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63 FLINT ST - BUILDING INSPECTION (3) LK b � zS 61D The Commonwealth of Massachrl vila'A L 5 Department of.Public Safety yu Massachusetts State Building Code(780 Cb7R) ��h {�1 P �u Building Permit Application for any Building other than a One-or 16M�b�aill Dwelling (This Section For Official Use Only) �- Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block k and Lot R for locations for which a street address is not available) 63 FVmr -lr S!• M-A oNg-lo L'"dry � RKtV-� Rays 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❑j Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition Cl (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction llnemnents being supplied as part of this permit application? Yes ❑ NoA9 Is an Independent Structural Engineering Peer Review required?. 1 rs Yes ❑ No 0 Brief Description of Proposed Work: E ree.-tr 0— 30 X 5c4eKt-ted vrs 6 !3 ( 1 r-{ 1 h p r �`l"k m \crE ti'yCr'r_fn r.Clt 5 IG'. 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 P osed n No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) pm Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) to A: Assembly A-1 ❑ A-2 Cl Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Edu Tonal F: Facto F-1❑ F2❑ H: Fli h Hazard H-1❑ H-2❑ H-3 ❑ H-4 El -5❑< 1: institutional I-1 ❑ 1-2❑ 1-3 El14❑ M: Mercantile❑' R: Residential R-ICI R-2❑ R-3❑ r�-f❑r n S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: N - Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA'❑ IIB ❑ IIIA ❑ IIIB ❑ I 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❑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 I h Ir i i �mlmi si n Il.y icw I uncas: -........ ..._; -_--.... 7 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: Occupant Load per Floor: S Does Ilie bmiilJiimg contain a an Sprinkler System?: Spacial Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION NaIlle a�}}nd A{{�1del 's°` Property Owner iNI H/, O CYGle,�d °�Y T2e..�oo 'A O\CEO Name(Print) v IOU No.and Street�.rci Sot Ci /Town Zip Propeftyt0400r C,6mact information: nic- 19 icc. lo'ioL 0191 q-Tg -532 4800 _- 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 buildinermit a2plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Append ,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 Nance(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 L41N, MCI:, , UJC,. r'teAa okFi o Street Address / City/Town State Zip Telephone No.!:. usiness Telephone No. cell e-mail address SECTION 11:IVOItKERS'CObIN1iNS,\170N INSURANCE AFFIDAbTf- M.G.L.c.1$2§ 25C 6 AN-orkers'Compensation nsurance Affidavit from the klA Department of Industrial Accidents must be completed and submytttted wWlf this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. �S Is a si ned Affidavit submitted with this application? Yes❑ No ❑ > SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE °pr�N,r It n Estimated Costs:(Labor Q It and Materials) Total Construction Cost(from Item 6)_$ xT 1. 8uil�(ing $ Building Permit Fee=Total Construction Cost x (Insert here 2.Elen�'t�rical ap $ appropriate municipal factor)_$ - 3. Plumbing $ _l.bfechanical ([{VAC) $ Note: Minimum fee=$ contact municipality) 5.Mechanical Other $ Enclose check Y•Wa able to 6.Total Cost $ O (contact municipality)and write chec 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 my knowledge and understanding. � d tr5 '--v -k� �/YU`^���r w�° ore m e<- �Z`� 5WO`t GLto t Please print and sign name Title Telephone No. Date co S�(ewt -r_xl`Y 010t10 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Z, & Name Date N 0 Ilt 0 a IL © ��n�u��nu��n�sCn�rr�r��rs�i�r�n�>r�r�u�Ln�r�r IMPORTANT D O C U M E N T Lnn�sr���uu����n�n�r��nsu�u�>s��nnu��n y C�rtitttaft of tamp �RoWtante 2 CC REGISTERED , IS,SU_E,D R - Dale of Manufacture c00 C APPLICATION ��oJ�a�u m 5 NUMBER Q(�ro. W cusTeres lNC OM1 DtIOO CCC ��IWi/� Order Number = FI2i.4 �G� EVANSVILLE, INDIANA 47711 Z 5 E 3I1311 MANUFACTURERS OF THE FINISHED 5 TENT PRODUCTS DESCRIBED HEREIN rn M: 5 This is to certify that the materials described have been flame-retardant treated s 5 5 (or are inherently noninflammable) and were supplied to: 5 216800 W1 IAM 3 ANCHARD COMPANY INC 8 MAIN e� WAKEFIELD MA D18803320 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 m 5 chemical and that the application of said chemical was done in conformance with California Fire 5 Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 The method of the FR chemical application is: 5 Senal C - f+ 80253%(2) I7 Description Of item certified: ti FI EXP MID 30W X 10 VL W W - Flame Retardant Process Used Will Not Be Removed By 5 Washing And Is Effective For The Life Of The Fabric � lOHN B(}YlE STATESVtLLE NC I Signed: Name 01 Applicalor of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. �° [P[11C1CJi1L1�[ICP[P[J�[J�CPL PLP[P[![P[PLF[F3cP[J�LI�[PCfcP[l1C ICl}[P[P[P[PCP[1�iP[PCP[Pi f[P[P[lLP[F[P[(LP[TcCPCP�[PCP[PCP[F3[F[FLfl[PCP[PCP[P[PLI�Cf[P[PCPC]�CPCI�CJ�rJ�[J�C1�CJ�CP[�CP ©° M m W a a m �Tf�rsr�sLQLPWL ss�ru�s�u�s�u IMPORTANT DOCUMENT gligrE RPT nr Pri E.rgrry�n�u���r�nu���� } errtlftrate of fYame Roi5taure5 z ISSUED BY - 5 [� REGISTERED { .w �p Date of Manufacture 5 0 5 APPLICATION NYne 0410000 U � - INWSTRIES iNC. 7 NUMBER = S (I F121.4 I EVANSVILLE, INDIANA 47711 Order Number C, a [ MANUFACTURERS OF THE FINISHED w TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated 3 5 (or are inherently noninflammable) and were supplied to: 216800 5 5 IL N S IA ANCHARD COMPANY INC Cj 5 WAKEFIELD MA 01880a320 5 Certification is hereby made that: The articles described on this Certificate have been treated with aflame-retardant approved a chemical and that the application of said chemical was done in conformance with California Fire 5 N Marshal Code, equal to exceeds NFPA 701, CPAt 84, ULC 109. I M The method of the FR chemical application is: 15+ m � Serial p: 8025000(i) Cj { u� Description of item certified: I �, F1 EXP TOP 30W X 30 VL W W L 5 _ Flame Retardant Process Used Will Not Be Removed By 5 Washing And Is Effective For The Life Of The Fabric 1OHN BOYLE STATESVILLEBOYLE NC� Signed: 5 m •-.� TENT DEPARTMENT—ANCHOR INDUSTRIES INC. Name of Appicator of Flame Resistant Finish QQ3fJ�r3FL3PL PLFL3FJ_rJ�rJ�cPtPrJ�rscP�PcPcPrJ�rJ�r�cnrJ�rJ�r??nr�EN—EErJar-PLPCRPrJPrlc_I�rJrJird_01 SrSarJ�cPriclrPcFrJ�J�rSrJ�rPrJ�cnclrJ�r�rJ�r�r1jffLrJ�cPrJ�rJ�r�cPcPr�rPSrJr�+cPScPrJ�rS