BP-85155!VL
H
PI—
2.1 Own,---nir Record:
rr
I mail
Name {pant) Contact Address Phone Number
•
2.2 Authorized Agent:•
Name (print)- Contact Address Phone Number
S
_1.1. zck 7.
U
Z: -V
E R, r.
-PPN Taif
I3.1 Licensed Construction Supervisor/Specialty License.- •License Number:
Company Name/Contractor U Name:
-- -- ft 1! 1 � s a - zjx,
Address: Expiration Date:
Signature: Telephone:
3.2 Homeowner 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: P-,:-iy 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 pers,,on(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the p . urpc!-Ses 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 in!','-,9nded 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 I not be considered a Homeowner.
If you are aipoplyi under this* ection sig elow:
Signature: a
4—,
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: ❑0 Yes ❑0 No
-.
- _
Y.-EK
cad .�� -
0 Deck Pool 0 Repairs 11 Alteration 0 Chimney/Fireplace 0 Wood stove/Pe I let Stove
El New'Construction* El Accessory Bldg. ❑0 Addition ❑0 Roofing/Siding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
rt
0 DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): 11 Dumpster on site 0 Dumpster On Street
Facility Name: Location:
*If new constrL.rction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family.- No of Bedrooms Unit I No. of Baths Unit I
No of Bedrooms Unit 2 r No. of Baths Unit 2
D Furnace (hot a 1r) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (pfy}seci:
0 HVAC (combir.lad unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air condition i nf--., - (separate unit)
0 None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
— -rX,
� ��N5 T 0
�,Z
-T
Item
Estimated Cost to be completed -by perrata Ppc nt
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total 0 +2+3+4)
7 :7
�r o-��-�l�.-`- S~- i
e a,gon
•
77 n 0 P e c ing,
omp W;-*
W Nz:�
z7f--
81 Rx
S t1l+
rac:.
(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
E GTION--7-B.--.�..OWNEWAUTHQttIZEQ--:,' 1E-NT---.DEC
0
informo. Li
as Owner/Authorized Agent hereby declare that the statements and o r(,Pj a aition
v on the foregoing dpplication are true and accurate, to the best of my knowledge and belief.
Sign"/d under the pains and penalties of perjury.
a I - a.
nature of Owner/Autlhorized Agent
Date
T1 QY.
'EC CEA.' SPE
-Nr
Less Application Fee: $25.00 Remaininit
g Balance: $
Total Permit Fee: $
Other $Amount $
Gross Area -New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: I(/��./� `lylr...��,.--. P%.r � `i, f �r�°" ���C:� �'-� � ! �� ���,�
I—#
lr
-0 mx
.0
E i7
t.lj
EP-TTT:
Nr -9-
% -Ift DATE RECEf VE,-��, :.Qj
ART`MOUT BUILDING DEPARTMENT � �w
400 Slocum Road
�:z = Dartmouth, MA 02747
°.� .-- -- s r� Phone: 508-910-1820 Fax: 508-910-1838 - `-
www.town.dartmouth.ma.us =�o- __�,.. �-.
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIN
S
JGN'�-
-TflS.-S T
... . ... ...
•
•
LDN
E. R-ED-I BI
_ tISSUED
�DATE-
00do
T.
-0e
OF
-DAT --S:I.G -R NAT
iA
•
7. _trr
1.
j.
himi:''sione
0i ding, s r nsr or.
t Jdr��
Tf
ST.
EIAf r. �o
h'in, :4) C- t
t_
L
P -W
E 0 T1 F.1 ED
UL
L ow 'A t-:-N 0r.
t ay
P1 . •. . .. .•nq neer
ro•
t -I �:
I h q
-,Add'*;
anning,
i.
oar A
ne( i p n•
S.
Off
17
Ut.
t
Off
wer
F
0.,. Oth*6r,",
d.
-1x.
• L�APFffOVA
MINT T R
N
10"
Board of Health: Signature. Date:
IConservation Commission:
D.P.W.:
Fire Chief:
Other:
Signature:
Signature:
Signature:
Signature:
Brief description of work being performed:
Date:
Date:
Date:
Date-
r
zicv
N 10
1.1 Property Address: dti roj IC,) LCU J.2 Assessors Mai) & Lot Number:
Contact Person: meuzio oil IJ4
ra 1,t
Phone Numer•,b
C
Map d 7 Lot
`7
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
0 Municipal 0 Municipal
W-*#<rivate Well 0 On Site Disposal System
1.3 Historical District 0 Yes VNo
Year Built �Ct 7
11 Altering more than 25% per side of building,
Has application been submitted to the Historic Corr-nmission?
0 Yes 0 No Date:
5 T u G ir 10"' N P LIE's
ed 5 113
EF N FF ("Y PH-"r-ft Fr-PE!m P2*'
MM L