Loading...
115 DERBY ST - TENT JACKET 2 @ — �3 ar The Commonwealth of ' h / Department of Public Safety Massachusetts State Building Cod19N0 Building Permit Application for any Building other than a.W0nVTA-1U4 Dwelling ^ (this Section For Official Use Only) (VnJ Building Permit Number: Date Applied: Building Official: y SECTION 1:LOCATION 1 117,13 Iq S 01570 HEUSE o LE . No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK l Edition of MA State Code used_ If New Construction check here ❑or check all that apply in the two rows below ` Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other )al Specify: TENT Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural EngmeerinI Peer Review required? f - Yes ❑ No ❑ Brief Description of Proposed 1Nork: _ l t'L 5 i[ 4e_. /Y� }�/tea- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)8r Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ I R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility ❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIBO IV 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check ifoutside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or.trench or specify:permit is enclosed❑ Railroad right-of-way: . Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: S p Lk- w vo r SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner b�( 0FW5Ev06,13bfs oI 76 Name(Print) • " No.and Street City/Town Zip Property Owner Contact Information: eutor Anj1* "9! 9�?-2`7X��� — cos 7gableS. S Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Ae-6 Cosh !(S tQLe.rb� 70 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor nt.c Eu'n: - CC- Company Name "T9-Y&61 f+�D6�s Name of Person Responsible for Construction License No. and Type if Applicable Sa ,w)C �f (`� 6ZOUC9877E2 "/� O/ 436 Street Address City/Town State Zip 9lFAff �f �{ _ �, tor@ r--en-k c 0 f-h Telephone No.(business) Tele hone No. (cell) e-mail address SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes O "No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 69- aO 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury,that all of the information contained in this application is true and acctirate to the best of my knowledge and understanding. a rr fa L&r ,.,- 6 f l6 Please not and sign na • e Telephone No. ate }�� �fl9 �2ccea�rr /11 ai; d _c xh @ an 4eP_tf•"_co+at Street Address City/Town State Zi Email Address Municipal Inspector to fill out this section upon application approval: �.' 1" Nam Date The Commonwealth of Massachusetts Department of Public Safety 4 P Massachusetts State Building Code(780 CMR) xx B�ti13ljtg Permit Application for any Building other than a One-or Two-Family Dwelling v (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: (1 SECTION 1:LOCATION 11S b4126`I S SAc£rn 01876 H&USE o L� No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other )31 Specify: TENT Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engmeerm Peer Review required? l ' / `{'� Yes ❑ No ❑ �ief Dgscriptiop� roposed FVork: ly15 I �-- 7_` () SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)8r Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑ I: Institutional I-1 ❑ I-2❑ I-3 ❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA O IB O IIA O IIB 0 IIIA O IIIB 0 IV 0 VA El VB O SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permih Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system 13required 13 or trench or specify:permit is enclosed ❑ - Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: h1RlL-eo 10(n— ♦ J SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner b�CMof SrUEQCoth3L-fS 1iSDfPR T 01T76 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: • - . . FUf,Krr InliNhe�61z- 2A-1Y`I oma! was 7g�bles. S Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: be6 (fosln- !(S' (Dear by S' f S'aJarn M# 01 q 70 Name Street Address City/Town State Zip to apply for and act on the propertv owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control fomis see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name 7�5Yrs H-6869s Name of Person Responsible for Construction License No. and Type if Applicable YD .wX `-f f`j 610c/C9�2 ,y/f o! 436 Street Address City/Town // State Zip q,,YA6_ q6i�'l — 2 mm� @ rzn-kVI-F. G O/2, Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11: WORKEI:S'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the derdal of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ M t oe:Minimum f (contact mum ee= conacmunicipality) 4.Mechanical (HVAC) $ N _ ( 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ t ��(� (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and acc rate to the best of my knowledge and understanding. (6/q// Please rittt and sign na Me Telephone No. ate �� Y/y ouces�cr a4& aj -C6 6;1 ren kwf— corp( Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts 1 y Board of Building Regulations and Standards FOR 4 ' r Massachusetts Stale Building Code, 780 ('MR. 7°i edition 1 1Slf Building Permit Application To Construct. Repair, Renovate Or Denolish it One- or Tmv-f'mnilt- Dm elling 1. 100S This Section For Official Use Only Building Permit Nut er: Date Applied: Signature: � Building Commissioned Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Properly Address: 1.2 Assessors Map & Parcel :Numbers C I 4?1e S+ -- 1.la Is (his an accepted street'.' yes_ nu_ Map Number Parcel Number 1. LgDl, ing Information: 1.4 Property Dimensions: — [ZoJ:miet _ Proposed Use Lot Area isq it) Frc:cage Ili)—"-- 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard ! Required Provided Required Provided Required Provided �6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: —I Zone: _ Outside Flood Zone:' Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.1g wnert of Re��PPrd: / I ' - IS sASc.- " eve..-- C-rA�i Name I Prino Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other 'Ig Specify: Brief Description of Proposed Work':_ t_c�. ��r Cih s A{0X70_31 aX 3y �1 12`)(1 Z A I.lG -r�"�.0 V ��l.�i tF.S. q 6� i C�R(�-C oh SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials) 1. Building $ 1. Building Permit Fee: $__ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ _ ❑Total Project Cost (Item 6) x multipli r x I 3. Plumbing $ 2. Other Fees: $ � �C 4. Mechanical (HVAC) $ List: �J I 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Cheek Amount: C:uh :\nuuuu: _ j b. fatal Project Cost: $ U�p _ o� ❑ Paid to Full ❑ Outstanding Balance Due:----- SECTION 5: CONSTRUCTION SERVICES ` — 5,1 Licensed Construction Supervisor (CSL) License Number Expiration Date Nance of CSL- Ilolder List CSI. Tcpe(see below) _ \ddress T• c Descri riion C Unrestricted (tip to 35.000(•u. Ft.l R Restricted 1&'_ Family Dwelling __I SignatureM MasaorN Onlv l RC Residential Ruotmg Co%cling Trlrpluntc \t '_ \\'S Rcsidcnlial \\ ndo,.-.aid SF Residential Solid Puel Burning \ t tliancc In,;- luwm D Rcgdenli:d Demolition 5.2 Registered home Improvement Contractor (HIC) HIC Company Name or FIIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed Lind submitted with this application. Failure to pn,vide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'? Yes .......... t4 No ........... ❑ - 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 mazer.: i relative to work authorized by this building permit application. SI Mature ill Owner Date � SECTION 7b: OWNER',OR ALITHORIZED AGENT DECLARATION I, _14rnA -R= -�/ [.Sit. 6- Mii\.s as Owner or Authorized Agent hereby deciare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. �—t� as• 6✓r+uTr� Print Name, Signature o(OwneO^wnee or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 and Construction Supervisor Licensing (CSL) can be found in 730 C'MR Regulations 110.R6 and 110.R5, respectively. '_. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics. decks or porchi Gross living area iSq. Ft.) Habitable room count _ Number of fireplaces Number of bedrooms Number of bathrooms Number of hall/baths Tvpe of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "rot i Project Cost" fawn �E AIAPROYED SY T*9 JNAR9 SOH PRIOR T0A AEaIlIT A9M GRAMS= CITY OF_SALEM N0.ze4— orG /� D 4.&-k.j Is►lopuq Loo.ro In tisoacsoa of so mm o ommo Yay,_No_ b4mi a in popmv Lamm in :- �GonoMr�Oa Awa1 Yo(_NO_ BU LUM PERWT APPLICATION FOR: PSMA ux lands wtdollawr apply) Root. Ranaf. Uwwall taldinp Deck. "" Pool, Rspair"plaos. Olhsr� PLBAm IF LL Wr L=KY i COYPLXMY TO AVOW DELAYS W PROCUW4 TO THE INSPECTOR OF BLNLDING& The hsraby appbs for a pw t to bWW acoom" a tha IouwmQ OwWa Nanw - k, c e .r c,1tw—e/ Address& wan. I is e E4e 571- Ambkods Nana Addraas t Phone j 1 AAachar= Name Address A wane j 1 war I.n.ago••it army `%'� -47 LrJP�I�, Nma"d a1WlgOt �dl .awwlp,for holy. y IwAla? �t«riarq oaaoaa a IorR ? r- z I EtlhoMo aool _�_ply Ilorw• tJ A aln.uoMna• ,� 81SWD LINDER THE PENALTY DucRrnom OF WORK TO U DONE OtsPERJURY J MAIL P RWT �� SON10—WW d0 OL7.�dSN� a s�l. NoUVDOI p t40 1 r OL AWWd Vol wouvorun 0N F i+L911VS�09liSfi�Efflf� ilfl APPROVED BY T44E MP CT IPI PR,iIOR TDA PERMIT B,EWG GRANTED CITY OF SALEM No. ��!/d _. �:t� '� p,�l\ Date �) y a s. Is Property Located In Location of L the Historic District? Yes_/No_ Building 1 1S -D /e 4�y .S'7 Is Property Located in the Conservation Area? Yes—No s BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: ieuY �ru 'o�. PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: it according to the following The undersigned hereby applies for a permit to bud g g specifications: Owner's Name 14yertf kor 1�,quest- v-� 7 6,bQes Address & Phone ( 1 Architect's Name Address & Phone 1 ( 1 Mechanics Name R' cE �e `�� I Ce u+er— Ceei14 Acc) Address & Phone 0 r5 e,e r� (979) 91 -5 619C� Nk What is the purpose of building? h °� Material of building? If a dwelling, for how many families? Will building conform to law? ` 5 Asbestos? ' Estimated cost CltYy License # N A State a se # Bone Improvement Lic. / x Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE (147.- 13reaC sera,, 07 10ilo6 - C',c • 7 oins9,1 MAIL PERMIT TO: No. `OO�i D6 APPLICATION FOR PERMIT TO I�RG'�T 7 xe� LOCATION PERMIT GRANTED APP 7 . IN P TOR OF BUIL INGS -AThe Commonwealth of Massachusetts �I CITY Board ol'Buikling Regulations and Standard � , s > tey j Massachusetts State Building Code. 780 MR. T"edition OF SALEM "'www�/ Revised Jmwan- Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Signature: ✓ /G�` /` �� Building Commissioned lnspcb&of Buildings Date SECTION 1: SITE INFORMATION 1.1 Pro arty Address: 1.2 Assessors Map& Parcel Numbers IIr bfe3y S 1 I.la Is this an accepted strect?yes no lMapNumbcr Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(R) From Yard Side Yams Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.(,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 if n❑ //SECCTT/ION2: PROPERTY OWNERSHIP' �� 2.1r wnerrofRL:/ n (%G�gs / be2Q�z J/ Name(Print) �^,{ Address for Service:9 '7 cff/ 7L/z/ Signature Telephonic SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Cl Addition JO Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': d d x Co ! 6 k O 0 7� za SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 011lclal Use Only Labor and Materials I. Building S 0Z0 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x 3. Plumbing s 2. Other Fees: S 4. Mechanical (flVAC) S List: 5. Mechanical (Fire S oppression) Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: r SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number F.Npimliun Date Name ut'CSI.• I IulJer List C'SL-type we below) r lxxri ion Address U unrest ;i 1 u w 13,000 Cu.Fl. R Restricted Id2 Famil (lwellin Signature M Mam (MI RC Residential Roulin C'overin I'eiepMme WS Residential Window and SiJin SF Residential Solid Fuel Bumin Appliance Installation D Residential Demolition 5.2 Regbtered Home Improvement Contractor(HIC) f IIC Company Name or 111C Registrant Name Registration Number Address Expiration Date Signature Telephonic 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 .......... 13 No...........O SECTION 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. SignatureofOwner Date rbdkalf SECTION 7b: OWNERtOR AUTHORIZED AGENT DECLARATION i n k ht as Owner or Authorized Agent hereby declare d information on the foregoing application are We and accurate,to the best of my knowledge and Si a ( er a Date`C Silino under the pains andpenalties of 'u NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will go 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 I O.R6 and I IO.R3,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 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" SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC „-Roofing Covering WS - Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone - Email address- D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/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 of the building permit. Signed Affidavit Attached? Yes ..........0 No...........O 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: OWNER' 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 application is true and accurate to the best of my knowledge and understanding. ba4l,e (�n,'Qlx 6 /Z mti t Owners or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.tL) 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" t Z' The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM I Revised Junnury Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: q e I Date Applied: Signature: �`G Building Commiss over/Inspntor Buildings Date SECTION 1: SITE INFORMATION 1.1 Property,Address: 1.2 Assessors Map& Parcel Numbers //cam L3 4/ I.la Is this an acceprfed street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(ft) 1.5 Building Setbacks(ft) 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ P po y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Re or fHmt.c2 A L%QlrX2S ��5 UP�f �atr 11 Not to(Print) AJ ress for Service' �(y77 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: 41 Brief Description o Proposed Wor -: t f t 2 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S i I. Building Permit Fee:S Indicate how tee is determined: ❑Standard City/Town Application Fee 2.Electrical S ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: (� 5. Mechanical (Fire S Total All Fees: S Suppression) Check No. Check Amount: Cash Amount: 6.Total Protect it: S 0 Paid in Full 13 Outstanding Balance Due: r' SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name ol'CSI.-l Iulder List CSL Type(see below) Address r Description U I Unrestricted up to 35,000 Cu.Ft. R I Restricted 1&2 Family Dwelling Signature M Masonry Only -RC Residential lko�olinii Covering feephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 3.2 Regbtered 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.§ 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 of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........13 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. Signature of Owner Date SECTION,7b:OWNE�Rrt7O�R AUTHORIZED AGENT DECLARATION 1 j' n/[ ll r't-L ���"r�d ,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 beIt r� P t e / Si re or is g Date (Signed un the 12in3 and penalties of 'u 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�o(have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/anics,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"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards AL EM y J Massachusetts State Building Code, 780 CMR, 7"edition OF dJanua 1 JJ Revised Januury Building Permit Application To Construct, Repair, Renovate Or Demolish a /. =008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: ,y q Signature: U4 C- 417 Building Commissi /liMpector of Buildings Date SECTION 1:SITE INFORMATION 1., P i Tgrty A��� S j 1.2 Assessors Map& Parcel Numbers L l a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Got Area(sq 11) Frontage(11) 1.5 Building Setbacks(R) 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❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesC SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of ecor ,Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ AccessoryBldg.O Number of Units_ I Other ❑ Specify: Brief Description of Proposed Wor ': (ems 1 t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) $ List: vl ) 5. Mechanical (Fire S Total All Fees:S Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: S I 0 Paid in Full 0 Outstanding Balance Due: t / SECTION 3: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of C'SI.• I(older List CSL"type(see below) r► i Address T'pe Description U Unrestricted(up to 35.000 Cu.Ft. R Restricted 1&2 Family Dwelling Signature M Masonry Only RC Residential Rooting Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regbtered Home Improvement Contractor(HIC) I IIC 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 ..........PO No...........O 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 7/b_:OWNERt OR AUTHORIZED AGENT DECLARATION 1, bon �114O�z t e ,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 beh If. hr` c`'()C/V G6 Prin Name SigqdPtkre o n A o z gent Date (Sighted Nnder 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 gd have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/ettics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number ofhalf7balhs 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" �yV The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 80 CMR, 7'"edition OF SALF.M J Revirrd Juuuury Building Permit Application To Construct, epair, Renovate Or Demolish a /. 008 One-or Two-Fumil Dwelling This Section F9f Official Use Only Building Permit Number;,,- Date Applied: Signature: Building CWthissionert IhspqArprBtXIUings Date S CTI 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map At Parcel Numbers I.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 11) 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' zHDLn f!Tor Name(Print) Address for Service: q7£s 7`444 0-7q / Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.Cl Number of Units_ Other 13 Specify:7�AlT Brief Description of Proposed Work-: ,S L 60 A-rT F IZ!2 r '7/ Z3 110 71f a2&ff 7 2S /b SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Ofltcial Use Only Labor and Materials I. Building S � I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All Fees: S Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: SECTION 3: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of C'SI.• Holder List CSL'i'ype(see below) Address r'Pe Description U Unrestricted(up to 35.000 Cu.Ft. R I Restricted 1&2 Family Dwelling Signature w Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 3.2 Regbtered Home Improvement Contractor(HIC) I IIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature - 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 of the building permit. Signed Affidavit Attached? Yes ..........ift No...........O 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. r Signature of Owner 'Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION I, 5a✓i -aen ✓e A24 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 beha f. Print N e Sign urc 'Owner or Authorized Agent D to (Signea,utulir the pains and penalties of 'u NOTES: 1. 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. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively. _'. 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 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" � , oq The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7ih edition Budding Dept Building Permit Application To Const ct, Repair, Renovate Or Demolish a One-o "0 U11111.1, t fling is Section For Offici 1 Use Only Building Permit Nu er: to plied: Signature: ''b Building Commissioner/Inspector o uild s Date SECTION : ITE INFORMATION I roPerty old re�}'(r SL 1.2 Assessors Map& Parcel Numbers I.I a+'Igo at�i acceptdd street?y99es_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: I, Zoning District Proposed Use Lot Area(sq 11) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required ProvidedpRequ'redProvided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: em:Zone: Outside Flood Zone? al system ❑Public❑ Private ❑ Check if es❑SECTION 2: PROPERTY OWNERSH2. Own r(of Recor Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ ExistinaBuilding WOwner-Occupiedrs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessther Specify: e&w'Brief Descrised 621 t SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S � � I. Building Permit Fee: E Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing E 2. Other Fees: S 4. Mechanical (HVAC) 5 List: 5. Mechanical (Fire S / Total All Fees: S - Su ression l Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: S C 5O� ❑ Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licenselif Construe ion upenisor(CSL) �O r � S LiCyp.,C Numbc r� Expi uon to r N4mc o CSL g er C L ype(see below) AJd -ss _. Type Desert tion 6 U Unrestricted u to 35,000 Cu. Ft.) Si nature R Restricted 1&2 FamilyDwellin ,/ M Mason Only w RC Residential Rooting Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance 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. 152.4 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 of the building permit. Signed Affidavit Attached? Yes ..........0 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. Signature of Owner Date SECTION 7 :OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the staterKents and information q t the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name z2 0 Signature of Owner or Authorized A nt Date (Signed under the pains and 2enaltids of perjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, 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 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' / � �/���- A�r- od The Commonwealth of Massachusetts 1 Board of Building Regulations and Standards CITY j Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM Revised January Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section FqfAfficial Use Only Building Permit Number: I 6ak Applied: Signature: /0 /V//0 Building Commissioner/Inspttmr of Buildings ate SECTION 1: S 1 ORMATION JP rert, Addfess: J� 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepied street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(ft) 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2LOwner of rLecord: Name(Print) Address for Service: �- 77oP'r .7�� C�y%� Signature Telephone 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_ I Other ❑ Specify: Brief Des rt tion o[Prglpo d Work'-: e" SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S �5 I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S H Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 'S 00 ❑Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Constructio Supervisor(CSL) f1/'1/iA7'J / r Ccri{/ 2 �6 I.ieense Number Ex nation Uate Nine of I S[.- I rider List CSL Type(see below) S �^ f.Pe Description d ss y� U Unrestricted u to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Sig/nal �/ // M Mason Only 77-,7r '�(��'C� RC Residential Roofing Coverin felephone _ WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance 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.§ 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 of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ 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 SECTIO 7b: OWNER'OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the s atem is and informatio n the foregoing application are true and accurate,to the best of my knowledge and behalf. / Print Name ( "7 Signature of Ow e- r Authorized Agent Dat Maned under the nains and P4nalties of r'u 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 Mol have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I 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 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" EITYL-O�' JAL 1 PUBLIC PROPERTY DEPARTMENT K1%(BF XYDRisCULL MAYOR 120 WASHisGmN STRFFr•1•=s,WAAACHLsn-rs 01970 Tm-973-745-959S R FAX 978.740-9&W APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION. DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1A SITE INFORMATION Location Name: D v C o.1-- 7CAjj,0S Building: Property Address: its C-D-crb S4. 5�... u Property is located in a;Conservation Area Y/N Historic DI 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: Address: Telephone: ? g — -7y y — per q 1 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building , I New Brief Description of Proposed Work: 1r-2 �� ,'0� 9 'C-- qD� X(pe)I /o� —— Mail Permit to: W&�{P o`� D/ e r6 y -------- �r4W[-e What is the current use of the Building? or0.,ry '�rYc'F o� of qd X6D 1 eu� Material of Building?J.4 If dwelling, how many units? Will the Building Conform to Law? e S Asbestos? y/ D Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of Project$ y� O Permit Fee Calculation Permit Fee$ Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build tothe ttheaboovve stated gyp specifications. Signed under penalty of perjury Date L v S v ,^ N �i V a o O F � V a1 G7 d `o L ip,r---- 1 � 1 t The Commonwealth`bf o a.