19 1-2 WASHINGTON SQUARE - BUILDING INSPECTION 3
b
A , The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
® Massachusetts Mar
Revised Mars State Building Code, 780 CMR SAM 2011
Building Permit Application To Construct,Repair,Renovate emolish a
One-or Two-Family Dwelling
; T s'SectionFor Q�Peiak>7s n1y � ? p `_
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uildmg OfficiaG(PrrntName"}r �,<� '. `" w,} ', , r ignaIt
E
a,, C.� ...t ^'' 7ECTIO(S 1 SII E INFORMA s ' s.
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
u a-s 1 iv"
1.1 a Is this an accepted street? es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage( t)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
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❑
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SIT"f N 2, tPROPTRTY OW VERS IXP f t s
2.1 Qwnerl of Record:
0 / (1 � � G
L I-rl.t ��J & tip.
Name(Print) City,State,ZIP
4. and Street Telephone Email Address
SECTiOv 3 rDESCRIPTION QFyPRPOED WO { (chec�C all that aQply)„IF, v >" _ ,
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": U �a
V X 7 4- o d o-
", SEC PI0N4wESPTATEDC0IVSTI2TI0I�xC0STS� � `; `
Estimated Costs:
Item O fi ra xl7se 0n1Y fi
Labor and Materials .
1.Building $ 1 Budd g Pam tt e€ ,� -Rumeateho u` e�is deC fed x
O'4Standar&UrtyjTrd, Ap I X-0 ee
2.Electrical $ x a
O IotakProaectCasl (tem6}xulttpltierx x
3.Plumbing $ 2�
4, Mechanical (HVAC)
5.Me (Fire 4 :�` "� �'� /ws� q�.1 ✓`"t a
Su ression $ I ta)AllFees $ � � �axu ar
Check No Cheek 6rc;ount 5 Cash Am�uat , _ t
6.Total Project Cost: $ p{ d n ll s O Ou ` nng al ceDue ,
SECTION Si CONSTRUCTION SERVICES ` ')
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type;" tt< Dckripuon
U r Unrestricted(Buildings up to 35,000 cu.ft.)4
R Restricted 1&2 Family Dwelling
City/Town, State,_ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP Telephone
''x:SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M GL c. 1,52. §, 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 .......... fC No-......... ❑
'SECTION 7a: OWNER AUTHORIZATIONTOBE'COWLETEDWHEN
OWNER'S A,GENT'OR CONTRACTOR APPLIES FOR I3UH.DING 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 Name(Electronic Signature) Date
SECTION 7b: OWNER' 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 m knowledge and understanding.
PP y g g•
nr�t Owner's or Authorized Agent's Name(Electronic Signature) Date
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
wwvv.rnass, o� v:%oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,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"
CITY OF SM.E.M. INLASSACHUSETTS
• BUILDING DEPAR`C LENT
t• 120 WASHINGTON STREET,3"m FLOOR
TEL (978) 745-9595
FA.e(978)740-9846
KiNBfR*La.EY DFISCOLL
yYa{lYOR �hiObfAS RR13 ST.PtE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant information \T 1 Please Print Legibly
Narne(BusiiiosOrganization/individual): J 1 �'i (r__ �P �i_rr Yl-�— CL
Address: FG iO7)6 4
/
City/State/Zip: �21� C.e S�C✓ A"h Phone#: ?7e -2 S ' tf
Are you an employer?Check tlyyappropriate box: Type of project(required):
I.Poll am a employer with i-3 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time),* have hired the sub-contractors 6. ❑Now construction
2.❑ Iran a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8..❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
(No workers comp.insurance S. ❑ We are a corporation and its
officers have exercised their 10.0Electrical repairs or additions
required.) of
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. (No workers'cump. c. 152,§1(4),and we have no 12,Q Roof repairs
insurance required.l t employees.[No workers'
comp. insurance required.] 13,@ Other
•Any applieum that chwks box B1 must alw Fill out the section blow showing their workcri compensation polity information.
t I huneown us who submit this affidavit indicating ihey arc doing all work and then hire outsidecontractora must submit anew affidavit indicating_sueh.
:Cop Iractors dtal check this box must attached an additional sheet shu wing the name of the sub<ontndon and their workers'comp.policy infomation.
1 am on employer that is providing workers'compensation insurance for my employees Below Is the polity and fob site
information.
