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187 FORT AVE - BUILDING INSPECTION 'rhe Commonwealth of Massachusetts RECEIV Board of Building Regulations and g1JBFE(¢.TIONAL SERVIC S CITY OF Massachusetts State Building Code, 780 CMR SALEM �. �evised Mar 20l l Building Perntit Application To Construct, Repair, IYe t�r1 j fish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: _ Date Ap led: Building Official(Print Name) Signature Date SECTION I:SITE INFORMATION 1.1 Property rA�ddrress: 1.2 Assessors Map& Parcel Numbers _ is -7 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 I.or Area(sq fQ Frontage(Il) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (MLO.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 OWNERSf11Pt 2.lnOwnsr•'of Rec rd• / �C e w� t S _ ! Go 1& ), . M� O l 4 7C) Name(Print) City,State,ZIP 1 & q +�(-fi S q 79- w y6oa _ 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. [I Number of Units I Other ❑ Specily:_ Brief Description of Proposed Work .�. Q� -�� -- ZO SECTION 4: FSTumATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Metenals) y I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard Cityfrown Application Fee ❑'rota) Project Cost'(Item 6)s multiplier s 3. Plumbing 2. Other Fees: $ 4. ibtechanical (IIVAC) $ Lis[: Q�s / d 5. Mechanical (Fire Suppression) $ Total All Fees: $ Check No. Check Amount: Cash Amount: C,. Total Project Cos[: .3G2 a-v v 0 paid in Full 0 Outstanding Balance Due: -- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ' .. .. .. r License Number Bxpiration Date Namc of CSL Holder, C List CSL."Type(see below) No.and Street Type Description U Unrestricted(Buildings u2 to 35,000 cu. ft.) Citylfown,Slate,LIP R Restricted M2 FamilyDwelling M Masonry RC Ra Cm Coverin WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date I IIC Company Name or FIIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6: WORKERS'CONIPENSAT[ON 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 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: OWNER' OR AUTFIORIZED 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. c (�cJo r �L-� 1e f.. �'— 3 rant Owner's or Authorized AgenPs urne(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 Florae 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/ocu Information on the Construction Supervisor License can be found at www.ntass.gov/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. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms _ Number ofhal0baths Type of healing system Number of decks/porches Type of cooling system Enclosed_ Open 3. Total Project Square Foolage"may be Substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 021I1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers ease t Ix b Applicant informatton .ter Name(Bminess/Organizatiodindividual) Address: C? /_/.. . f Pbone#: y 7� City/State/Zip:6v,riL6Sf r'1 4c O/mot Are you an employer?Check the appropriate box: Type of project(required): 1. I am an employer with_L_ 4. 0 I am a general contractor and I 6.0 New construction employees(full and/or part time).` have hired the sub-contractors 7.0 Remodeling 2. 0 I am a an proprietor or partner- listed on the attached sheet. g 0 Demolition ship and have no employees These sub-contractors have working forme in any capacity employees and have workers' y 0 Building addition [No workers'comp.insurance comp.insurance.j required] 5.0 Ao area corporation and its 10. El Electrical repays or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions in [No workers'comp. right of exemption perm MGL 12 ❑Roof airs insurance required]t c. 152,§ 1(4),and we have no repairs employees.[no workers' 13.f_[Other Q6 " 5 comp.insurance required.] -All,appncaat that cheeks heir Nl most also(al oat the sectloa below showing Weir workers'compeosanon poHry ioformaaon. fibunwo nen who submit this affidavit indimdng they are doing as work and Wen hire outside contractors must submit a oew affidavit indicating sash. #Contaeton that check this bus must ansch an additional sheet showing the name of the sub-contractors and state whether or not those canna have employee. If the subcontractors have em to th mark rovide Weir workers'com . a number. p Below is the I and job site I am an employer that is providing workers'compensation insurance for my em layam policy information. Insmance Company Name: "r ✓ 1 ( I Policy#or Self-ins.Lic.