�. w : Department f Public Safety Massachusetts State Buildi off CMR . = t tur Building Permit Application for any Building of er t n r%*Wamily Dwelling n (This Section For Official Use Only) l� Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION 1rS DCZBM ST 01976 ZZ o LS No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here ❑ or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ 1 Change of Occupancy ❑ Other J13 Specify: TENT Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief D cription of Proposed Work I n 5�t� / 0.. D Y /U Kl�i 0 47= 9�7-- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B. Business ElE: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ I-3❑ 14 ❑ M: Mercantile ❑ 1 R: Residential R-113 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ 1 Special Use❑ and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB 13 IIA ❑ IIB ❑ 1 IIIA Cl IIIB E3 I IV E3 I VA ❑ VB O SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify,Zone: or on site system❑ required❑or trench or specify: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: MA Hstoric Commission Review Prcvess: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: 5 ffn P-Il.-wo T-d P,0-e3j LtL ct (PtZ-( SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner L(Qcts� OF EUCA 0 t 76 Name(Print) _ '' "'No.and Street City/Town Zip Property Owner Contact Information:,) v Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Ae6 (f, Me-- ((5' De.r6j s' f S'aQem M# G1g70 Name Street Address City/Town State Zip to applV for and act on the propertv owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip - Discipline Expiration Date 10.2 General Contractor - Company Name Name of Person Responsible for Construction License No. and Type if Applicable - - Street Address City/Town State Zip q1yope - _— 2au , I6 r@ r''en-k n--_ c 0 r, Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor nn and Materials) Total Construction Cost(from Item 6)_$ C; —1 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13: SIGNAT'URE OF BUILDING PERMIT APPLICANT -By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and acctirate to the best of my knowledge and understanding. 2&3-�f� 6dl o Please rmt and sign no Me Telephone No. Date /'� ,c �izcces � /11 O[�Rd can@_�ene�ff.__Corsl Street Address City/Town' State Zip � Email Address /�w J Municipal Inspector to fill out this section upon application approval: ""'° �2(, Name Date l —� The Commonwealth of Massac twee Department of Public SafetyL nfl j . Massachusetts State Building Code(780 C j ) 1 Building Permit Application for any Building o OW4-Wn)4y Mling (This Section For Official Use Only) n Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION 1ES D1gIZ131-I S ,SALfm 01976 H&USE o Lf No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # 1111 SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here ❑ or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other )al Specify: TEIU I Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? �/� J�Yes ❑ No ❑ Brief Des ri tion of P opo ed Work: l n 5 40. -C V SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as ap licable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B. Business ❑ E: Educational ❑ F: Factory F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ 1-3❑ 14 ❑ M: Mercantile❑ 1 R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage 5-1 ❑ S-2❑ U: Utility ❑ 1 Special Use❑and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA Ill IIA ❑ till IIIA ❑ IIIB ❑ IVY VAO VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentif},Zone: or on site system ❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: 5 Mnct-EO To 4t`f (0( Z\ 1 , SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner tJuS� o F ff.S€�E�cJ� L�� 115_b4 w6T o f 70 Name(Print) '' No.and Street City/Town Zip Property Owner Contact Information: 'ur1 FU�luT 'rYlAn%� '(L' uz ow/ coS 7ga-bles. 09 Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: b e 6 (fc s4c, (($' Dt Ir 6�j S f sa_P_e 01 )i# Q) 7 70 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control fonns see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name T�fyL�-e Name of Person Responsible for Construction - License No. and Type if Applicable �D ?dJ� `f (`t' �LOUC� (z O/ 436 Street Address City/Town State Zip qly� f`{ s� _— -tau., to r@ r"en-kn-F. c 01'r, Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ /3.2=6 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ I (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accLIrate to the best of my knowledge and understanding. Please rint and sign nan�j Me Telephone No. ate 0 Y/y �2v�ar / O/�Rd cxh@�ene�ff.cord Street Address City/Town State Zip' Email Address Municipal Inspector to fill out this section upon application approval: %W A101 G� Name ate ,z SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner t16('a o F f S IJ OABLES lrs eRy.CT 519`2rrn o r 76 Name(Print) No.and Street City/Town Zip Property Owner ConttacgInformation: ,+ ( - eutoF C-,coSk. (d 77ab(eS• Title Telephone No.(business) Telephone No. (cell) e-mail address - If applicable,the property owner hereby authorizes: 1�e6 (foss (($` N_r6j S _ S'aQe,rt Mif 0 'q 70 Name Street Address City/Town State Zip to apply for and act on the propertv owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 't'I,tt Evan- �- Company Name T�yLOF-' ►+�6 Name of Person Responsible for Construction License No. and Type if Applicable & .30K q1F (5LOUc 2 1&,q-- 0/936 Street Address City/Town State Zip _ glFAB _ a /o r@ r'e rl-k rrf-_ G 0 kt., Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item - Estimated Costs:(Labor and Materials) Total Construction.Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ _ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check. payable to. 6.Total Cost $ (contact inunicipali y)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT - By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and acc rate to the best of my knowledge and understanding. n nc Fu �`&rlaacr 9 2 Fs 3_ '6 /6 Please rint and sign na '1''1 e Telephone No. ate �� fly �iccce8�er 211L <: x _ -Cen leaf- con( Street Address City/Town State Zip Email Address J Municipal Inspector to fill out this section upon application approval: °'l•�✓ ' ame Dat The Common*99d i'6'&usetts Department of Public Safety `��•��/ Massachusetts S u t d 8 Building Permit Application for any But ding other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION T r S O o M wt 76 L-f No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # -- SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here ❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ 1 Other Jal Specify: TENT Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? /- Yes ❑ No ❑ Br re scription of Propo,ed Work: I✓L 5 4zL /i K�0.3 7�-f 1. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) D Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ B. Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H4 ❑ H-5❑ I: Institutional I-1 ❑ I-2❑ 1-3❑ I4 ❑ M: Mercantile ❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ 1 Special Use❑ and please describe below: Special Use Description' SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IBD IIAD IIBD IIIAO IIIBD 1 IVD VAD VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. • Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system ❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No ❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: 5 p E yZ-M t,-S m n t t✓aro Vo ,fj_&tCt 4 12 SECTION 9: PROPERTY OWNER AUTHORIZATION 'N/ame and Address of Property Owner ti •- C&5-' 0 F77ff S�UFicJC� L� '.' r/SDELFjrST 5101�Lrlw o IF70 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ' i'. '= ) {�Iqt EUt — MAyA66tz- Z rY-- O(M cJ cos 7gableS• ou Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: b e 6 (fosFc-- !lS Der 6�j Sf So.Jaol M0 Q1C770 Name Street Address City/Town State . Zip ' to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 33,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control (the Professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name T'fYt-cry. Ef�Ds�s Name of Person Responsible for Construction License No. and Type if Applicable �Q ,WK �f(`� 6zeuCE&E(z �� 01436 Street Address City/Town State Zip ' g1FAff £ _ 4r /o r@ r zn-fen--_ C ors Telephone No.(business) Tele hone No. (cell) e-mail address SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and 1 submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and.Materials) TotalConstruction Cost(from Item 6) 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (FIVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ /5-M (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and acc rate to the best of my knowledge and understanding. Al"i-en Please rint and sign nan�j Telephone No. ate �o �f/y �2tce8�tr / D[y3 d cL h @_den k k i f..-c_off t Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: 04v, iwr Y/ Name Date- The Commonwealth of Massachusetts W Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling 0 (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) l) ! `/ 76 ( '" S e' tGten- C2ZC r No.and Stree[ City/Town Zip Code Name of Budding(if applicable) SECTION 2:PROPOSED WORK m N I Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two roWbelo�t. Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appeadix 1) Change of Use ❑ Change of Occupancy ❑ Other A Specify: )zr-1 'fS r— Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Ism Independent Structural Engineering Peer Review required? ( L Yes ❑ No Brief q scription of crop Work: I'I' Gd-- w� -- -/fS— 7/17j� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ E2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ RA❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ II1A ❑ Hill 1 IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ permit is enccl or indentify Zone: or on site system❑ required❑ trench or specify: osed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Comnussion Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: i SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner P Name(Print) - No.and Street City/Town Zip Property Owner Contact Information: �&Iff A 3 J xp6lrs. 7f Tie —� Telephone No.(business) Telephone No. (cell) a-mail add s If a plicable,the property owner hereby authorizes 6 Cas�cc ll r�� .��' hti O1 i 1G Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. s_, SECTION 30:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of emlosed space and/or not under Construction Control then check here 0 and skip Section 10.7 10.1 Registered Professional Responsible for Construction Control }� k Name(Registrant) Telephone No. e-mail address Registration Number e^� Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name II '' o C 4-t-d q'-e S Nanie f Person Responsi or construction License No. and Type if Applicable H kY, Ut n 6,11/0-i2Ge sot- At G/93 () Street Addr�etssy , I City/Town State Zip .. Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFPID.A\RT M.G.L.c.152.§ZSC 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes,' No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(labor Item and Materials) Total Construction Cost(from Item 6)_ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ //� Enclose check payable to 6.Total Cost $ T (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby test under the pains and penalties of perjury that all of the information contained in this pplication is true and accur f to tl �st of my knowledge and understanding. U, Jn r nee �1� 1 fs�S 516146 Ple , fn d sign name ,�2� 'j'itl _ _.,,Telep01 e N3o. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date 2- The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (n� (This Section For Official Use Only) rV� Building Permit Number: Date Applied: Building Official: U J SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 1 ( 1r Derby 'Si "Wt -yI 9 76 ( uS� �(c e� 6z 6,1 �Q No.and Street City/Town Zip Code Name of Budding(if applicable) 1 SECTION 2:PROPOSED WORK ,}Y Edition of MA State Code used If New Construction check here❑or check all that apply in the two rolgbe1mg ( Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)r'rt l Change of Use ❑ Change of Occupancy ❑ Other )a Specify: -2/1 l Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 1' Is an Independent Structural Engineering Peer Review required? 1 I Yes ❑ No� .r Brie Descriptio of posed Work: GC.. `"'} 3 CA ' T7 0001 M Li SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ 14❑ M. Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site O Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Conmussion Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: M n,Uev, -T-0 v t_�D 0 c . 511 8 i SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner V Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 1 /6's or Ti a Telephone No.(business) Telephone No. (cell) e-mail addze s If a plicable,the property owner hereby authorizes 6 Cush Name Street A dress City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building unit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date -y 10.2 General,Contractor Company-Name qXA �d� y'� S Nance f Person orS(onstmction License No. and Type if Applicable Street Addreelssy City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L,c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes,* No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor ' and Materials) Total Construction Cost(from Item 6) 1.Building $ 070 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$_ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby est under the pains and penalties of perjury that all of the information contained in this pplication is true and accur to t st of my knowledge and understanding. Iz�f(u�cetrsr � `fFs�� 5 16 h Pie ^r m d sign name '"�itl _ Telephone 3 G Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date � o 2, (� The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) 1 Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) -l�l)erb4 7G No.and Street City/Town - Zip Code Name of Budding(if applicable) SECTION 2•PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit App 1) Change of Use ❑ Change of Occupancy ❑ Other ,tC Specify:_ fLn 7 S Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No -iz Is an Independent Structural Engineering Peer Review required? Yes ❑ No 00 Brief Dy��ipiio of Proposed Work: o� a t �G 1 1:6 r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR" - CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E. Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6.CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal Cl A trench will not be Licensed Disposal Site❑ or Private❑ or indentify Zone: or on site system❑ required❑permit is enccll trench or specify: osed❑ Railroad right-of-way: Hazards to Air Navigation: 1,9A Historic Conunission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9, PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title U— Telephone No.(business) Telephone No. (cell) e-mail addk s If applicable,the property owner hereby authorizes ire h co %G Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application, SECTION 30:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 m.ft.of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number ,Street Address City/Town State Zip Discipline Expiration Date y_ 102 Gen aa" a l'Contractor Company Name ' or Name f Person Responsibl or onstruction License No. and Type if Applicable � H n L-" I�—`� (-2/Glue s4er At °? J 0 Street Address City/Town State Zip 7 Telephone No.(business) Tele hone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes,9 No O SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ S__ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name 5ffbat? est under the pains and penalties of perjury that all of the information contained in this pplication is true andst of my knowledge and understanding. lelLI`"III?rlj,,� �/ f£s��� 5 /6 h Ple irin d sign name iti Telephone No. Dale 2z ce � n/ 3 G Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: - Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 1 ( IS 1)erb e St SC2�71 lrl � 76 ( tLs� .f tu-erl 6e cS No.and Street City/Town Zip Code Name of Budding(if applicable) 1 I SECTION 2:PROPOSED WORK Y Edition of MA State Code used If New Construction check here❑or check all that apply in the two ra belo L Existing Building❑ Repa r❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit App lix 1)-= Change of Use ❑ Change of Occupancy ❑ Other ,Bt Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Br fl), onof�rogo�s dWor� D' K60` .. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&'Area Per Floor(sq.ft.) - Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a plicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ I VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner a Name(Print) No.and Street City/Town Zip Property Owner Contact nInformation: e Tie T� Telephone No.(business) Telephone No. (cell) a-mail add s If a plicable,the property owner hereby authorizes ,. j�a 6 Cvs I� l/.5 1�e r�� .S�- 3a_�n AL Name Street Address City/Town State Zip . to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10:1.Registered Professional Responsible for Construction Control r% Name(Registrant) Telephone No. e-mail address Registration Number .-Street Address City/Town - State Zip Discipline Expiration Date 100..2^Gnenerraall Contractor Company Name p 0 rc Na me f Person Responsi or(onstruction License No. and Type if Applicable n a-&, , V-`\ 6/Oatce ;4et-. N& Gi930, Street Addr�etssy ' ( City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'CONVENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a si ed Affidavit submitted with this application? Yes)4 No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor 121 and Materials) Total Construction Cost(from Item 6)_$ O�J 1.Building $ 5 Building Permit Fee=Total Construction Cost x.(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost - $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby est under the pains and penalties of perjury that all of the information contained in this pplication is true and accur to t st of my knowledge and understanding. Pletrin d sign name '` iti Telephone No. Date ) 2 e_e.�� - 0� �� 3 Street Address City/Town State Zip i Municipal Inspector to fill out this section upon application approval: Name Date SECTION 9: PROPERTY OWNER AUTHORIZATION t Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: - Title - �— Telephone No.(business) Telephone No. (cell) e-maii addrle s If a le,the property owner hereby authorizes SM Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 N.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2'General Contractor Company Nfime or, 4 '- S Name f Person Responsit orsonstructiou License No. and Type if Applicable I` �_ Kin 1�vt �'In't Sit- A& 3 U Street AddYeelssy City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes)9 No O SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ / � (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby est under the pains and penalties of perjury that all of the information contained in this pplication is true and accur to t i st of my knowledge and understanding. Ple ^ rint�nd sign name tU� Telephone No. Date ��22 ce A� O/ 3 6 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date IMPORTANT DOCUMENT Certif sate of Tfame ftAstance ISSUED BY Date of Shipment 5/7/2014 IYCNR® Registration Number �'�'71NDUSTFIIE59 NC. Sales 3796 F-140.01 SO-603796 EVANSVILLE,INDIANA 47726 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: 74634 DTH INC(B)(S78080) DBA/THE EVENT COMPANY P O BOX 419 GLOUCESTER MA 01930 USA G%5 E Q��pf CAC/O9 G � Z 'V.y Fri©�H'4'a P Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial# 81507011) Description of item certified: CENTURY LOOP END 50WX20 WHITE SNYDER BLOCKOUT SINGLE POLE Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MANUFACTURING INC PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC 2S t s zz The Commonwealth of Massachusetts W Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) I Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) (JS er6� Sfi •S cis ari n l 7 76 ( vu see W . 1 No.and Street CityTown Zi Code Name of Budding rE a he / P g( pP &) rn SECTION 2 PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows belog c; Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appidix 1)r-C Change of Use ❑ 1 Change of Occupancy ❑ Other X3 Specify: ) 2r'1 7 E D .fin Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Q: .� Is an Independent Structural Engineering Peer Review r�r d? r ( p x 3�s ❑ N o J L F) Brief Descrf ti n of Propo�Wprk: a vri M — to S /E, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2 High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ -1❑ I-2 I4M:I: Institutional 1 Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use 13 and please describe below: kr� Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ I VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner t Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �L-3�Qolfju 130- (a ' ks. or Tie Telephone No.(business) Telephone No. (cell) e-mail—addk4s If a plicable,the property owner hereby authorizes b Cos-la !!.� hzrb�, , S 4- of iG Name Street Address City/Town State Zip to act on the-property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Re 'skered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor _�� me - Company Na Or S Name f Person Responsi or construction License No. and Type if Applicable Street Addreelssy ' I City/Town state Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes,)} No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ _ - Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ S (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this pplication is true and accur to t I st of my knowledge and understanding. ,an 17s-Ze`fS6c 5 !G ,6 Ple ^ rint-�ttd sign name rUr Telephone No. Date � r�c ce s Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date --- I'lie 0)111I11011%PCa1111 of\Iassachtisols Iluard ul Iuilding R"uLuions anJ Standards ( I'I'1' l)F r) NI;lssachusells State Building CuJe, 7SU C NIR SALE'\I Building Permit Apphcmion 'ro C-onslruct, Repair. Renovate Or Demolish a Otte-ur ro(j-Funuh Du d1big This Section Fur Olticial Use Only Building Permit Number: Date Ap ied: llui Id,ny OI I'll IaI II'rinl N;une) Silpwture p SECTION I:SITE INFORMATION 1.1 Property AdJr 1.2 Assessors Map S Parcel Numbers I.la Is this an;ma ted street? -es no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Luning District I'mpuxd Use Lot Area lsq 11) Fmnluge III) 1.5 Building Setbacks(R) From Yard Side Yards Rear Yard Required Provided Required Provided Required :T— Provided 1.6 Water Supply:(M.G. d Zone Informatlont 1.8 Savino Disposal System: Ihrblic❑ Prismo❑ Y011p _ Outside Flood Zone?Check if vcs0 Municipal ClOn site disposal s).vtcm ❑ SECTION 1: PROPERTY OWNERSHIP' 2.I�f ReSord� G`/'�'/!S Mane l Print) CO�'CC C ity.State' ZIP rl� `��(Z �7 s� y�� � oft(Nu.:wJ Stn.1 relcphune Email Address SECTION J: DESCRIPTION OF PROPOSED WORKS(chock all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteratlon(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number ofUnin_ Other ❑ Spccily: BriefDescri IionorPro osed Work': - i — Lo Zi o r SECTION a: ESTIMATED CONSTRUCTION COSTS liens Mac Official Use Only Y I. Building 1. Building Permit Fee: f Indicate how fee is determined: ❑Standard City.?own Application Fee ❑Tutal Project C'ost'(,ltesn 6).x multiplierOther Fees: S J. \Icch.ulicdl IIH\ Wit List:II ❑e�u,vcaiom meal .\II Fees:he.A No. ( 11"J, Am��unc C.i,h \m��uni: I'rnject CuH: ❑ P.rid in Full 0 Uwsl;mdiog 11.1l,mce Due: SF( 1ION 5: ('ON.SI'Rll("rION SFH%'iCFS 5.1 ( unslrucliun Supcnisur License(('SI.) I icen,g Nunlhcr -. .... I'spirauon H.uu Wallis ul L. I I L,Jer I st l'S1. l)pc l,ea belu,s l 1)pg I)cscriptiun Nu. .utJ Ntreel (i 1 hlrestricicJ IOudJin s li to )5,000.u. It.l it He,tricteJ I:C 2 Pumi1 Dssellin SI \luinn HC' HlMnllt Gus Grin A Window.uld$IJIII SF Solid Fuel Burning;\ppliances I Insulation I lc hung fnlail:IJJrc.+ 1) Denulliliun .4.2 Registered Ilutnt Improvement Cuntractor(HIC) IIIC Iteg6tr Lion Nunlhcr F.spiruliun Dalg. IIIC Cunlpan) Nanlg or IIIC I(ggistrunt Nanig [-mall address No. mid Sucet CitvtTown. State ZIPfele hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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 of the building permit. Signed Affldavit Attached? Yes ......... No O SECTION 7a:OWNER AUTHORIZATION TO BE C0111PLETED 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. Date Print Uwner's Nune(Electronic Signature) SECTION 7b:OWNERI OR AUTIIORIZED 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 application is true and accurate to the best of my knowledge and understanding, A M (.(/" r."1'Ze 'n, S( cw,�Cel— 6 aW j-,4liromivriae:\udnlrircJ,\gentsNanwHJestrunwNlgn,uun) VOTES: I. .\n Uwngr sshu obtains a building permit to do his her own \wrk,or an owner who hires an unregistered cuntraOur i nut registered in the Hurtle Improvement Contractor(HICI Program).will no have access to the arbitration prngranl or guarunt) land under M.G.L. c. 142.k. Other important information on the HIC Program can be found at „,„s 111.111 „ ••, 1 Information on the Construction Supenisor License can be found at,,,, ' nl.l.