50 WINTER ISLAND RD - BUILDING INSPECTION (2) ��oo � /`2;6 d�`,C dPD.,, Ts!
TO Yc 0-
/ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2077
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offic l Use Only
Building Permit Number: Da Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORM ATIO
1.1 Prop rty ddre s: 1.2 Assessors 14a c rcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard r
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❑
SECTION 2: PROPERTY OWNERSHIP'
2. ,O er�Re orb d:,, �_ ^ yl�/4-
Na—the(Pr fit) ��`_ n City,State,ZIP , `"!
r,m� ZA
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief De riptionofPr sed Work Z: v�5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (IfVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
NC
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: 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 Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP ` M Mwo
nry
' RC Roofing Covering
v WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) c'
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 ..........67 No...........❑
SECTION 7a: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.
i
Print Owner's Name(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.
Lb'A
Print Owner's or Authorized Agent s Name(Electronic Signature) Date
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 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
3nnK.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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"
Certificate of Flame Resistance
REGISTERED ISSUED BY
FABRIC JOHNSON OUTDOORS INC. Date of Manufacture
NUMBER BINGHAMTON, NEW YORK 13902 SEPTEMBER 2008
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. i
Type,color and weight of material 14 OZ
Description of item certifies 20 X 40 1 PC POLE TENT
ame Ketardant Process Used WillO e en-love y Washing Ana
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinvi Laminates TENT DEPAR ENT,J01117SON OUTOO¢RS'7AC"'
\ 'Large Scale
6 ext LGUjG (9- WCUTMel
ISSUED BY Manufactured by Date tretuated or
`� manufacred
���� verseidag Fred's Tents & Canopies
Et 973-252-1189 7 Tent Lane
Stillwater,NY 12170 03/11
This is to certify that the materials described below have been flame-retardant treated(or are inherently nonflammable)
FOR Event Company
PO Box 0419
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)
Trade name of flame-resistant fabric or material used WHITE Reg.No. F50501
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Fred's Studio Tents & Canopies, Inc. lJ�
Plant Supervisor
Product Description (25)7x20 Cathedral Window Walls Customer Invoice# 12244
Jun 05 12 07:55p The Event Co 978-283-4163 p.1
T/te Cnmrnnmvenith ofMassaehuselis
Department nf.Tkiha vntAce0eWs
q QjJ4eeofinV M igagens
4 600 WaddugtonStreet
Bastoty MA oalll
Wwww.massgotr&a
Workers' Compensation Insurance Affidavit:Builders/ContractorsMectricions/Plumbers
Applicant Information Please Print Legibly
Name(susia--;310 gaavafionftdividuat):' 1 i - [=I l2"n+ Cc-,.
Address: E gig
City/staW/Zi : 6
Are y�an employer?Check the appropriate bow
L I am a employer with JZ 4. ❑ I am a ge carol rnntractor and I Type of Project(relluued)-
employees(full and/or jxUtd e).+ have Idled the sob-contrdctos 6. ❑New construction
2.❑ I am a sole paoprietor or partner- listed on the attached sheet 7_ ❑Remodeling
ship and have no employees These sub contractors have g, ❑Demolition
working for me in any capacity. emplopcesi and have worlmfs'
[No wodoce comp.insurance comp.jnsumi _t 9. ❑Building addition
ra9uirefi.) 5. ❑ We an:a corporation and its 10-0 Electrical repairs or additions
3.❑I am a humeownerdoing all work offrcers bave mmiser tbea 1I.0 Plumbing repairs or additions
myself [No workers,comp, xi&of eremptionperNIM 12.0�Roof repairrequired.]insurance required.]t c.15Z§I(4),anlwe have no 13.Ly
��.
employees![No wodsers,
�.hisurance 1
'�7/applicantthat eheclm bmAr tamtatmfia adthe cacti®hclow ai»uiggtF,eirvworken•rnmpmsatiaapoacy mro=Mion
t lioaaaowoan who sdbadtthisaflidnit®da;amgtbay an:doing an work aodthm him ootsida eotr,,Wn ran#submitanaw 4EMva inai"fi's och
iaWa®as that chct dib bmrtmst Mldmd m adddiooal lbwtshowrog tbaname of the aulrcooitaamts and slate v hcgm anal Ihase have
emPloyees. If tlx hax emP1oYVM fbar-Vsl pwvida a—--k—.—.p.pd1wynombw
I am as Maya that fsprovfdargworkew mmpmsasm h sinamaefor my enrloyem Behr is&epo&ry a
&f0rmafion- trd}ob ate
Insurance Company Name: `� t/t l e!S �t
Policy#or Self-ins.Lic_ �V�st��9 I '�/J�j £ncpiralionDate: 1 Zajl
Job Site Address: 0?,L1a r-> CAylStafe/Z>p: �t
Attach a copy of the workers'compeusafion policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required order Secdon 25A of MM c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 an lorone-yearimprisoument,as well as civil penalties in the form of a STOP WORK ORDER and a free
Of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DL.for imurance coverage Verification.
I do hereby crr8)fy U7!.!µ ire vans andpen�ofP=j that the ixforma6aa provided above Jis true and correct
Si>nature A 1C�/Ip Da `4& le;"
Phone#- 7 - 9-O 3- 7 C] a 7
Of(Icial use only. Do not write in th8 area to be completed!ry tsty err tmen official
i
City orTown• Permit/License#.
Issuing Authority(circle one):
1.Board ofIlealth ZBnHdingDeparfinent 3.Cityfrown Clerk d.Electrical Inspector S.PlumbinglaVector
6.Other
Contact Person: Phone#.