BP-67537'd
RMrnFHBoM
■ a& min ii a o m Y ■ae
•
_ _...
-SECTIoi .2 - PR PE
_..
T
RtZE A T.
2.1 Owner Record:
�5t
• Contact Address Phone Number
Name � -(print) .
2.2 Authorized Ag t: •
1J�U\
i rj A
A
Contact dress wrm - Phone Number
Qb UName {print} _
IJ L
.. ... ..... . . . . . . . . . .8
F� J 5R C'
""C"'O"''N' T t CTION
:.
• :' .: .:
3.1 Licensed
• construction Supervisor/Specialty License: License Number:
Corr' 0
an Name/Contractor Name: 1
r
Addr .ss. 1:5
Expiration Date:
• r Telephone:
n .�tu e.
S i e....
9 .
S LaA&(&iU
3.2 Homeowner Exemption - One & Two Family Only Section 114.R5.1.3.1 Exception:
FOR H.IEOWNERS 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
engac es a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For Vne rP
u oses of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land an which he/she resides or intends to reside, on which
P
there i` , or 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 youare applyingder this section sign be
low: ow:
,
Signature:
i {f{rih�■( �I{{}}�,,•���j�}J. CE�•A•FFtDA'lT:.GL•c':':52:� •:::25 - - . -.
...:....:...:..':::::... SECT�ot --4 1�vQR�{ER :S I PEN
l §.
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. ❑ lies ❑ No
..
.._ .. ... .... .....ORO:..:-�we.-.::.:.::.:�.::...:.$:: ::.:.._�•���::��:�_-:......:..........:.
oF: : C�SEh
oRK. Check .att:a _ .......:..... -
I p
❑ Deck ❑ Poo ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
0 New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report re re(Shed/Garage) {Specify below}
quired}
Replacement window/door
0 Addition ❑ Demolition p .
(Energy report re re No. of windows ^ Doors {Specify below}
required) }
*If new construction, please complete the following:
Singre Family: No. of Bedrooms No. of Baths
Two �, amily: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Fu-nace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Bo7ler (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)
❑ Nci-ne of the above to be provided
0 Hc'l Water: Gas Electric Fuel Oil Other
Signature of Owner
:..... .
' .:......:..............
.l.-: •..... ... • -
G N D
CLARA
E A ..:.. �.
.. UTHOR �...
o �vE
� w
SE
CT[Q N 8
I I vl�'
Va.i_ i—, as Owne uthorized Agent hereby declare that the statements and inforrmation
I,
on the foregoing application are true and accurate, to the best of my knowledge and belief.
erN
9 9 PP�
SigneAr�der�i�ie �Ins '�nd penalties of perjury.
1
Signature of Owner Auth�TAgent
Total Permit Fee: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit issued to:
is
o
CT R
C IQ�V 8 0 F FI
c Ell
SP
:S T
E
kk 1/ 1-:7
Less Application Fee: $25.00
Other $Amount $
S
�
101ci
1, 1 �6
R
Date
Remaining Balance:
}
' `-a i t}
• % ' ,iT -
I.Jti I
❑ Phased Approval (R 1 06.3. 3)
$25-00 APPLI[C.�.TION FEE IS 1' ON_ � EwFU �D.BLE & I�T0N=T1'ANSF f'117 :�.
s...l�■rww�..r'.�.,.,,�..
.1 -
r ; _11 `.R�E�OEI /ED-
S t
• +
uAK I IVIUU I ti tiUILUING UtPAKT MENT
1 s
400 Slocu o d .O
m R a P .Box 79399
. 1 �•
- `�& Dartmouth MA 02747
t__ f ._ • :ter !
G� - � ��� Phone: 508-910-1820 Fax: 508-910-1838
���� . r
• www.town.dartmouth.Ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DI!NELLING .
:'
_... .
'..:.t:... ...� .. :...••.......,a
r�..
-?
,,
:..
I
':
. "t
t.
:.. : .. .: .:.. : .: ... .::.. ! - ... - . , - :... . L-..: .
.. _..
�.
CT,FF�IA a�SE.ONLY':
�. :�'
:.
a' f
t i .,
• {:.
r•
r
\,
t
t
♦ /'• ' t:
J' —
T
:T
_-.. y
�!
1
Y'
t
♦:
r.
�..
>.
_ t,
t
3 t.
t
0
a
} .'
1
S <.
t
}:.« !.t
R
ti
':
f
i�.
r
'r: -
i
t
L"
v
} t
♦ t
.II)
R
EC
t'
1-
RR t.:'
• r/r+
'LD'
I
N: F
R T`:
l�h
ti
I
h-
:-f.;
y
i
r•
— S
t:'
J!•—
:+
:1„
T.'
.�
/. }
{' '
. ly':
•t
t. - t
1:
7i a,
i.'
1
ti z.
3.
L
L
J-
Y
C•
}:
1•.
t'.
'C'
t. �. .
i4
n- ..•...
:•: �"+
•:n ..+: ..::. i.: ...
t
l:
�:f
t ...
"f'
1':
L 'a
\ '
` !.'
T.t.
t:t <
`.
5..
Y ).
t
i
tti
r
D
T
t
t
A E1
S
SUE
•
:�,'
,.:
t
,:
y':
:r.:
i• . _
:�:
�,
�,
t•::.:
s
y..
':+'. :'i :. t
�:
t.
t•..:
t
t
i:''
:i:- .L.
