19 1-2 N WASHINGTON SQUARE - BUILDING INSPECTION The Commonwealth of Massachusetts
RECEIVED Department of Public Safety
` iti S P E C R C� J �� t/ p Massachusetts State Building Code(780 CMR) ,
BQi'&mJ Pr"'W4plication for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Q Building Perm r: •Date Applied: Building Official:
SECTION 1:LOCATION
70
No.and Street City/Town = Zip Code Name of Building(if applicable)
Assessors Map# • Block#and/or Lot # '
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy ❑ Other )Q Specify: 2
Are building plans and/or construction documents being supplied as part f this per }t application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Re 'ew required. 6 / 7 L/ Imo.• f / Yes ❑ No ❑
Brief Description of Proposed Work: ) S ? �/'; 'X
/ ' '-k✓1 s cm 9 /S S/d �' '
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
Z CWCKGE IN USE OR OCCUPANCY
Check here if an Existing Building Investig42Nartil Eval t' n is enclosed(See 7,80 C R 34) 0
Existing Use Group(s): Pro d e se roup(s):
/ SECTI :B DING G ND AREA
Existing Proposed
No.of Floor /Stories(include baseme y 1{dpeIs)&Area
Total Area,(sq.ft.)and Total Height(ft.) �f
SECTIO SE (Check as applicable),,
A. Assembly A-1❑ A-2❑ Nightclub ❑ ❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto \,F-1 ❑ F2❑ H• Hazard r H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1'O_L ❑2 I-3 13—I-4-❑� M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1❑ 5-2❑ 1 U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 180 IIA0 IIBD IILAD IIIBD IVD VAD VB0
SECTION 7.SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information:, ' Sewage Disposal:• Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑permit is enclosed
trench or specify:
❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ f Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space: I 'A
t
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street U City/Town Zip
Property Owner Contact Information:
�rfn*OL- hf d" q7F 2ff- .q — s ec"r car(
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes: 1
�lc�an (t cnfz,� • 1�{ fon t. �c) 6/a Ca5+Cr
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide construction control forms see section 107 in the code as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals
h
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
`f C�
. -e> tr
Company Name A4
Name of erson Responsi e for Construction License No. and Type if Applicable
L11y &ek AV,4 d/Q3cy
Street Address 6/7 City/Town State Zip
M283 4 - AlY sz 66Ilor�
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Ye42 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ yoo Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ ( (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application' e accurate to the best of my knowledge and understanding.
, l If!7W-
lease p ' t and me TWO Telephone No. Date
treet Address City/Town State Zip Email Address
tt>
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth ofMaxsaehusetts
Deparimene,of Industrial Accidents
offions
6M of ingion Street
600 R'ashitlglon Street
-lug Boston,Mass. 021.11
wrvw-nears gow1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Legibly
A bcant Information
f L
Name(8mineWorgwimonandividual)
[
Address: i (� A 3J-
City/State/Zip:� il� rl /�. /�1. ') Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L Qf I am an employer with / �: 4.0 1 am a general contractor and 1 6.0 New construction
employees(full and/or part time).' have hired the sob-contractors 7.0 Remodeling
2.0 I am a sole proprietor or partner- listed on the attached sheet
ship and have no employees These subcontractors have 8.O Demolition
wodting for me in any capacity.. employees and have workers' 9.0 Building addition
(No workers'comp.insurance comp.insurance.j
regWred) 5.0 we are a corporation and its 10.D Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11. 0 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm Mt3L
insurance required]t c.152,§ 1(4),and we have no 12. 0 Roof repairs f
employees.(no workers' 13.A'0ther /--/ .5
comp.insurance required]
•Auy appaewd that ebeeb bax 01 meal ako In art the aeltlee beWW chow ft}hetr workem'cwpetrsedee Pesky teformatloo.
t8omeownerewho whmft this dadaHt indlur6rg they are dotug ea work end thm hire omade a inert mbmtt a eew afadava hrdldaCng such.
"
tCmteetaes that dheck aftboz:mma et an aditdnnel dwd shawivg the owe of 0e-sub-man'acmes and alum wkelhs or mathme eent[n have empby«s tt
the sebconnedore bave moat de thdrwork
I am as mmpfoyer that isp vviffng workers'co.pmsadron iasanmw for my employees.Bdm is the polley and job site
information,
Insurance Company Name: �(u✓P r S
Policy#or Self-ins.Liu#:. X V 7/1�?6 T_5f2 S// Expiration Date:_J Q
Job Site Address:�t.Lf=L Cny/Statemp. .&e& QI7 7-
Attach a copy of the workers'com �bn polity declaration page(showing the policy number and expiration(date).
Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine
up to$1,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of
$250.00 a day against violator.Be,advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penal0 as 0 pehjury that the information provided above is true and correct
Prim Name Phone
60%clal use only Do not write in this area to be completed by city or town official
City or Town; Permidlicense#:
Issuing Authority(circle one): .
1.Board of Reath 2. Building Department 3.CRyli'own'Clerk 4.ElecMfnl Inspector S.Plumbing Inspector
6.Other +
Contact person: Pbone#-
Certificate of Flame Resistance
REGISTERED ISSUED BY
FABRIC Date of Manufacture
NUMBER JOHNSON OUTDOORS INC.
BINGHAMTON, NEW YORK 13902 5/22/2009
FA-49303 Manufacturers of the Finest
Tent Products Described Herein
This is to certify that the products herein have been manufactured from material inherently flame retardant as
here after specified by the material supplier.
NAME: THE EVENT CO.
CITY: GLOUCESTER STATE: MA
certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
California State Fire Marshal Code, NFPA-701',
Tvpe,color and weight of material: 13 oz Vinyl Snyder white block Out
Description of item certified: 15x20 frame tent
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
HANWHA POLYMER CO.
TENT DEPARTMENT,JOHNSON OU ORS C.
-Large Scale
a,.,�„�,„a .. �c YY�tlfy6lE mawo»�Aor
"� � YH7l enntdaztvw
s � tYlmfwBFWRJiGtRt59 � ir;�G.'.ux;-aafid7ntt
.. � 4Rr°t3e � 7oU Hmi Hpp9MAH18 p6on•:rnd.$6R.iHA7
«? s t a 3ini a"tit 4 mates??ta{a YL su t d i`tu*^ kl hore09 have m flaffi84msr wA ,
®tlY ,14�va§ r
WC tC he Ptly 114?fl�thank(Checkle Of°b°j
'iLtncyCrlaNa�"�..9n"et.,rat ' .R:kufa. .,cs;w�siis¢a�aenvo�dr�tihoAmre«»::'s+c �>�elt.^:�;a�i
€adaq:.�.�34r�i3e83Aii Ftsu A.�HAa?tul�thHt?iaa'dsH?ninaAiopalwaHflaHsmpar¢am?nnoorA3aSfp
i €^^.•Ha#titn t �i ..• .k. : z w,» t tt..,�-+ -:a0#0aweF69&latshal.
?�aemaea+ww ?an All 1 1'».1?XL� 6X/ � 9 �;u X 15
wdeext9�danv"tsHen�+atanroNlsutthtsCere'7laaivaranr3dan4e,YlHmoteaialot Woermate:WiagOWW
3 � attdAt�tr?dky+4hCStamhitelSateF�totaidtuae. a_ _
TradHnarrr�atfleme�risck�7et49s?Kiu or ri;,y�iat amnli_ �:}.--� iim3.Wn k"���9�R i,
i ha 1 atria Fletamwd Ptacess Used t 8 g R;a BY W381Y4tg•