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�� TOWN OF DARTMOUTH
�� r y�h APPLICATION FOR
\c� - jy BUILDING PERMIT
LOCATION OF BUILDING 161 y‘(v (a//gs roR /or-/2 /7
/�, #0 `-/ne7uW7
01 Street & Number�6Fe � OM1 t /475 Corner R 01.1 Zoning District>> t II
q 02 Cross S /Street (b02 —etween)
F and
03 Lot lat 04 Subdivision Lot
OWNERSHIP COST
05 EX Private (individual, corporation, 36 Cost of Improvement /25Ll)• 0.00
non-profit institution, etc.) 36.1 To be installed but not
06 ❑ Public (Federal, State, or local government) included in the above cost
TYPE OF CONSTRUCTION 36.2 Electrical
07 ®'New Construction 36.3 Plumbing
08 ❑ Addition -Type of Room(s) 36.4 HVAC
09 ❑ Alteration 36.5 Other - Specify
10 ❑ Foundation Only example: elevator
11 ❑ Demolition (#of units if residential) 37 TOTAL )o2✓��W• in
12 ❑ Moving (relocation)
STRUCTURE
STATISTICS 38 2/Wood Frame
13 Number of Bedrooms 2- 39 ❑ Masonry (wall bearing)
14 Number of Bathrooms (Total) t 40 ❑ Structural Steel
Full-Tub 41 ❑ Reinforced concrete
3/4 - Shower 42 ❑ Other- Specify
1/2 - Toilet Only
RESIDENTIAL-PROPOSED USE DIMENSIONS
15 E "One-Family 43 Number of stories 1
16 ❑ Two or more families 44 Total square feet of floor area, all floors, ��
Number of units based on exterior dimensions
18 ❑ hedge 45 Total land area, square feet /)f 2,733 �y
6,6
19 ❑ Carport Q
20 ❑ Swimming Pool SEWAGE DISPOSAL
In-Ground Above-Ground
21 ❑ Woodstove 46 El Public or private company
22 ❑ Fireplace 47 l 'Private (septic tank, etc.)
23 ❑ Other- Specify
WATER SUPPLY
48 ❑public or private company
NON-RESIDENTIAL- PROPOSED USE 49 G'Private, (well, cistern)
-24-0 Amusement, recreational PRINCIPAL El Church, other religious TYPE OF HEATING FUEL
26 ❑ Industrial 50 ❑ Gas
27 ❑ Parki Garage 51 L 'Oil
28 ❑ Service's ion, Repair garage 52 ❑ Electricity
29 ❑ Hospital,in 'tutional 53 ❑ Coal
30 ❑ Office, bank, ofessional 54 ❑ Other - Specify
31 ❑ Public utility..,
32 ❑ School, library, r educational TYPE OF MECHANICAL
33 ❑ Stores, mercantile 55 Will there be central air conditioning? NI/Noean elevator? g'
34 ❑ Tanks, towers 56 Will thereb ❑Yes
35 ❑ Other- Specify ❑Yes Ga No
t.___, _
PARKING PER ZONING BY-LAWS
57 Inclosed 58 0 Outside
59 Does this building contain asbestos? ❑ YES GAO If yes complete the following:
Name & Address of Asbestos Removal Firm:
Submit copy of notification sent to DEQE and the State Dept. of Labor Industries and result of air sample analysis after
asbestos removal is complete.
IDENTIFICATION -To be completed by all applicants PLEASE PRINT Mal)? 3'
60 Owner (print) Sandra- A- - .Sboi'cs 1/ £/v/27FirA/F /V6 . /9.399 thrPlc-'
NAME MAILING ADDRESS TELEPHONE NO.
61 Signature /DATE c'01
Builder's
62 Contractor (print) License No.
NAME MAILING ADDRESS TELEPHONE NO.
63 Signature DATE
64 Architect or Engineer (print)
NAME MAILING ADDRESS TELEPHONE NO.
65 Signature DATE
CERTIFICATION TO PERFORM WORK
66 I/We hereby appoint
NAME ADDRESS
as my/our agent for the purpose of applying for and obtaining a building permit for the work to be done described in this
application.
