10 WHITE ST - BUILDING INSPECTION (18) 4.73
The Commonwealth of Massachusetts
Department of Public Safety
W
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One or Two-Famil in ,
(Ibis Section For Official Use Only)
Building Permit Number: Date Applied: Building Offici
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for w . a street ad ess is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other P Specify: 'y"CAtT'
Are building plans and/or construction documents being supplied as part of this permit application? Yes.,,❑ No ❑
Is an Independent Structural Engineering Peer Review required? ff /Yes ❑ No ❑
Brief Descripption of Proposed Work: 1.N 5 4,—& 1- �l0 SC `K + -F Yc✓»
Fs/ aLC 4
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
• CHANGE IN'USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing. Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft)and Total Height(ft.)
SECTION 5.USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: HI Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I 1 ElM: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as applicable)
IA Ill IIA ❑ IIB ❑ MA IIIB ❑ IV VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information Sewage Disposal: Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
or
Private❑ or indentify Zone: or on site system❑ required❑permit is encl trench or specify:
dosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ " '' Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
13 yu, y 14"Aww l/nn 110 L �,_.�� S-+ Se'� 01 4 76
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
/Jsab. _rlaktrl- 91 0- Z&�&— - -
Title U Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10,CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor n
Cmpany Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
- -7P Z4W4
Tele hone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 11:CONSTRUCTIONS.COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �v1 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
7 I �
application is true and ac orate to the best of my knowledge and understtaanding.
Please
�rint and sign —Title Telephone No. Date
1„ �h,c' U'`s <6tilk VCE— O 14 ?d
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
� t
L ; +
JQX The Commonwealth ofAfassachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
I
NalnelBusinesslOrganizationrindividuatl: I he- E(/Z^y. —/ `U
Address:
City/State/Zip. GBJ�� /tA� �j/`/3® Phone #: ? 7Z eZ,3— Ve'�
Are you an employer?Check the.appropriate box:
r� rp�ef project (required):
I. 1 am a employer with (� 4. ❑ 1 am a general contractor and I
employees(full and/or—part-time).* have hired the sub-contractors New construction2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remodelingship and have no employees These sub-contractors have ❑ Demolitionworking forme in any capacity, workers' comp. insurance.[No workers' com insurance 5. ❑ Building additionp• ❑ We are a cor}wretion and its
required.) officers have exercised their .❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. Y� c. 152, §1(4),and we have no 12.❑Roof repairs
_insurance required:) ' employees.[No workers'
comp. insurance required.) 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers,compensation policy information.
*Homeowners who submit this affdavitindicating they ate doing all work and than hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-cootraMors and their workers'comp.policy information.
Ijormatlon.am an employer that is providhlg workers'compensa
m tion Insurance for my employees. Below is the poltcy and Job site
`
Insurance Company Name: ck
I� -
/ 6 Cl
Policy#or Self-ins. Lic.#_� J�t/ 6 Z f A/ / (j 0��
Expiration Date:
Job Site Address:
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
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 fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do herebr cer"w1 unaerifte� ins nd names ofperJury that the information provided above is true and correct.
Si nature: j
ate:
Phone#: / �7
Ofcial use only. Do not write in this area,to be completed by city or town Official
City or Town
Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Df.....w N.
Certificate of Flame Resistance
REGISTERED ISSUED BY
FABRIC JOHNSON OUTDOORS INC. Date of Manufacture
NUMBER BINGHAMTON, NEW YORK 13902 MARCH 2O10
F-140.01 Manufacturers of the Finest
Tent Products Described Herein
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
CITY: GLOUCESTER,MA
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', Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test
Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G.
Type,color and weight of material 14 OZ.WBO
Description of item certifies 40 X 40 2 PC Twin Tube+WBO
aMe Ketardant Process Used Willo e KOMoved Ely Washing n
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARYMENT,JOHMSON OUTDO 0R5'1NC'
\\ 'Large Scale
Certificate of Flame Resistance
REGISTERED ISSUED BY
FABRIC JOHNSON OUTDOORS INC. Date of Manufacture
NUMBER BINGHAMTON, NEW YORK 13902 NNE 2009
F-140.01 Manufacturers of the Finest
Tent Products Described Herein
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
CITY: GLOUCESTER,MA
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', Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test
Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G.
Type,color and weight of material 14 OZ.WBO
Description of item certifies TT+10 MID 40 WBO
a
ame Ketardant Process Used Willo e Kemoved By Washing n
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinvl Laminates TENT DEPAR ENT,JOHNSON OUTDO¢RSIRC" Large Scale