0000 WASHINGTON SQUARE SOUTH SALEM COMMON BPA-10-59 A
The Commonwealth of Massachuseus
Board of Building Regulations and Standards CITY
.r+ , Massachusetts Stale Building Code, 780 C'MR, 7,n edition OF SALEM
�r Rrvisrd Jmmm�•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or rivu-Family Dwelling
This SectigifForlpfficial Use Only.
Building Permit mber: to Applied:
Signature: 61A7 `� Jv
Building Cummimioncr/Inspector of Bdldin fate
SECTIO 1:S E INFORMATION
1.1 Property Address: 1.2 Assesson Mop& Parcel Numbers
S��era C�wrmon/
Via Is this an accepted street°yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lw Area(sit 11) Frontage(11)
1.5 Building Setbacks(In
From Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.ao,§sec) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zom7
Public O Private O — Cheek i! n0 Municipal On site disposal system O
SECTION2: PROPERTY OWNERSHIP'
LI Ownert of Record:
C�VY�
Name(Print) Address fw Service:
t
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek aR that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Alterstion(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work':
rae-aT 3 TAN,s -- as x 20 CZ) 20 x 7. 6
5Ace-tt C: -rtm/-FeSf —.25'. 2a /o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
ing S
O Total Project Cosl (Item 6)x multiplier x
). Plumb 2. Other Fees: S
a. Mechanical (IIVAC) S List:
S. Mechanical (Fire S
Suppression) Total All Fees:f
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor W I
L iccnse Number F%pitaliun 1}ate
Name us l'SL-I lulder List CSL f)pe(sue below)
f Descritition
Address I U I Unrestricted(up to 35.000 Cu.Fs.
R IRestricted 1A2 Family Uwellin
Signature M Mal
RC Raidemial Routing Covering
fclephune I WS I Residenlial Window and Sidi"
SF ResL_!!l Solid Fuel Burning Appliance Installaliun
D Rnidemial Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name d II1C Registrant Name Registration Number
Address Expiration Dale
Signusura Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. S MOP
Workers Compensation Insurance airtdsvit 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.
Signed Affidavit Attached? Yes.......... O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(
1. I /IDW 4,1) 4• Cyo LD�Pry✓ as Owner of the subject property hereby
authorize /3 3 D. /////V G • to act on my behalf,in all matters
relati to work a this/ ed this building permit application. /
Zzz
O
Si ore of Owner Doa
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will gg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and I WAS. respectively.
2. When substantial work is planned,provide the information below:
Total floors area ISq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Total Project Cost"
� Flame
O
`f ISSUED BY:
4 ` EUREKA! TENTS / a div. of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest ���'S`FR�o
r' Tent Products Described Herein
F RETP`�
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading STATE/ZIP: MA 01864
O ♦ O
This is to certify that the products herein have been manufactured from material inherently flame
retardant as here after specified by the material supplier.
Certification is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code, NFPA-701, Underwriters Laboratory of Canada(ULC-S109-M87), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C-43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 30' Traditional Parry Canopy—WBO solid white 13 oz. vinyl
Date of manufacture March 27, 2007. - Serial #V007114
Flame-Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNS01 UTD ORS INC.
O 1
ISSUED BY: N&QI
EUREKA! TENTS / a div. of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest ��`G;CAL
Tent Products Described Herein q \j} �•,
R E,T
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading STATE/ZIP: MA 01864
O ♦ O
This is to certify that the products herein have been manufactured from material inherently Flame
retardant as here after specified by the material supplier.
certification is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code, NFPA-701, Underwriters Laboratory of Canada(ULC-S109-M87), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C-43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 20' Traditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture June 09, 2006 - Serial#009744
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSG UTD ORS INC.
PbM�
ft
it
01
HaMe
R ,
ISSUED BY:
A EUREKA! TENTS / a div. of Johnson Outdoors Inc. c4�ti
BINGHAMTON, NEW YORK 13902 �►'y
Manufacturers of the Finest ��`G;5` 0
Tent Products Described Herein
Q
3F R ET P•�
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading STATE/ZIP: MA 01864
O ♦ O
This is to certify that the products herein have been manufactured from material inherently flame
retardant as here after specified by the material supplier.
Certification is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code, NFPA-701, Underwriters Laboratory of Canada (ULC-S109-M87), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C-43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 20' Traditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture June 2006
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSO UTD ORS INC.