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The Commonwealth of Massachusetts CITY OF
° Board of Building Regulations and�ta��a�-r�(s�IRECEI1 SALEM
Massachusetts State Building Code,780 C`r�f 10`i,1 L S_ ,
tZ AJC �2evised Mar 2011
Building Permit Application To Construct,Repair,RMgvjft0r Demolish a
One-or Two-Family Dwelling llll S (>
This Section For Official Use Only
Building Permit Number: - Date plied:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
^ I 1.1 Pro Address: n1.2 Assessors Map&Parcel Numbers
`V c-1 e vl^ l_6 r\
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
r
I (1 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
—/ 1.5 Building Setbacks(ft)
( I _ Front Yard Side Yards Rear Yard
(� r Required Provided Required Provided Required Provided
1 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: _J'e"' n �
Name(Print) - City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
3 T:e PJ i S 71 e2 a 5 tp, evl A�fin, �x.,vr o n� fio/L-
,r'e S7'( dA/_ CST/, 34"Ohmt4i r/��APl�BST� 'Tn iR
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Penult Fee:$ Indicate bow fee is determined:
2.Electrical $ 11Standard City/Town Application Fee - -
0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:.$ -
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$ -
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 �� p Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Co
nstruction Supervisor Luse(CSL)
' \ L�s S�4 IT License Number Expiation Date
Name of CSL Holder
List CSL Type(see below)
No.and eeet-�t Type Description
/ �/l„Imo,/� � U Unrestricted(Buildings u to 35,000 cu.ft.
l Y�Ji�( R Restricted 1&2 Family Dwelling
City/Tom State,ZIP ^, M Masonry
RC Roofing Covering
V LL rl/'1 \/ \PLC iM WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit 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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
toact on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con d in this application r e and accurate to the best of my knowledge and understanding.
,rx.t
ri Owner's or-Authorized Ag nt's Name(Electronic Signature) Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.so; c%ocst Information on the Construction Supervisor License can be found at www.niass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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ISSUED BY:
EUREKA! TENTS / a div. of Johnson Outdoors Inc.
` BINGHAMTON, NEW YORK 13902 "
Manufacturers of the Finest G`STFQ �
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Tent Products Described Herein
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DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY. North Reading STATE/ZIP: MA 01864
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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 b A-A-55308.
P Y
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,JOHNSOI -UTD ORS INC.
rtfi*
pFlame
ISSUED BY:
EUREKA! TENTS / a div. of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest S f'4F
Tent Products Described Herein
'�1F RETP`�
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading STATE/ZIP: MA 01864
This is to certify that the products herein have been manufactured from material inherently flame
retardant as here after specked 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 Hem certified: 20' x 20' Traditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture June 09, 2006 - Serial#009823
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNS01 UTo ORSINC.
MEW
01 Flaine ,q
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ISSUED BY: ,
EUREKA! TENTS / a div. of Johnson Outdoors Inc. ` '1
BINGHAMTON, NEW YORK 13902 -`
Manufacturers of the Finest ��;5;4�F
Tent Products Described Herein „ ''•°
F RE7P�
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading MA 01864
STATE/ZIP:
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 Party 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
TEM DEPARTMENT,JOHNS044RDJORS INC.
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t The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,ALL 02114-2017
www.massgov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED VVITH THE PERMITTING AUTHORITY.
Applicant Information - • ' ' Please Print Leal
Name(Business/oiganization/Indiviaual): 7A C - �onl D H (1'/01-1 AnAW
Address: I(t4 �Q1ii}RL 5 i
City/State/Zip: S T 1--Q 01`9 ?O Phone#:
Are you an employer?Check the appropriate box: Type of project(rEQnired):
I.❑I not a employer with employees(full and/or part-time).• 7. Ej New construction
2.1 I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.(No workers'comp.insumuc requited.]
3.E]I am a homeowner doing all work myself.[No worker'comp.insmance required.]/ 9: El Demolition
4.F1I ant a homeowner and will be hiving contractors to conduct all work on my property. I will 10 0 Building addition. _
ensure that all contractor either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietor with no employees. 12.Q Plumbing repairs or additions
5.❑I am a general contactor and I have hired the sub-tontiactors listed on the attached sheet 13. Roof repairs
These subcontracton have employees and have workers'comp.immm ro t
6. We are a corporation and it officers have exercised their right of exemption per MGL c. 14.�Other Pu r(,� P- JW T S -
152,§1(4),and we have no employees.[No workers'comp.insurance requited.]
-Any applicant that checks box#1 must also fill ora the sector below sbowing their workercompensation polity information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside won==must submit a new-affidavit indicating such
lContrzemrs that check this box most attached an additional sheet showing the rnme of the sub-contactor and state wbettier or not Those entities have -
employee& If the sub-contractor have employees,they must provide thea worker'-eomp.policy number...
I am an employer that is providing workers'compensation insurance for my employees.-Below is the policy and job-site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
lob Site Address: City/Statemp:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 line of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerci nder the pains and p res perjury that the information provided above is true and corree7.
, -' Date: J/I�'/2e tr
Sitmattue•'
Phone# -7 911- NOS-
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to lme an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insuredcompanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number: -
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017,
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia