7 PATTON RD - BUILDING INSPECTION (2) Z S7O zlie
The Commonwealth of Massachusetts ": ON'At � 9�(�
N Board of Building Regulations and Standards 6�T1 OF
M
1 vyd Massachusetts State Building Code, 780 CMNJ6 S�� _� p SALEM
1,,7 (t Vfar 2011
.Y Building Permit Application To Construct, Repair, Renovate Or Demolish a 7
One-or Tiro-Fconily Dwelling
This Section For Official Use Only
Building Permit Number: Date Aped: _
Building 0111cia3(Prina Name) Signature �— �e
SECTION 1: SITE INFORMATION
1.1 Prµpe v. ddress: 1„2 Assessors Map& Parcel Numbers
7 Y AMi p o—.._ _
Lla Is this an accepted street?ves no Map Number Parecl Number
1.3 Toning Information: 1,4 Property Dimensions:
Toning District Proposed Use Lot.Arca(sq fl) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required provided Required Provided Required F Provided
1.6 Water Supply:(NI.G.1.,c.40,§i4) L7 Flood Tone Information: 1.8 Sewage Disposal System:
zone: _ Outside Flood Zone?
public❑ private❑ Check if ves❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
—4 iLc
Name(Print) _ City,State,7,1P'
'7 117 ,�&:L
No.and Street telephone —fit Addmss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alwration(s) ❑ 1 Addition ❑
Demolition ❑ Accessan• Bldg.❑ Number of Units Other ❑ SpeciF•:_I,�. j� „_„__,� G”
BriefDescription of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
t. Building $ 1. Building Permit Fee:3 Indicate how fee is determined:
2.Electrical 5 ❑Standard City/Town Application Fee
❑Total Project Cost}( tem 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:_,_
5. Mechanical (Fire
Suppression) Total All Fees: $
f /\ Check No. _Check Amount: Cash.Amount:
6.Total Project Cost: S ❑paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
ulr1 tr \ J" Ew�s d icense Number Expiration Date
Name of CSI.I fold
Mw t- p Teo hist CSL Type(sec below)
No.and Street '�{•UN 1�11 Tr pc Description
S 1C3Wlk 1 ���� ' '1 U Unrestricted(Buildings up to 35.000 cu.fl.)
1 R Restricted IR2 Family Dwelling
city/Town.Statc,ZIP
M ivtamnry
RC Roofing Covering
WS Windo%%and Sidinta
��y o'.01� SF Solid Fuel Burning Appliances
�s/. 63Y��36�'� ►n�c���►��`r"""`-"tl" ' � I Insulation
'fele hone Email address D Dc not it a
5.2 Registered Home Improvement Contractor(111C)
IiIC Reeistmtion Number Es iration Date
HIC Company Name or FIIC Registrant Name P
No.and Street Frond address
Cit /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 o.the building permit.
Signed Affidavit Attached? Yes .......... Nb...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR//APPLIES FOR BUILDING PERMIT
1,as Ownerof the subject property,hereby authorize��p/�/,o
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Oomc s Namc(IIcctmnic Signature) Date
• SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury tl all of the 7n
ort it application is true nd accurat tot the best of know) ge and a tan
Print Owner's or AuthorizeAgent's Name(Electronic Signature)- - Ude
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 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
wwmv.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
Z. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/auics,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"
ff
. yq
CALIFORNIA DEPARTMENT OF FORESTRY and FIRE PROTECTION
OFFICE OF THE STATE FIRE MARSHAL
REGISTERED FLAME RESISTANT PRODUCT
Product: Reqistration No.
TENT CANOPIES AND SIDEWALLS, $TT160ZBO F-88001
Product Marketed By:
TENT AND TABLE.COM, LLC _
2845 BAILEY AVE
BUFFALO, NY 14215
This product meets the minimum requirements of flame resistance established by the California
State Fire Marshal for products identified in Section 13"1.15, California Health and Safety Code.
The scope of the approved use of this product is provided in the current edition of the
CALIFORNIA APPROVED LIST OF FLAME RETARDANT CHEMICALS AND
FABRICS, GENERAL AND LIMITED APPLICATIONS CONCERNS published by the
California State Fire Marshal.
Expire: 6/30/2014
Oepu State Fire a hal
rR-a
J