BROAD ST - BUILDING INSPECTION \ The Commonwealth of Massachusetts
`i Board of Building Regulations and Standards CI"I'1' OF
Massachusetts State Building Code, 780 C'MR SALENI
V Re rised.I fur?011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(Due-or Two-Famih Dwvllhrg
This Section For Ot7icial sc Onl
Building Permit Number: Date A pliieedd�',"�
Building Olticial(Print Nmne) Signature Date
/
SECTION 1:SITE INFORMATION
1.1 Pro erty essq- 1.2 Assessors NIap& Parcel Numbers
1.1 a Is this an accepted street?yes mhn_ no Map Nu Parcel.Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
I.S Building Setbacks(h)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Cl Private❑ Zone: _ Outside Flood Zone?Check Municipal ❑ On site disposal system ❑
it' es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 one{t of Re Ford: i �r� �7��
f7 t .— fJ�—c S� AIX
N;mie(�Pr�inq�,Q- C iiitty.State,ZIP
Z�IP�!
N and Street 7 �O !
'relephune Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Speedy:
Brief Descri/pftion of Proposed \Vork': r7how
Glo-�_SECTION 4: ESTIMATED CONSTRUC"�\
Estimated Costs: Oat(Labor and .\latnrials) ying $ I. Building Permit Feicate how fee is detennineJ:ical S ❑Standard City/Towe❑Total Project Cost'( lier ___xing S - —
_. Other Fees: S
nical ill\':\C) S List: ---- -- --
nical 'Fireiunl S Fl-y,_„ Check Nu. Check :\mount: Cash amount:
Project Cost: 3 ❑pnid in Full ❑Outstanding Balance Due: __- ..-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
I.ianse Number---- --- IxpiratT..D:ue
Name al'l'SI. I Inlder -.. ---
List C'SI"1)PC(sce belutvf
1ppe Description
No. and Street -------- --------
U Unrestricted(Buddin s uo to 35,000 cu. Il.)
_ .._ R Restricted I&?Famil - Doellin
C II%f_11mn,state.ZIP M Mason
RC' Roulin Covcrin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I J Insulation
I'cic hone [:mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
I IIC Compact) Name or I11C Registrant Name
No. and Street Email address
City/Town.State,ZIP relc hone
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 .......... ❑ No........... 0
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.
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
�stained in this application is true and accurate to the best of my knowledge and understanding.
oM 6al�to%4-e-- �1 8 /2
P ' hmer's or Authorized Agent's Name(Electronic Signature) Dale
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 Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
w~%. Information on the Construction Supervisor License can be found at ��_����iiias .!�p� Ups
2. When substantial work is planned, provide the information below:
Total flour area(sq. ft.) - (including garage, finished basement'attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms _.. . . .. . ..- -
Number ot'bathroums -_. --- - - Number of Ralf h,uhs _. ._ .__ ...
Nuntberot'deck>, porrtlies - ...- _-
I\Pe afpwling s)stem ., _ !inclosed -_-Open
1, "final Project Square Footage"may he Substituted for''I'otal Project Cost"
Oct 05 10 08:47p Carol Hedges 978-283-4163 p.7
Certificate of Flame Resistance
REGISTERED ISSUED BY Date of Manufacture
FABRIC JOHNSON OUTDOORS INC.
NUMBER BINGHAMTON,NEW YORK 13902 M[AY 2009
F-14D.01 Manufadwe s offhe 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,bfA
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved fame 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.
Type,color and weight of material 14 OZ.WBO
Descrifltion of item certifies EFS 30 X 30 2 PC WBO
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
i Snyder Manufacturing, Inc.
Ma.i factumr of Flame Retardam viml Laminates TENT OEPARTMEMT,JOHNSON OUT ORS IN
- 'large Scale
Oct 05 10 08:48p Carol Hedges 978-283-4163 p.10
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