19 1-2 WASHINGTON SQ - BUILDING INSPECTION 1'he Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
✓ 'r';. Massachusetts State Building Code, 780 Chin SALEM
'ti•�.• Revised.11m•-'Ol t
Building Permit Application To Construct, Repair, Renovate r Demoli h a
One-or Twvr-Flunk DnYllhi v
This Section For OlTcia e only
Building Permit Number. Date ppiied:
fludding Official(Print Munc) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Nlap& ar I Numbers
I.I a Is 'his n accept
reef?yes�� no M;:p Numhcr I'urcul Num!><r
I.J Zoning Information: 1.4 Property Dimensions:
Zwming District Proposed Use Lot Area IN It) Frontage(II)
I.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd Provided Reyuircd Provided
1.6 Water Supply:(M.G.1.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood-Zoo-? Munici al❑ On site disposals)
Check it' cs❑ P stem ❑
SECTION 2: PROPERTY OWNERSHIP'
2, Ow,ger'of Rpcgrd:l -h ( ,
�1/ vy, L.rJ i 1"a; /l'(.C.ri,
Wunee IPrmt) City,Slate.ZIP
(N�`slun a� h sG I?S- �V/ l6 �Z
No. and Street V if Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Cl I Repairs Is) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory'Bidg: ❑ Number of Units Other ❑ Spccify:
Brief Descriptiop of Proposed \Nock &fO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs:
(Labor and .Materials) Ofilcial Use Only
I. Building g /* Z 0 I. Building Permit Fee: S Indicate how fee is determined:
-'. Electrical g ❑Standard CityiTown Application Fee
j
❑Total Project Cast'(Item 6)x multiplier x 1. 1'luubing g —.--
:. Other Fees: S
1. \Ieebanical Ili\':\CI S List:
Sutuessionl S rotaiAllFees: S_ ----'- -
o. Total Project Cost: g Chak No. __Check:\mount•. _ C ash ,\mouse _
19 2C) ❑Paid in Full 0 Outstanding Balance Due: -
SECTION 5: l'ONS fRDCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number. Pspira(iou Date
N:ntw of C'.S I. I Folder
List C'SL I,)PC(see helowl
.f. Pe Description
No, and Street
11 1lnrestricted I I uddin Ts ti to 35,000 cu. 11 )
R Restricted IK2 Fuutil D%%ellin
Citci faun.Slate.LlP --- %I Masonry _
RC Rooling Covering
A Window and Soling
SF .Solid Fuel Burning Appliances
1 Insulation
I ele hone I(mail address U Demoli to)n
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number F.\pirttiun Date
I IIC Company Name or I IIC Itcgistrant Numw
No. and Street Emuil address
Ci !(own.State,ZIP Telc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(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
contained in this application is true and accurate to the best of my knowledge and understanding.
YL-R- �".cr�r•-�� � �,,,,, 1.r 11�-cn rz lze �i Z z
Prim Uu ncr's ur\udutrircJ Agents Name(Flectrunic Signature) Daw
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 Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under M.G.L. c. 1 q'_A.Other important information on the HIC Program can be found at
,N%n inns Information on the Construction Supervisor License can be found at tt)ky.mi>a ,Ills
2. \\'lien substantial work is planned, pro%ide the information below:
Total fluor area Csq. ft.) _ I including garage, finished basement attics.decks or porch)
Gross living area t sq. 11.1 _ _ . Habitable room count
\untber of fireplaces,---,. Number of bedrooms __--
Vunther of bathrooms . ._ — _ Number of half haths
I)pe of heating Sy Stem .. ._ . ._ Number of decks, porches.
I'ypc l an+ling System - - _ - Fncloscd .. .. - _ Open . .
I
t. 'Total Project Square Footage-ma\ he substituted fur"Total Project Cost"
Ce
rtificate of Flame
Resistance
Date treated or
v t. ISSUED BY Manufactured by manufactured
Harlan Corporation Fred's Tents&Canopies
.— 1-704-867-3548 7 Tent lame 07/03
Stillwater,NY 12170
This is to certify that the materials described below have been flame-retardant treated(or are inherently nonflammable)
FOR Event Company
PO Box 419
Gloucester MA 01930
Certification is hereby made that:(Check"a" or"b")
a)The articles described below this Certificate have been treated with a flame-retardant chemical approved and
registered by the State Fire Marshal and that the application of said chemical was done in conformance with the
laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Name of chemical used Chem.Reg.No.
Method of application
(b)The articles described below are made from a flame-resistant fabric or material registered and approved by
the State Fire Marshal for such use.
NFPA-701 (large scale) &CPAI-84
Trade name of flame-resistant fabric or material used Blockout White Reg.No. F-76101
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Fred's Studio Tents & Canopies, Inc. ^" _
Plant Supervisor
Product Description (2) 6x30 Marquee Customer Invoice# 10950
Certificate of Flame
Resistance
Date treated or
_ ISSUED BY Manufactured by manufactured
?' P Fred's Tents&Canopies
�;-,� Burlan Corporation
.— 1-704-867-3548 7 Tent lane 06/05
Stillwater, NY 12170
This is to certify that the materials described below have been flame-retardant treated(or are inherently nonflammable)
FOR Event Company
PO Box 419
Gloucester MA 01930
Certification is hereby made that:(Check"a"or"b")
a)The articles described below this Certificate have been treated with a flame-retardant chemical approved and
registered by the State Fire Marshal and that the application of said chemical was done in conformance with the
laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Name of chemical used Chem.Reg.No.
Method of application
(b)The articles described below are made from a flame-resistant fabric or material registered and approved by
the State Fire Marshal for such use.
LI NFPA-701 (large scale) &CPAI-84
Trade name of flame-resistant fabric or material used Blockout White Reg.No. F-76101
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Fred's Studio Tents & Canopies, Inc. � —
Plant Supervisor
Product Description 6x10 Marquee Customer Invoice# 14914
6x5 Marquee
9x18 Marquee