Name: '"
Address: c, �/�l//� Qvq
Expiration Date: -
Signature: Telephone —J'(0'- V,?,V0
3.2 Homeowner 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 peeson(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, or is rntended 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:
, r fCTl i ItUUk f l ' t 1Ut 1�5�► QAI IN UR I,C>~ F JDA�l1T f1) 1<c fi t 2*
�- 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
V.
❑ Deck ❑ Pool ❑ Repairs XAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
11Sct [&
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows— Doors
❑ DEMOLITION (specify):
Location of debris removal (per Mr1GL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
f
Facility Name �i,i,Qwat- V g(�U"�
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 Wa,er, Gas Electric Fuel Oil Other
Item
Estimated Cast ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
-
tp)et vvh owner's �tgerit or c�nf�actof apPfi f6i bufldtrFt tmit
_ � Q e ca n ._ _
(Please Print)
/ / d I, mue l c 1 , 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. IJSignature
of Owner Date
SECTION �B OWNitz//�llTOR1ZED AGl„NT�E#�RA CIC3f�t„ ,' .
f, b as Owner/Authorized Agent hereby declare that the statements and inforW. ation
on the foregoing 4dication are true and accurate, to the best of my knowledge and belief.
Signed and pains a �er�altie o perjury.
/
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Signatur ner/A horized Agent Date
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.
Permit Issued to:
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For bZM/n;AJ
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RESIDENTIAL
❑ Phased Approval (R106,3,3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & "N-T RA'SFEK LE
I-�_ -DATE REGEIV .
f4 . 9s DARTMOUTH BUILDING DEPARTMENT
400 Slocum H L
i� um Road 15 .��1:� 2 7 P 1 9: 21
?z Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
1664
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 perfonned.
'` �::, � SECTION SIfiE;[t+tl~QRMA'ftON, � i
1.1 Property Address:AJ K/O f w u 4 6r • 1.2 Assessors Map & Lot Number:
Contact Person: J'\ it Map Lot -
Phone Number:
.1.3 Historical District ❑ Yes ❑ No
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic CommiIssion?
❑ Yes ❑ No Date:
ReviW ,1
ElCONSTRUCTION PLANS El SITE PLAN ® ENERGY REPO�[f