10 WHITE ST - BUILDING INSPECTION (24) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
i
a OF SALF.M Massachusetts State Building Code, 780 CMR, 7 edition
Revirrrl Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. =0011
One-or Two-Family Dwelling
This Section For Official Use Only
1 Building Permit Numb r: �� Date Applied:
Signature: ' "`tYw l D
Building Commissioner/InspiP60 of Buildings Date
SECTION 1:SITE INFORMATION
1 Property Vressq 1.2 Assessors Map& Parcel Numbers
6tJ{a.t ie
61a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: sA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
From 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private El Zone:
if es❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
z'1 Owillri of Recurs(
Name(Print) Address for Service:
`f'78s -7ytd 9<S aC,
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that aW
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Allera[iNumber of Units Other ❑ Specify:
Bri�scriptionofProposedWork-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMcial Use Only
Labor and Materials
I. Building S ' I. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
r �
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I folder List C'SL"f
Ype(see below)
Address T'Pe I Description
U I Unrestricted(up to 33,D00 Cu.Ft.
R I Restricted IB2 Family Dwelling
Signature M Masonry Only
RC Residential Roaring Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 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.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 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
II --SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
��I, NNOA, .L.�l n VI-FIr C }�Gc1Lt't ,as Owner or Authorized Agent hereby declare
that t e statements and information on the foregoing application are true and accurate,to the best of my knowledge and
beh�
/Q
Pri e
Z ,c)
Signs ( neror r gent DdW
(Six0ed unde a pains and penaltics of 'u
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 gol have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 10.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
e 'r
Certijt cote q Flame Resistance
REGISTERED - ISSUED BY Date of Manufacture
FABRIC JOHNSON OUTDOORS INC.
NUMBER BINGHAMTON, NEW YORK 13902 JUNE 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 COMPANY
CITY: GLOUCESTER,NU
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
Califomia 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+40 X 40 2PC WBO
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinci laminates TENT DEPARTMENT,JOHNSON OUT RS IN -
'Large Scale
r 1
S
Cert cafe e
REGISTERED
FABRIC
NUMBER BINGHAfk4TC;0. '-IE`jk/ IRK. 2003
FA-44303 'izncr=, r o.m � a — I
This is to cee'tify that the products herein_ mn material inherently -,a ins retardant as
hereafter specified by the material supplier, -
NAME: THE EVENT CO
CI1"Y:
GLOUCESTER STATE: iAA
Cer0l'Ica4on is hereby made that: _
The articles descntied on this certificate have been manufactured with ar. approved flame retardant cnen:ical in compliance vrith
California State Fue Marshal Cade,NFPA-701`.
Type cdorandweightofmaterial NC-16 BOA' Vinyi ENDURA WHITE LAMINATED ,
Description of item certified: 10' MID FOR 40' TWIN TUBE PLUS -
Flame Retardant Process Used Will Not Be Removed By Washing And.
Is Effective For The Life Of The Fabric
HANWHA POLYMER CO. �.
--v
' TENT DEPARTMENT,JOHNSON O CJRS GrC. -
. •'-Zfye Sc'Lle
RAPID KICRO BIOSYSTEBS
07/Y9/08 08:44 FAX 9782719908
The COMMOftwealth of ilassachusfids
Department ofladststrW AccMwtfs
Office of InMdjagions
600 Waskingfort Street
Bosmn,AAA 02111
www.massgov/due
Workers' Compensadou Imsnrsnee Affrdavdr Bruder6/ContrAppsdors/Electriraanslptnmbers
' t Informs '
a aradren � ✓ t�if7
Name�`aasiuo"a.v:aa.�"—••-•----/--•
Addiess:
City/State/Zip:
I
an employer'Chow th appropriau bow aA 1 6. E Nww cu (�4u�
�_ 4- Q I em a general cones � Q NeW ucdon
a ayployer w& , Lave hued the sub-coadraclocs
loyCe5(fall Muvor part-time)- listed on the attached sheet 7. Q Rcmod6li
a Baia ptoprietor or partner- These sub-con�ermy have g- Q Demolition
andbave no eMVl0yees uVicyees and have wares' 9. ❑Belding addition
ning for me many capacity. . �- _r' or additioos
avdrece comp• 5. Q We we a corpomdoa and its l0.[]Electrical rquas
uNed j �_ all work of acers have wcaciaed the r 11.0 PLmthing rePa'ra or adi mtms
3-Q I on&homeowncr mg. . Tptofexempemr per MOL 12.Q Roof repa�
myself[No workers'ccroV ;�. 1=§1(4�and we have no -
prw=requira)t cavloyem LNa workers• 13 Other
mmp.insurance re9uir,47
•MYaPP�atdurchsin box#1 auerarso 9tl am tbs s,ayrrbehav shwwj"axtrrxatms' aaa Ponarbffi � ®.
ee .
- tltaruewoers who ssismeEtise1dssir iad�ta6 msy an du-ingla war and*w hire oaida wavemn nnst=bMitsaewa
:(,:anaaetorr dwrebcdcdtisbox ipaftaaachad�aadiaaai dwae aftbe sub4WW MOM X�sWewhefaCaeortbaceeaaaecluw
,reloYees rf the vbD lraeorsbavc"Play"%tw mut p �ift duv wrrI= 'emrp.POW WRaft— .
o on employer is providing workers'coaspeaaawn iarayrces far arY PfOY *• O1°k the paLry ardfoh site
I a
Insurance
Coa pany Name:policy A or self-ins.Inc.M f/'` {
r 7 20 f EVirationl},W:
A
lob Site Ad&c= ��GT lOt/� City/S+a»�'mm z ft' —
Attach a copy of the workers'oompmsatian panty dederadan page(showing the policy number and evimtion dare
Failure w secure coverap as requised carder Section 25A of MGL c-152 can had to the hvpuvitian of criminal peashim of 1
firna up to S1.500.00 and/or one-year impdsortment as well as Civil penalties in the form of a STOP wORg ORDEB•aad 1 flat
of up to 8290.GO a day agamsr"vfolaruw- Be advised that a copy of this srdtem®t nanyybe&rwarded to the Office Of
logq< - oft%e DIAL for' v
e ofp® Aran aka igfartuarton provld is arse sad rnrrett
I do hereby terrify under ace pains sal peasaai M i+ay
�i phi pX•�
use only. Do not wrI in this area,w compiew &Y or 9~of^a-iaL
my or Town:
Issuing Awherhy(c4ele am):
1.Board ofHealth 2.Banding Department 3.C ty/1'owo� 4.Wetlriea raspeetor 5.M=dit ImPeer.
6.Other
Contact
Person: -