BP-76454�. a
f
9
M
PhasedEl Aoproval (R 106.3.3)
$25.00 APPLICATRON FEE IS NON REmFUNUABLE & NO],
Pe� DARTMOUTH BUILDING DEPARTMENT
Board of Health: Signature:
� Conservation Commission: Signature:
D.P.W.:
Fire Chief:
Other:
_lL DATE RECEIV y
Date:
Date:
Signature: Date:
Signature:
Date:
Signature: Date:
brief description of work being performed.,., U�/`����1 �-� �� °��
Contact Person:
Phone Number: 505i- -I�
1.4 Water Supply (MGL c40 s54): 11.5 Sewage Disposal System:
❑ Municipal ❑Municipal
❑ Private Well
❑ O'n Site Disposal System
A i E
Ma 0
r Lot
1.3 Historical District ❑ Yes ❑ l;10
Year Built
❑ Altering more than 25% per side of bt:�ailding
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
U CONSTRUCTION PLANS
_ e E14
1 i `i