Insurance Company Name: ✓ YS
Policy N or Sclf--ins. Lic. N: x f L)l(3 ,� i ( Expiration Date: Z
Job Site Address: V t2t V t !ff [ S City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 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 up to 5250.00 a day against the violator. fie adviwd that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby ce under the o and "allies ofperfury that the infornmJlon provided above is tru and corraca
S i,tn.nufe� � ''// Date:
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Phone#• 9 79 2q3 68--6—
Official use only. Do not write in this area,to be completed by city or town offirfal
I
City or,rown: _._ Permit/Lkcnse H
Issuing Authority(circle one): --�-
1.Board of Health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.01her,—
Contact Person: Phone#:
Certijteate of Flame Resistance
j REGISTERED
I FABRIC ISSUED BY Date of Manufacture
NUMBER JOHNSON OUTDOORS INC-
NUMBER NEW YORK M02 51221206
FA 49303 Manufacturers of the Finest
Tent Products Described Herein
i
j 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.
4; CITY: GLOUCESTER STATE: MA
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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',
I
Tvpe.color and weioht of material: 14 oZ vrwl Snyder white block out '
Description of item certified: 15 x 30 Frame System
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
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HANWHA POLYMER CO.
TENT DEPARTMENT,JOHNSON ORS C.
'Large Scale
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� SEFTEfIEER, 2000 � -
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' THE F_VENT COMPANY A'" PG Eox_419
GLOUOESTER, W--,,. 01 931-04 19
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NFPA 701
a'\ INHERENTLY FLAME RESISTANT
a . 3 HI GLOSS VINYL
F-419,01
WILL f`•�T
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WHITE 14 OZ, HI GLOSS
PAIR OF GABLE ENDS FOR A 6' WIDE TENT 3-10' MIDDLES
TOMMY SC I ORT 1 NO - t SHOP FOREMAN
1111 1 11
,��y,\✓ '�.. \ �, i � i` �"` \.i \J.'� /'�/.tea 4r.� `�;"s"k'" ,-.'�N.'`C"a.�^^�`� `-+„F"�" �-
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' - a>, r 3� $9ts� �. "'S �;,��a �'9$P9 ��t 'n'�:7g,.'m;•,.yy„
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Certificate of Flame
Resistance
c Date treated or
ISSUED BY Manufactured by manufactured
Burlan Corporation Fred's Tents&Canopies
1-704-867-3548 7 Tent Lane 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
Ex (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.
17X1 NFPA-701 (large scale) &CPAI-84
Trade name of flame-resistant fabric or material used Blockout Whitc . 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) 600 Marquee Customer Invoice It 10950
IYV, 1JlV
Sep, 8. 2008 2: 13PM
SEONGSOO WOOLIM E-ETL CENTER11709
N (/_ 2BD-21,SEONWOO 20A.3-DOf1G
PLAST �10''ORP r Te &-2N2,0 4 340UL.KOREA
- PW�B�va�vw:irt est.co.kr
CERTIFICATE OF FLAME RETARDANT
BUYER CERTIFICATE NO. - 07-0M()-COI
ECONOMY TENT INTERNATIONAL
2995 N.W. 75TH STREET MIAMI,
FL 38147,t7SA ISSUE PATE; JULY 2Dth, 20D7
We hereby certify the below-products pleat NFPA 191 ik Calrtomla Fire Mashal
for the flame retardant.
1. ITEM CODE. : I-TEI+T TARP , *z WEIGHT. 62" WICIM
I
2. DETAILED SPECIFfCA'TION.
PVC LAMINATED FABRIC
110D 4Tex (81£9/sq.inch)
WI" ; 62 +
WEIGHT : 18 OZ.
F/R, UN, Mn-MILDEW TREATED
COLOR : WHITE OPAQUE
3. TEST
1) FLAME PUARQMT TEST NFPA 701
RESULT - PASS
2) FLAME RETARDANT TFST, CAUFORNIA FIRE (uIASHAL
RESULT : PASS
AUT}tORVED BY
flVPLAST CORPORATION
PRmwitm
Certificate of Flame
Resistance
Date treated or
ISSUED BY Manufactured by manufactured
BurlanCor oration
P Fred's Tents&Canopies
--- 1-704-867-3548 7 Tent Lane 07/04
Stillwater,NY 12170
This is to certify that the materials described below have been flame-reiardani treated(or are inherently nonflammable)
FOR Eve t[t 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 Stale 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.
1XI NFPA-701 (large scale) &CPAI-84
Trade name of flame-resistant fabric or material used Blackout White Reg.No. F-76101
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Fred's Studio Tents & Canopies, Inc. Uk;D
Plant Supervisor
Product Description 9x18 Marquee Customer Invoice k 12994
Certificate of Flame
Resistance
Date treated o
y r
ISSUED BY Manufactured b manufactured
— y Burlan Corporation Fred's Tents & Canopies
--- 1-704-867-3548 7 Tent Lane 07/05
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 0 193 0
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
Dx (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.
V 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.
dk;D
Plant Supervisor
Product Description 9x10 Marquee Customer Invoice# 15026