Signature DATE
ADDITIONAL INFORMATION
67 Addition to No.
�'' . TOWN OF DARTMOUTH
It j°fin WIRE iDEPARTM NT /)
y / j � 'Date ��.
y 5 Name in P :IL,
Amount
/6:7 �-x-a 46,1c,� G /°Aid e: ��i/.C-�, 075/2 o d
1 '
REQUEST FOR ASSIGNMENT OF HOUSE NUMBER
Owner(s) of Property Sonclr&. A Soairs
Present Address it EMMf4 R 1 at Nn 1Mr4-n ou-l-k
Telephone Number qq - -77361q
House Location: Mat j7 Lot /5
Subdivision s'\\,,,4, c tct ee o r cT Lot \G
Corner. Lot ? Yes No ✓
Street 5k i nc3t e _T_ vAncl La
Single Family ✓ Multi Family _ Condominium # of Units
Site Pldn Submitted ? Yes No Date Submitted
rlpi22 C -,Fi�Cr/�P/1
Signature of Owner
House Number Assigned4c0 1,4 ,,4(As. \fie - L - Date Assigned a• 3i - b�7
Date Assessors Notified a- a1 -69 Date Building Dept. Notified o - 31 -&j
Date Owner Notified
WAS G.fA P.w o"%A 9 - a- s9 � ���
�, Department of Public
Speed Message
lt� To t\.•O't iL-1..c `1 '.TG From `0`-P T. OF' '71/4"vaa c. N.IOSZ 6GS
• ay.C.,t -.E. i t �� ' .
Subject \—a n11G i-- Ls.SS KCE1V ED
Date S P g 19 a_
A-ov SAD -Tt�A-c "�ia� ASR t<-,tv TD
0t.4.. - :s1 -69 FEZ LcT 15 (Or St-& 1t, L t< Ar` c T= ST
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Sutti.ct�= ISr Cst= G ATTACHe
Signed i�`<� -er/
WilsonJones $5
ORAYLINE FORM 44-9W P-PART
c1963•PFINTEO IN LLS A.
�,. ..
BOARD OF HEALTH
No 9- / L.I7Mrn OF ebad.td142414..1 FE ,5`40 f1P-
Elispunat Pinks ppOnunnirnrtinn rnuit �T'
Permission is hereby granted G4M..C�I..(St. tQL'J.G.na
to Construct '-)`or Repair ( ) an Ijidividual Sewage Dkposl Syst
at No teat... �7)._..eras /5 J��LwG<r.1L4%n6�.._ cix[�
Street �q C
as shown on the application for Disposal Works Construction Permit No..._Q 9-0/ Dated.._.._r _�,a -�9
llet
DATE...
Z S �y�p Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Na O !- d/
This permit must be shown upon request of any agent or Inspector of the•Health Department.
--)44 '-` is hereby granted a
NAME
permit for co uction or alter on of a septic system
at No. . . e eA-e- /5,, • C24. - subject to
' rC�O ApfDRESS
the rules and regulations of the Health Department.
jet dip / D
For the Board of Health
Dartmouth, Mass.
�. .p?,: 19 /9
•
-NTOWN OF DARTMOUTH
BOARD OF HEALTH
CK
Date r , y �7
AMOUNT
Received of: zitCt I /
/79lei. l" 7/ e /5_
1
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FOR: )(4/72 C=c Iv) `,cam 7
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BY: 7 _.. 11 Ac¢.Ie
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BOARD OF HEALTH INSpECTIOtj
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REQUIRED WHEN EXCAVATED LJCD, C)F- PV--
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BOARD OF HEALTH INSPECTJO�l
REQUIRED WHEN EXCAVATED lu,5-TALLFc) lu Accc)op4sjoa vjqw -mLp- 5 C)G-
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ELEVATIONS MUST NOT BE
EY -,115MUG -T
CHANGED WITHOUT BOARD Cou 1 OU2�5
OF HEALTH APPROVAL PeoposED CIOUTOUE5
-w VJILITF:52 UU�
0 \&JQLL—
THIS Sys-
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Your Drawing Must Be Kept A IN 0
tt The Building During The4:, P�e�oeATEc PIPE
DAPITMOUTH WARD OF HEA -TGW-v L0jLj-T,5(P
LTH V.c)
Progress Of This Work. 4'CN51 12DU PIPS
BUILDING DEPARTMENT 01F--� r2 I -T k C��V_j P0,
Town T
artmouth of D:
rrC;APPZ.3VAL BYTHIS OFFICE OF
DOES NOT GUARANTEE THE
11p,
71 BENJAMIN
r-yc EFFECTIVENESS Of ANY 4,R.,
A.
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INSTALLATION 0 V e 41f 00,J et-(: C-3 GILK,10RE 11
NO
C-ARTMUTH BOARD OF HEALTH 110 No. 2-0074
vA
Ij I An As Built Survey must be APPJQ, 0; V F D U
Nei -7
RAL"' of B F:,,
submittcd to th-- Buildin gr
Da --e
�ej JU
Dept. prior to calling. for ---,r 4f 41 t\J G 1 MG I wc.
a foundation inspection or k -T Q �-j ss
A 5 PO. E50y,
japy further construction. T W xf 'ir),,; -a 1 0 U T U 1 -7 PO �50\/, cp Jou7w c1X2\JG, w" C)Z�-� J� L- 4c0I
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