#: X r, l/rs E(x1piration Date- n / /_ 7 � city/State/zip: \!S`�� //�/� �( 9 Xd Job Site Address: i o r -f't7('� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for covers a verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct Date: Si ature: �j �'.. Phone#: l — — Print Name: Offtcial 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 Heath 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 3.Plumbing Inspector 6.Other Phone#: Contact person'. r— I Certificate of Flame Resistance REGISTERED FABRIC ISSUED BY Date of Manufacture NUMBER JOHNSON OUTDOORS INC. BINGHAMTON, NEW YORK 13902 MAY2008 F-140-01 Manrdachuers ofthe Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame n;tardant as here after specified by the material supplier. NAME. THE EVENT CO CITY; GLOUCESTER,MA Certification is hereby made that The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA,7D1•, Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C43W6G. 13OZ.WHITE BL.00KOUT MARQUEE 1 W MID Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufedurer o(Ilanre Retardant vinyl l.arninates TENT DEPARTMENT.JOHNSON OUT L -- 'Large Scale Certificate of Flame Resistance REGISTERED ISSUED BY Date at Manufacture FABRIC NUMBER JOH14SON OUTDOORS INC. BINGHAMTON, NEW YORK 13902 MAY2009 F-140.01 Marxdactwers of the Fmesf Tent Products Descrtbed Herein This is to certify that the products herein have been manufactured from matieriai inherently flame retardant as here arfer specified by the material supplier. NAME THE EVENT COMPANY CRY, GIAUCESrElt,MA Certification is hereby made that The articles deed on this c�'rcate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code,NFPA-701% Undenwkers taborawry of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or mEeed the Military Rase Specittptims of MR-p43006G. Type,color and weight of material 13 OZ WBO Description of mem cenUies MARQUEE 10 MID W80 Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing,Inc. LimuracWmrafPaw RetardaMVirntlaaurmles TENT pePARjmENT,jdHNSONO aJq 'large Smte Certificate of Flame Resistance REGISTERED ISSUED BY FABRIC JOHNSON OUTDOORS INC. Date of Manufacture NUMBER BINGHAMTON, NEW YORK 13902 SEPTEMBER 2008 F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: THE EVENT CO CITY: GLOUCESTER,MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701", Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type, color and weight of material 14 OZ Description of item certifies 20 X 40 1 PC POLE TENT ame Ketardant Process Used Willo e KOrnoved By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARTMENT,JOH ON OUTDOQ'RS"IRC \ `Large Scale Certificate of Flame Resistance REGISTERED ISSUED BY FABRIC JOHNSON OUTDOORS INC. Date of Manufacture NUMBER BINGHAMTON, NEW YORK 13902 MARCH 2O10 _ F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: THE EVENT CO CITY: GLOUCESTER,MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701`, Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type,color and weight of material 14 OZ Description of item certifies 20 X 30 1 PC POLE TENT ante Ketardant Process Used WillO e Kerroved By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufacturer of Flame Retardant Vinvl Laminates TENT D�NT,JOHNSON OUTDOJZRS'7AC \ `Large Scale Certificate of Flame Resistance I REGISTERED ISSUED BY Date oFManufactum FABRIC JOHNSON OUTDOORS INC. NUMBER BINGHAMTON,NEW YORK 13902 APRIL 2009 F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. Made in the USA. NAME: THE EVENT CO l CITY: GLOUSTER, MA Certification is hereby made that The articles described on this certificate have been manufactured with an appmved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701•,A-A-55308,FMVSS-302,CAN/ULC-S109-MB7,CPAI-84, Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type, color, &weight of material: 14 OZ Vinyl: WHITE BLOCK OUT Description of item certified: EFS 20X20 2PC Flame Retardant Process Will Not Be Removed By Washing. Eureka!Tent tops that are designed to meet Temporary Building codes are supported with a Registered Architect Stamp. For that stamp to remain valid, the tent top mast be installed with 100%Eurekal Manufactured fabric components. Snyder Manufacturing, Inc. i Manufacturer of Flare Retarnam YmA Laminates TENr DEPARTMENT,MHNSON OUT SIN 'large Swle . a cer, 9�y rJ1� rye �� t5 L�1 �5�&i nt�:1' •... o � . vnt�s��~ r��-r��F��c F6iity oad�r �� }aivii446BA��'1 Eya�4:�sn�.'a�=�•rrxa�<<3doa� °� =Ssia `. ?off wranr�tl0.7Q8�981� �ldoned'IYYVt•�7�36�8 �� 1 3 ' R ? to f i a 3F dci 00 l Omd have bew fISMI-vouldw� cy gt tii d isif is horeby wide t (ChOO s'W f -ram W9 mr✓7 ? ` a' @,aia:'rt, '1�i' vi;2yrtf l"c��'t"fit Yif�Wiilmbwn waftd wqh a ww7uUW--at+i 4: rr�v i �9r�Pe9�sreBrmt nd 43aat 4t� �f atdstadu�i a dcai�3rr am*mdaaeeewvm Asa 4W,V4 i.1"-i awid U uj.,jaa — t Py9:.cE°�� ua.,,;�.