115 DERBY STREET - HOUSE OF SEVEN GABLES/TENT l ;
.� i'hc (\luuuomvealth of Massaelutsetls �
t� 13oard of Budding RCgulatiom :m)d Standards I OIZ
4 \II Nll ll'.\III l
t ' • � 11aSsachusrtls Slaty 13uilJtng ('11Je. 7511('M11R. 7"' CJition
j
Building Pet init Application To Consuuct. Repair. Rciim ate Or Demoli,h a R J
(h)r- „r Tit u-f,rmih lhrrllia,¢ 1. _rm,\'
— —i
This Section For Official Use Only
Building Permit Numb Date Applied:
Budding Conunl.vonar, In.pceturut B uddlugs Dam
SECTI 1: T : INFORMATION
1.1 Property Address: /� / �.� 2 Assessors Map & Parcel `umbers ----
_ IJ err VJ• _ _ _ __ _ _
i.to r..s rids in accepted street.' IIO %l Ip Nurilhe( —- i',du \u ❑ho
1
1.3 Zoning Information: l.a Properly Dimensions:
Zoning District Proposed Use Lot Area(sq to Frontage Ili)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
I Required Provided Required Provided Required I'm,idcd
1.6 Water Supply: 1Nt.G.L c. 4Q §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' Munici al ❑ On sne dis xlsal s ,rcm ❑
Public ❑ Private❑ Check if yes❑ P
SECTION 2: PROPERTY OWNERSHIP(
2.1 Ownert,uf Record:5 s
l-e flaisi- �� ✓P,-, 7a l4hi� /
Nane iPrint) i Address for,Aervice:
Signature Telephone
SE ION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repans(s) ❑ Alteration(s) ❑ Aelditn,n ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: <�
Brief Descrip�bu��n u/j ropused Work 2: _
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and M:ueri:dsf Official Use Only
I. 13:rilJing I $ 1250� L se Building Permit Fee: $ Indicate how tee is deicr n nucd:
❑ Standard City/Tuwn Application Fee
2. Electrical ❑T
S 1
otal Project Guar (Item 6) x multiplier x _
3. Plumbing S D 2. Other Fees: S
J. ,Mechanical iHVACI $ List: C �� ) L_•_(_J__
5. Mechanical (Eire ,�
Sit ressionl Total :\II Fees: 5
.r Check No. Check Amount: _ Ca,h Am„unt'.
0 festal Prvrjee[ Cmst S Z� D 0 Paid in Full 0 Outstanding Balance Doc_ -__-
SECTION 5: CONSTRUCTION SERVICES
5.1 tr
I C'u.icenst•d 1. action Supervisor IC'SL) '� �"� _-../ Y_ay
_ _ -- -- V
LuCn,e\anther I`.�pila kin 1.11.•i
alli Ili Ida i.iol C SI. l\Ix• (,Cc hi loos I
'I'�. •• De,el1 ilia❑ �
\JJIc � 1,It ,l11J "?. A)p 11 F1.1 __
_— R Resu Ietad I.\c'_ Fanu I D��cll,ne
\I:Ivonn only
RraJ:uual R....litre ('"'Cr ul___
fCle phone \15 � K["d:nli.J \\,nuu�� .old Sidn,
SF Re"&II(lal S,diJ I .ICI ISunln,_
U It C.,JCnlwl Urinohuun
5.2 Registered home Improvement Contractor(IIIC) --
HIC Company Name or IIIC Registrant Naule Rcgulrauun ::Nu ether
x
Eapuaoon Date l
�h Signature I'eiephone
L SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be completed :md submitted with this application. F Ilure to lMo ode
r this affidavit will result in the denial of the Issuance of the building permit.
Signed Afficlavit Attached? Yes ........_ No _ ..... ... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S .AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the suhjr:L I property hereby
autbnrnze --- —_-- to act on my hehair. in all matters
:.!ato' to •.uork . thonzed by Ihis building permit application.
I
Si nature of Owner -------- - - Date—--
SEC TI N 7b: OW'NERI OR AUTHORIZED AGENT DECLARATION
I C;,,_ l J— , as Owner or Authorized Agent heichy declare
that the stal ents and inform tion on the,foregoing application are true and accurate, to the best of my knowledge and
I behalf. J�_
Pont Name
Signature of Owner or uthorized :\gent Date
(Sinned under the r sand end,... 1 er urvl
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner vvho hires an unregistered conuaelor
(not registered in the Hume Improvement Contractor(HIC) Program), will not have access to the arhitr;uion
program or guaranty fund under M.G.L. c. la_A. Other important information on the HIC Program :Ind
Construction Supervisor Licensing (CSL) can be tound in 780 CNIR Regulations I I0.R6 and 1 I0R5, iespecnvely.
' When substamnd work is planned, pioN de the information below
Total flours area lSq. Ft.I Imcluding garage, finished basemen Ualtics. decks or
s pinrhi
Gros living area ISy. Fr.) Habitable room count �Q_
Number of rueplaces Number of hedroonm
Numberof hal Ubatl-N ----- -
I Number of hathnln ins -- -- ---- --
I\pr of heanng system ---- Number n(decks/ plln lies
Q—
l vpe of i')o illg sU1em 4ZO — 1tn lu J — G -,.—Often ---
i. "Total Project Square Footage- may he ,nb,taated for rota) ptolect c',I,r' 2crne
�r
i
Certificate o,f' Flame Desistance
REGISTERED - -i
FABRIC iSSUED BY Date of Manufacture
.JHA TO OUTDOORS INC.
NUMBER -
B4NGHAAkTON,NEW t3947_ 1 APRfL 2003
FA-49303 Marfuraca4m of Me Finest
Tent procuru Dew:nt,,ed He21n I
i
This is to certify that the products herein have ben manufactured from material inherently flame retardant as
here after specified by the material supplier. j
i
NAME: -THE EVENT CO
CITY: GLOUCESTER STATE: MA
I
cartmoation to hereby rrlade that; `
The articles described on this certificate, have been menufacWred with an approved flame retardant chemiW in compliance vvith
Celffomia Slate Fire Marshal Coda,NFPA-701', i
I
Type,o�larend weigte of matelot: NC-16-BOR `✓irM ENDURAWHITEL�MINATED
I
Description of hem cert[ied; 40X40 2PC TW tN TUBE PLUS i
Flame Retardant Process Used Wig Not Be Removed`By Washing And
Is Effective For The Life Of The Fabri
HANWHA POLYMER CO. — l
TENT OB'ARTMBJr,JOHNSON RS" C.
•i.arga Sceio
j
i
I