BP-79289OF'N
Name (print)
2.2 Authiorized Agent:
Name (P-Lint)
_Contact Address
Phone Number
Contact Address Phone Number
Comp anv Name/Contractor Name:
Expiration Date:
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Signatur. - � ,�� �'� -�' p
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
Excep tior.: y An 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 persons) for hire to do such work, that such Homeowner shall act as supervisor.
For the P �.:trP oses 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
the
re 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 home ii a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
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Worker's Compa sation Insurance Affidavit must be com leted and submitted with this application. Failure to provide this
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affidavit will r g result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes ❑ No
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Repairs ❑ Alteration ❑ Chimney/Fireplace Cl Deck 0 Pool C� Repa ❑ Wood stove/Pe I let Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding ❑ Replacement window/door
(Ene�gy report required) (Shed/Garage) (Energy report required) No. of windows Doors
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❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): El Dumpster on site ❑ Dumpster On Street
Facili-Yy. Name:
*If new construction, please complete the following:
Location:
Single Family: No. of Bedrooms No. of Baths
Two Fa ,lily: No of Bedrooms
Unit 1
No. of Baths Unit 1
No of Bedrooms
Unit 2
No. of Baths Unit 2
❑
Furna^e hot air - fuel gas (natural
or propane), fuel oil, electricity, other (specify):
❑
Boiler ((heating) - fuel as (natural or propane), fuel
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oil, electricity, other (specify): ` •
❑
HVAG (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑
Air conditioning - (separate unit)
❑
None of the above to be provided
Hot Water: Gas
Electric
Fuel Oil Other
❑
Signakfre of Owner ,l
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as Owner/Authorized Agent hereby declare that the statements and information
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i application are true and accurate, to the best of my knowledge and belief.
on the foregoing pp
Total Permit Fee: $ �S
Gross Area New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
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Permit Issued to:
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Less Application Fee: $25.00
Other $Amount $
Remaining
ainin Balance: $
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Board of Health:
❑ Phased Approval
pp (R 106.3.3)
,00 APPLICATION FEE IS NON REwFUNBABLE &1VONoTIMANSFERABLE
_ DATE RECEIVE in
DARTMOUTH BUILDING DEPARTMEV
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Conservation Commission:
D.P.W.:
Fire Chief:
Other:
Signature:
Date..
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Signature: Date:
Signature:
Signature:
Signature:
IBrie�description of work being performed.,
Contact Person: `_i
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PhoneNumber:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑Municipal
;9 Private Well ❑ On Site Disposal System
Date:
Date:
Date:
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Map
Lot
1.3 Historical District ❑ Yes 11 No
Year Built
17 Altering more than 25% per side of buildihn
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Has application been submitted to the Historic Qw-ommission?
❑ Yes ❑ No Date:
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U CONZAN'i!�TRUCTION PLANS
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U SITE PLAN