64 SUMMER ST - BUILDING INSPECTION The Corrunru wealth of Massachusetts
-;i Board of Budding Regulations and Standards
Massachusetts State Building Code, 780 CM 7° edition I ,tit[
t
O Building Permit Application To Construct, Repair. IZrnocatr Or Denuilislt ❑ Krri,rJ.lwnhu, I
One- or Tu o-F anvil t- Dar efliu,q !. _00S
' This Section For Official Use Only
Building Permit Nw err to Applied:
Si_nature: "vt+19 �Gr� /d �g — ---
Building CUn11n1f51011• nspcaor of Buildings Date
SECTION 1: SITE INFORMATION _
1.1 Property Address: F 1.2 Assessors Map & Parcel Numbers
toy Su vn ng Strzt _—_--
. . 1.Ia Is this an accepted street? yes, ✓ no Map Number P;uecl Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq Ii) Frontage ili)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Providc!1
y
1.6 Water Supply: (M.O.L.c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' Municipal ❑ On site disposal s aem ❑
Public ❑ Private ❑ Check if yes❑ P' I )'
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
,DOnxPnic. <t „A,u,�e n1 izzo G1i Suwsrret2 S� Sca(e�
Names) _ Address for Service:
9-) V- 14u-030Z _
Signature U Telephone 4
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Rep,irs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work�':�, ---
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor Lind Materials)
1. Building $ t. Building Permit Fee: $ Indicate haw fee is de(ermined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost} (Item 6) x multiplier x
3. Plumbing $ 2.
Other Fees: $
4. Mechanical (HVAC) $ List: O
5. Mechanical (Fire S
' Suppression) Total All Fees: $
Check No. Check Amount: Cu,h -Amount: _
b. 'Tutal Project CosU $ ❑ Paid in Full ❑ Outstanding Balance Due:--._---
/��� 162
el
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numher I:api ration Daic
Name of CSL- Holder
List CSL'f�pe(see below)
\ddrns l c Descri )(ion
L- t:nresuictcd ul i to 3i.000 Cu. FL)
- R Restricted 1&2 FarmIN DwcllwL,
Signature M Nlasonr Only
RC Relldenllal Routine CoAcrina
Telephone \1'S Residential Windr,\� ,md Sidlne
SF Residential SObd Fuel BLI III till' \>>lumc< II151.II l ewu)
D Residential Ul'i1WIIn U11
5.2 Registered Ilorne Improvement Contractor (HIC)
HIC CompanyName or HIC Registrant Name Registration Number --
Address
Expiration Date
Signature Telephone
i
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. I! § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provlcle
this affidavit will result in the denial of the Issuance of the building permit.
Sieved Affidavit Attached'? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize - to act on my behalf, in all m:nten
rely e to rk authorized b this uilding permit application. n�
Si natu o Owner Date _ - --
SECTION 7b: OWNEW 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 2ains and penalties of er'u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will nor have access to the atbitranon
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 780 C'MR Regulations I I0.R6 and I IO.RS, respectively.
- When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basemendattics, decks or porch i
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms -_
Number of bathrooms Number of haltlbalhs
Tvpe of heating system Number of decks/ porches
Type of cooling system Enclosed Open _ ---- .
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
° '`I'`P`I'`r'`f'Lf'�f'rJ'7"ff,1 M P O RTA N T DOCUMENT
5 Certif ieaW of ]Fiance Resis", ee 5
5 REGISTRATION i ISSUED BY 5
Date of Manufacture
5 5 APPLICATION v °s tJY(`NAR® 05/08/03
NUMBER v �NousTRIE INc.
EVANSVILLE, INDIANA 47725 Order Number 5
5 F121.4 c� ° MANUFACTURERS OFTHE FINISHED 368094 5
5 5 TENT PRODUCTS DESCRIBED HEREIN 5
This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
III' S 692825 5
5 5 RICE RENTAL CENTER 5
TAYLOR RENTAL CENTER#14978-4 5
5 115 CABOT STREET 5
S BEVERLY MA 019155108 5
5 T
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that.the application of said chemical was done in conformance with California 5
5 Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
55 The method of the FR chemical application is: 5
Serial # 8b05960(4) �.
ram, Description of item cer'W:WAL 6_10 x 30 VL w w 3/CA
M5 5
Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 5 JOHN BOYLE STATESVILLE NC Signed:
Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5
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5 Certificate of ]Fla Re is 5
5 REGISTRATION t ISSUED BYCe e5
5 �` IICH R Date of Manufacture 5
5 APPLICATION Q 0
NUMBER 5
5 ��J�Q s NDUSTRIES INC® 05/08/03
5 ri EVANSVILLE, INDIANA 47725 Order Number 5
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5 F121.4 MANUFACTURERS OF THE FINISHED 368094
5 5 TENT PRODUCTS DESCRIBED HEREIN 5
This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5 5 692825 5
RICE RENTAL CENTER 5
5 TAYLOR RENTAL CENTER#14978-4 5
5 115 CABOT STREET 5
5 BEVERLY MA 019155108 5
5 5
5 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
chemical and that the application of said chemical was done in conformance with California 5
55 Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial # 8025000p1 S
5 Description of item cert VIM TOP 30W X 30 VL W W 5
5
5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of TheFabric 5
5 JOHNBOYLE STATESVILLENC Si ned:5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5
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