• "." ,Ip, \\'hen substamial ourk is planned, provide the infurniatiun below: fatal hour area I+y R.1 . ____,._1 including garage, finished basement attics,dVv" or porch Cross io ing ea Irea I sy. Il.l .... Habitable rount count Crosslroflircplaces -... -... . - Vuniherol'bedrnmilllbv . . \uulherotbadtrowns .. ._ ._ --- \unlhcrul'halt'h:uhs Ni,mherof Jcikf porches I)pc of heating Open ' 1)pgol'an,ling :�ueln I'nchl,cJ . . lllt pl IPf I�II,II 1'r lje❑ (,„t" "I'ol.11 Proled sgtow Fool.l1e III,1\ I,e ,1lh,l l GK l 2 ISO r RE CEIVED The Commonwealth o Massachusetts rr t o Department of Pub�'fj(��f ' I�I� Massachusetts State Building L 101kq k A 8: 33 Building Permit Application far any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) I Building Permit Number: Date,applied: Building Official: SECTION 1:LOCATION(Please indicate Block it and Lot H for locations for which a street address is not available) y 1155_D_E_RW S_T S1rLEM MA 01970 HOUSE OF Sey -4AS FS No.and Street City/Town Zip Code Nance of Building(if applicable) SECTION 2•PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Buikfing❑ Repair❑ rVler.Vinn ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: 16 )c llo jPRAtsAE AM tm ASF— ���n1 CvFRt�c s Q {S P Ir-ftAE3 —5 :.7 e►c" %a& SEPTENIB61L7t CA C SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4 CIA-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ IH: Ili h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ 1-3 Cl 14❑ hlo Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-4 ❑ S2❑ U: Utility❑ Special Use❑and please describe below: Special Use. SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA ❑ I10 ❑ IIIA ❑ [fill ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood-Lone Information: Sewage Disposal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ Permit is enclosed❑ ltailrnad right-of-way: Hazards to Air Navigation: �In 1.tianli•! gno,n.6•::)_,•.fcw.l•o::��:.: i\'ot Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECT[ON 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): TVpe of QlilitraCtion: Occupant Load per Floor: � Does the building mnlain aann Sprinkler System?: Special Stipulations: I . • fa tL--lej O � `� SECTION9: PROPERTY OWNER AU111ORIZATION Name and Address of Property Owner IIS of.Qey Sr 5AIEM MA O1g10 Name(Print) No.and Street City/Town Zip Property Owner Con -v19forl lion: y CC IIt - 0991 eu+• �- dcosta(J'�(,AB� —S- R{, �\ "rille Telephone No.(business) "telephone No. (cull) a-mac address If applicable,the property owner hereby authorizes S5NA M ITS S C tlnr ICl( AV EE PLA-IS-MW 0981p ' Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized bV this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2). If building is less than 35,9W cu.ft.of enclosed space and or not under Construction Control then check here 13 and ski 5ection'loa 10.1 Registered Professional Responsible for Construction Control \N VENEV WALLACE U-� Nann(Re is ran( Tcle �nc�-nm(a_ail address nsf3bm tt�+s• .Rg�tr, ra�n _ No Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor SCMST O TENT 2tN rM_.S Company Name WHin4Ey WAlLkpc NA Name of Person Responsible for Construction Licert.a No. and Type if Applicable Strm Address City/Town State Zip Telephone No. business Telephone No. cell c-mail address SECTION 11: INSURANCE FFI1.bA1'I' M.G.L.c.152 25C 6 A lVorkers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and subnottod with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from item 6)=S L Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 3. Mechanical (HVAC) S Note.Minimum fee=$ (contactmunicipal�) 5..\Icch payable Other $ Enclose check to fi.'total cost S 4 00o (contact municipality)and write check number Ike SECTION 13:SIGNATURE OF BUILDING PERMFr APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true dad accurate to the best of my knowledge and understanding. wl+m1`)fy WA11AC� )1A) 03 31%,- 3D010 S _ Please riot and sign name �� Title "telephone No. 5 rk Row 1 cr A"VF_ PLJh c Street Address City/Torun State Zip Q .Municipal Inspector to fill out this section upon application approval: C7 Name Date e, The Commonwealth omgmr`�Hk ",gICES VVV Department of Public Safety Massachusetts State Building������@@(7��}C 3 S Building Permit Application for any Building othetq�idn�d'�ror Two-Family Family Dwelling (This Section For Official Use Only) Q9, Building Permit Number: Date Applied: Building Official: NSECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK ( Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: I Are building plans and/or construction documents being supplied as part of this permit application.? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required?� 2 , /Yes ❑ No ❑ Brief Description of Pro osed Work: 1(� `ffiyvY �r�� /�� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Us and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IILA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone El Indicate municipal❑ A trench will not be P or Private❑ or indentify Zone: or on site system❑ required❑permit is enccll trench or specify: osed ❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: e Group(s): - T e of Construction: Occupant Load per Floor: Use Type C p Does the building contain an Sprinkler System?: Special Stipulations: - SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner t � a C7 7U Name(Pr' t) No.and Street City/Town Zip Property Owner ContactSnfdrmation_ !+ 1b1;c"V1- 7g - q� Orn Q/ Title Telephone No.(business) Telephone No. (cell) e-mail addn� Iff applicable,the property owner hereby authorizes I )�2 C d5"w //4;— 1'(-�t �� �e K69� U/�K "fig 70 Name Street Adhress City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) [f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10y � .2t General Contractor Company Name r ge5 Name Person Respons' e for Construction License No. and Type if Applicable ?b &(- q (1 G Sa -tea Street Address - City/Town State Zip qy-)O qC �tc�,QoY (�p (2i 1 � r F. com Telephone No. (business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 13 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ LiH 0 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ (�- LZ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accu to to the best of y kno ge and understanding. 3 �7 �s Pleases pant and lime T' le )„_�Telephone�Now. Da Street Address City/Town q. State Zip ( Municipal Inspector to fill out this section upon application approval: "' `k' q I r1l l Il/7 Name Date The Commonwealth '�r' US Department ofPu tc �L SERVICES Massachusetts State Building Code(780 CMR) Building Permit Application for any Building otlM �2cf-pTylplignily Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: ` SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 7-0 9 No.and Street City/Town OZip Code Name of Building(if applicable) - SECTION 2:PROPOSED WORK " Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below IExisting Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineerin Peer� Re��jjew required? ❑ No ❑ Pro�i Brief De iption of P osed Work: �tK g � 9�(�/is SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR ,. ' CHANGE IN USE OR OCCUPANCY - - Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): . SECTION 4:BUILDING HEIGHT AND AREA _ Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) l3.fo 17 SECTION 5:USE GROUP(Check as applicable) - A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ M Hi Hazard H-1❑ H-2❑ H-3 ElH-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M. Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special UseA and please describe below: Special Use: "T- SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ - Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):. - Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION N me and Address of Property Owner ran (�ns ((5: bze ©f97d Name(Print) No.and Street City/Town Zip Property Owner Contact Information: /� Try A 9/9 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes I )D l C6 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name f e �rson Responsib for Construction License No. and Type if Applicable Street Address City/Town State Zip 979-2_F�3 low Teri (er, coviv Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ C{ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest er the airs and penalties of perjury that all of the information contained in this application is true and accu1te to the best on'y 1 ledge and understanding. ( 978 �71 9Sl /� Please prinKt and sign nam Title Telephone No. to �l� � Street Address City/Town �` State Zip Municipal Inspector to fill out this section upon application approval: / Name Date The Commonwealth of s� c SERVICES S Department Public e Massachusetts State Building Code e(780 CMR) Building Permit Application for any Building other tharII15)i�ULoO9vognBly3lwelling (This Section For Official Use Only) ^ Building Permit Number: Date Applied: Building Official: J1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 1 No.and Street City/Town Zip Code Name of Building(if applicable) Lj SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Nt— Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: —• Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ ` Is an Independent Structural EngineermQ7�Peer�R�evi/1e�jrequired? tom, `/ i Yes ❑ No ❑ Brief Description of Proposed Work: Un 6 fL(X X Ar �J rC�O d a8 VL e t m — Q' �y SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA - Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) - j ? SECTION 5:USE GROUP(Check as applicable), A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ i H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ M.. Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE Check as applicable) IA ❑ Ill IIA0 IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: - Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ or Private❑ or indentify Zone: or on site system❑ required❑permit is enccll trench or specify: osed❑ Railroad right-of-way: 7Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ e within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: ti SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ame(Print) No.and Stree - City/Town Zip Property Owner Contact_Information: Dr rt r , ' - -9w5 Title Telephone No. (business) Telephone No. (cell) e-mail add If applicable,the property owner hereby authorizes �e}, re�r,In, I s- IDe.r U ti S4 Name �Str Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date ,1_0.22 General Contractor Company Name cat�v r t7c�t gfZS Name Responsible Or Construction License No. and Type if Applicable Street Address City/Town J State Zip 97P-&3- �� _-_- TCLr t la,r (P T.e.17kn+ Telephone No. (business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ ( (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and curate to the best f my wledge and understanding. '?—k Aease!-r t and sign am T' e elephone No. Date iCZf�n 4 / 0/ 30 Street Address City/Town /State Zip Municipal Inspector to fill out this section upon application approval: '6' 9 y Name Date The Commonwealth of Massachusetts Department of Industrial Accidents , I Congress Street, Suite 100 Boston,MA 02114-2017. www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO,BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print -LeSd Name (Business/Organizat[on/ludi idual):The Event Co Address:PO Box 419 City/State/Zip:Gloucester MA 01931 Phone#:978-283-4884 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 20 employees(full and/or part-time).- 7. New constriction 2.❑I am sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 ❑Demolition 10 Q Building addition ' 4.[:]I am a homcowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.�ROOTrepairs These sub-contractors have employees and have workers'comp.insurance? 6.M We are a corporation and its offices have exercised then right of exemption perMGL c. 14.❑✓ Other Tents 152,§1(4),and we have no employees.[No workers'comp.insurance required] "Any applicant that checks box#1 mast also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. :Contractors that check this box mast attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they man.provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is:the policy and job site information. Insurance Company Name:Tavelers Policy#or Self-ins.Lic.#`.XEUB2186T50511 Expiration Date:1/12/16 Job Site Address: City/State/Zip: Attach-acopy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fore up to$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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain as d enahles o erjury that the information provided above tr ayl correct. Signature: y / Date: �S/ Phone#: Ojjiciat use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# ' Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r -�� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY !, Massachusetts State Building Code, 780 CMR. 7'"edition OF SALEM 'w Revised Junaun• Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 1)(AY One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: / Date Applied: Signature: ✓Gr6`"'o. 9)ly/l-o Building Commissioned Inspect 'Buildings Date SECTION 1: SITE INFORMATION kPublic e Address: 1.2 Assessors Map& Parcel Numbers ian acce ted street?yes no Map Number Parcel Number log loformatbo: 1.4 Property Dtmenalooa: istrict Proposed Use Lot Area Isq 11) Frontage(it) ing Setbacks(R) Front Yard Side Yards Rear Yard ed Provided Required Provided Required Provided r Supply:(M.G.L c.40,§54) 1.1 Flood Zone Information: 1.8 Sewage Disposal System: Private O Zone: _ Outside Flood Zone Municipal O On site disposal system ❑ Check if es❑ �2.1 vYyy��� �+ SECTION 2: PROPERTY OWNERSHIPt Name(Print) Address for Service: 97e . 741q o9f/ Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ClAlteration(s) CIAdditioJ103 Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': J'STfiZC {� LG'i kG>d -r �A.1-1 FEOrl-- SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S �l U 1. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City/I'own Application Fee ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S a. Mechanical (IIVAC) S List: . 5. Mechanical (Fire S Suppression) Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 0 Paid in Full O Outstanding Balance Due: i SECTION 5: CONSTRUCTION SERVICES 5,1 Licensed Supervisor(CSL) JR e Number Expintion Date Name ul'C'SL•I lulder SL Type(sea below) Dewri ion Address timestricted u to 35,000 Cu. Ft. I Restricted IR2 Famil Dwellin Signature M I Masomy Only RC I Residential Roofing Covering I'deplume WS I Residential Window and Siding SF I Residential Solid Fuel Burning Appliance InstallatiU D 1 Residential Demolition =A-ddmn provement Contractor(HIC) Registrant Name Registration Number Expiration Dale Telephone SECTION 6: KERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 MOD 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 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. Signature of Owner Date / SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, 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 beha Pr t ame 1�7\ p /,�� 0 Si t of Owner A Date V_, Si dcrthe sins and nalties of 'u NOTES: rl. 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. IJ2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and I IO.RS, respectively. 2. When substantial work is planned,provide the information below: l floors 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 ). "Total Project Square Footage"maybe substituted for"Total Project Cost" 5 y� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF tl' Massachusetts State Building Code, 780 CMR SALEM Revised,Nor 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use Only. BuildingPePmitNumber: - - bate Applied: uA� Building OlTicial(Print Ngme igna[u - Date SECTION 1:SITE INFO RrNI ION'• 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 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 ft) Frontage(I1) 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 if yes❑ SECTION 2: PROPERTY OWNERSHIP. 2.1 gwnert of Record: RVn (Print City,State,ZIP liC r( 97<- -7qV � No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief DescXi/o�n of Pro sed Work': ✓t a 7l &O e `�-e '1 0 — o�— SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate.how fee is determined: �. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost?(item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (PIVAC) S List: . 5. Mechanical (Fire Suppression) Total All Fees: S Check No. Check Amount' Cash Amount: 6. Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due: i SECTION 5: CONSTRUCTION SERVICES, 5.1 Construction Supervisor License(CSL) z License Number Expiration Date Name orCSL Holder List CSL'rype(see below) No. Lind Street Type Description' U Unrestricted(Buildings tip to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling Citylrown,Stale,ZIP - M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Buming Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name - No. and Street Email address City/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 IsAuance of the building permit. Signed Affidavit Attached? Yes .........X No...........❑ 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 t4 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7h: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 application is t ue;and to the best of my knowledge and understanding. L e 7 I rmt Owner's or Authorized Age Ns IName(Electronic Signature) Date— NOTES: 1. 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 1M.G.L.c. I42A. Other important information on the HIC Program can be found at wwvv mass.yov:'oca Information on the Construction Supervisor License can be found at www.mass.,,ov/clps 2. When substantial work is planned, provide the information below: Total Boor 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 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' fx The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF �j Massachusetts State Building Code, 730 UYIR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Tivo-Family Dwelling This SectiiiiFbrOfficial UsaOnl .. Building P•rmitNu b r. [)atti,Applied Building official(Print Name) $tgnaturo. Date SECTION 1:SITE INFORMATION 1.1 Proper t�Address: 1.2 Assessors Milo It Parcel Numbers Jl i),e 2��1 <<sr L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information- 1.4 Property Dimensions: Zarin-District Proposed Use Lot Area(sgR) Frontage(fi) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.L a 40,§54) 1.1 Flood Zone Information: 1.S Sewage Disposal System: Public❑ Private❑' Zone: _ Outside Flood Zone? Muniei d❑ On site dis oral Check if aQ F P system ❑ SECTIONZ;' PROPERTV-OWiVERSIIIP! 2.1 Owners of Rocord• Name nnt) Ury,state,WY _0 97 5-1- No,and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSEDAVORK 6beck all that apply) New Construction❑ Existing Building❑ Owner-Occupied Q Repairs(s) ❑ Alteration(s) Cl Addition ❑ Demolition Cl Accessory Bldg. ❑ NumberofUnita Other ❑ Specity; Brief Dyyscription of Proposed Work': t SECTION 4: ESTENIATED CONSTRUCTION CO7Fe Item Estimated Costs: OfRelal Labor and Materials . I. Building g I. Building Permit Fee:S w fee is determined: �. Electrical CI Standard.CityfrownApplicati ❑'rotatRolectCoati(Item6)Trx]. Plumbin:; i ) OtherFaes:'.S ,\L<hanic.tl (IIV.\C) i List:.1'0fal all Fecs:S lAliluinitI' it'll Project ( 'oil (] I'.ti�l in l•iill (]thd;f:m I?n0: -- SECTION 5: ct):vSTRUCrION SERVICES 5.1 Construction Supervisor License(CSI,) _ License Number Expiration Date Nmnc of CSL I luldcr List CSL rype(ice below) Type Description No. and Street U Unrestricted(Buildings UR to 35.000 cu. R. It Rcsuicted 112 Family DWa11111 Cityf rowvn, State, ZIP bl \lasonr RC Roolin Cuverin 1VS window and Sidin SF Solid Fuel flunsing Appliances ( Insulation 1'cle hung Email address U Demolition 5.2 Registered Home Improvement Contractor(I11C) fIIC Registration Number Expiration Date I IIC Company Name or 111C RcSistrmt Nmme Email address No.and Street City/Town, State 'LIP Tele hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 152. 1 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 of the building'permit. Signed Affidavit Attached? Yes.......... No... E3 SECTION 7e:OWNER AUTHORIZATION TO OE 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. Dnro Print Uwncr9 Noma(Electronic Signature) SECTION 7h: OWNERu OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information c ntained in this application is truo and accurate tothe best ofmy knowledge and understanding. t Uwvner s or Audwritcd:lgcut i glide(Electrons;Signature) Dana NOTES: I. ;\n Uwnar who obtains a building punnit to do hisihcr own work,ur:m owner who hires an unregistered cuntractur (nut registered in the house Iinprovement Cuntractor(HIC) Program),will nu have access to the arbitration program or guaranty timd under M.01. c. 142A. Other important information on the HIC Prograut can be found at Ivww nru; auvroc:t Iururmation on the Cunstruction Supervisor Liecnse can be found at,k tvwv.uuass.•,,Lv',IL} 2 IvIlen iub;tantial work is planned,provi,lo the inform'.. .. elurr't a finished basanenVattics,decls or porch) I'utalthwr.trea(;,I. 11.) ----' —(includingS; : g f(abir.tblo room count _ t lrls: living arc.0(';y. tt.l _-- Number of badrulnn•u Numl+erot'h.tlt,bmhs wlunlbcr of b.uhroouu __ - - ---. . ----- --- f ncla;e, ---- ft pC Ot Gndin; ;y.tcin t ..I'.0 ll l'n,p•�.t ��pl u•: P� l ,�•t" dr;a"luny be ;ul,,and,�1 6a "I�d.11 Pwl'.,t , a7, The Commonwealth of Massachusetts "i Board of Building Regulations and Standards CI"I'Y OF Massachusetts State Building Code, 780 CMR SALE\I yb� Nerrsrd.t lur_'lJl l ^^ Building Permit Application To Construct, Repair, Renovate Or Demolish a ( J Uur-or Ttvu-Finnill- Dmelthkit This Section For Official Use Only Building Permit Number. ate Applied: _c lAiilJing OlTicial(Print N;une) Signatu e - Date SECTION I: SITE INFORr*IATION LI Pro erty Address: ,.r— 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Toning District Proposed Use Lot Area(sq IT) Frontage(11) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:tM.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check W--M SECTION 2: PROPERTY OWNERSHIP' Owner'of Recoj,d: No.:u�treel'- / ��'' re / Emuil AJdmss SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteretion(., ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description 9fProposed Work': a ,fre ril r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and.\laterials) y I. Building g I. Building Permit Fee: $ Indicate how fee is determined: '. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x _ 1. Plumbing S 2. Other Fees: S 4. .Mechanical (MAC) S List__ 5. .\Icchanirnl 1 Fire tiut,rassionl 5 Total :\II Fees: S -- G. Check No. Check Amount: Cush :\mount:_Total Project Cost: S ------ '2 7 ❑Paid in Full 13 Outstanding Balance Due: 4 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) License N.... --- — I[spiralion Date ----- I.ist CSI,l)pe(see below)_- No. and Socet TS.Pe Description lI Unrestricted(Buildings up to 35,000 co. It.) R Restricted M2 Family Dttcllin Oily/I'uwn. State.ZIP bt Masonry RC Routing Covering W'S Window and Siding SF Solid Fuel Burning Appli:mces Insulation Telephone ('.mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I IIC Registration Number Expiration Date I IIC Company None or I IIC Registrant Name No. and Street Email address City/Town,State,ZIP "rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 IssMMuance of the building permit. Signed Affidavit Attached? Yes .........lam/ No.—....... ❑ 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. 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 is true and accurate to the best of my knowledge and understanding. /7 !/ int Owner's or Authoriz agent's N;une(llectronic Signawre) Dale NOTES: I. :\n 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 I.G.L.c. I42A.Other important information on the HIC Program can be found at \~\ mat>, %o% ,,c.t Information on the Construction Supervisor License can be found at 9"\k Ji ,s y;o\ 11ps 2. When substantial work is planned, provide the information below: Total floor area(sq. R.) (including garage, finished bascntent'attics,decks or porch) Gross lixing area(sq. it.) _ - Habitable room count Number of fireplaces__- Number of bedrooms Numher of bathrooms Number of half haths 1)pe of heating system - _ -- — Number of decks, porches I)pcofcoolingsy,tcnt _ ...... Fnclosed _—Open 3. "total Project Syunre Fuoinge"may he substituted fix"total Project Cost" The Commonwealth of Massachusetts — CITY OF - Q Board of Building Regulations and Standards S SALGM Massachusetts State Building Code, 780 CMR AL 3`,a Rerised.Ilur 2011 ((x Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dire(ling This Section For Official Use Oi Building Permit Number: Date plie . Building Official(Print Name) Sign ure Date SECTION I: SITE INFORMATION 1.1 Pro er Address: 1.2 Assessors Map& Parcel Numbers Tl LierS — 1.la Is this an accepted s eet?yes_ no Map Numhcr Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Fronlage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1,c.qo.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal [3On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Rec 'A:;1 r� �� n�4- Natae(PrinQ City-state.ZIP !'