1 WASHINGTON ST - BUILDING INSPECTION (3) t The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards
Massachusetts State Budding Code, 780 CMR. T"edition Building Dept
Budding Permit Application To Construct. Repair. Renovate Or Demolish a �
One.or Tu'o-Fmrtils Duelling
This Sectictit For Official Use Only
Budding Permit Num Date Applied: a •ZZ�6
Signature: r
Buddin Commissioned o uddmgs Date
SECTION I: SITE INFORMATION
1.1 Propertyd drew 1.2 Assessors Map 6 Parcel Numbers
r mss^
I.I a Is this an acct ted street?yes U no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(B)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system C3Public❑ Private O Check if es❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'of Retor ` �
Name(Print) Address far Service:
--/7h'- 714- /G/ z
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Belding f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
1 Elecin ca1 f ❑Total Project Cost'(Item 6)x multiplierT x
J Plumbing S 2. Other Fees: f �
4. Mechanical (HVAC) S List:
t Mechanical (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 2 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licen sedC, rnvuctl n Supers/isor(CSL) ?� G�
• �Gv D GJ License Numhr Eapua ion DuteJXL
N,,poe of CSSLCIplder Livt CSL Type Jwv Blow) C7r ^`(J
AJdss T' Descn tion
U
UnreenFt.)
R Restricted I&2 Famd DCLn
Signatur J6vM Masonry Only
f RC LRcsidential Roaring Covering
Telep one wS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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........... 0
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 matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the sta ements and inform ton on the foregoing application are true and accurate,to the best of my knowledge and
behalf_
Prim Name of 22
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 P&have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfbaths
Type of heating system Number of decks/porches
Ts pe of cooling system Enclosed Open
3 "Total Pro)ect Square Footage' may he wMtitu(ed for 'Total Project Cosy
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treated (oy am tnhoten1ly nonfiamri abJo).
ADDRESS
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No. 3340 r. I
Sep. 8. 2000 2: 13PM
SEONGSW WOOLIM E-'BIZ CENTER8709
496-2/.SEONG800 2OA.3-DONG
IN P LAST CORP O 8€ON -2024
-mlM KOREA
!t�tEB 51TE = wvrw:inWast.cakr -
CEFITIRCATE OF FLAME RETARDANT
BUYER = CERTIFICATF, NO. : 07-072D-COI
ECONOMY TENT INTERNATIONAL
2W N.W. 75TH STREET MIAMI.
FL 39147,USA tMUE 1YATE ; JULY 20th, 2007
! We hereby cL-rtity the below•products niem AIFPA 701 $i-Caiitomla Fire MaehW
' toT the flame retardant.
1. ITEM CODE. : I-TENT TARP . 1E1oz WEIGHT'. 62" McIth
i
1
2, DETAILED SPECWFCATION.
PVC LAMINATED FABRIC
1100 4Tbx (a9/stl.inew
WIDTH : 62
WEIGHT : 18 OZ
F/R, M, ANTI-MILDEW TREATED
COLOR : WHITE OPAQUE
3. TEST
1) FLAME RETARRAhtT TEST NFPA 701
RESULT : PASS
2) FLAME RETARDANT TEST, CAUFORNIq FIRE MASHAL
RE$UL-: PASS
AUTHORFZED BY
iNgLmT CORPORATION
CITY OF S.U. .M, , LxsS.XCHUSETTS
BUILDING DEPARTtENT
120 WASHINGTON STREET, 3aa FLOOR
TEL (978) 745-9595
FAX(978) 74069836
KIN
CBgjtIBY DRISCOLL
THobtAs ST.PmiRs
MAYOR EYDR
DIRECTOR OF PL{LIC PROPERTY/{CI DING COSMIISSIONER
Workers' Compensation Insurance AMdavit: builders/Contractors/Electriclans/Plumbers
Ayolicant Information Please Print Leaiblr
VaRle 1BusimsaorpntratiomindavtdtsalC
Address:
P� ✓ <
City/StaWZip ���r� Cra �sr� �j(j� e1�� phone* `�70
Are you to employer?Cheek the appropriate hos: Type of project(required): -
1.[P I am a employer with //2 4. [] I am a general contrsetor and 1
6. 0 New COnytlUetitan
employees(full and/or put-time).• have hired the*&&contractors
2.❑ I am a sok pmprietor or partner listed on the attached sheat : 7. C]Remodeling
:hip and have no employees Then sub-contractors have V. 0 Demolition
working for me in any capacity.h• workers'comp.instrarte
9. 0 Building addition
[No workers'comp. insurance S. 0 We aro a corporation and its 10.0 Electrical repairs or additions
required.) officers haw exercised their
J. 1 am a homeowner doing all worst right of exemption per MGL 11.0 Plumbing repairs or additions
myself No workers'co c. 132,41(4),and we have no
y ( ceps 12.0 Roof repairs
insurance requited.) t employc a.[No workers' 1I.❑Other
—
;Any
insurance required.]
•Any applicant tht Choc"boa A mugalwr rill tea the lactim below, wp
Ageing their wait='cnnarnun policy infien atlas.
'I l.vtteowmas whe submit this aMdavit indicting they ata doing all work and this hits narids contracting tram minnit a near aMdavil indicating ask
:C,aatsanots that chtsk this bat mut aemhed an additional AM%hoeing do r of Ihe a&h Mraaswa and then wontnta'catnap.policy iarotnatteta.
/am an employer that b prsvid/nr workers'Coes station tasunrace jar any employe edrsw b the pe/fey atrd/ot rids
information. <'
Insurance Company Name: i/r� ,
Pnlicy M or Self-ins. Liffe.b: �l�j Expiration Date:
Job Site Address: l✓ e CityiStatetZip: 4�L
.%track a copy of the workers'c mpaasatlo ilcy declarsdom pap(showing the policy ottmber and explrsdon date).
Failure to secure coverage as required under Section 25A of MGL c._132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonmenk as well as civil penalties in the form of a STOP WORK ORDER and a fits
Of upto S250.00.i day against the violator. Ile advised that a copy of this statement maybe forwarded to the OlYice of
Invcnngminna ul'dte DIA for insurance coverage verification.
I do hereby certify Under that pains and pellizes of per the he information provided above s true add correct.
Phone A: L 7,,2— 4,
O/Jlclal use ditty. Do nor write in this area, to be camp/eted by riry or town n/Jta iaL
I I
City or ruwn: _- _ Pcrmit/1.lccnseM__
)%suing.itulhurity (circle gine):
I. Ituard uI Ilealth 2. Rwlding Department J.Cilytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Luntact Perion: _ ._. _. Phone tt•