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Owner Reco d:
2.1 o�.►v / .
'Contact Address Phone Number
Name {print}
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2.2 AWh ized Agent"
Contact Add ss
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Phone Number
`Name (print)
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• License Number
• Construction Su ervisor/Specialty License.
3.1 Licensed Constru p '
LCompany Name/Contractor Nam
0, Expiration Date:
Ar4Ar=q_q-, on .
�., Telephone: Y//-/
signature:
Y Y Section 110.R5.1.3.1 Exception:
wo Family Only 3,2 Homeov��ner Exemption -One
RIVI AND BE RESPONSIBLE FOR THEIR OWN PROJECT
FOR HOMEOWNERS WHO INTEND TO PERFORM .. provides that if a Homeowner
which a Building Permit is required shall be exempt from the provisions of this section, p
Excption� And Homeowner performing work for wh 9
aces a ersol(s) for hire to do such work, that such Homeowner shall act as supervisor. hick he/she resides or intends to reside, on which
eng p a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on w more than
For tine purposes of this section only,
• d structures accessory to such use and/or farm structures. A person who constructs
e =s or is intended to be, a one or two family dwelling, attached or detached
Cher � � e considered a Homeowner.
one home in a by year period shall not b
If you are aPpY
applying under this section sign below:
Sigr iature:
• with this application. Failure to provide this
nce Affidavit must be completed and submitted pp
Vlla��Cer s Compensation Insurance /� � ached; 0 Yes Q No
f the building permit. Signed Attached: �} i avit will r?sult in the denial of the issuance o 9 id Affidavit _
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Q eck ❑ Pool
❑ New Construction*
(Energy report required)
❑ Chimney/Fireplace ❑ Wood stove/Pel I et Stove
,.
❑ AccessoryB(d ❑Addition ['Roofing/Siding 9 —
(Shed/Garage) (Energy report required)
❑ Repairs
❑ Alteration
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54):
=acuity Name:
* f new construction, please complete the following:
l
umpster on site ❑ Dumpster On Street
Location: / V
SMgleFamiy. N it • o. of Bedrooms No. of Baths
Two Family: No of Bedro
oms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
{ as(natural or ropane), fuel oil, electricity, other (specify):
C Furnace {hot air} - fue g P
el as(natural or ropane), fue[ oil, electricity, other (specify):C� Bo�[er {heating) fu g P
HVAC (combined unit) primary ,
rims fuel, natural gas, propane, electricity, other (specify):
0 Air conditioning - {separate unit}
0 None of the above to be provided
Q Hot Water: Gas
Electric Fuel Oil .Other
❑ Replacement window/door
No. of windows Doors
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DATE RECE=IVED
♦................♦,
TN . �•L+.
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f¢♦ ° '�-��: DARTMOUTH BUILDING DEPARTMENT
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�'� 400 Slocum Road
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" = Dartmouth, MA 02747
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_ �• �•:• Phone: 508-910-1820 Fax: 508-910-1838t
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•' ~•-•••64N www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE70R./TW,0EAMIL�Y= )VV tLLING�.
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Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
• Signature: Date:
D.P.W..
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed.
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1.1 Property Address: 1*100 1.2 Assessors Map & Lot dumber:
Contact Person: Map Lot �
Phone Number:
1
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.3 Historical District 0 Yes ❑ No
Year Built
❑ Altering more than 25% per sidoa of building
Has application been submitted to the 'Historic Commission
0 Yes ❑ N o D ate; :
CONbIFERUCT %jN rLAN88
)7JeI+raJl1,•a SITE F"LA'a"U"
iElb PIS op
P L r { ? •a.,� � r
�vised 5 /1