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1 Owner Record:
Name (print)
Phone Number
45,07-0 1?-
2.2 Authorized AgAaV
Phone Number
Contact Address
Name (print)
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• Supervisor/Specialty License. License
3.1 Licensed Construction Supervisor/Sp ty ..
6 q,�
Co
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Expiration Date:
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Address,.-
S1�T �? r1l y
tune: Telephone.
Signs
' Family- Only Section 11g.R5.1.'.'i Exception:
3.2 Homeowner Exemption - One & Two y Y
PERFORM AND BE RESPONSIBLE FOR HOMEOWNERS WHO INTEND TOP E FOR THEIR OWN PROJECT.. work for which a Building Permit is required shall be exempt from the provisions of this section, provides that if a Homeowner
Exception: Any Homeowner performing
engages a Jerson s for hire to do such work, that such Homeowner shall act as supervisor. or intends to reside, on which
P � }
• r" is defined as follows: Person(s) who owns a parcel of land on which he/she resides
section only, a "Homeowner" ore than
ss constructs
this � r of t s ons ose c Y o �. h
the on w
For
pe
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F s: A
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farm s
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tr ct ures ac Ces SO
detached u
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ch ed or
r,. dwelling, it dw
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of
there is, or i�-� intended to be, a one or two y 9
one home it a two-year period shall not be considered a Homeowner.
If you areapplying under this section sign below:
Signature:.
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Contact Address
•w �',►y; »t.e -rr.' - ;--'"aC." _ _ 'v t � �' 7:] t .ti +' .G _ n�, �•
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_4 .L1 Li.• '. st.s _ -
• this application. Failure to provide this
' Affidavit must be completed and submitted with pp
Vllorkers Compensation Insurance
affidavit tivill result in the denial of the ip Yes 0 No
building permit. Signed Affidavit Attached, issuance of the bu I g p -
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❑ Deck Cool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pell et Stove
El New Construction*
(Energy report required)
El Accessory Bldg. ❑ Addition
(Shed/Garage) (Energy report required)
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Bu
ilding din
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2. Electrical
3. Plumbing
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4. Mechanical (HVAC) ��.C�'>
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(Please Print _ �. rite'
sub ect roe hereby authorize
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4,n . � 5 a _Owne of the j p p rtY Ot/01 �.
autho b this building permit application.
behalf, in all matters relative to workY
to act on my z
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_ Date
Signature -of Owner
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6dA declare that the statements and inforr�nation
,� /�`•..� as Owner/Authore hereby
• to the best of my knowledge and belief.
foregoing application are true and accurate,
o e g g pP
Sig
ned ned under the pains and penalties of perjury.
4 A �- A J -
Date
Signature of caner/Authorized Agent
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• Remaining Balance: $
Less Application Fee. $25.00 R g
Total Permit Fee: $ .
Other $Amount $
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Gross Area
New W Construction
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Gross Area •- Alteration total sq. ft.
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- Permit issued to:/IV "014 ZZ00
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❑ Roofing/Siding ❑ Replacement window/door
No. of windows Doors
D DEMOLITION* (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site 0 Dumpster On Street
Facility Name: Location:
cif new construction, please complete the following:
• No. of Bedrooms
Single Family. No. of Baths_
Two Farniiy: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedroom
s Unit 2 No. of Baths Unit 2
• orpropane), fuel oil, electricity, other (specify):
❑ Furnace (hot air) -fuel gas (natural
- fuel as(natural or ropane), fuel oil, electricity,other (specify):
❑ Boiler (heating) g P
y - rims fuel, natural gas, propane, electricity, other (specify):
•❑ HVAC {combined unit) primary
❑ Air co-nditioning - (separate unit)
❑ None 'of the above to be provided
� Electric Fuel Oil Other
❑ Hot Water: Gas
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;! � 'i- � 2 J �' �•� � � " 't ~� $ �' ; a ..� '� .k '�q : 1 i � �� .1 #�� `g���'< ? } `y• 'i ` Jt�%-
DARTMOUTH EUiLDIN DEPARTMENT. :
DATLw=
RENCEivED
1C4 n 400 Slocum Road = t
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Dartmouth, MA 02747
°.� Phone: 508-910-1820 Fax: 508-910-1838 t
1664
~'"�"�''"• www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMlld � G
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Board of Health: Signature: i Date
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Conservation Commission: i ,<t.: -� - �..,,
S gnature. --- � Date.
D.P.W.: Signature: •
9 Date.
Fire Chief: Signature: Date. •
Other: Signature: Date:
ol
Brief description of work being p
contact Person: JCojer" &
Qt
10im PLANS E PLAN ENER..,,
SIT
Revised 5
EEO 1