�'I g 7e5 71tq 0 99i No.mtd Street "telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units__ Other ❑ Specify:_ Brief escrip -7kz_tion of Proposed Work'-: ' t V — 2 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and \laterials) Official Use Only I. Building S I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee '_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (I1V:\C) S List: JC7 //) ?. Mechanical (Fire S — Su trCSsion) Total All Fees:S_ Check No. _Check Amount: Cash G. Total Project Cost: S V ❑ paid in Full 0 Outstanding Balance Due: r � SECTION 5: CONSTRUCTION SERVICES 5.1 C'onstruction Supervisor License(CSL) License Number Fspiration Date Name of C'S1- lloldcr --------- List CSL I'pe(see below) No.and Street Type Description 11 1 finrestricled(Buildings u' to 35,000 cu. It.) R Restricted I&2 Tamil Dwelling City/town.Slide,ZIP M Mason ry RC Roofing Covering W'S Window and Siding SF Solid Fuel Burning Appliances I Insulation 'Felt hone Finail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I IIC Registration Number I?cpiration Date I IIC Company Name or I IIC Registrant Name No. mid Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 of the building permit. Signed Affidavit Attached? Yes ...........* No........... ❑ _• - -- 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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my naive below. I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and ace rate to the best of my knowledge and understanding. t I Ainer's or Apthorized Agent's Name(I7ectronic Signature) Me NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (lot registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. I 4'_A.Other important information on the HIC Program can be found at g„c {rig Information on the Construction Supervisor License can be found at ply io n;u>. -o Ip, 2. When substantial work is planned, provide the information below: Total fluor 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 --- ----- ------ Nuntber of bathrootms Nuniber of half.'baths 1, pe of heating system _-_"-------- -- Number of decks,porches " _---__----- _. Typeofcoolingsysfcnt --- Enclosed _ Open ------- - 3. ""Fo(al Project Square Footage"nia) be substituted fix"total Project Cost" JI�� Hie Common' of Massachusetts } Board of Building Regulations and Standards CITY OF 4 Massachusetts State Building Code, 780 CMR SALEAf / •L..,.. Revised.11 _'l)( `nu( Building Permit Application To Construct, Repair, Renova Or Demolish a �. One-or Two-Fwnity Duelling 1 This Section For Official U e Onl Building Permit Number: Date �plvid/r: _ Building Official(Print N:une) , i ature Date SECTION 1:SITE INFORM ION I.1�lro erty A dress: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted stre t?yes no Map Number Parcel Number ' 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 1.5 Building Setbacks(ft) l 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal Check ifyesp P system ❑ - SECTION 2: PROPERTY OWNERSHIP' 2. Owner'of Record: N;une(Pri' n City.State,ZIP �'i 7& 711-yla59/ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brie escription of Propose Work: rL I SECTION 4: ESTIMATED CONSTRUCTION COSTS Rent Estimated Costs: Official Use Only Labor and Materials) I. Building S I. Building Permit Fee:$ Indicate how fee is determined: 2 Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 4. PlumMechanical S 2. Other Fees: $ T. Mechanical (lf\'AC) S List: 5. ,Mechanical (Fire Suppression) Total :\11 Fees: $ _ Check No. _Check Amount: _ _Cash G. Total Project Cost: S 0 paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Dale Name List CSL Type(see helow) No.and Street — - — Type Description LI Unrestricted lBuildin gs up to 35,000 cu. 11.) R Restricted 1&2 Family Dwellin Cit.0'oon,State.ZIP' - '2e_ _ M Mason ry RC' Rooling Covering W'S Window and Siding SF Solid Fuel Iluming Appliances I Insulation 1'cle hone Email address D Demolition 5.2 Registered Ilome Improvement Contractor(HIC) I IIC'Registration Number Expiration Date I IIC'Gmtpuny Name or I IIC Registrant Nome No.and Street Email address City/Town, State,ZIP Telephone -• SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.It. 152.1 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 of the building permit. Signed Affidavit Attached? Yes ..........11120No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE CONIPLETED 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: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information c tained in this a lication's true and accurat o the best of my knowledge and understanding. { rint( wncr's or Authorized Agent's Name(Electronic Signature) Date 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 tc the arbitration program or guaranty fund under I.G.L. c. I42A.Other important information on the HIC Program can be found a( ncp.gov vc,i Information on the Construction Supervisor License can be found at ook._mas.,go%'Jps 2. When substantial work is planned, provide the information below: Total Floor area tsq. ft.) _(including garage, finished basementlattics,decks or porch) Gross living area(sq. fl.) _ Habitable room count `'umber of lireplaces __—_—_--— Number of bedrooms - -----__----- N Lill]ber of bathrooms Number of half balks 1)pe of heating System _ ------- -- Number of decks porches l\peofcoolingsystem._-.--_ _.____—_— _--_ Enclosed 3. "I'olal Project Square Footage"may be Substituted for"rotel Project Cost- 1� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7'"cJition OF SALF.M J i Revirrd Junnury Building Permit Application To Construct, Repair, Renovate Demolish a 1. 10011 One-or Two-F milt/ welling This Sep6on For Oial Use On Building Permit Number-leDat plied: Signature: Building Commissioner/Ins to Buildtogs to SEC ION 1: E ORMATION 1.1 Property Address* I Assessors Map& Parcel Numbers I15, Dorbu R L l a Is this an accepted street°yes no ap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq B) Frontage(II) 1.5 Building Setbacks(fl) 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 77� qQrr //!! / SECTION 2: PROPERTY OWNERSHIP' 2.I'LnASCrIoOiMIPAI{,1'� VQ�3�•fS _ It be( � �YS Name(Print) Address for Service: e 7� T7q BR R Signature Telephone 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 ❑ Specify: Brief Description of Proposed Work': ' i 7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OlTlcial Use Only Labor and Materials 1. Building S I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost(hem 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) $ List: S. Mechanical (Fire S Total All fees: E Su ression Check No. _Check Amount: Cash Amount:_ 6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of C'SI.• I lulder List CSL"type(see below) .Address F5 Pe I Description WDResidential nrestricted u to 35,000 Cu.Ft. estricted 1&2 Famil DwellinSignature - uso Onlesidential Routin Coverinfelephone esidential Window and Sidinesidential Solid Fuel Bumin A liance Installation Demolition 5.2 Registered Home Improvement Contractor(HIC) IIIC Company Name or IIIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 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 of the building permit. Signed Affidavit Attached? Yes ..........W No...........O 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. _ Signature of Owner Date SECTION 71b: OWNER'OR AUTHORIZED AGENT DECLARATION I. �� (.D ,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 l3chnIfoo (a c Print e 1 Sign ure (Owner or Awfiorized Agent Qbtc Sin under the pains and penalties of 'u 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 al have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I 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 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" The Conunonwealth of Massachusetts Board of Building Regulations and Standards I ( )R Mt'NI('ll'.AI.I IY ,z Massachusetts State Building Code. 7Sll CN1R. 7"' edition ,. t'SI[ Building Permit Application To ('onsh'uct. Repair. Renovate Or Demolish a Hr ri,rd.hnrmu r One- or Two-Fami1v 1)" llin,y '00S This Section For Official Use Only Building Permit umhe . Date Applied: t t_4_7�_ Bwldin Cumnus.iuner/ Inspector tit Buildings Dale V SECTION 1: SITE INFORMATION 1.1 Pro ert address: 1.2 Assessors Nlup & Parcel Numbers A .� 'ce [ed s[reet'7 es nu A1ap Number Parcel NUnIhCI' I.Lt is this :m .c p Y 1.3 Zoning Information: LA Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frunlage(it) 1.5 Building Setbacks(ft) ~— Side Yards Rear Yard Front Yard it ReyuireJ Provided Required Provided Required Pr....dcd i 1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System: ! Zone: _ Outside Flood Zone:' ,tifunici of ❑ On site disposal system ❑ Public ❑ Private ❑ Check if yes❑ p I ys SECTION 2: PROPERTY OWNERSHIP' 2 1 Own�I'fI''of Recorrt},, / TA Ko ube of fke scift criii, S 1.15 b if f h y St(CC7 j Name l P it Address for Service: tgnature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) —{ New Qms[ructi in ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alter:uion(s) ❑ AJJili�ai ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other spceity:�PN 1..5 Brief Description of Propos Work-, 1 VIP_ et� teats G[ l-Q 6s tp� t o flte , •r o t - S ✓c-n � � rPwtp e t o SECTIO J: ESTIMATED CONSTRUCTION COSTS Item Estimated Crests: Official Use Only (Labor and Materials) _ I. Building $ I. Building Permit Fee: $ Indicate how tee is deterrmined j ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier .x 3. Plumbing $ 2. Other Fees: $4. Mechanical (HV:\C) .8 List: ��� G'� boarl 5. Mechanical (Fire $ Sup ression) Total All Fees: S Check No. —Check Amoune Cash Amount: b. Total Project Cost: $ 0 Paid In Full• ❑ OutstanditiL Balance Due ______ SECTION 5: CONSTRUCTION SERVICES j 5.1 Licensed Construction Supervisor(CSL) Licanse Number li\pi r;u ion Date i Nano of C'SI.- IIu IJer Lai C'SI_ 'fcpe iscr brlutr) Vddres, Tv c Descri niun _ ' f- tin l'e%ll'IC led I❑t lu i�,lN)O lu. I'1.� R Restricted I.2 Famih Dssrllitn, 1 Signuutrr .N Masonry Onk RC Residemial Roofing Cmenn_ Telepl ume \1'S Residcnl ial \Nlndom and Siding, SF Rrsidenu:d Suhd Furl liwninc \ >>liance Imi.illaiiu .J D Residential Demolition 5.2 Registered Ilome Improvement Contractor 011C) HIC Comp:mv Name or HIC Registrant Name Registration Number Address Expiration Date ! 5ii gnature Telephone I 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 piocid. this affidavit will result in the denial of the Issuance of the building permit. Si,,ne.d Affidavit Attached? Yes .......... ❑ No ........... O j SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I I j I. _—_------.—,-- as Owner of the ,subject proper:,; �e-zbv maihortzc -- . . .,,, bcf;; r ❑ relatis'e to work authorized by this build^g permit application. ----- - ---...------- ------ - ' Signature;:1 Dace 0.crer _--'_ SECTION 71): OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized AI,em hereby declare I that the.statements and information on the for4going application are true and accurate, to the best of my knowled-e and j behalf. Print(Jame Signature o ner or Authori •d Agent Date f Siencd under ne pains and penalties of perjury) _ NOTES: 1. An Ovmer who obtains a building permit to du his/her owr. worF.. or an owner who hires an unregistered con(raclor (nut registered in the Hume Improvement Contractor MIC; P.ogram), will trot have access to the whitialikm program or guaranty fund under M.U.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing tCSL)can be found in 730 CMR Regulations I I0,R0 and 110.Ri, respectively. i '. When substamial work is planned• prov:de the infurrnariun belew: j Total flours area (Sq. Ft.) (including garage, finished basement/:utics, decks or porch: l Gioss living area iSq. Ft.) Hahirable room count Number of fireplaces Number of bedrooms : Number of bathrooms :Number of haR7ba;hs _ I ype of heating system Number of decks/ porches Type of cooling system Enclosed Opcn 3. "Total Project Square Footage- may be substituted for "Total Project Cost" i I What is the current use of the Bui ing4 �/4-1 Material of Buildings A11MA If Ming,how many units? Win the Building Conform to L _ Aabeatos4 Architect's Name Address and Phone ) Meclum-d s Name Address and Phone Construction Supervisors ucer"0 7��3� HIC Registration S Estimated Cost of Project: PertnM Fee CaMulation Permit Fee i 2 5� Estimated Cost X$7I51000 Residential —_- _--- Estimated CostX Sf1/s100f1Cmnmwclal-----------. - - - An Additional $5.00 Is added as an Administrable charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The underalgned dose hereby apply for a Building Permit uild to the abo 6 stated specifications. Signed under penalty of perjury o e �� �1 N 7. V \ a, Ci EI'1'7tOF 11 PUBLIC PROPERTY DEPARTMENT MAYa 130 WAMUNGTM hrRM 3AtaiK 4AaAoa:ftrM 01970 APPLICATION FOR TM REPAIR RENOVATION_ CONSTRUCTION DELMOLTTIOM OR CHANGZ OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUUJMG- E !47 TION DP�6 f7 in a; Ama YM Histarb t)ht a YM 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land �- Name: e / D dl if d Tti e f Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN E]gSYIl+IG BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor(sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: --- -- - ---- Mail Permit to: Client#•36038 9900021E: AC-ORD. CERTIFICATE OF LIABILITY INSURANCE o�11 °A" PRDDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION US[Rental Specialties-E? ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 53310 - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Irvine,CA 92619-3310 INSURERS AFFORDING COVERAGE 800 854.3298 INSURED INSURER A: St.Paul Fire and Marine Insurance DTH, Inc. INSURER B. dba:The Event Company INSURER C PO Box 419 INSURER D: Gloucester,MA 01930 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR POLICY EFFECTIVE POLICY EXPIRATION LIMBS LTR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD ATE MMMD LIABILITY OCCURRENCE $ GENERAL LIABIL T M ERCIAL GENERAL LIAB ILITY FIRE DAMAGE(Any one fire) $ CLAIMS MADE 0OCCUR MED EXP(Any one person) s PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIM ITAPPLIES PER: PRODUCTS -COMP/OP AGG $ POLICY 1FC) LOC El A AUTOMOBILE LIABILITY MA00200282 06/O8/07 06/08/08 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS X Physical Damage Comp: $1000 Ded. PROPERTY DAMAGE $ Scheduled Autos Coll: $1000 Dad. (Per acddem) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG Is EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEUUCTIBLE $ RETENTION $ $ CRY UM1U- OTH- WORKERSCOMPENSATTONAND R fi TER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIYEHICLESMXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Below referenced certificate holder is added as loss payee and additional protected person to Auto Coverage.*Except 10 days notice of cancellation for non-payment. Re: 2005 Chevrolet Silverado vin:1 GCEK14V452352352 CERTIFICATE HOLDER ADDITIONAL INSURED'INSURER LETTER: CANCELLATION SHOULD ANYOF TH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TH E EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TOMAIL3D• DAYS WRITTEN NOTICETOTHE CERTIFICATE HOLDERNAMED TOTHE LEFT,BUT FAILURE TO DOSO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURERJTS AGENTS OR -' - _ REPRESENTATIVES. AUTIJOR17FP REPRESENTATIVE i What is the current use of the Building? -t�' Material at Building? <� If dwelling.how many units?� WiN the Building Conform to Law? Asbestos? ArchiteaCs Name Address and Photo ( 1 Mechanids Name — Address and Phone Al Construction supervisors Licenses d3 187S1v HIC Registration# Estimated Cost�of�Pr�ojed S Permit Fee Calailadon PerrnU Fse:st Estimated Cost X$7/$1000 Residential _-- Estimated Cost X$11/ti1000 Commercial--- An Additional $5.00 is added as an AdmtnlstraWe charge. Make sure that all folds are properly and legibly written to avoid delays In processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury x Date 7' of N s o � U 9 F $ V i 3 3 � The Commonwealth of Massachusetts j Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official: 9 SECTION 1:LOCATION l ST olq7o LOUSE 1 No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Nlap# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of N-IA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other JM Specify: TENT Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Enguteerin Peer Review required? Yes ❑ No 11Brief Description of Pr)posed Work: n 5�1� Q �G (p 36 2_T. 3 — qi 2 5, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) [3 Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ AS❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑ I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4 ❑ M: Mercantile ❑ 1 R: Residential R-1 13 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ I Special Use❑and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑- IB 0 IIA 0 IIB ❑ IIIA t7 IIIB O IV 0 VA O VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside.Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentifv Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: .A1A Historic l'onunission I:<•riw I'r,c.•+s: Not Applicable 13 Is Structure within airport approach area? Is their review completed?. or Consent to Build enclosed❑ 1 Yes❑ or No❑ - Yes ❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly_ space: >✓u n - a(z� SECTION 9: PROPERTY OWNER AUTHORIZATION t Name and Address of Property Owner jkW0Ej&5f0QV6 Lei Its-7 eRyCT 516tern OIT76 Name(Print) No.and Street Cit'/Town Zip Property Owner Contact Information: c� cosi Co gab(eS• ogF Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: ,t �. b e 6 CoM l(S Der 6j Sa001 Q1470 Name Street Address City/Town State Zip to applv for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name _T_'�Yzz� H�D6�s Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 9WAU 4cS�'4 -_ 4&-<4 Io r@ tern-k k l-f _ C 0 f�f, Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11: F AtHUAV77 M.G.L.c 152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes O No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=5 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=S 3.Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) $. Mechanical (Other) S Enclose" check payable to 6.Total Cost $(59-,375- (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I herebv attest under the pains and penalties of perjury that all of the information contained in this application is true and acc rate to the best of my knowledge and understanding. n re h-< Please rinC and sign nan Tf e Telephone No. ate �Q Y/y �iue�8�cr / 05F30_ @6enkktl-. Cors-( Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: bAmt3 . a y Name Date 1.Je�ld le.t•c,e R-e-t) What is the current use of the Building? It dwelling.how many units?------ Material of Building? Asbestos? Will the Building Conform to law? _ Architects Name ( 1 Address and Phone Med+anWil Name Address and Photo HIC ROGIMMtion 0 Construction Supervisors license# Estimated Cost of Pro S Permit Fee Calauidion Estimated Cost X$71:1000 Residential Permit Fee i Estimated Cost X$ '$'000 Commercial--- - - An Additional$5.00 is added as an Administrable charge. Make sure that all fields are Property and legibly written to avoid delays In Processing. The undersigned does hereby aPPy for a Bu"ding�P(ermit to build to the above stated [mow speciations. Signed under penalty of perjury Date I N a E. •�° a G7(� y � g PU13LIC PROPERTY DEPARTIVI NT 130 WAfHIN41[7N SnLM•1Uk3%-MAMAan:sArM 01970 TZL 9r US.9S"•FA1C 97e.7409W APPLICATION FOR THE REPAIR RENOVATr N CONSTRUCTION_ DE_rIOLITION, OR CHANGE OF USE OR f'Crp STRUC MIC OR BUIL.DD(G FOR ANY EXISTIN 1.0 SITE INFORMATION Location Name: I S2 _ 7 crsa l0 2S Budding- (I - cat S�of yi Property Address:--- �Scttee�n l�-1V�- � c�ft� Property Is located in a:Conservation Area Y/N-=Historic oh&ld Y/N 2.0 OWNERSHIP INFORMATION 7.1 Owner of Land ' Name: IfDUS D 6 , Address: " r S A� y �c�-�er� "A?- D C 9 tS Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN "IsImrs 13UILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation Of existing building New Beef Description of Proposed Work: - -- Mail Permit to: - li T13 - I q— s REC FJVFn The Commonwealth of Massachusetts SERVICES aj J Department of Public Safety Massachusetts state Building code VW CMR) ""' AN -4 Building Permit Application for any Building other than a One-or Two-Family Dwelling 8 (This Section For Official Use Onl ) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block##and Lot#for locations for whicha street address is not available) (P� -er bl 5L �n�m M6 01ci 70 !IlJu -2c�e S2 a-F � h L-z,- (es No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below :Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) of Use ❑ Change of Occupancy ❑ 1 Other 11 Specify: TC Mj— Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 91 Is an Independent Structural Engineerin Peer Review required? / I I/ / Yes ❑ No Brief escnption of Pro osed Work: a- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): i SECTION 4:BUILDING HEIGHT AND AREA 1 Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) SECTION S.USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B. Business ❑ E: Educational ❑ F: Fact F-1❑ F2❑ I H-. High Hazard' H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ I1B0 ILIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) t Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal• Trench Permit. Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A french will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or an permit is enccll site system❑ required❑ bench or specify: osed❑ Railroad rightof-way: Hazards to Air Navigatiom MA Historic Commission Review Process: Not Applicable❑ i Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ orNo❑ Yes❑ No ❑ SECTION 8-.CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction Occupant load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Nam,-en tAddi�e o{,Pr perty Owner ,' /Ilk 70 ante(Print) No.and Street City/Town Zip u �F7,u'perly Owner Coidacct Ldormation Title Telephone No.(business) Telephone No. (cell) e-mail adATESS If applicable,the property owner hereby authorizes `� F.t eweC B1&)L--f(4 l'la.A a'iF3a Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft of enclosed space and/or not under Construction Cnmrol then check here O and sk!E Section 101 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor /y Company Name , �c2a.t�n r� I� szS Nam f Peen Res;onsible for Construction License No. and Type if Applicable Ph hays- q/f gloz�cp- 5 c — ?& 0(736 Street Addresssue`/ City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 1E WORYERS'COWENSATION INSURANCE AFFIDAVIT M.G.L.c.152§25C A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 1Z CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact/mum'cjpaEty) 5.Mechanical Other payable to �$ rl f 5 161() Enclose check .1 6.Total Cost $ Q 6 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accumbeto the best of my knowledge and understanding. 1 h i, i [ ),.,�, e prmt and si a Title Telephone No_ Date Prs� ,re 6/ouce,s�e,- RZI elf-340 Street Address City/Town State Zip Municipal inspector to fill out this section upon application approval• - 4V-11� Name Date f � SZ�S4 75- RECEIVED 11-f - 1 tr� ►NSPECt1UNAL SERVICES The Commonwealth of MassachuptN _4 Department of Public Safety - . . A Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 16� er b4 _�E SA=Q m #711- 70 ffiiUse o F _S h leS No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2.PROPOSED WORK Edition of MA State Code used if New Construction check here❑or check all that apply in the two rows below -Existing BuBding❑. Repair Cl I Alteration ❑- - -AdditioA 0 1 Demolition ❑ (Please fill out and submit Appendix 1) - _ - --- Change of Use ❑ Change of Occupancy ❑ Other (rl specify-- Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M Is anIndependent Structural Engmeen Peer Reviewrequired? V Yes ❑ No Brief ription of Pro used Work h 61-. It a ,-n 'r 1�t A t'�t SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY ' Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CUR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4 BUILDING IMG14T AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.fL)and Total Height(ft-) SECTION 5:USE GROUP(Check as applicable) -- A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ 1- Educational ❑` F: Fact F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage Sl❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use. SECTION&CONSTRUCTION TYPE(Check as applicable) IA ❑ 111 Cl IIA ❑ lIB ❑ 1 HIA ❑ BIB ❑ 1 W EI VA ❑ VB ❑ SECTION 7-SITE INFORMATION(refer to 780 CMR i1L0 for details on each item) i Trench Permit. Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal• Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8.CONTENT OF CERTIFICATE OF OCCUPANCY Editiun of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: r r 1 SECTION9: PROPERTY OWNER AUTHORIZATION Name and46ddress"o 4A,oicrty Owner �J r �I, G'ss� �c?�l�,1„G �� /f�J- C I '\l ✓PI /fI O ame(Print) A It ., �I{71. N((;5 No.and Street City/Town Zip 4 Property Owner Contact Information �c�4 S,OfJY�I g_1L- s1 �1.��- - COS Tithe Telephone No.(business) Telephone No. (cell) e-mail adAress v" if applrcabie,the property owner hereby authorizes k�r7�3c, '-f l 4 4'(da_eAS-4'<- Ln1� of�t3a Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less Oran 35,000 cu.ft of enclosed space and/or not under Construction Cnntrnl then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mailaddres Registration Number �- Street Address City/Town Sate Zip Discipline Expiration Date 102 General Contractor i rL T Company Name 'I r 17CJ Nam f Person Res onsible for Construction License No. and Type if Applicable Street Address City/Town Sate Zip M-ASAEA— - - /Gr(Q r-e kl 1<n 4 - c o.z Tele hone No.