38 MARCH ST - BUILDING INSPECTION r ~ �• l ���^ �� v,� (`l cmc�'�l 35-sr�
The Commonwealth of Massachusetts Ea *kvosodku%
,t— Board of Building Regulations and Standards
J Massachusetts State Building Code, 780 CMR, 7'"editionBuilding
Building Permit Application To Construct. Repair, Renovate Or Demoli
One-or Tiro-Fain ly re ing
This Section,For Officiall Use Only
Building Permit Nu r: D t Ap lied:
Signature:
Budding Commissioner/Inspector of Buildi gs Date
SECTION 1. E INFORMATION
I.1 Property Address: 1.2 Assessors Map dt Parcel Numbers
1.]a 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(B)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP''
2.1 Owner of�Recofdt 3� l�k��Gt S� - SQ /C Ur
//110 e///
Na (Print) Address for Service:
Signa ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New EConstruction❑ EAccessory
isting ElBuilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Dem ❑ ldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': l-EG-�,' D `oLD' -C 4 -f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building f I. Building Permit Fee: S Indicate how fee is determined:
C3 Standard City/Town Application Fee
2. Electrical E ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. .Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S g
J 3 Op 0Paid in Full ❑Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
� License Number Expiration Date
N:(mc of CSL-Hylder List CSL Type(see below)
a – .
Address EDResidential
Description
tncmd u to)5,000 Cu. Ft)
Signaturenmal ti—nn CoveTelephone ntial Window and Sidinmial Solid Fuel Bumin A fiance Installation
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 2SC(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 .......... O 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:OWNEW OR AUTHORIZED AGENT DECLARATION
le"--e (k✓e7�5 For rC e�J ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Cf
Print Nam
ignatu f Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 no 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 I IO.R6 and 1 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 halfbaths
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•
9
-"b CITY OF S.1I.E%I, NickSSACHI;SETTS
BUILDING DEPARTMLNT
\ was 120 WASHINGTON STREET, )eco FLOOR
TEL (978) 745-959S
FAx(978) 7.0-9846
KIN BEJU FY DRISCOLL
.MAYOR THOaL1S ST.PrERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\RSSIO-.ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AI)nliCant Information Plcase Print Legibly
NatTIC (Busima&Organistiiomindividuah'
l): t��-/�I 4S O r lee f
Address: y& t:1 G, D t.�11 / /5 _
City/State/Zip: AN 04 1"1 a' 0/2 (cad Phone N: 9 7k' —5 0 'SS
i
eye to employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4. ❑ I am a general connector and I
employees(full and/or part-time).• have hired the sub-contracmry 6. C]New constnaction
2.❑ I am a sole proprietor or partner- listed on the attached shceL : 7. ❑ Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
I No workers'comp. insurance S. ❑ We are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 132,§1(4),and we have no 12.C] Roof repairs
insurance required.] t employees. [No workers' 13.❑Otho
comp. insurance requited.)
'Any upplicara th t checks box sl must alio fill out the aectioa belowstmwing their worktxs•compaiusio"policy information.
'I hvmc wncrs who submit this affidavit indicating they ate doing all worts and then hire outside contractors must submit a new affidavit indicating such.
-Contraxon that check this box must attached m additional sheet showing itte name of the sub- mncton and their worker'wmp.policy intmtaaq,
I ung an employer that Is providing workers'comparmadon Insurance for my employees Below Is the policy urtd Job std
information. //�/
Insurance Company Name: Wee,0rrK
Policy 4 or Self-ins. Lie. r^')A .S�/—9 D .-
— 7.� —OD Expiration Date:
!'!// ,
Job Site Address: 29 Q 1-e-k 5.1, City/State/zip.. —,Ce f vv/
/ ,tT .
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. 132 can lead to the imposition of criminal penalties of a
fine 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. Be adviw:d that a copy of this statement may be forwarded to the Office of
Invesitgatiuns of die DIA for insurance coverage verification.
!do hereby certify under the i s aannd penahles of perjury that the information provided above is true and correct.
nUure ` r�S�/A�G< Date.
Phone X: g7�- .J 35 50-�5
Oficial use only. Do not write in this area, to be completed by city or town o1fciuL
City or Tuwa: __. Permit/f.icense p
Issuing Authurily (circle one):
I. hoard of fleallh 2. Ruilding Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Impeetor
6. Other
i
Contact Person:_- .. _ -- -_ Phone p•
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5 REGISTRATION , ISSUED BY 5
Date of ����f�cture 5
APPLICATION 5
5 NUMBER uousraie mc.
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5 5 �� �� EVANSVILLE, INDIANA 47725 373453
FI2J.a ' MANUFACTURERS OF THE FINISHED 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
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(or are inherently noninflammable) and were supplied to: 5
5 293200 5
EVENTS FOR RENT INC#13528-8
5 464 LOWELL ST 5
5 W PEABODY MA 019602741 5
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5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
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5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial # 5
5 8001500(2) 5
5 Description of item certified: 5
5 FI TOP tow X 20 V1.W W
5 Flame Retardant Process Used Will Not Be Removed B 57
5 Washing And Is Effective For The Life Of 5 The Fabric JOHN BOYLE STATESVILLE NC Signed: � 5
5 TENT DEPARTMENT•ANCHOR INDUSTRIES INC. 5
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REGISTERED Date of Manufacture
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NUMBEREVANSVILLE, INDIANA 47711 Order Number
F190/191 MANUFACTURERS OF THE FINISHED 1116015
TENT PRODUCTS DESCRIBED HEREIN
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5 1101119 5
5 PAUL W. RILLO CO. #13528-8
464 LOWS S
5 5
5 PEABODY MA 01960
Certification is hereby made that:
5 The articles described on this Certificate have been treated with a flame-retardant approved
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NFPA 701 CPAI 84
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c5 Serial #:
5 Description of item certified: 5
5 5
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5 ame of App icator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC.
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