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2.1 Owner Record:
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N;Ame 1(print)
Contact Address Phone Number
2.2 Authorized Apeft.
O
1`4ame ,(print)
Contact Address C..;,L Phone Number
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3.1 Lio.-3ensed Construction Supervisor/Specialty License
license Number:
Comp2my Name/Contractor Name: 66) 106
4!514
Address Expiration Date-
3 i g n atu re:%Z�.,T n e: Z>_�
Telepho
3.2 Homeowner Exemption - One & Two Family Only Section 1 10.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Except'on: 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 person(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 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 horri-e in a two-year period shall not be considered a Homeowner.
If you CF,i e applying under this section sign below:
Signat,,.Jre:
-
-:!$ SA1;-710_QN::_4N_4 5W M, C__ rtvv Gyr
Worke--'s Compensation Insurance Affidavit must be completed and submitted with this application. Failure.to provide this
affidaw't will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes 0 No
T X_W 0 K_�11
SF-V C
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0 Dec* 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
11 Nev,, Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of window s5_ Door i
11 DEN401_1TION (specify):
Location of debris removal (per MGL C.40 Sec 54): 11 Dumpster on site Q Dumpster On Street
Faci!"Ity Nc6me: Location:
*If new +construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Fcarnily: No of Bedrooms Unit I No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
11 Boilevi- (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
11 HVAG (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air cc-nditioning - (separate unit)
11 None of the above to be provided
11 Hot Vi"ater: Gas Electric Fuel Oil Other
ON 6 S_ T;� I TTR
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Item Estimated Cost to be completed by permit a1306�ant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2+3+4)
.0 7
7
W. N E R;'-,, fir, G.R.11
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nwper ft
(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 r Date
----------
17
R Oft
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7 WN E F;O 4 0 R Z E NT
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as Owner/Authorized Agent hereby declare that the statements andlinformation
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on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains a d penalties of perjury.
W_
SignarLVt15fOwner/Au `tMer1_Ke gen Date
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-8 F. -if,-E/IMP S PR! 1N
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Less Application Fee: $25.00 Remaining Balance: $ _��"
Total Permit Fee:
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq.
Per Issued to:..--
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OPhased Approval (R106.3.3)
$25,00 APPLICATION FEE IS NON NE.FF7N&DABb,E & N0i4m'P'�E--A4"- S*FEbBAIUF.E
n;.DATERECEIVED
s: DARTMOUTH BUILDING DEPARTMENT
Slocum
400 Road AID
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Z = Dartmouth, MA 02747
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Phone: 508-910-1820 Fax: 508-910-1838
(14
wwwftown.dartmouth . ma. us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Board of Health: Signature: Date:
Conservation Commission: Signature: - Date: -
D.P.W.: Signature: Date:
Fire Chief: Signature: Date. •
Other: Signature: Date:
Brief description off' era being �r i
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1.1 Property AddresS12 1.2 Assessors Map Number:
& Lot Nu • Person. �J�l aContact M Lot
Phone Number: — Z 2
1.3 Historical District 0 Yes D No
l Year i r Bunt
1.4 water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
P Y
Ci Municipal ❑ Municipal D Altering more than 25% per side of building
g
D Private Well •Q On Site Disposal System Hasa application been submitted to the HistoricCo R
PP rr�miss� on
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0 Yes 0 No Date:
Re ised