(business) Telephone No. cell e-mail address SECTION 11--WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-G.L.c.152§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes No O SECTION i2 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(tabor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2 Electrical $ appropriate municipal actor)=$ 3.Plumbing $ 4.Mechanical WAC) $ Note:Minimum fee=$ (contact mu agpality) 5.Mechanical Other $ Endow check payable to _ 6.Total Cost Is 6 (conact municipality)and write check number Rem SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurato to the�best of may knowledge and understanding. .r�`—.�I���� `, print and si a Title Telephone No. Date )( T/ r 6/rizcce5�er /1T 13, O/y36 Street Address City/Town State Zip Munhdpai Inspector to fill out this section upon application approval: 'a"'" Y / Name Date Il � z(Y�vis The Commonwealth of Massachv5 tts ` {Y Department of public Safety JUN —4 �t c VYl Massachusetts State Building Code(780 CMR) ~ Building Permit Application for any Building other than a One-or Two-Fantily Dwelling (This Section For Official Use Only) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 6 erb4 .5k /VA 61c; 70 &05C 141 6z"WeS No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other (�7 Specify t Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M Is an Independent Structural Engineerin Peer Review required? t y L O IYes ❑ No 19 BriefRescription ot�pose¢Work:1yl tS-i/w `lam YZ vet 7 J 24/ '-i - '7 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Gmup(s): I Proposed Use Group(s): SECTION 4 BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E. Educational ❑ R Facto F-1❑ F2❑ H: High Hazar& H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ I-3 ElI 1❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ HA ❑ IIB ❑ 1 MA ❑ HIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 117A for details on each item) Water Supply: Flood Zone Information: Sewage Permit Debris Removal:Sewage Disposal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone O Indicate' ❑ A trench will not be F Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach areal? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ A) Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: �,r*rt.a,yay SECTION 9: PROPERTY OWNER AUTHORIZATION Name and•n(dan s'4 o OiXrier 70 er ame(Prim A d9Q� No.and street City/Town Zip qqa �+- YUL Property Owner Contact Information- 77Be Telephone No.(business) Telephone No. (cell) e-mail a Tess If applicable,the property owner hereby authorizes Ef ewEC'a PO &Y q14 6 Name Street Address 6ty/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) E building is less atoll 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1R 'stered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor CompanyName /lui Nam f Person Re onsible for Construction License No. and Type if Applicable p .Rn u- fig r7&Llcz!Lkc z2zff 007 eStnreeet�Aaddreesssue`, City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with tiffs a lication? Yesi No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE item Estimated Costs:(labor and Materiels) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact Incipahty) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ a (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that an of the information contained in this application is true and accuratF,to the best of my knowledge and understanding. ALL,j / 1, 6e [ . � t t- 9V A3_ tf&fig( )' )prin Me 7'i0e Telephone No. Date _ 6�oucz5le, /�_ alf 30 Street Address city/Town State Zip Municipal inspector to fin out this section upon application approval• Name Dare ZS SZss��l2S 7-5 — L� oz o , 8 Z of-- s RECEIVED The Commonwealth of Massachusetts RVICES Department of Public Safety ' 4 A 1014 JUN — 158 Massachusetts State Building Code 80 CMR . Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use On ) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block✓1#and Lot#for locations for which a street address is not available) IG: e.r b4 5F lC'.JCP rn /r/ 6, 0' ZQ hb(i5e G-F -�-P.v , 6. '-es No and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used if New Construction check here O or check all that apply in the two rows below Existing Building❑ Repair Cl Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other 10 Specify: C Are building plans and/or construction documents being supplied as part of"permit application? Yes ❑ No @1 Is an Independent Structural Engineerin Peer Rteview required? // � Yes ❑ No Brief ption ofproposed ork,- 5iL�.(l Q- Y---Y1 'lam "Sol X 1p l71 7�3/a-OI i SECTION 3:COMPETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4.BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.it) Total Area(sq.ft.)and Total Height(ft) -, SECTION 5.USE GROUP(Check as applicable) A: Assembly A4❑ A-2❑ Nighulub ❑ A3 ❑ A-4❑ A-5❑ B. Business ❑ E: Educational ❑ R Factory F-1❑ F2❑ I Tit High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile[IR: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2 Cl U: Utility❑ i Special Use O and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill Cl IIA ❑ IIB O IIIA ❑ IHB ❑ 1V ❑ VA ❑ VB ❑ SECTION T SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit Debris Removal: Water Supply: Flood Zone Information Sewage Disposal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed 0 Railroad right-of-way: - Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8.CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor- Does the building contain an Sprinkler System?: Special Stipulations: f . SECTION 9- PROPERTY OWNER AUTHORIZATION Nome and t4bifT¢:^,sofl'io OylOwner - 1vJI— ' ;Ik(t y�'f �A' h)!1; r A g7a 1 s �c�Kf,,,� r� //�( erbu C� m /�I O/ ame(Print) ��J No.and Street' City/Town Zip Ft"o�erty Owner Con�ett7nf�fi¢tsaHon: (ayl-A ty" r" 2`f 6 15o -_ ccskt 6,ees Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes `(lrc Ec e v. M &)a ' f l 4 G� tl.c.s� n't ai iya Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If bu ilding is less than 35,000 cu.ft.of enclosed space and/or not under Construction Cmmml then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. a-mail address Registration Number • - Street Address City/Town„ State Zip Discipline Expiration Date 10�.2 General Contractor o ^ .. Company Name ``�f Nam"f Person Res onsible for Construction t License No. and Type if Applicable -P() hen /- y/? �luuce r%r ZVhL o f 93 t5 Street Address City/Town State Zip tr Telephone No. sines Telephone No. cell > e-mail address SECTION 11•WORKERS'COMPENSATION INSURANCE AFFIDAVIT M_G.L c.152§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? ; YesX No O SECTION 1Z:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact Municipality) S.Mechanical Other $ A Enclose check payable to r-r 6.TOW Cost Is 6 (contact municipality)and write check number here SECTION 11 SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application/.is true and accurat to the�best of my knowledge and understanding. 12 print and si a Title Telephone No. Date / 6/ouce544- /m O/936 Stmet Address City/Town State Zip Municipal Inspector to fill out this section upon application approval• Name Date Tom' I q 1 S RECEIVEDone The Commonwealth of assac use 11," Department of Public Saf Massachusetts State Building Code —4. A 156, Building Permit Application for any Building other than a One-or TWo-Family Dwelling (This Section For Official Use Only) - Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)' 'I 7o lOUSe of _S h C 6(es No.and Street City/Town Zip Code Name of Budding(B applicable) SECTION 2:PROPOSED WORK Edition of MA Slate Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of occupancy ❑ 1 Other p Specify: C - Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No @J Is an Independent Structural Engineerin Peer Review required? \/ Yes ❑ No Brief escnption of Pro$used Work a n +- F`T v- + �xtt SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4.BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft.) SECTION S:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ 1- Educational ❑ R. Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H 1❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M Mercarrtile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage Sl❑ S-217 U: Utility❑ Special Use O and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IAO IB ❑ 11A0 , BB ❑ MA M ❑ I tV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111-0 for details on each item) Trench Permit. Debris Removal: Water Supply: Flood Zone a Flood tion:Zone Sewage municipal A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 1 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of P.roperty.Owner e(Print) No.and Street City/Town Zip .n x ttt dins Property Owner_Contact4Ynformatiom, -7#- 01?4 ccs Zq,, e .ar Title Telephone No.(business) Telephone No. (cell) e-mail ad ress If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 1Q CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.It of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. - -e-maitaddress - -- — Registration Number Street Address City/Town State Zip Discipline Expiation Date 101 General LContractor ( C--o/}-m—pany NameI ' Nam f Person Res,Lons si ible for Construction �+/ License No. and Type if Applicable _Pr') hen W- 7 / ( (�[O-t-,C.z 5- w &Zff of 710 Street�A¢d{ eedr /sss City/Town State Zip/ 11/L-2il" �n /{0n a� re Telephone No. business Telephone No. cell e-mail address SECTION 11•WORKERS COMPENSATION INSURANCE AFFIDAVIT M_G.L c 152§25C A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes No O SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accuratr1to the best of my knowledge and understanding. law GL1,7re , r L/X-2K3_C(&&t( print and si e n TiOe Telephone No. Date P[Y�__ � f/�GLCG2S4� /� Street Addm_ss City/Town State Zip Municipal Inspector to fill out this section upon application approvaL• Name Date l Hie Commonwealth of Massachusetts is Board of Building Regulations and Standards Cl M'OF r MaSSaehUSCR5 State Building Code, 730 C NIR SALLM Building Permit Application To Construct, Repair, Renovate Or Demolish a Our-or Tuw-Familc Dmrllit{jr This Section For 01' cial Use Onl Building Permit Number: D to Applicd: Mudding Oirmil(Print N;une) Signature Ualc SECTION 1: SITE INFORMATION 1.1 1.2 Assessors Ylap 5s Parcel mben I.I a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zaning District Proposed Use Lot Area(sq It) Frontage(Il) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.§Sq) 1.7 Flood Zone Information: 1.9 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)Check ifesO i P posal s stem ❑ SECTION2: PROPERTY OWNERSHIP' - 2.1 Ownert of Rec d• ono(" mint) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Des ription QlfProposed Work: LEQ U SECTION 4: ESTIDIATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only I. Building S I. Building permit Fee: S Indicate how fee is determined: '. Electrical S ❑Standard City/Tosv'n Application Fee ❑Total Project Costa(Item 6)x multiplier _ _ x i i. Plumbing S 2. Other Fees: S — ------ a. Mechanical tll\:1('1 S Lisl: \Icchaniral tFirc _ ----- --- - -- Simiressionl S 'rood :\I1 Fees: S --__ - -------- ----..._.- . Total Project Cost: s Check No. __('heck AluounC - --.—Cash Amount: ❑P:iid in Full 0 Outstanding IlaLmce Due: 1 SECTION 5: CONSI'RUcrION SERVICES 5.1 Construction Supervisor License(C'SL) N LIlle ol'CSI. I luldcr _—.._.___._. License Number P\piraliou Date List C'SI.1)Pe I>ce helu\cl No, and Street "I)PC Description l I I Inrestneled I Iluildin Es L10 m 35,000 cu. It.I R Restricted I C2 Fan1i1 Deellin g Citci fo\\n.Sluts.LlP NI Masonry RC Rooling Covering W'S Windo\v and Siding SF Solid fuel Ilurning Appliances I Insulation 'I'elc hone [(mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) II1C Registration Number F.\pirnion Date I IIC C'ompan) Name or I IIC Registrant Name No.and Street Email address City/Town, State,ZIP rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 of the building permit. Signed Affidavit Attached? Yes .......... O No...........❑ 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 D\vncr's Name(Electronic Signature) Date SECTION 7b:OWNER' 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 application is true and accurate to the best of my knowledge and understanding. Liu 11 ✓e/z a l -e 4 z 'r, Oe ner's or:\ulhorired Agent s NaIle Ihl Writ nm Signature) Date 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.I.G.L.c. 1 q2A.Other important information on the HIC Program can be lilund at m.n, I\ •ti I Information on the Construction Supervisor License can be found at 2. \\'lien substantial\wrk is planned, provide the information below: Total floor area(sq. ft.) _ Iincluding garage. finished basenlenL'attics,decks or porch) Gross living area(sq. ft.) _ Habitable room count Number of fireplaces _-_ - - Number of bedrooms Numberofbathroolns Number ofhalf'hatlu I')pc arheating system .. _ - -. --- Ntanher of decks, porches I\Ile of cooling s\slept _ _. _ 17I1cloied - _ 01'ell . }. -l of l Project Square Footage"nta) he substiuned for"Total Project Cost" The Commonw'ralth of Massachusetts Board of Building Regulations and Standards Fc lR Massachusetts State Building Code. 730 C NIR. 7 edition PSI.. O Building Permit Application To Construct. Repair. Renovate Or Demolish a Rri is,l hmiwi One-m Tit o4 amih, Du ellitl This Section ForOtfjelall Use my - I�}V�\`' Building Permit Number: to Ap tic Signature: Ar", — Building Comm1N,110nel'/ Inspector of Buildings SECTION 1: SITE FO IATION 1.1 Property Addres: 1.2 Assessors Map & Parcel Numbers npf�v 'St � I.1 a is this an accepted street'' yes nu_ M1111p Number Parcel \umber 1.3 Zoning Information.: l 1.4 Property Dimensions: Zoning District Proposed Use I Lot Hrca(sy fU Frontuec (li) r 1 1.5 Building Setbacks (fU — Front Yard Side Yards Rear Yard ! Rcyuir;r; Provided Required Provided Required Pnoe'ided - i 1.6 Water Supply: (M.G.L c. 10. §54) L7 FIlaind 2o'c Information: 1.3 Sewage Disposal System: Zone: Outside Flood Zone'' Public ❑ Private❑ Municipal.❑.On Hite disposal System ❑ Check if yes❑ SECTION 2: PROPER/T/YOWNER: i11^I`T-Y" T---' 2rr°` Re rfs� �1_The- tIS O SN)agmn nn nlG Address for Service y e ephone : --- tir SECTI 3: DESCRIPTION OF PROPOSED WORK'(check all that apply.) �New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs( kl. Al�telutirm(s)O�\ddiu.m ❑ Demolition ❑ Accessuly Bldg Number of Units Other Spccily I-ed- tBriel- Description tit Pro�p`�,�ed \Vo k';_`- -�- if exit e TOuS� ��V P n t `.,O�t� _n�_l�.Sr��1.3���mo���a-_Q� sr��..�=.1�• SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Ntaterialsl _ L--- I Building $ 1. Building Permit Fee: $_ Indicate how fee is determined: ❑Standard Citylrown Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x 1. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) .$ List: 5. Mechanical (Fire $ Total All Fees: S Suppression) Check No. Check Amount: Cash :\mount _ b. Total Project Cost: $ 0 Paid in Full ❑ Outstanding Balance Due:__..___,- SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) z , License Numher lixpiralion Dale N'ante of CS L- I)older List CSI_T)pe (see hclow) lddreas .I ' c Descri itiun l Unrestricted (tit)to 15.M0 Co. FI.I R Restricted L@'_ F:nuIN Dvi,ellme Signature .\1 �lasonn Unly -- RC Residential Roulinc Cocenne � rciephone WS Re.:dential Wm6m attd Siding _ SF Residential .Srrhd Furl Iturl)n)e ,\ r rlian.r In,(,illal 1, 1i_ - D Ite>idenliul Deuuthuun 5.2 Registered Home Improvement Contractor (HIC) I _ HIC Company Name or FIIC Registrant Name Regisira;ion N:i.mh¢r, 1 Address Expiration Date �i::^dWS'C —— Telephony I i I SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. M. § 25C(6)) frkers Compensation Insurance attidavit must be completed and submitted with this appl,,atic•n. Failure to pro•:ids affidavit will result in the :ie,(iai of the Issuance of the building permit. Sired AFtidavit Attached? Yes .......... ❑ No ..... ..... ❑ ' i SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN JWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT the as Owner of su.`, -t _ I. _'.�I'f - .- _ ., lee proper..; .rerebv ; [U >C:' .. n., o v .,.;. .:uthorred cv _ Si�n:.turr cf Ova re; _ _ Date -- SECTION 71.: OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare I i that G,e state menrsard :::formation the foregourg application are true and accurate, to the best of my knowledge and j i Jel:al+ ,l t�l , � e �1�L�s_,. • /-�,`�-r1��4 c-E ��ti_✓e J I fc�c fog "Prim Sier,ature of O ner or Authonnd gout •Dare CI t (Si ncd under the sins and penalties oi'perpuy) _ _NOTES: _a 1. An Owner who obtains ;t buii.ling permit to do hisiher own work, or ar,,w er who hires an unregiSlered contractor (not registered in the Hume Improvement Contractor(HIC; r ogra^t), wiii not have access to the iiihitiati„n program or guaranty fund undo: M. i=.L. c. Id=A. Other ;mportant information on the HIC Program and j Construction Supervisor Licensing :C.SL) can be hiund in 780 CMR Regulations I I O.R6 and I I0.R5. respectively. '. When substantial work is planned, pro•::de ttc inform::tiun beiev/: j Total floors area(Sq. Ft.I _ _.(ins:luding garage, finished base men Ua it ics, decks ur pinch) Gross living area I Sq. Ft.) habitable room count _ Number of fireplaces ___ Number of bc•dro,rm.s Number of bathrooms Number of halt/b:uhs 'Cype of heating system Number of decks/ porches "Cype of cooling system L.nciosed Open 3. "Total Project Square Fuot:tge" may be substitwed for "Total Project Cost" The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY \ Massachusetts State Building Code, 780 CMR, 7a edition OFSALEM Revised Junnu!v Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling f� This Section or O icial Use O Building Permit Number: `•- D Ap ie Signature: "r"""' a/-wo Building Commissioner/Inspectur of Buildings 1 Date SECTION 1: SITE INFORMATION 1.1 Prop�rry A ress:/ / 1.2 Assessors Map At Parcel Numbers L l a Is this an acceptedl/ttr✓eet?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq B) Frontage(R) 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? Public O Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 .Owner'of Rgeor /� • (l S ,n !�/ �� Name Print) - Address for Service: �/�. Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': _ G Y SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Olflelal Use Only Labor and Materials I. Building Is Gam- 1. Building Permit Fee: S Indicate how fee is determined: O Standard City/Town Application Fee ?. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire S suppression Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S ��( 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construe Ion 'upervlsor(CSL) Q 1f7g�� I.icense Number Ex iration Date TIC '1.•I lu Jer ( List CSL Type(see below) ��cc I's Pe bQription :\JJ / U IlnmiricteJ u to 35,000 Cu.Ft. �-7/ /^7 OSF Restricted l&2 FamilyDwelling SigV/ !�b / ` �+ M Only 9 Residential Roofing Coverin felephone Residential Window and Siding Residential Solid Fuel Bumin A liance Installation Residential Demolition 5.2 Registered Horne Improvement Contractor(HIC) I nt: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 ..........❑ No...........❑ 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 as Owner or Authorized Agent hereby declare . that the statements and inf rmati on the foregoing application a true and accurate,to the best of my knowledge and behalf^ � are Print Name Signature of Owner or Authorized Agent Date !9 (Siancd under the pains and penalties of 'u 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 IHIC)Program),will NJ have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively. �. 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 half/baths Type of heating system Number of decks/porches T)'pe of cooling system Enclosed Open J. "Total Project Square Footage"may be substituted for"Total Project Cost" rt ZZs �K (,00 / 7 Al. The Commonwealth of Massachusetts Department of Public Safety i lassachusetts State Building Code(780 CI IR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit.'Number: Date Applied: Building Official: O SECTION 1:LOCATION t m 01970 H&USE o L No.and Street City/Town Zip Code Name of Building(if applicable) Assessors'%Ia # Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA Stale Code used If New Construction check here ❑ or check all that apph•in the two rows below Existing Building❑ Repair 13Alteration ❑ Addition❑ Demolition 13 (Please fill out and submit Appendix 2) IIY� Change of Use ❑ Change of Occupancv ❑ Other Jdl Specifl•: TEI�IT' Are building,plans and/or construction documents being supplied as part of this permit application? yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? ye ❑ No ❑ Brief a cription of Pro ns d Work: l Vl.5�'tt t' G1 . }� 6!� -�Piyt�'� �T eNY- �� 3o fla,��f,l� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Buildfhg,Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)& .Area Per Floor(sq. ft.) Total Area (sq,ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h HazrdaH-1 13H-2❑ H-3 El H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ I-3 13I-4❑ D1: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB 0 IIA D IIB ❑ IIIA O IIIB D 1 IV O 1 VA 0 VB ❑ - SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site❑ Private❑ or indentifv Zone: or on site wstem❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: A9A Historic commission Rc�i�•w Prom•ss: Not Applicable❑ Is Struchue within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION" Name and Address of Property Owner �Dt,S� a F7�f S�yE�cJ��f3L�� lis.�Ry.CT S��n� >• o r �0 Nance(Print) No.and Street City/Town Zip Property Owner Contact Information: Eo$wr mazh6; (z- 1Y 0�yl_ cjCO's �a 7�g0tbles. Title Telephone No.(business) Telephone No. (cell) e-mailaddress If applicable,the property owner hereby authorizes: 7l '.T 1 1�e 6 (fo s-F-, !(S (7e.tr 6j S i- Sa.-0 Milt Q 4 70 Name Street Address City/Town State Zip to apply for and act on the propertv owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 33,M)cu.ft.of enclosed space and/or not under Construction Control then check here O. otherwise provide,onstru<ton r"nhol coma see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor _'t_ Lc Eu cn± Company Name —T9 y c f6b6es Nance of Person Responsible for Construction License No. and Type if Applicable FJO .fW)C `f IF GJUCESTEIZ -;*,q- of 436 Street Address City/Town / `State Zip q1YOPE � r@ rZn-k Vl�_ C 0 ktx Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11: kVoRKrItS'l ON1I11'_N1,AT[ON INSURANI'F AFHUAVIT M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Budding $ Building,Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=5 3.Plumbing $ 4.lflechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ IOU (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and ace rate to the best of an,knowledge and understanding. n re h� iii 2&3_�(o 6 Please rine and si ,n nan e Tele hone No. ate � � d r�2cce8�c� / O/��?d can@den uf. cors( Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Awl Name Date t The Commonwealth of Massachusetts �0 Board of Building Regulations and Standards CITY 7 ) Massachusetts State Building Code, 780 CMR, T°edition OF SALEM �lssrr Hevised Junuury Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, .(1(, C� One-or Two-Family Dwelling This Section For OfTtcial Use only Building Permit Number: IDate Applied: Signature: Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION Pro 1.I perty 264S Address: 1.2 Assessors Map At Parcel Numbers ( DL � L l a Is this an accepted street?yes_ no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Check ifes❑ Y 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 ZoneT Municipal❑ On site disposals stem ❑ SECTION 2: PROPERTY OWNERSHIP' 2.� p wner'of Kdr�SG Name �'-`— (Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑TExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other 10 Specify: 1 Brief Description of Proposed Work-: -S& x 66, — ur rp 712L4 �l��a� ��7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only I. Building S I. Building Permit Fee:S Indicate how fee is determined: �. Electrical S Cl Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S \ 2. Other Fees: S 4. Mechanical (BVAC) S List:_ Chi ! 66 5. Mechanical (Fire —�J Su ression) S `' Total All Fees: S 6.Total Project Cast: S Check No. Check Amount: Cash Amount: /� (/ ❑Paid in Full ❑Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) I.iccnse Number Expiration Date Name of CSI.- I lulder List CSL"1'ype(see below) Type Description Address U l Inrestricted(up to 35,000 Cu. Ft. R Restricted I&2 Family Dwelling Signature M Masonry Only RC Residential Rooting Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel Bumina Appliance Installation D Residential Demolition 5.2 Reg stered Home Improvement Contractor(HIC) 111C Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.4 25CM) 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 ..........d No...........13 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to w rk authorized b thi buildin ermit application. - 6 x Si alum n D° SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION I ,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 (Signed under the pains and penalties of 'u 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 Fj have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115. 