37 WINTER ISLAND RD - BUILDING INSPECTION The Commonwealth of Massachusetts
o — Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR. 7'"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *k
One-or Ttco-Fun g ANN&
This ction For ORcial 'e Onl
Building Permit Nu er/:�� pOateied: / q
Signature:
Building Commissioner spector o*But Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Number
1.1 a Is this an accepted street?yes o Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
1.5 Building Setbacks(ft)
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:
Public 101, Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if ycsC1
SECTION 2: PROPERTY OWNERSHIP'
j,�Owner'of Reeord:
i'LvmtneuL �ayrva For i3otir0 3–i w vie ZS �V�
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 13Owner-Occupied ❑ Repairs(s) C! Alteration(s) 13 Addition ❑
Demolition ❑ 1 Accessory Bldg. Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building E I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical E ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: f
4. Mechanical (HVAC) 5 List: U (�
5. .Nechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licen d Construction Su ervisoi L)
License Number Espuuuon Date .y
N4MC 0 fpi er
Lot CSL Type(sec below)
T� Description
Address
U Unrestricted(up to 15.000 Cu. Ft.)
R Restricted 1&2 Family Dwelhn
Signature .N Slason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A fiance 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. 152.0 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...........O
SECTION 7s: 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
1, ,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.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the ains 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 W 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 110.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 halfibaths
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"
IMPORTANT D O C U M E MTsgJ�`-r`,-L,LPLP�LPr P RPO o
5 CertifieaW of frlant c esistartee 5
5
5ISSUED BY 5
5 REGISTRATION Date of Shipment 5
sICb�lR�5
NUMBER 4/17200655'� INDUSTRIE INC.
EVANSVILLE, INDIANA 47725 Tent Identification 5
MANUFACTURERS OF THE FINISHED 04595788
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated
5 (or are inherently noninflammable) and were supplied to: 5
76556 C5J
5 APEX TENT RENTAL 5
5. 7 COTEVILLE RD 5
5 5
5 LONDONDERRY NH 3053 5
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5 S
5 5
5 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPA184, ULC 109. 5
5 Serial# 5
5 8,50501(1) 5
5 Description of item certified: 5
5 CENTURY MIDDLE 50WX30 W141TE 55
5 SNYDER VINYL-SINGLE POLE 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 C5 SNYDERMFG NEW PHILADELPHIA,OH Signed: _ _`_� ��Lcsa /1� 5
Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. lj
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