CORNER OF FEDERAL & WASHINGTON - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
� Revised,Llnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Build.ing Permit Num r: D pplie
r
building 017icial(Print Na $ignalu Out
SECTION I:SITE INFORMATION
1.1 Property Addr *,1 / 1.2 Assessors Nlap&Parcel Numbers
lcor n e r r fo.�. t�—l.✓tc., iv�nt�il.
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP'.
21 f Own rlo Record:
i J d:
sU 1,-� /ems ,r2�
rhme(Prir t) City, ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specily:
Briet'Description of Proposed Wo k2: ram., ! — 3e O - ZG 2G j—/6 2Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S `6 I. Building Permit Fee:$ Indicate how ree is determined:
2. Electrical ,$ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 7. Other Fees: $
4. Mcchanical (fIVAC) $ List:
5. Mechanical (Fire $
Su nression) Cotal All Pees:$
Check NO._Check Amount: Cash Amount:
6. 'row Project Cost: S 0 Paid in Full 0 Outstmnding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Lic use(CSL)
C,�/r—
License Number Expiration Date
Name of CS fn`older
�36 J` �/I�w ^s/ rat S� List CSL'fype(see below)
No.and Street Type Description "
�y/� U Unrestricted(Buildings Lip to 35,000 cu.R.)
R Restricted 1&2 Family Dwelling
Citylrown,Stale,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
'�(%00 SF Solid Fuel Doming Appliances
6 pf Y � 1 Insulation
Fete hung .r it addre s D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HICRegistration Number Expiration Date
I IIC Company Name or FIIC Registrant Name . -
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.,152.g 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 Muance 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
t9 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
contained in this applicati true and accurate to the best of my knowledge and understanding.
lD
Print Owner's or Aut uvized 492,n
Name ' unic Signature) D:ue
NOTES:
I. An Owner whoWains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the[tome Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under N.G.L.c. 142A, Other important information on the HIC Program can be found at
Www.mass.eov'oca Information on the Construction Supervisor License can be found at www.masSsov/d"Qs
2, When substantial work is planned,provide the information below:
Total floor area(sq. RJ 2AOd (including garage, finished basernent/attics,decks or porch)
Gross living area(sq. R.) 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
J. `l'otal Project Square Footage"may be substituted ror"Tot:d Project Cost"
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Certificate of Flame Resistance
I
REGISTERED
FABRIC ISSUED BY Date of Manufacture
NUMBER JOHNSON OUTDOORS INC.
BINGHAMTON, NEW YORK 13902 April 2008
F-140.01 Manufacturers of the Finest
Tent Products Described Herein
i
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:
CITY:
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
Cal I
F Type,color and weight of material 1 Ooz Whde Blockout - !
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Description of item certifies IOx10 1 oiece too
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Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc. I
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Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN .
'Large Scale
I
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Milli
I
Certificate of Flame Resistance
REGISTERED
FABRIC ISSUED BY Date of Manufacture
NUMBER JOHNSON OUTDOORS INC.
BINGHAMTON, NEW YORK 13902 April 2008
F-140.01 Manufacturers of the Finest I
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:
CITY:
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
Cal
Fe Type,color and weight of material 14 oz White Blockout
I
Description of Rem certifies 10x10 1 piece top j
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
j
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vnvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN
'Large Scale
I
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Certificate of Flame Resistance
REGISTERED
FABRIC ISSUED BY Date of Manufacture
NUMBER JOHNSON OUTDOORS INC.
BINGHAMTON, NEW YORK 13902 5/22/206
FA-49303 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 STATE: 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•,
Tvoe,color and weight of material: 14 oZ Vinvl Snyder white block out
Description of item certified: EFS 20X 20 2PC
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
HANWHA POLYMER CO.
TENT DEPARTMENT,JOHNSON OU OORS C.
'Large Scala
Certificate of Flame Resistance
I
REGISTERED
FABRIC ISSUED BY Date of Manufacture
JOHNSON OUTDOORS INC.
NUMBER BINGHAMTON, NEW YORK 13902 May 2010
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.
I
NAME:
i
i
CITY:
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance wit
Cal I
Fe Type,color and weight of material 14 oz While Blockout
j
Description of Rem certifies 30 x 15 mid for EFS Sectional too
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN
-Large Scale
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__
Certificate of Flame Resistance
REGISTERED ISSUED BY
FABRIC JOHNSON OUTDOORS INC. Date of Manufacture
NUMBER
BINGHAMTON, NEW YORK 13902 May 2009
7140.01 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.
i
NAME:
CITY:
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
Cal
Fe Type,wlor and weight of material t4 oz Whde Blockout
I
Description of Rem certifies 30 x 30 2 Dc EFS Sectional too _
i
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN
'Large Scale
I
i
Certificate of Flame Resistance
i
REGISTERED
FABRIC ISSUED BY Date of Manufacture
NUMBER JOHNSON OUTDOORS INC.
BINGHAMTON, NEW YORK 13902 May 2010
F-140.01 Manufacturers of the Finest
Tent Products Described Herein
I
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:
CITY:
Certification is hereby made that:
The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with
Cal
Fe Type,color and weight of material 14 oz White Blockout
I
I
I
I
Description of Rem certifies 30 x 15 mid for EFS Sectional too
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
Snyder Manufacturing, Inc.
Manufacturer of Flame Retardant Vnvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN
'Large Scale
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!° CITY OF SM.F-M, N'LkSSACHUSETTS
BUILDING DEPARTMENT
� N< 120 WASHIINGTON STREET, 3aa FLOOR
TFi- (978) 745-9595
F.kx(978) 740-9946
KI\iBFRi EY DRISCOLL THOMASST.PSERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CONLUISSIONER
Workers' Cornpensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i ficant Information Please Print Legibly
Nalne(Bueinas' rganizaiio vindvictual): /
Address: // a0 7 //
City/State/z'ip:� Phone
Are you an employer'Check thg:Cppropriate box: Type of project(required):
1.El am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ lama sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their l0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.[1 Roof repairs
insurance required.]t emp loyacs. [No workers' 13.❑ Other
comp.insurance required.]
-Any applicant that chucks box#1 moat also Fill out the section below showing their worken'compensation policy inlbrmation.
'I1,.cownon;oho submit this affi lavit indicating they are doing all work and then hire outside contractors most quhrait a new arridavit indicating such.
$:amraewra shut check Ibis box mtu t attached an addiiiunal sb:t showing the name of the subcontractors and their worken'comp.policy infonration.
f ant on employer that is providing workers'conipeusadon insurance fir my etepinyees. Below is the policy and fob site
injonnarinn. r
Insurance Company Name:—/✓/w�i yJ/
Policy 4 or Self-iris. Lic. #: r` / (?—.L—;) �- / Expiration Date: / �7
Job Site Address: L55 t�iG"l � City/State/Zip:
,knach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as regtined under Section 25A ofVIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00;and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigutions of the DIA for insurance coverage verification.
l do hereby certify reeler the pains oil Iries ojperfury that the information provided above is true and correct
i b'nauure: I_ ,
Phone tt: ��0 �tr ' `7 "Gir
Official use only. Do not write in this area,to be completed by city or town officialt
City mr,rawn: --_._.._..._ Permit/Llccnse
Issuing Authority(circle one):
1. Board of Health L Building Department 3.C'itytrown Clerk S. Electrical Inspector 5. Plumbing Inspector
6.
Contact Person: ....._-._..____ Phone th