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 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" The Commonwealth of Massach -us Board of Building Regulations an tanda s CITY 'It y j Massachusetts State Building Code, 0 CM , 7ih edition OF SALEM 11 �� Revised Junuury Building Permit Application To Consult , Repa' , enovate Or Demolish a One-or Two- milt' elling This S lion r Official Use Only Building Permit Number: Date Applied: Signature: 5�,2�• Buildi4CommissidWrf I spector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Pro e�y.Addre,+ r 1.2 Assessors Map& Parcel Numbers - 1_b: k11 L l a Is this an accepted street?yes— no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1 Zoning District Proposed Use Lot Area(sit 11) Frontage(it) 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? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECT`IIONN2: PROPERTY OWNERSHIP' J 2.F�rySC t of I;eeor rues. �srl�rGf J ( 1� as� ­54 Name(Print) crJ— Address for Servi r. 617,9- Sign Telephone SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Dec "ption of Proposed Work': - ,E' r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Oflicial Use Only Labor and Materials I. Building S 7 �?S I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Su ression) Total All Fees: S g � Check No. Check Amount: Cash Amount: ��6. Total Project Cost: S ! 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL IleJG*- �,� License Number 4F, ,1..%D1 1�'C/tw C r'� List CSL Type(see below) G Y �jk7 G� L✓7 "r Description Adddr� U Unrestricted(up to 35,000 Cu. Ft. R Restricted 1&2 Family Dwelling Si n�a�{�rc pp _ M Masonry Onl RC Residential Roofin Coverin Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) 111C Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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 of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........Cl 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 SECTI N 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby declare that the st ements and infarnati on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Namp,1 L Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of 'u NOTES: 1. 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 M have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively. 2 When substantial work ' pl,3/n�gqlhed,provide the information below: Total floors area(Sq. Ft.) `Ol/� (including garage, finished basementlattics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" IL 1 ' The Commonwealth of Massachusetts p OF Board of Building Regulations and Standards CITY S M VVV Massachusetts State Building Code, 780 CMR Revised dMar Mar 2011 \V Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only -TM Building Permit Number: Date Ap lied: (� 4 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Proper,"Tess: 1.2 Assessors Map& Parcel Numbers L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Informaiion: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(8) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Regdoed 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 if yes❑ SECTION 2: PROPERTYOWNERS.HIP' 2.1 Vwner' of Record: -< o--P �- (� .Pts C'�� 1J-1) In�t 1�r esHW6-S Name(Print) / City,State,ZIP i t� 7yy.. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Altemtion(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Briapescriptionof roposed Work: 2 t SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Of Use Only (Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cos['(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ p dttl) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES f5AConstruction Supervisor License(CSL) License Number Expimtion Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildin s u to 35,000 cu.ft. C�ty/Town,State,ZIP - t. R Restricted t&2 Famil Dwellin M Maso 1, .. _. �•• - - RC Roofin Coverin WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition _ 5.2 Registered Rome Improvement Contractor(HIC) HIC Company Name or BIC Registrant Name HIC Registration Number 'Expiration Date No.and Street Email address Ci /Town, State,ZIP Tele hone 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 of the building permit. - SiFOwner d Affidiached? Yes ...........`4 No...........❑ ECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT bject property,hereby authorizen all matters relative to work authorized by this building permit application. Print Owners Name(Electronic Signature) Date SECTION 7b: OWNER'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 application is true and accurate to the:best of my knowledge and understanding. Print Owners or Authorized Agent s Name(Electronic Signature) , b Date NOTES: 1. 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 www.mass gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns th 2. When substantial work is planned,provide e information below: Total floor 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 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" The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State� Building Code, 780 CMR SALEM/ Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a 111 One-or Two-Family Dwelling This Section For Pfficial Use Only Building Permit Number: ate Applied: l� Building Official(Print Name) Sigm Date SECTION 1:SITE INFORMATOK 1.1 PropertyyAddress: 1.2 Assessors Map&Parcel Numbers Lla 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(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone?' Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.t1Lt Owner'of Record: fft c,Z !M `7 rJ Name(Print) City,State,ZIP 9 7-: 79qG�y� 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) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work?%. 1i1. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ .Z 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ j 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ) 7,00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted I&2 FamilyDwelling City/Town,_State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) , . ' ) 1 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name . No.and Street - Email address City/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 of the building permit. Signed Affidavit Attached? Yes ..........1)6 No...........❑ 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 contained in this application is true and accurate-to the best of my knowledge and understanding. )N.In � LAYI e-0—`1 / N4 t,,V'Ptil 6i r 'Pri—nt Owne s or Authorized Agent's Name(Electronic Signature) Date NOTES: l. 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 www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost" e \/ The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M assac Mar R Massachusetts State Building Code, 780 CMR SA \ Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Offie'al Use Only Building Permit Number: Dat Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1. Property Address: 1.2 Assessors Map& Parcel Numbers i� L 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 ft) Frontage(ft) 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 if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: i.l- s e- G:� I (Safi,&S <4L-cA" I rn A 01q 70 tAame(Print) City,State,ZIP it I r tZ Si q-,79- 7�t� OM No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Descriptionf reposed Work': X d SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ —PST Su ression Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ l 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling CityfFown,State,ZIP M Masonry RC Roofing Covering WS. Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration,Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/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 of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ 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 contained in this application is true and accurate to the best of my knowledge and understanding. )PA-ar-A 1 21 7 /Z PrIfit Owner's or Authorized Agent's Name(Electronic Signature) Date 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(FBC)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 www.mass. og v/oca Information on the Construction Supervisor License can be found at manK.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" f i t The Commonwealth of { k *etf&R' 4ICES Department of Public Safety 7 Massachusetts State Building Code > A g 38 Building Permit Application for any Building other th Otte-or$Two-Family Dwelling (This Section For Official Use Only) J - Building Permit Number: Date Applied: Building Official: PP g SECTION 1:LOCATION _115 Derby St Salem 01970 House of the Seven Gables No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:—Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—install a 40'x 60'tent from 6/12/15-6/14/15 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ RIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ specify: required ❑or trench ors Private❑ or indentify Zone: or on site system❑ P fy: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: - Special Stipulations: Design Occupant Load per Floor and Assembly space: mAt j" slZ.l SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ( House of the Seven Gables 115 Derby St Salem _01970_ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: _Deb Costa 978=_744_-_0991 dcosta@7gables.org Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building rmit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.It of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin donu lent submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 101 General Contractor _The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 _Gloucester _MA _01930 Street Address City/Town State Zip 978=_283-_4884 617_=967__5666 taylor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $1,680.00 2.Electrical $ Building Permit Fee=Total Construction Cost x (Insert here 3.Plumbing $ appropriate municipal factor)=$ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ 6.Total Cost $1,680.00 Enclose check payable to (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is tru d accurate to the best o my o ge and understanding. Daniel Wemrebe 978_-771_-_9561 Please print and ign n me Title Telephone No. Date _15 Whittier St Beverly _MA _01915 _dweinrebe@gmail.com Street Address City/Town State Zip A Email Address Municipal Inspector to fill out this section upon application approval: "" �� GK 5 S5 �R- -To-na u $150 The Commonwealth of Massachusettg 4 * Department of Public Safe�ty�p REIVV Rl'16ES Massachusetts State Building Code(fir "rsAT10WA L StBuilding Permit Application for any Building other than a One-or Tw -F i lling n (This Section For Official Use Only) NO t to ('t 1 Building Permit Number: Date Applied: Building Official: 9 SECTION 1:LOCATION _115 Derby St Salem 01970 House of the Seven Gables I 1 No.an treet J City/Town Zip Code Name of Building(if applicable) t� I Assessors Map k Block#and/or Lot # SECTION 2:PROPOSED WORK 1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:—Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install 40'x 60'&15'x 30'tents from 9/11/15-9/13/15 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I 4❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage Sl❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IHS ❑ IHA ❑ HIB ❑ 1 IV O VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: M rkl L-I10 5 l 2\ SECTION 9: PROPERTY OWNER AUTHORIZATION l '�*vne and Address of Property Owner t ~House of the Seven Gables_ 115 Derby St Salem _01970_ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: _Deb Costa 978=_744=_0991 == dcosta@7gables.org- Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 ca.It of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the prafessional coordinatin document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 _Gloucester _MA _01930 Street Address City/Town State Zip 978_-_283-_4884 617=_967_-_5666 taylor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $2,055.00 2.Electrical $ Building Permit Fee=Total Construction Cost x (Insert here 3.Plumbing $ appropriate municipal factor)=$ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ 6.Total Cost $2,055.00 Enclose check Payable to (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is tru%daccurate to the best of y ledge and understanding. Daniel Weimebe 978 -771 - 9561 Please print and Title Telephone No. Date _15 Whittier St _Beverly _MA _01915 _dweinrebe@gmail.com_ Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: ""i �I� ' � ZS S55g r The Commonwealth of %fie Z,410ES Department of Public afety Massachusetts State Building Codpe�� gg) A 38 Building Permit Application for any Building other tt�Y1 CNie i or Two-Family Dwelling (This Section For Official Use Only) V Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION _115 Derby St Salem 01970 House of the Seven Gables ' No.and Street City frown Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK t Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 2) F Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install a 44'x 63'tent from 8/13/15-8/15/15 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: f11AtL,tP S� 21 I SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner House of the Seven Gables_ 115 Derby St Salem _01970_ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: _Deb Costa 978=_744=_0991 - - dcosta@7&ables.org Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as reqLfired. 10.1 Registered Professional Responsible for Construction Control(the professional coo rdinatin document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 101 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction license No. and Type if Applicable _PO Box 419 _Gloucester _MA _01930 Street Address City/Town State Zip 978_-_283-_4884 617=_967_=5666 taylor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $1,500.00 2.Electrical $ Building Permit Fee=Total Construction Cost x_(Insert here 3.Plumbing $ appropriate municipal factor)=$ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ 6.Total Cost $1,5M.00 Enclose check payable to (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name low,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and a curate to the best f incno dge and understanding. Daniel Weimebe 978 -771 - 9561 Please print and sign me Title Telephone No. Date _15 Whittier St _Beverly _MA _01915 _dweinrebe@gmail.com_ Street Address City/I'own State Zi / Email Address Municipal Inspector to fill out this section upon application approval: ' �2S sss � W The Commonwealth of Massachusett$ Department of Public XRECEIVEU Massachusetts State BuildingdjgB� E SERVICES Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION N _115 Derby St _ Salem 01970 House of the Seven Gables No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK LP Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) 1 Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:—Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install a 50'x 60'tent from 7/10/15—7/12/15 iWt-,TA =rxr —,% eM SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ l Existing Use Group(s): Proposed Use Group(s): PSECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3 ❑ 14❑ M: Mercantile❑ R. Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ HB ❑ IIIA ❑ 11IB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 1053 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Private Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ ❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: �1IN I t-t-D SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner House of the Seven Gables_ l 15 Derby St Salem 01970 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: '_Deb Costa 978_-_744_-_0991 - dcosta@7gables.org Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address CitylTown State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control the professional coordinating document submittals Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Pown State Zip Discipline Expiration Date 10.2 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 _Gloucester MA 01930 Street Address -- City/Town State Zip 978 - 283-_4884 617_-_967 - 5666 tavlor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ LBuilding $1,800.00 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $1,800.00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate the best of my knowled a and uplderstanding. Daniel Weinrebe 978 -771 - 9561 Please print and ' n e Title Telephone No. Date _15 Whittier St Beverly _MA _01915 dweinrebe@gmail.com Sheet Address City/Town State Zip Email Address 1/ Municipal Inspector to fill out this section upon application approval: st^r Name Date ' The Commonwealth ohblussachuseus t\ Board of Building Regulations and Standards I ( tit Massachusetts State Building Code, 7511('MR. 7 edition Building Permit Application To Cons !u epair. Relimate Or Demolish \ Un<•- orTn - •an(ih trellb)g -- I'hi.Acnon FA OlficiaJ Use Only Building Permit Number: D' It u d Lime('k)I onto n onto s+Ine In. •.mr of l ,s U:ue �. —_ SECTION 1: SITE INFORMATION --- -- 1.1 Pro eC.(y' Address'. — 1.2 :\ssessars .Nlup & Parcel Numbers ----- -._._ I.la Is this an accepted oneel? ties no \lop Numher I'ar,cl .Nuinher 1.3 Zoning Information: I 1.4 t'roperty Dimensions: Zoning District Proposed Use Lot Area Isy In Fhnuuge I lit 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard ! Required Provided Reyuued Provided Rcyuurd PIo�IJUJ 1.6 Water Supply: uM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone:' Public Cl Private❑ Check if yes❑ Municipal ❑ On site disposal syslam ❑ SECTION 2: PROPERTY OWNERSHIP' 2. wnert of ord: �6� , prjin/ r A ress to rrvicc: 1' --- Signature - telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(,) ❑ Addition ❑ r / Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Speedy, V Brief Description of Proposed Work'': , SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Laborand Materials) Official Use Only I. Buildine 5 I. Build Permit Fee: $ Indicate how tee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑ Total Project Cost' (Item 6) x multiplier x 1. Plumbing S 2. Other Fees: S - a. Mechanical IHVAC) S List: 5. Mechanical (Fire S --- ------ Su rcesion) To(al All Fees: S Check No. Check .\mount: _- (',i,h Anio un:-- --. . 0 Tutal Project Cost: S I 0 Paid in Full 13 Outat:mdmr' B.J:mce I)ur SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor ICSIJ Numhrr -_— — L\jlirauou D,uc Nucor ul ('51.- Ilulder _- LL( l\pr i per heluu I WJros l nn•slnctrJ ni t io )�.1N10 Co FI.i R,:go,LaJ 14_' F.mnl\ D,Clline SI_nat a rr - >I \t.uonrn Onit - _ _- Rl �� ILrsiJenlial Roolum lot grin_ __ --_ —: frlrphooe Ri•ldiul i.J 1l''Id", "Ild "iJuime _ S I- K.tiJaniul SohJ l .iel liuiiiin_ \ rl li.in�_In.l.illuwu_ U Rr.�J:noal Drinolwial 5.2 Registered Ilome Improvement Contractor I IIIC) I11C Company Name ur 111C Reguoant Name Regutnuuu Nuudtrr Address iFlplruuun Daly slgnalure ~_ Felephrme r— SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (INI.G.L. c. 152. § 2506)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prat 1Je this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No ..... SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 as Owner of the SuhjeCt property hereby authorize _ ____ to act till illy hchalf, in all matters ra!un%e to •.vork authorized by this building permit application. i Sion tune of Owner ---_- ---- ----- Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 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. Pont dame Sienature tit Owner or Authorized :1gent Dale i Sign d under the pains and penaltiesol perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work or an otcner who hires an unrogutered ca nlnaclor (nut registered in the Home Improvement Contractor (HIC) Program). will not have access to the arbllratlon program or guaranty fund under M.G.L. c. 112A. Other important information on the fi1C Progimn and Construction Supervisor Licensing (CSL) can be timnd In 780 CNIR Regulations 110.R6 and I I0.R5, rcylecntrly. ' When substantial work is planned, provide the intormation below.Total thxrcs area I,Sy. Ft.) (including garage, finished basemenU:uucS, decks or porch) 1 Gross living area ISy. Ft.) Habitable room count _-- Number of tireplaces Number tit hedrooms 1 Nunlher of bathrooms Number of(tall/b.uhs hope of healing system _-- Number otdecks/ ponccs I\pe of cooling system z. "Total Project Syuare Footage' nlav be substituted for "Total Prnlec( .......... 7 .... .. 7 tit kil&M iii�Wi�ii -T X., 1 Massachusetts State Building Code-780-CMR-17?edthon ... . MUNIUSI�,\l 111 ........... Hutlding Permit pphcattonTo ConstntcG Rep rr,Re r --.',�Pfthd.. .:This M: 4�! Building Permit Numbe = '' Dote Applied MsCOn Stgnntun R, IT M 0 16W - i,. ....... IOPOI(.�s W F ....... Assessors Mop A'PqrciWNuj -a- z!Punct Numhl.r 13 Zoning IutormnUoa'_+ 14-Property Dimensions: 's d, Mse V ft,- 'Pro Ci Y P, 17 Floods Zone IoformatMo 4XSeW-IWJ-,-.Disposal System- 'Ste, -4 _0 -j� "IN ti, SECTION,3,1)ESCRIPT[ON O< PROPOSED ATM Abir po!ypIll ........... F A-4�4i��Okoml ttt, 11"T S— U r. IS: -t;ipc lidefDescription uuro!p,'O- ...11"ir it 'A4 V ...... SECTION Estimated Costs Ill de d atcAllsy tem 2., OtHciel Use Ord I N-4-5., fee is determtrrcd ding --il.Bud 'A:7 ce Project C, IV ­Wr I ............. ....... ...... ff sElivicku -.0 - CONSTRUCTION .... . ..... tog, } Yaw' -W :�w -T ............................. ........ 's 110 .7 At 4W py-0-y ....................................... D MdffiE W H EW&M "IMAM own vq' is W R soon I 191 "far v .......... Al Win; VMS- not 11 Wo Oman -4 m ........... To* .......... Date , ep ljmatuM ,` SECTION 6 IWORICERS'COMPENSATION INSURANCE AFFIDAVIT(MGL.c`132.�$25C(6)) ., ,, ;� Magma m urc:tuprovide'�A� Workers a diililgiitdhi�eiiffidivitmuittwlcOnw C andsubmitted! in the demai of thaissuance ;the btfllding�V,&MIC.� WORit E M 00 .110 In.I u t iiidl Af f idd-it Adi fowr� .......U MUM; _SECTIQNyINTO BR COMPLETED%,WHM .i 1'r�­ i9,,'0W NERYAUTHORIZATIC OWNERIFS, CONTRACTOR"' P.UMFOWSUING.PERMIT 2. AIGENVOW N YOO ................... as Owner of fhe subject property hereby v� ,......... 4� nos ............. WNW Si MIT, vvy, A Mods q 2 ri -.1 .1 ........ ..............that)the stdtements and information on the foregtring............... tT. r '� .�'' , '-- n ' -5 as Owner or Authorized Agent hereby declore.�` ."M KIM,, lk�wo` tru-e' daccurate- tiehatf .......... -S Oyu; ....... ...... .. .......... plot ....... ---- ---------- Wo .1..........�jap ................... Wner, HR'SNfb61Wft,'jk,'MIR'a m i cr:own. 0 Mr-Wownerw D. res ! lot W 9_v�,_Mnl 4'1��AWO ­"E'Who...bd t A h i& - -4--m!" 11-11.1--, - who tures cidn-tri-actrier' .0 ( registerediWthiffl fi- h dr,burdfit'in-, 1.­,,�,-,,',�,� 'Whd mgmmc[rgua ra,H vit t-p ......... 4 fel ck ng4CSL):can;Wr' a Bu V j 4Wpanfl i'Provil m r1Tm Ion MOETotal1 lud aeint/attec'C',"d' 16i" h nolars, Ims ;DLL�" cL:- W p4c Umssl fin le r00m,CDuW14umber of ';, Mo, a cm so DU 9CKSF'p0rCUCSW Type of toolingis s f 7 "Total Project.Square .. ... WW; tray be rtdedmr--�Idi TAPE, • r The Commonwealth of ,U RVICES Department of Public Safety Massachusetts State Building Code.(,?gp )I 8 A � 3 8 Building Permit Application for any Building other a] e-or Two-Family Dwelling (This Section For Official Use Only) 1 Building Permit Number: Date Applied: Building Official: �n SECTION 1:LOCATION _115 Derby St Salem 01970 House of the Seven Gables �.f 1 No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block k and/or Lot N SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install a 50'x 60'tent from 7/17/15-7/20/15 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VBO SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: M fa i ( �!)/ ZI SECTION 9: PROPERTY OWNER AUTHORIZATION ,Name and Address of Property Owner House of the Seven Gables 115 Derby St Salem _01970_ Name(Print) No.and Street City/Town Zip 1 Property Owner Contact Information: _Deb Costa 978_-_744_-_0991 - - dcosta@7gables.org, Special Events Director_ Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 Gloucester MA_ _01930 Street Address City/Town State Zip 978=_283-_4884 617_-_967_-_5666 taVlor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $1,800.00 2.Electrical $ Building Permit Fee=Total Construction Cost x (Insert here 3.Plumbing $ appropriate municipal factor)=$ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ 6.Total Cost $1,800.00 Enclose check payable to (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true accurate to the be t of kno ge and understanding. Daniel Weinrebe trot 978 -771 - 9561 Please print and si ame Title Telephone No. Date _15 Whittier St _Beverly _MA _01915 _dweinrebe@gmail.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Co CMG ZOS Ss S\ The Commonwealth of Massachusetts WBoard of Building Regulations and Standards REC IVE ITY OF Massachusetts State Building Code, 780 CMR INSPECTION Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling 2 15 MAY 19 A 3: 00 This Section For Official Use Only Building Penult Number: Date A plied: Building Official(Print Name) Signature - Bat 7 J-- SECTION 1:SITE INFORMATION 1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers IIS L 12L�i� 1.1 a Is this an accepted street?yes no Map Number Parcel Number ��((I 1.3 Zoning Information: 1.4 Property Dimensions: 1\� Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) l6 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: �1 ,�q j u$♦° a-'� f l z fit- (7/' C .