+%•~
a. -
3.
i
- C'
i a
J_ ^.
i'' \
�.:
:r
t; t
_ _ ci
t:•: -
t -
'! -
:i
t
ti• 't:
1.
\.
:r
.�
`-
i.
't
:''
~.a'
•t .
;,
t.
'3
f .
/'
t
..
t..
't •
5
••l . t
s
t:.
i• r
r
x
L.
t 1
i
4.:
•t
..
j
L
3
t
i� y.
t
\..
1
ei E.
r A
;ej ::
�'
t
.ATE,.
"i.
"Vbo1. b
:•
t.' G'
�•
t. _
:i
J
:i
,- `::
t
t
r
.t
=Bu
•i
Id :G
r a s
n r� io
m e- ..s.
l
�.ln e' o.
:o :B
f: u
�f S
t
,.
a:..
:.
i t7 •1
�:
•.
::
�.:
9..
t:
:.,
-:z.
Y
:'.
......•..
•...•. .
.t'3
.t: .
-
.... ... .. .• -• •... J..• :•:.. — .1
_ t y.:..
t
7'
t•
yt
J{'.
;'
{,
5'
f
i'1.
t
t
..ti'
\.
v... '...
\• rt
a
t
:�'
O
1
3• 1
r
. 3,:
:)..
's `i
v .•
G
•t
a
�Q Erl` 1
r
::
a
Q
ne
-o
a erg
i4.
fi
Ire
. r
♦' v
. .......
t'
..
of ::
Y
?.
j..
t
r
t
r
�. .
i'.
,:
i — — J:
l: :i.
t
s
1•
v.
t
`,
.4
t
�.
:r
J
— J _
t
:.`
t
i
{..
. t- ...... t•.. _.
t .s.
t:'
�:.
L'
{' ` t
}••
«.: r''
n
t♦
3
J. 1.
ti
t'
r
r.:
`l:
1
t
i
i ., '.: ..
i......
.. - .. ..; ... .. t ... •.. .
T . _F
L
.. ... ....., ..._... t
> ._.
HE. �L OWING .AGEI�LCES.. .... l
SHOULD .BE..IOTIF E
a
tD
..
::_
1• r
Y:
r
t.
'N •. t' a:.i
t
f
T t
4 ,
,'.
1
R
— } - ;:
rt
C
T.
C..- r.
s
t_.:
3�.
�'
L . ^'i t
:'S '~
::.^
�-
r�
:::
:�.
a>
v
ti.
j� -
• ::'
..
.• ....•. .. ... .. .... .. •.., t. .. t.. .... ..:....•
T
.... ... .. .' .•. .....
i'.
•:l
..i t
i'
:.'
t:
oar. Ll
a
r :of::
d t
:❑ o.
°C ns.
:❑
:b
0
D.
eriI P
�.:..' 0
f.
<:
ec
L�'. E
er
R
t
r� o
rt
. . .......... .
9Y R.
..
:: :.
...:...... ... :
.... ... ...
t
t�.
>:
eai r..
•A s He It
_ a h ...... • . t..
0
+...... ,
t m«s�or�.
A
fed
a. r.....
P i
'�
a
d.
e
R�...,..
�0�.
(,
J
:.
0
VSI-U
1
A
I.
p
.i.
.F::
�...
,::
/:
:r. :.
:t
r:
:.
i..:r
3
., ❑ • I
r
e has
f
s
la! n n r
Q r� L7.
P:
ea d f�
e r
at a
C d
: ni.
9:
:❑
0
n
C3
't' :o
r
t
:3. , .
9 tip
:C
u
t.
ff.
;:
:.
>� ,
h
ofard
G:
ut:.
:..
.:
r.
ff
:�
;s
:::;; : �:
{':
t..
+. 1"
a :,-
�:::
t .'.
r t
5'' ' �.
:.ti ,
J.:
1
r..
},
J•
t':
t. :J
t. }
:\
.+. ... r '.:...:'...
.•.
t
-:: .
L
t_
- ._.. -... .. ..... .. .�
�:�
Y
. t:
Z'.
;,::
t:
-t ... -
•. t.
. ti J.
........:...:. :•:.. .. RE
to I
R S:.•
E IES ::EC :O.
P T
R R E E ;::..
:...:
_ BEF.C:RE�:TE:SSU E:
A D O:F E R 1i T..
t-
r _
,:
�:
;. t
t
_ / ;1 L
t.
y
J: Q P
r.
A FAT
E
TA AP :R: V
P A
•C:.
••i���� r
:.
r� L
•ram• t t
Board of Health: Signature: Date:
Conservation Commission:
Other:
Signature:
Signature:
Signature:
Date:
D ate:
Date:
Date:
Brief description of work being performed,• fr� � , '�li ���
Lot Area (sf.)
Required
Front Yard
Side Yard
Rear Yard
�gnature:
ntage
Provided
Map
1.3 Historical District ❑Yes ❑ No
Year Built
❑ Altering mare than 25°/a per side.cof building
1.4
Water Supply (MGL
c�40 s54):
1.5 Sewage
Disposal System:
Has application been
submitted
to the Hiistoric Commission?
❑
Municipal ❑Private
Well
❑Municipal
❑ On Site Disposal System
❑Yes
❑ No
Date::_
C� CONSTRUCTIOf� PLAf�S
SITE PLArf�
�U�� Rom". `a%�li�; l 5 ise(�d 1Q/a,v J
Ef�ERGIf` R�PO�t