��pis;¢s@ a• _.___ �. Sel•�irai,E��f�Pdq...�.�._. .r.,. � a�gti�d�d�� ttada r le r � 94ze; K f $Q �yThe aro dwdbad anIMraop$dm8 ot or mompu Mowed i. mrrdaap t+s dinp16� 1aFlr* r®EsfDtfluchun. op. tAd s g' -- Roo.t�� x i'sa�r+txrv�a Of�IaaSe-e&R�F®nt* tip or rrdanvsla9 sS e d i tarr �� By MOW prucgsa Umd klLLM, At Ye Mtn u. Certificate of Flame Resistance REGISTERED ISSUED BY FABRIC JOHNSON OUTDOORS INC. Gate of Manufacture NUMBER BINGHAMTON,NEW YORK 13902 F-140.01 Manufacturers of the Finest JANUARY 2008 Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. Made in the USA- NAME: THE EVENT COMPANY CITY: GLOUCESTER, MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code,NFPA-701',A-A-55308,FMVSS-302,CANIULC-S109-M07,CPAI-84,Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type, color, &weight of material: 14 OZ Vinyl: WHITE BLOCK OUT Description of item certified: EFS 20X20 2PC Flame Retardant Process Will Not Be Removed By Washing. Eureka[Tent tops that are designed to meet Temporary Building codes are supported with a Registered Architect Stamp. For that stamp to remain valid,the tent top must be Installed with 100%Eurekai Manufactured fabric components. Snyder Manufacturing,Inc. Manufacturer of Rama Retardant Vind laminates TENT DEPARTMENT,J60HNSON OUT RS IN 'Large Scale i S i-- Certificate of Flame Resistance ' REGISTERED - ISSUED BY FABRIC Data of Manufacture NUMBER JOHNSNEW OUTDOORS INC. i BINGMAMTOTON,NEW YORK 77902 AI'Rii 2808 F-140.01 Manufacturers offhe Finest lent Products Described Herein This Is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. Made in the USA. NAME: THEEVENTCO I CITY: GLOUSTER,MA Certification Is hereby made that: The articles described on In*cetlltiCate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code,NFPA401',A-A-55308,FMVSS-302,CANIULC 3109-MB1,CPA684,Undenrtiter5 Laboratory of Canada.and hove been tested in accordance win the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. - 1 Type,color,&weight of material: 14 OZ Vinyl: WHITE BLOCK OUT Description of item certified: EFS 20'MID 20' Flame Retardant Process Will Not Be Removed By Washing.Eurekal Tent tops that are designed to meet Temporary Building codes are supported with a Registered Architect Stamp. For that stamp to remain valid,the tent top must be Installed with 100%Eurekal Manufactured fabric components. ! Snyder Manufacturing,Inc. n V Manu!acturerefneme ROMMant Vmvl Lam,nates TENT DEPARTMENT.JOHNSON OUi ORS iN . Certificate of Flame Resistance REGISTERED ISSUED BY FABRIC Date of Manufacture NUMBER JOHNSON OUTDOORS INC. BINGHAMTON, NEW YORK 13902 MAY 2004 F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: THE EVENT CO CITY: GLOUCESTER,MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved Flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701', Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type,color and weight of material 14 OZ Description of item certifies EFS 10 MID 20 WBO ame Ketardantrocess se I o e emove y as Ing n Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufacturer of Flame Retardant Vmvl Laminates TENT DEPAR ENT,JOHIRWN OUTDOQRS'7� \ -Large Scale Ic (si'i Wa/rn/c/ WG�,10AJa1n1c1c1 fO ISSUED BY Manufactured by Date treated or Verseidag Fred's Tents & Canopies manufactured 973-252-1189 7 Tent Lane Stillwater,NY 12170 03/11 This is to certify that the materials described below have been flame-retardant treated(or are inherently nonflammable) FOR Event Company PO Box 0419 Gloucester MA 0 193 0 Certification is hereby made that:(Check"a"or"b") a)The articles described below this Certificate have been treated with a flame-retardant chemical approved and E registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used Chem.Reg.No. Method of application (b)The articles described below are made from a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use. Fx NFPA-701 (large scale) Trade name of flame-resistant fabric or material used WHITE Reg.No. F50501 The Flame-Retardant Process Used WILL NOT Be Removed By Washing Fred's Studio Tents & Canopies, Inc. Plant Supervisor Product Description (25) 7x20 Cathedral Window Walls Customer Invoice# 12244