�6—'cr'r'^, /!'/ 0) nl 70 Name(Print) City,State,ZIP �a� 97LNyO591 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORT{''(check all that apply) New Constmction❑ Existing Building❑ Owner-Occupied ❑ 1 RepaUs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other l5 Specify: rjittJ 1` Brief escription of Proposed Work: $7 G d IOX30 k r a el AC'f/f I I.IDA Fx r �PGTt 1_ r�Use) SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 7 — 1. Building Permit Fee:$ Indicate bow fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ � 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ To o Su ression tal All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ / 7> ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) '&te &". f (..t0 License Number Expiration Date Nam�eof CSL Holder 7 (Q � List CSL Type(see below) No.and Street Type Description O/( 2 U Unrestricted(Buildings u to 35,000 cu.ft. 7 .J R Restricted]&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering W S Window and Siding q�/ SF Solid Fuel Burning Appliances /[ �2fr 3 t($ - I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 of the building permit. Signed Affidavit Attached? Yes ..........d No...........❑ 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 7bt OWNER' 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-application is a and accurate to the b st of my knowledge and understanding. barl10 ✓ �C l ��/qZ/S Print Owner's or Authorized Ag t' Name(Electronic Signature) Date NOTES: 1. 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 www.mass. oP v,,oca Information on the Construction Supervisor License can be found at www.mass.Yot v/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.11.) (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 hanaths 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" The Commonwealth of Mass VED Department of Public Sa L SERVICES Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than�MeNgy owisnAiing (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: / SECTION 1:LOCATION _115 Derby St Salem 01970 House of the Seven Gables W No.and Street City/Town Zip Code Name of Building(if applicable) (� Assessors M # Block#and/or Lot # lJ) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below 1(I Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) v Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:_Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install 30'x 60'&20'x 20'tents from 6/5-6/9/15 1A11T1.� F X t T SI .-NAC�: r' S CTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq,ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Factor F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ HA ❑ HB ❑ 1 IIIA ❑ HIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Private Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ ❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of--way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: r I S SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner House of the Seven Gables 115 Derby S[ Salem _01970_ Name(Print) No.and Street Cityfrown Zip Property Owner Contact Information: _Deb Costa 978_-_744_-_0991 deosta@pables.org Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address Cily Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.R of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address Cityfrown State Zip Discipline Expiration Date 10.2 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 _Gloucester MA 01930 Street Address City/Town State Zip 978 -_283- 4884 617_-_967_-_5666 taylor@cdrentent.com Telephone No.(business) Tele hone No.(cell) e-mail address SECTION 11: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this a lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $1,450.00 BuildingPermit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $1,450.00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest and the pains and penalties of perjury that all of the information contained in this application is true and accurate to a best of my knowledge d unde .ding. Daniel Weinrebe 978 -771 - 9561 Please print and sig&4ajm Title Telephone No. Date _15 Whittier St _Beverly _MA _01915 dweinrebe@gmail.com Street Address Cityfrown State Zip Email Address Municipal Inspector to fill out this section upon application approval: JOY Name Date 2-S I Zq RECEIVED IUt�AL SERVICES' The Common wealth of Massachusetts t Department of Public Safetyn14 AUG -b P 3 33 j iYhassachusettsstate Building Code(730 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SE.CTIOyN�1:LOCATION(Please indicate Block q and Lot k for locations for which a street address is not available) Nu.and Street City/Town Zip Code Name of Budding(if applicable) - SECTION2 PROPOSED WORK _ Edition of MA State Code used_ If New Construction check here❑or check all that apply m the two rows below pP y Existing Building O Repair❑ Altcraliun ❑ Addition❑ DemoliIton ❑ (Please fill out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineerin Peer Review required? Yes ❑ No ❑ Brief Description of Pr s W rk: a 5el SECTION 3:COMMETE TIIIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing BuilJing Investigation and Evaluation is enclosed(See 780 CrVIR 34) ❑ Existing Use Group(s): Propose)Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&AreaEPerlatt ffsq.ft.) EE[ Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub O A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H:—High Huard H-1 Cl H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-I ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) G1 ❑ IB ❑ IIA ❑ !IB ❑ W L ❑ [JIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Swage Disposal: Trench Permit Debris Removal: Public❑ Check if outside Flood Zone❑ indicate municipal❑ A tmnch will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: Not Applicable❑ Is Struehare within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:, Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: __ Special Stipulations: — w SECTION 9: PROPERTY OWNER AUTHORIZATION Name and.Ad resiluf:pro ctyw Oner 'r 1�7rr 7a ame(Print), No.and Street j City/Town Zip Property Owner ontectlnfifnatton(�: ��'�[/(� . ille Telephone No.(business) Telephone No. (cell) a-mail address If applicable, the property owner hereby authorizes Name - Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) if building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address - Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip �N-4�63 tE�:+ Telephone No. business - Telephone No. cell mail address SECTION 11:lV0Rk KS'CQN111VN5,"HON INSURANCE AFFIDAVIT M.C.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the budding permit. Is a signed Affidavit submitted with this application? Yes 0 No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) - Total Construction Cost(from Item 6)_$ 1. Building S Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3.-Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical y Other $ Enclose check payable able to 6.Total Cost $ CID (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this ❑pplication is true and accurate to he best of my - m 1 dge and understanding. 01W 21&3b ( P pease pr' t and sign name p Ti _ Telephone No. Date � Street Address City/Town State Zip Q Municipal Inspector to fill out this section upon application approval: -'° O ��k Name Date ZS INSPE '%CEIVED n The Commonwealth of chusetts Mass 4 rNI JCE.S. Department of Public Safe Massachusetts State Building Code _b P 3: 21 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot q for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Budding(if applicable) SECTION 2 PROPOSED WORK � Edition of MA State Code used_ If New Construction check here❑or check all that apply I inthe two rows below Existing Building❑ I Repair❑ Alteration ❑ ' Addition❑ Demulition ❑ (Please fill out and submit Appendix t) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: T—�Gll T— Are building plans and construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review req ' ? r t - Yes ❑ No ❑ Brie Description RI Pro used Work: }Y U 9 SECiTON 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANCE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑ Existing Use Group(s) Proposed Use Croup(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE CROUP(Check as a licable) A: Assembly A•t ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ F: Facto F-t ❑ F2❑ E: Educational ❑ fl: Hi h Huud H-t❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I•1❑ I-2❑ 1-3❑ 14❑ Ivt: Mercantile❑ R: Restdential R-I❑ R-2❑ R•3❑ R-4❑ S: Storage S-t❑ S-2❑ U: Utility❑ Special Use CI and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as It licable) IA 111 IIA ❑ IIB ❑ IRA ❑ IIIB ❑ IV VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details an each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if Outside Flood Zone Cl htdicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentily Zone: or On site system❑ required❑Or trench or specify: permit is enclosed❑ Railroad right-of-way: Ilazards to Air Navigation: \I\I lint,rn l'pnniiui n B ,.igg_ Not Applicable❑ Is Structure within airport approach area . ? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION N:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Coastnictiom Occupant Load per Floor: Does the building canlaio an Sprinkler System?: __ Special Stipulations: �SG1UT SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addressof,Pro c�ity Owner /r r u �a �js Uer .9dT 7O Name(print) No.and Street City/Town Zip i Property Owner Cuntactilnforin t o'n�.l Title Telephone No.(business) Telephone No. (cell) a-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf, mall matters relative to work authorized by this building permit aeElication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Rea onsible for Construction Control Name(Registrant) Telephone No. e-mail address - Registration Number Street Address _ City/Town State Zip Discipline Expiration Date 10.2 General Contractor 11� � (� Company Name Name of Person Responsible for Construction / License/No. a�nd Type if Applicable XQ 3&-X ZY �/ 6^l/ ce- S tom- -M 3 O f 6 Street Address I City/Town State Zip Tcle hone No. business - Tele hone No. cell - e-mail address SECTION 11:FVORKEF&CONiPEN6A"I'ION INSURANCI'.AITIUAVIt M.C.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes I] No Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) - Total Construction Cost(from Item 6)_$ 1. Building _$ Building Permit Fee-Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.-Plumbing $. 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) S. Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this a plica Lion is t and a rate to the best of my knowledge and understanding. Ple se print and sign name Title/ m Tele�hfm 3 0, to Street Address City/Town State Zip Q u Municipal Inspector to fill out this section upon application approval: Name Date 2S T i3— ► q— 12�j 8 RECE1VEo INSPECTIONAL SERVICE-5 The Commonwealth of Mas "14 P � 34 : A� Department of Public Safet yr Massachuseus State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) BuOdingPermitNumber: Dale Applied: Building Official: SECTION 1:LOCATION Please indicate BI\ ( ock wand Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply I inthe two rows below Existing Building❑ Repair❑ I Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix t) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Struchrral Engimerin Peer Review re •red? Yes ❑ No Brie ascription of Pr posed ork: SECTION 3:COMPLETE TFH SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Croup(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) - Total Area(sq.ft.)and Total Height(ft.) SECTIONS:USE GROUP(Check as an licable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ F44❑ H-5❑ h Institutional I-I❑ 1-2 Cl 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S•l❑ -S-2❑ U: Utility❑ Special Use❑and please describe below: Spacial Use: - SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ ID ❑ IIA ❑ !IB ❑ 1 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB Cl SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: IWards to Air Navigation: �L_\I l�avu C .nnnisum R .jcy I'n4cs: Not Applicable❑ Is Structure within airport approach area? Is their review completed? _ or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?:-"_ Special Stipulations: f T „�•i 7 SECTION 9: PROPERTY OWNER AUTHORIZATION Na��e,atoofd'Addiess;off Pwpe wn� Letr,R,• / Y--1 n may; 1' � L -l /r/�GO /?-Y L _lY_�-C/lam^ /v Name(Pitii� C'� ��� �� N o.and Stre� City/Town Zip - r, mperty Owner C(u�n tact Information�:(� `�/�/�6pQ z the Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip toad on the property owner's behalf, in all matters relative to work authorized by this budding permit application, SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.it.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Respon i e for Construction License No. and Type if Applicable Street Address - City/Town State Zip 4 �8341&q Telephone No. business Telephone No. cell e-mail address SECTION 11:4VOI:KERS'COAiI'ENSAI'ION INSURANCE AI TIDAM M.C.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the IVIA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes O No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Totil Construction Cost(from Item 6)_$ 1. Budding S - Building Permit Fee-Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3. Plumbing 5 cal (HVAC) Note:Minimum fee=$ (contact municipality) d.Mechani $ 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the aa//ns and penalties of perjury that all of the information contained in this application is true;md accur: to the best of kn v Edge and understanding. A3 �{ Pigase pruit and sign name Til Telephone No. Date Street Address City/Town - State Zip municipal Inspector to fill out this section upon application approval: Name - Date ZS 12-% RECEIVED ti INSPECTIgL SERVICES The Commonwealth of Mas � 1 qDepartment of Public S ��uu'Vib 3: 28 Y° Massachusetts State Building Code(780CMR) � Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Onl ) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block N and Lot q for locations for which a street address is not available) r 9 76 IrAny V -7 No.and Street Ij City/Town Zip Code Name of Bn riding(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑Or check all that apply I inthe two rows below Existing Building❑ Repair❑ Alteration ❑ A,dttton❑ Demolition G (Please fill Out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/Or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is art Independent Structural Engineers g Peer Revi required. - Yes ❑ No ❑ Brief De cription f Proposed Wor . �Qt r 3 _ dr, SECTION 3:COMPLETE THIS SECTION IF EXISTING DUILDING UNDERGOING RENOVATION,ADDITION,OR CHANCE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No,of Floors/Slories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a licable) A: Assembly A-1 Cl A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ F: Facto F-1 ❑ F2 E: Educational ❑ ❑ It, High Huard H-1 ❑ H-2❑ H-3 ❑ I1-4 CIH-5❑ L Institutional 1-I❑ 1-2❑ 1-3❑ 1-4❑ NI; Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-0❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as a licable) IA ❑ 111 IIA ❑ 116 ❑ IIIA ❑ 11111 ❑ IV VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public.❑ Check if Outside Flood Zone❑ indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify,Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: %Ir\I lint ru u nnmisi ai It ucg I'rH:c_4: Not Applicable CIis Structure within airport approach area? _ Is their review completed? or Consent to Budd enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of COdc: Use Group(s): type Of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: _ Special Stipulations: r SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address -Property OwneroI , to ;" 7�'� ✓�1 tar O(Y 70 r Mime(Print) No.and Street City/Town Zip � BE :E cl a— wA VIES open Own Contact Informatio-o:� Q o� e Telephone No.(business) Telephone No. (cell) a-ma6 address If applicable,the property owner hereby authorizes N:une Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit ae2lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number _ Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable t`� 5'o.-.c off R �'/r�.<.rr<�— ✓d1� � �Street Addr ss City/Town State Zip 7}Z13 _- Telephone No. business Telephone No. cell e-mail address SECTION 11:wol2KEh9'COMPENSA I(ON INSURAN('F AFFIDAVf f M.C.L.c.152. 25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building _S - Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical "� appropriate municipal factor)=$ 3.Plumbing S 4.Mechanical (HVAC) $ _ Note:Minimum fee=S (contact municipality) 5. Mechanical Other $ _ Enclose check payable to 6.Total Cost $ I S-07) I (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I I •reby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate the best of my wl ge and understanding. rz rpm Please print and sign 0aule Title Telephone No. Date � �r4�- � Street Address City/Town State Zip o Municipal Inspector to fill out this section upon application approval: A'V Name Date The Commonwcallh of Massachusetts A �I+ Board of Building Regulations and Standards Massachusetts State Bwlding Cade. 780 CMR, T"editionBwlding Permit Application To Construct, Repair, Renovate Or Demolis One. or riso-Pmnih Dwelling I doom This S ion For Official U Onl \ Building Permit Number: Date Appli : t \J� Signature: Bwlding Commissi er/ for of Buildi s Date SECTION 1 jINFORMATION 1.1 P,ro��ertr y A ress: el'Assessors Map& Parcel Numbers 5 1.1 a Is this an accepted sir el?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(fl) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ 0,site disposal system ❑ Public❑ Private O Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Qwner'o(RejArd: P T Yl icG T 7 encr J - ` Name(Prim) Address for Service: Signature Telephone SECTION J:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Unity_ Other ❑ Specify: Brief Descriptio of Proposed SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: 011lelaf Use Only Item Labor and Materials I. Bwlding f —7 - 1. Building Permit Fee: f Indicate how fee is determined: O Standard City/Town Application Fee 2 Electrical f ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing S 2. Other Fees: S / 4. Mechanical (HVAC) $ List: 01 .M 5 .Mechanical (Fire S Total All Fees: f Su ression Check No. _Check Amount: Cash Amount:_ 6 Total Project Cost S � FJv 13 Paid in Full O Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICESIq i 5.1 Licensed Comtru�ctlOn Supersisor(CSL) Pp �� ` rY104e.� License Number E.pi Lion Date NNyoe of(' iplJer /-e6/ /e� ID Type Isce below) AJd as Type Description �� Unrestricted u to)5,00 Restricted 1&2 FamilyD%ellin Sig fur /'y ,Mason Only 7l� �1J ( Residential RooOn Covering Telephone Residential Window and Siding Residential Solid Fuel Bumm Appliance Installation 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.e. 152.f 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 Afrdsvit Attached? Yes .......... No........... O SECTION 7a:OWNER AUTHORIZATIQN TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRA TOR APPLIES FOR BUILDING PERMIT I, �— as Owner of the subject property hereby authorize n my behalf,in all matters relat to work authori ed by this buildin rmit ap lic W n. Si ■tu fOwner Date ECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby declare that the stateme is and information o the foregoing application are true and accurate,to the best of my knowledge and beh . / Print Name Signature of tier or Authoriz Agent Date (Signed under the pains and penalties of to NOTES: 1. 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 I O.R6 and 110 R3,respectively. 2. When substantial work is planned,provide the information below: Total floors area Total 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 half baths Type of heating system Number of decks/porches Typeof cooling system Enclosed Open 1 "Total Project Square Footage"may he substituted for 'Total Project Cost' The Commonwealth of Massachuscas Town of I Board of Building Regulations and Standards 110!!!" 1 s� Massachusetts State Budding Code, 780 CMR, 7"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish al omemdoo One- or AS o-Fwrtif •Dsceffing is Section For fficial Use Only Building Permit Number: ate Applied: s e D Signature: ( s t Building issioner/Ins f d mgs Date CT WON 1: SITE INFORMATION 1.1 Procper(y rAddores : 1.2 Assessors Map& Parcel Numbers c I.la Is this an accepted street!yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed UseLa Arca(sq R) Frontage(R) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L e.ail,fsa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1. Owner'of or / r /1 Nam (Print) Address for Service: '—� �/L�/y/ k to +— T / Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check ail that apply) New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O Demolition O 1 Accessory Bldg.O Number of Units_ I Other O Specify: Brief Description of Proposed Work': — SECTION a: ESTIMATED CONSTRUCTION COSTS Estimated Cos': Official Use Only Item Labor and Materials I. Building f 1. Building Permit Fee: f Indicate how fee is determined: ❑Standard City/Town Application Fee 2 Electrical S O Total Project Cost'(Item 6)x multiplier x 3 Plumbing f 2. Other Fees: S a. .Mechanical IHVAC) f List: 5 Mechanical (Fire S Total All Fees. f Su ression /, Check No. _Check Amount: Cash Amount: 6 Total Project Cost: f 2 � O Paid m Full O Outstanding Balance Due: „ , r SECTIONS: CONSTRUCTION SERVICES 5.1 Licem Construe ion upenisor(CSL) PLF75�d Lrcense Number E4irititth ate N' ut' SL- Hylder List CSL Type(sre below) r ~ T Descn lion AJJrr � U Unrestricted(up to 15,000 Cu. Ft.) R Restricted I&2 Family Duelling Stgnamrec / 7�� _ r�l� .N ,Hawn Only 7 G RC Residential Roofing Covering Telephone WS Residential Window and Sidra SF I Residential Solid Fuel Burning Appliance 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.e. 152.J 15C(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 Afrdavit 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. Si nature of Owner Date SECTIO b:OWNE t)DR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby declare that the statements and ' oration on the regoing application are true and accurate,to the best of my knowledge and behalf._ / Lo�l Print N Signatu of Owner or Au,#drizcd Agent - Date (Signed under the painlXnd penalties or perjury) 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. I42A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be round in 780 CMR Regulations 110.R6 and I IO.R5,respectively. 1. When substantial work is planned, provide the information below Total floors area(Sq. Ft.) (including garage, finished basemenNattics,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 Ts pe of ciwlmg syvem Enclosed Open 1 'Total Project Square Footage"may he suh,lituted for 'Total Project Cost' I OD4 6 Q The Commonwealth of Massachusetts Town of J/�// a► Board of Building Regulations and Standards a� Massachusetts State Building Code, 780 CMR. 7'a edition Building Dept Building Permit Application To Construct, Repair. Renovate Or Demolish a One- or Tico-Familt Duelling This Section For Official Use Onl Budding Permit Number: Date Applied: (/ Signature: Budding Co stoner/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Prop Adddrgsa:/ ` / 1.2 Assessors Map& Parcel Numbers f t. (O0.- )c j"" Ma Number Parcel Number 1.la Is this an accept street!yes no p 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) 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.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system O Public 0 Private ❑ Check if yesCI Q SECTION 2: PROPERTY OWNERSHIP' L 2.d [ a/SGf ReeardF l/ h✓ S7 of }L�f/Cy� Name(Print) Address for Service qzg- 7�14- G9�i / Signature Telephone SECTION 7: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition O Demolition O 1 Accessory Bldg. O Number of Units_ Other 7 Specify: e� Brief Description oftProposcd Wo SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimaled Costs: Official Use Only Item Labor and Materials 1. Building S I. Building Permit Fee: S Indicate how fee is determined: O Standard City/Town Application Fee 2 Electrical $ Cl Total Project Cost'(Item 6)x multiplier x ) Plumbing S 2. Other Fees: S a. Mechanical (HVAC) S list: 5 .Mechanical (Fire S Total All Fees: S Su ression Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost S 1501 0 Paid in Full O Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construy(Ion uper%isor(CSL) /F 7C/ / r � L JJ bb t� r�/LG. / r f f , !'� L.cen,c Number Expuation Date N.4mc SL figl r 1(r/!/Y/ r (p List CSL Type Iscr below) IL I r rr rn J Adders T' Description U Unrestricted u to 35.000 Cu. Ft.) Signature R Restricted 1&2 Family Dwelhn G f7 i� —S6C� •, •,ason �nl RC Residential Rooln Covenn Telephone IF- Revdemtal Window and Sidin SF Revdenual Solid Fuel Burning Appliance Installation D I 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.; 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 ..........1WNo...........0 SECTION 7m: 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:OWNER` OR AUTHORIZED AGENT DECLARATION 1• ,as Owner or Authorized Agent hereby declare that the statem nts and informati on t e foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or A orized Agent Date d Si ned under the ain and nalties of r u NOTES: 1. 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. I42A. 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.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors area ISq. 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 ofcooling system -g Enclosed Open t. "Total Pro)ecl Square Footage"may he substituted for"Total Project Cost" G� P t G 3 1:;� c'% The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800 One-or Two-Fanti(y Dwelling Ext 118 This Section For Official Use Only Building Permit Nu er: Date Applied: Signature: .!a Building Commissi er/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address:� o , !s /y 1.2 Assessors Map& Parcel Numbers aisG � n l/< 654 I.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 ft) Frontage(ft) 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?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[Of ord: Name(Print) Address for rvice: _ _ y7�-1?15�P3 Z � Signature Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other R'Specify �.•- Brief Description of Pr osed Work': qo2 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ (S&?o ❑ Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Constr ctton Supervisor(CSL) /���6 G License Number Exp ration Date Na of CSL,L- o'ldel // J! / List CSL Type(see below) 536WGL �H PAN. JP" �/ �� Type Description Address �J _ U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwellin Signa ore /` M Mason Onl 6Ga RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name I Registration Number. Address Expiration Date Signature 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 of the building permit. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ 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. Si nature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the sta eme�rmatio on the foregoing application are true and accurate,to the best of my knowledge and behalf. /" Print—Name / �'-'(-----JG? ..— Signature of Own or Aulhonie gent Dal, (Signed under the pains and a ties of perjury 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R5,respectively. 2. When substantial work is planned, provide the information below: Total Floors area(Sq. Ft.) 2, f3O (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 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" CK It g 1 $530' xf"SERVtsl The Commonwealth of &M c Nsetts Department Public Safe 1, 3 qt. ➢V Massachusetts Slate Building lding Code S� P Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) s I i5 berb, 9t )A Je ► MA D jo 141114ju, 2. "1 No.and Street City/Town Zip Code N me of Building(if appl le) SECTION 2,PROPOSED WORK �aq U�J Edition of bfr\State C de used If New Construction check here❑or check all that apply in the two rows below Q ExistingBuilding Repair Alteration g N ❑ 1 Addition❑ Demolition ❑ Please fill out and submit Appendix 1 ( PP ) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No / Is an Independent Structural Engineering Peer Review rer uir\ed? t Yes ❑ N Q]/ 2 ^ Brief Description of Proposed Work: r),eim wuoap $ f la SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR a CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): - j\ SECTION 4:BUILDING HEIGHT AND AREA �! /\ Existing Proposed �VJ No,of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) - A: Assembly A-1 O A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional M ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U:.Utility❑ Special Use❑and please describe below: Special Use: SECTION ION 6:CONSTRUCTION TYPE(Check as a plicable) - IA ❑ IB ❑ IN ❑ ❑B ❑ 1 IIIA ❑ IIIB ❑ IV ❑ I VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Sup`pII Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public lH' Check if outside Flood Zone❑ Indicate in A trenchawi�not be Licensed Disposal Site❑ t requiredVortrench or specify: Private❑ or indentify Zoned or on site system❑ permit is enclosed❑ ur Cons of�Build enclosed❑ Is Structure within for No a ach area? Yes v iv n i< s IetC i'm�c�� Railroad right-of-way, Hazards to Air Navigation: MA I I„t n �onum Applicable P P Is thur rcviuv completed? No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the budding contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Ad( 53;Wf Pn ertyfOwnet Name(Print) Pr _f No.and Street Cityjm Zip c- } +t 9 Property Owner Contact Information., iUltnItif Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. . SECTION 10:CONSTRUCTION CONTROL(Please fill out:Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company me Soso, f9er�C D21326 Name___non slon Respnn 'ble fur Construction Lic,nse No. and Type ff Ap licable 2_o � -�a-��t C lovers l t 0lR3o Street Ack ess City/Town t State Zip �$- -D6 _-_- 1oenczpt�a`�g wLa ` L, cb m Telephone No.(business) Telephone No. cellh ress SECTION 11:1V0RKFB.1Y C.0NHTNA I ION INSURANCP.AFFIDAVI'1, M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of th�issuance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ L Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ a. Mechanical (FIVAC) $ Note: Minimum fee=$ (ccoo--n��tact mhunicippaa-liitt`y) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 hereby attest and r tlie as and penalties of perjury that all of the information contained in this application is true and accurate to the best of my kn r I ge and understanding. Please Pori t an j 'gn n ��}/—� �t�ur nSt t ylTclepho Dat Street Address l( — (OjCity/Town State Zip Zip Municipal Inspector to fill out this section upon application approval: 4 " �^^ Name Date ' �`� 4b,, o�c � S� � ` RECEIVEO � ;� � The Commonwealth of Massachusetts �` � nep�en��rubu�s��I b MAR ( 5 P 1� 2 S Ma.ssachusetts State Building Code(7S0 CMR) � Building Permit Application for any Building other than a One-or Two-Family Dwelling � � ` �-(Ttus Secfion For Official Use Only) �:. �.- , .. . ,. . . N Building Permit Numbex: ` Date AppGed: ' Building Officiy]: � . SECITON 1:LOCt11TON.(Please indicaM Block#and-Lot#for��locations for which�a sireet address u�not available) � � � S � Q.,b y St'. S o. a� -D I°I � O �ovse o� �-v¢�. �ro.}� e 5 � No.and Street � City/Town Zip Code Name of Building(if applicable) � � �� � . ..�. � .';� �. �... .- .... SECCION2:PROPOSEDWORK .�- - . �. ...:, ._ .: . .'..,. � �.,. Edition of MA Stare Code used_ If New Construction check here O or check all that apply in the two rows below � Existing Building❑ Repair$� Alteratlon ❑ Addition❑ Demolition 0 (Please fill out and submit Appendix 1) Change oE Use ❑� Change of Occupancy ❑ Other ❑ Specify: Are building pians and/or construction documenls being supplied as part of this permit application? Yes � No ❑ Is an Independent Shvctural Engineering Peer Review required? �y� � p7o p Brief Descripdon of Proposed Work: 5 T v wc"Fv,..w.� re.�„� ¢b�u„�,e..� r O Sv.+�.�».�v 10¢a�n .SECITON 3:COMPI.ETE THIS.SECTION IF EXISTING BUII,DING UNDERGOING RINOVATION,ADDTI'ION,OR � � � � CFIANGE IN USE OR OCCUPANCY� � -- � . � - Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): . . . .. .� .SEC770N 4:BUII,DING HEIGHT AND AREA�- �' - � � � � E�dsting Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft) � � � � - �. �SEC7'ION 5:USE GROUP(Check.as a�plicable) � -� � �� � A: AssemblyA-1❑ A-2❑ Nightclub ❑ A�3 ❑ A11❑ AS❑ B: Business ❑ � ��E: Educaflonal F: Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2 O H3 ❑ H11❑ H-5❑ I: InstituHonal I-1❑ I-2❑ I3❑ I-4❑ M: Mercantile❑ R Residential R-lO R-2❑ R3❑ Rh❑ S: Storage Sl❑ S2❑ U: Utility❑ Special Use O and please describe below: Special Use: � -� � � � � SECTION 6:CONSTRUC7'ION�1'YPE(Check ak applicable) -� - IA 0 IB ❑ IIA ❑ IIB ❑ IIIA � IIIB ❑ IV ❑� ... VA O VB �'.�. . SECITON 7:STI'E�IIVFORMAI'ION(refer to 780 CMR 111:0 for:details on each item) Water Su 1 Flood Zone Information: Sewage Disposal: Trench Permih Debris Removal:� � PP 9� Public O Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Bisposal Site❑ Private❑ or indentify Zone: or on site system❑ required O or nench or specify: permit is enclwed❑ Railioad riglltbf-Way: Aa�a[ds[p Aii NaVigalion: MA Historic Commission Review Process: Not Applicable❑ Is S�ucmre within auport approach area? Ls their review completed? or Consent to Build enclosed❑ Yes O or No❑ Yes,� No ❑ -- .. . � . � _SECTION8:�CONTIIVTOFCERTIFIGTEOF�OCCUPANCY -; � . - . Edition of Code: Use�Group(s): Type of Construcuion: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 3 f�5 S�� � _R� CA IV-�^ �-�' v? II �1'� ,�l . .. - . >.' SECCION?'PROPERTYOWNERAUTHORIZATION. ..' . . � Name and Address of Properry Owner � � ` �av�, rn�L.a��,�.i.�, I ► S fla� �yst. S���� o �9za � Name(Print) � No.and Street Ciry/Town Zip � Property Owner Contact Informarion: ` q,t+. �99 p.kcc.v'�'iJc p� r<c�'ov 9>�`��_- 099 I --- k�..t,Cavo�1;R(d.)4e.lbs•or� Tifle Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name StreetAddress CiTy/Town State Zip to aM on the ro ownefs behalf,in all matters reladve to work authorized b this buildin ermit a lication. � . --SEEITONI@CONSTRUCI'IONCONTROL�(Please�filloutAppendix2)�.� ����� - �. buildin� is less than 35,000 cu:h.of.enclosed� ace and or not under Constructlon-ConCol�then check here O and sld Section 10.1 10.1 Re 'stered Professional Res onsible for Conslruction Contiol�� � - � � � ST�.,.c.fi,,..cs �o•r`� 4`1£f74S- 64f1'1 ,�wiq��...<�7 st...�..���• 3�-ly2o Name(Registrant) Tele hone No. e-mail address "'���o.n Registration N mbq 6 p W Ag�,,..g j•s— Si^. .SPa-\c.�-� Yrf� ��9�0 5'krvo�c.r�.� 6 30 I 6 Street Address Ciry/Town StaM Zip Discipline ExpirationDate � 102 General�Con&actor -� � � � � � � - � � � � � �} w�e.,..Co...,� S�¢��e. � � a�..c�.i CO. � �ti.C . Company Name S-f-e.,� (3va.i CS - o5�340 ��' 03 IZ� t v - Name of Person Responsibl for Construcdon License No. and Type iE Applicable i I�j� P 3 � 3 �ss�x sfi . So.1��-, � o�°r?o c�2�s Sheet Address City/Town SYate Zip �yX6_74� 7 l9 �{ p$ _qSCf_ I�i4b ro��� a� ay.�e���a..lt..a�lc. v�s� � Tele hone No. usiness Tele hone No. cell �mail address . `SECT'IONYli WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152§25C(6) � � '. A Workers Compensation Insurance Affidavit from the MA Departrnent of Industrial Accidents must be rnmpleted and subatitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building pemut. I Is a si ed Affidavit subautted with this a liwtion? Yes�, No O '�� � � ��` �SECITON 12 CONSTRUCTION COSTS AND PERMIT FEE � -- Item Estimated Costs:(Labor and Mateiials) Total Construction Cost(from Item 6)_$ 1.Bnilding $ guilding P�it Fee=Total Construction Cost x_(Insert h2rE 2.Electrical $ appropriate municipal factor)_$ . 3.Plumbing $ 4.Mechanical (HVAC� $ Note:Muumum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ g � �OO. (contact miuucipality)and write check number here �'I . : � ��SECITON 13:SIGNATURE OF BUILDING.PERMIT APPLICANT • � ��-�' . ��� By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this � a�pypli ation is hve and accurate to the best of my knowledge and understanding. 9�Vpa.,�,.,q.*t �y,_L,a.1c6RV-c S�' . K�r+\A �.-�.,s.....�._ � � 't�•a-s���— 9�� _��►y_ �19y 31516 Please rint and sign nam Title . Telephone No. Date 37 � �- SSex S'1'. Sa��w� V�n } b�9?o � Street Address City/Town State Zip .Municipal Inspector M fill oat this section upon application approval: "�^ ' .�' � � � � Name�-r � Date� � � ° _ `:iT`f GF° ��`�i.�ivi, iv,'���5.���;L'�ETI'S • SLu��c uEr�xr�1:��rL1 ` i?v w�SA4.iGTGFi S?REnT,J�l'Ll7�w ' `. �.r� -rE;_ �o�a� ���--�cgc a �i v� " F�.r(978)7�9&46 (ti�tg�y DRISCOLL VIAYOR Tttoaz�s ST.Pff.xnE DIREGTOA OF PL'HLIC PROPEA'fY/BL:II.DL�iG CO�L�RSSIO�iHR Wurkers' Compensation Insurance AfFidavit: Builders/ContractorslElectricians/Plum6ers Applicant Informatiote Plcese Print Le iblv . V BITIC(Busi�nss.Or�aniZatioN[ndividuul); ��^^�"� C Cn�-. �J�t e PI� � I 6 w a� C O. r•�� adaress: 3'�3 C sSe,� s-�. Ciry/StatelZip:_ Sa�e�^'�, m 1� O tq ?o Phone I!: °I7 B" - 74 y - � I9� Are you an employer?Check the appropriate boz: Type of project(required): 1.0 I am a cmployer with�_ 4. Q I am a getuerai contcactor and I 6. ❑New canat[ucuoq em�,��yzes(fu{t u�,�br aan-arne}.' hav�hi:�dce sus-coa ectars i 2_[] 1 am a sole omprictor nr pmtncr- listed on[he attached sheet� � �• ❑�mOdeling >hip and have no employees These subcontractors have ' I S. ❑ pemolition .vorking for mc in•rny capamty, �wrkers'comp.insurance. I q, �guilding addipon [No wo��cus'comy. in;u�anez 5. 0 l'.�e aw a:.orgaratior.m��it; � requireJ.) officers have zxereised the'u I � �0.[�Electrical repairs or addi�ions 3.Q 1 am a homeuwuer doing all work right of cxemption per MGL i I l t.Q Plumbing repairs or additions myself.(\o workery comp. c. t 52,§I(4),and we have no � insurancercquieeC.Jt cmF:ayecs.[A'ow;,.,cer� 12-� �0°frepairs ! como. insurancerequired.j I! 13•�O�herSt��dt'��4� .��:,.r i 'Any opphrant thal chixks 6ox 91 must alw till uw�he sectim beiow showing�h<ir worken'wmpensa'ian policY informa�ion. �14�m.:owne's who su6mif ihis aflidavit indidting Ihey��e duing all uro'Ic and ihea hirc ouuide cuntractora must submd a xw�Javit indiming suck -Contmeion�ha�cheek�hie hoF m�nt atlachpl an aJ4itia141.hss1 ahnwirte e!�name ottM_sutrtentrse4^.:and their uc.':e�a's,my.poliry irfoem.:ioa. !an, rtr.eiap(ayer 1he:3s providing w�rke.s'coryerssatfoa insurttnce jor my empioyeex deFaw Ls tne po7tcy and Jab stte in(ormution. -7� Ll J \ In,urance Company?1ame: 1 ��- f��Y L�0..�0� Policy il or Self-ins.Lic.#: � 6 O l P�,�" c6— I 3 • Expiration Date: `� ��� � � b Job Site AdJress: I I S De�b./ $�. City/Statr/Zip:Sq���, fl'�f} 019�C7 .\ttac6 a copy oi the workers'compensation pollry deciaration page(ssowing the pollcy number and e:plraHoe dat¢). Failurc to su;ure covecage as required umkr Section ZSq of�i�iGL c. 152 can lead to the imposition oFcriminal penaltiea ofa fine up ro 51,500.00 nnd/or one-year imprisonmcn�as well as civit pcn•rlties in the:o�m of n STOP WORK ORDER aml a fine of up to 5250.00 a day against rht violaror. 13e advi,ed that a copy uf this statement may be torwarded to the Office of Inves�iga�io�u ul'tUe D1A for insurrnce mverage verificatiun. /do l�ereby certijy uuder the pa ds mid pei�alties njperJurq that the iejarmafion providrJ ubave is(rue mrd carrrct Si�•n:nure• � �� ��-- ��-�1 � pare 3�r S I � 6 PhoneX: q�'— �4�f ' 7 � R l'f �J�:in!«5E C:ilj: !;c not:v:i:e i:,d�is a�eq ta be cuen�ltte6 by city ur iown o,jrcia[ City or"Cownv __. PcrmiUl.Iccnye# � Issuing Authority(circle onc): � I . I. ISu•rrJ uf Ile�rl�h 2.Building Department J.City/1'own Clerk J.Electrical Inspector S. Plumbing Insp¢eto� I 6.Qther _- ContaM Pcrson: ___ Phone#• Appendix 1 . For the demolition of structures the building permit applicant shall attest that utility and other service connections aze properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot#for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Flectricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) - —� , Appendix 2 F. , Construction Documents are required for stcuclures that must comply with 7S0 CMR 107.The � ' checklist below is a compilation of the documents that may be required for this.The applicant ' shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit ' application. Checklist for ConstrucHon Documents* Mazk"rz"wh�e a licable No. Item SubmiHed Incom lete Not Re uired 1 Architxtural 2 Foundation 3 Siructural � ./ 4 F'ue Su ression 5 Fire Alarm ma r uire re eaters 6 HVAC 7 Electrical 8 Plumbin inciude local connections 9 Gas atural,Pro ane,Medical or other 10 �Surve ed Site Plan tilities,Wetland,etc. ll 5 ecifica[ions 12 Struc[ural Peer Review 13 Structural Tests&Ins ections Pro am 14 Fire Protection Nazrative Re ort 15 F�dstin Buildin Sury /Inves(i tion 16 Ener Conservaaon Re ort 17 Architect�ual Access Review 521 CMR 18 Workers Com ensadon Insvrance 19 Hazardous Material Miti tion DocumenTation 20 Other S 21 Other S 22 Other S 'Areas of Design or Constivction for which plans aze not complete at the time of application submittal must be identified herein.Work so identified must not be mmmenced until this application has been amended and the proposed construction document a[nendment has been approved by the authority t�aving jurisdiction.Work started prior to approval may be subjected to triqle the origival permit fee. Registered Professional Contact Information S�f'r.,-�.'}�.,.�5'V�o„ ��.. �7�fs_ 6ssi � - ho-t�.• �or.,"w� ,... 3 �i�-12D Name(Registrant) Telephone No. e-mail address Registr'ation Nuatber � 60 ti�s�.���ohs�: So.��k-, � Dt9 )o St.,,.�T�.4\ C 30� �6 SReet Address City/Town State Zip Discipline F.�cpiration Date Name(Registrant) Telephone No. e-mail address Regishatlon Number Street Address Ci /Town State � Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Regis�ation Number . Street Address Ci /Town State Zi Discipline Fxp'uation Date ,< �IT z' �� �ALEl1.i, i�'�.i��ACF-€L'�EiT� '�<� Biu.D�G DEr�x��.��r J �� i?�W.i�ri�iGTON STREET,3"F�Oc�k `:� "T'€i_ (�370�7't5-25�1� Fwx{978) 7�90-9846 (Q�{gFat FY DRiSCOLL �YOR THObL►s SI'.PtERR& . DIREGTOR OF PI:BLIC PROP£R'IY�BL'II.DL�IG CO�L�RSSIONER Construetion �ebris I9isposal Affdav�t (required for all demolition and renovation work) �:2 2CC0l�3RCC'.::':*�:.�:5 SiX:.f: �`j1.:C.^.af Lhe v�2��8111�wia�^�'J(�iC� �i ov �.ivirl jcCtlUl1 'l!1.� Debris, and t4?e grovisions of MGL c 4Q, S 54; l3uilding Permit # is issue�with the r�nditien that the debris resu?ting from inis woric snaii oe disposcd oi in a properiy iicenseci waste disposal fac�lity as defined by MGL c 111, S 150A. The debris wilt be transported by: � �� t�. (name of hauler) The debris�vill be disposed of in : I-+��1 �z p�s P�s�.. � � (name of facility) G\O�.G.GS�d`r 7 m � (address of facility) 4��� . �-�--`Y signahue of perm�t applicant 3� � SIIb date dcbnial I.d�M EXTERIOR WALL CENERAL NOTES 8��� � Structures Nort L7. WORK SHALL CONFORM i0 THE REQUIREMENTS OF iHE COMMONWEALTH OF coxrvnixo�xuix�ns��� $f — MASSACHUSETTS STAiE BUILDING CODE. ��,�„��„a "' . J — — — — — - — — — — — J TYR�,6�I�IF W6]16G0! ¢ EM E S BFL R Q L2. EXCAVATIONS AGAINST EXISTING STONE MASONRY FOUNDATIONS SHALL NOT TAKE """'miiv°"'" , � PLA OV S ME � � PLACE WITHOUT FIRST DIGGING AN APPROACH TRENCH AND INVESiIGATING THE _ � - BE 0 Y � CONSTRUCTION IN THE PRESENCE OF THE ENGWEER. j � I � � I � L3. 7HE CONTRACTOR SHALL NOTIFY iHE ENGINEER WHEN, IN THE COURSE OF z I z CONSTRUCTION OR DEMOLITION, CONDIiIONS ARE UNCOVERED THAT ARE (E� 2'3/a�� ��� OIST I ( 23/4";4�" JOIS UNANiICIPAiED OR OTHERWISE APPEAR TO PRESEN7 A DANGEROUS CONDITION. L4. INFORMATION REGARDING EXISTING CONS7RUCTION OR CONDITIONS IS BASED ON - �N� C3x SIS R I I ,f � C x6 TE AVAILABLE RECORD DRAWINGS WHICH MAY OR MAY NOT TRULY REFLECi EXISTING � CONDITIONS. SUCH INFORMATION IS INCLUDED ON THE ASSUMPTION THAT IT � _ _ _ _ _ _ _ _ - - � MAY BE OF INiEREST TO THE CONTRACTOR BUT iHE ARCHITECT ASSUMES NO RESPONSIBILITI' FOR IiS ACCURACY OR COMPLETENESS. ' LDE ST CTU AL T E D PP IN ' ORTI C IN TO OF UM R AM S- L5. VERIFY ALL DIMENSIONS AND CONDITIONS ON THE JOB. DISCREPANCIES SHALL i � BE BROUGHi IMMEDIATELY TO THE ATTENTION OF THE ENGMEER BEFORE . j - - - - - -- - - - - - - I PROCEEDWG WITH THAT PART OF THE WORK. > I I L6. WHERE NEW WORK WILL BE ADJACENT TO OR FRAMING EXISTWG CONSTRUCTION, VERIFY - DIMENSIONS OF EXISTING CONSTRUCTION, PRIOR TO FABRICATION OF NEW MEMBERS. � S - ' I U. PROVIDE ALL LABOR AND MATERIAL PoR ANY FRAMING REQUIRED TO CONNECT NEW � � � I FRAMING TO EXI571NG CONSTRUCTION. WHEREVER IT IS NECFSSARY ?0 REMOVE � n I EXISTING CONS7RUCTION IN ORDER TO CONSTRUCT NEW WORK, iHE AFFECTED � I AREA SHALL BE PATCHED AND REBUILi TO MAiCH EXISTING ADJACENi WORK � � ' TY TO SATISFACiION OF THE ARCHITEC7. � � 0 ; TY ICAL � I I �P� L8. DETAILS SHOWN ON ANY DRAWING SHALL BE CONSIDERED TYPICAL FOR ALL SIMILAR � W � � — � s—� A coNoirioNs. G� � ._.� - - - — — — I C—, I S 2 STRUCTURAL STEEL G� � O � � � � � - Si. STRUCTURAL STEEL WORK SHALL CONFORM 70 "SPECIRCAiION FOR STRUCTURAL ' - - - - - - - - - - - - I - - - - - - - - - - STEEL BUILDINGS"' (AISC 2005), "CODE OF STANDARD PRACTICE FOR STEEL �y � � ? BUILDINGS AND BRIDGES" (AISC 2005); AND SiRUCTURAL WELDING CODE - O �i ; I I I S7EEL (AWS D7.1-04). w � � � �- -- - - - - - - - - - -- - - - I - - - - - - - - - - - S2. STRUCTURAL STEEL SHALL BE NEW STEEL CONFORMING TO THE FOLLOWWG � N I ROLLED STEEL SHAPES: A992 GRADE 50 � � a' � PLATES ASTM A 572 GRADE 50 O ~ � i E /y��x �'� J ISTS I I WELDING ELECiRODES: AWS E60-XX, LOW HYDROGEN FOR EXISTING STEEL � `~ ; _ _ _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ AWS E70-XX FOR NEW METAL C 6 S TER w ; - __ S3. STRUCiURAL STEEL SHALL BE DETAILED AND, WHERE REQUIRED, DESIGNED IN � ? __ ACCORDANCE WITH THE AISC SPECIFICAiIONS FOR STRUCiURAL STEEL BUILDINGS � � AND iHE SHOP DRAFTING MANUAL, CURREN7 EDITIONS. , � REMOVE 20TH C. , r pARTITION � INTERIOR WALL � S4. WELDING SHALL BE DONE BY APPROVED CERTIFIED WELDERS, AND SHA M - PLASTER CEILING BELOW WALL W/ FIREPLACE To THE AMERICAN WELDING SOCiETI' CODE SEE SPECIFICATIONS. A �ds � TO ACCESS WORK.� � . SHALL BE MADE WITH A REiURN LEG ON THE WELD END. THE M �ay � ; �. � � B FILLET WELDS SHALL BE DE7ERMINED IN ACCORDANCE WITH PAR ,�T�s.¢$.F�,g, � �- � '. � - S-3 STRUCTURAL: oF THE AISC SPECIFICATIONS FOR STRUCTURaL STEEL BUILDW k;1-:�.?� 's?� - � � DESIGN OCCUPANCY LIMIT: 30 PERSONS � ��':���"5.���L v�, I �� � � � 55. ELECTRODES FOR ALL FIELD AND SHOP WELDING SHALL CONF ,�tc�2��� i - (CLASS 70). _e ��.�' W � � F�LAN NOTE: FABRICATE STEEL �!&T��' r� � � m ' COMPONENTS TO FOLLOW 75� OF ss. srRucruRa� sTEE� oerai�s Nor sPEciFica��r sHowN sHa�� eE si 6f "� ��� = o m � , � q � . 3/e» _ � �_�» CURVATURE OF EXISTING MEMBERS SHOWN FOR MOSi NEARLY SIMILAR SITUATIONS AS DETERMWED BY THE R. � ,q 'kz � q w 1 y O C (Zj � S7. STRUCTURAL STEEL FRAMING SHALL BE TRUE AND PWMB BEFORE CONNECTIONS py,aNS aND 2 � 2 4 6 ARE RNALLY BOLiED OR WELDED. No7'es .. Drawing No: � � S8. SPLICING STRUCTURAL MEMBERS WHERE NOi DEiAILED ON THE DRAWWGS IS . SCALE OF FEET PROHIBITED WITHOUT PRIOR APPROVAL OF 7HE SiRUCTURAL ENGWEER. S- I e��� Swctures Nort �o.,�„�.o�.��.��..�., w���� �,K.a�„ (E) SUMMER BEAM �"a,;,16B°"'�„'�° (7 OF 2 ROWS) �" DIA. (E) JOIST R �/e"x6" x4" LAG SCREWS @12" ' R 3/4"x8" SET INTO STAGGERED IN 3/8"x7%" 3/4" "1 �a�� 4" ��� �/8"x8�n° SAWCUT �4� DIA. RECESSES MORTISE — — X I � \���� \ � � I j �—_____-- — � +i s�s„ 3„�6„ III I o _ � III I N - � L _ '-- ----- ' EXIST. � C3x6 � i i���f I, BEAM ER '- (1 OF 2)�"� ,r � A325 BOLTS _ ' R 3j8„X4»x4» c 1J�d'f��l, w ' REMOVE SUBFLOOR � AND PLASTER ONLY P�N � 5—� i�" = i'-0" � , WHERE n!EEDEn FOR (SECTION VIEW) STEEL CONNECTION (1 OF 2) �"6 x4" LAG SCREWS � „1 " „ � , i �� � � � �-f �' 3/8 x4 x8 /a � LAG x3' SCREWS � w p � 18' O.C. TOP 3" � — , �' ---n—r' w � rr4�i-- � C3x6 THREADED � (� � ' 1" SHIM � TO SPACE TOP � �" O � OF C3 OFF OF PLASTER � � " REMOVE, REPLACE 20TH 3/a"0 THR. �'+ � 3 C. PLSTER CEILING TO ROD � i __ ALLOW INSTALLATION OF � (.Yy � --- — -- STEEL SISTERS. , (E) JOIST w � '^�� w � w _ (E) SUMMER BEAM N � F� %" FITTED �O "' � ' sriFF. �4" ro ,�" sPacE ^+ � F.P. ; E�Evariory w > � , � � SISTER E1VD CONNECTION DETAIL � s—� � j 3" = 1'-0" (REVIEW AND CONFIRM WORK IN FIELD) �" 3" � � q�� w r � .fi,�' -. � � , �, � .. � � � I, ; (VIEW PERP. (VIEW PAR. s��,, V�'.'��Fx�� � � , TO BEAM) TO BEAM) c�i �T�==%'�•�•=�-Rt � o ; 6 3 0 6 r;�,.;sa,�;�� � _ � � " m �: ; ��_�::=' f� a � � � SCALE OF INCHES DETAII' ��X�� 4 '^��L�'`�� � � � _ NOTE: FABRICATE STEEL 3" = 1 '-0" DETAtrs COMPONENTS TO FOLLOW 75% OF Drawing No: CURVAT URE OF EXISTING MEMBERS Cy m 2 ' �.J e��� Structures Nort �o..��.�.<,.a�.��..�., (tJ �a w xv mw.++s.�a.msai LAG SCREWS °"""'`0'"0"" TpB��6pM1 I Fpl6)li/AI MILLED HOR. R %e"x6" AS PART OF TEE TERMINATE VERTICAL �� OAK SHIM SUMMER BEAM REWFORCEMENT— �� ` TERMINATE %" SHORT OF 1 " R, AND � B PLATE IN MORTISE WITH 45 ;, 72" SHORT OF POST AT FAR ENDS. DEGREE "CLIP" (EACH END) I I (N) 2x4 BLOCKING EA. 71�"t II SIDE OF SUMMER BEAM FOR SUBFLOOR SUPPORT EXIST. SHIM I I (2) 3/4"� LAG SCREWS EXIST. CHIMNEY I I IN %8" RECESSED I i " CLIP GIRT (7�x3�t) � HOLES EA. CORNICE � i N I I I � (2) 3/4 � THRU—RODS EXISL � � -- , W/ 3°x3" LET—W SUMMER I I I ; � HANGER BLOCKS (SEE BEAM (N) 2x4 BLOCKING EA. SIDE EXIST. SUMMER ' � ) OF SUMMER BEAM FOR I I I � EXIST. SUMMER DET. "X" . BEAM BELOW SUBFLOOR SUPPORT � BEAM (11�x11�f) SE7INTO WET � w EXIST. BRICK PASTE ADHESIVE � � HAUNCH ^ �-1 � � P � F� ' BB S�' C�ION � � (2) 3i4»� HarvcER— (� oF 4)2"�x h" oEEP � w � ; S-3 7�" = 1'-0" RODS & NUTS IN i i RECESSES CTD. AROUND (� � %e" RECESSED HOLES —� � � — �/a" HOLES � E—+ � � EXIST. HEARTH w � ? � � HEADER � ,� � � '- - — — � '- +i � �i � ;�N � w � � + - - - (1 OF6) 3�a"0 � � �7 � `�� I I HOLOR—NAILING � � � � , — — — — � � > i i , +� � � w ; � �� � � � / �+ , � (N) R 7"x 1 1» �„ 3�» 3�» 2„ EXIST. I � x40" GIRT NEY � ' � SOLID MILLED OAK � I , �� ; sHiM eE�ow R B ���Ywcv�r�a�; _ Q,� ��� �_ � o o W . � F � ; m � ` .^u - •..,;; o N ,� }..���:.��:^.hi ���, W o � � ] h �`ia. 3r':i:' tn ` o : .q � ....t.� F Y � � m �'i T�n°"-.�+� � o o � NOTE: FABRICATE STEEL B DETAIL - �,���t:<" flEratts COMPONENTS TO FOLLOW 75� OF S—� 1�" = 1 '-0" CURVATURE OF EXISTING MEMBERS Drawing No: S�3