63 1-2 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Mp�§aprgsetts
Department of SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building othatpne- r amily Dwelling
.� (This Section For Official Use CWYI
-9 Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION
, n 144f- mil c L-
V O No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
LEdition 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 ❑ 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 Q
Briefppascription of Proposed Work: }e}"✓/0 D I-- 3
/5 / e a,LjP&We off- / 'u tie er-r S,fvva i0i311iz
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❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-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 Description:
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 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❑ 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
L: {y1(g-_ J e4cersou ge
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information"r
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If ap licable,the property owner hereby authorizes:
/<eu1z- N /=dwell eej b
Name Street Address City/To t 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 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
i
�w i g L-E-
Name of Person Responsible for Construction License No. and Type if Applicable
4-4 q `. o icy e,/ S Y PF�i Lin f :'.i y/ c&- 0/'�-4 0
Street Address 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 $ 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 $ 0(7 U ' (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 rate to the best of my knowledge and understanding.
,ah ;`ct �� T z r 7d-3 33� fv o S
Please print and sign name Title Telephone No. Date
51
Street Address City/Town State Zip Email Address �7
Municipal Inspector to fill out this section upon application approval: �v
Name Date
Appendix I
• Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. 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 Construction Documents*
Mark"x"where applicable
No. Item Submitted Incom lete Not Re aired
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
Appendix 2
(For total demolition only)
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are 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
No. and Street City /Town Zip Name of Building (if applicable)
Assessors Map # Block # and/or Lot #
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 ❑
Electricity 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)
-7
The Commonwealth Of Massach usetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
y Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Pr__rnt_ f Aa t,t
Name(Business/Organization/Individual): 1ERei,
Address:_ qc
City/State/lip: E-'k�er, - g 0 Phone #: �' S✓�5 r(J 3S�
FrIam
loyer?Check the propritte box: --------
loyer with ! 4. ❑ I am a general contractor acid I Type of project(required):(full and/or part-time).r have hired the sub-contractors 6. ❑ New construction
proprietor or partner- listed on the attached sheet. 7. [] Remodelingve no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t y ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I- Plumb'
myself. ❑ mg repairs or additions
[No workers'comp. right of exemption per MOL insurance required.] t c. 152, §1(4),and we have no 12.❑ Roof repairs
employees. [No workers' 13.Q Other 7e,t
comp. insurance required.]
'Any applicant that checks box#1 must also fill oul the s
t Homeowners who submit this affidavit indicating they a notion below showing then workers'oompensadon policy information,
iContrac[o re doing all work and then hire outside contractors must submit a new affidavit indicating such.
rs that check this box must attached an additional sheet showing the name of the mb- raractors end state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
!am an employer that is providing workers'compensation insurance or
information. / my employees. Below lr the policy and job site
Insurance Company Name:—.,—. ^I`L� k t ,
Policy#or Self-ins. Lic. #:_ Le,G SD Expiration Date:
Job Site Address: f Joff-116 ff-5oi 1.4✓5 City/State/Zip: tL
r*�1/C aid zC>
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
fie uFailure to secure coverage one-year
i under Section 25A of MGL c. 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby cernfj a uler the in//s and pen fees ofperjury that the information provided above is true and correct
Signature Ll/ _ Date: f� 65�
Phone# 7ff-�35 5 o3S
FFCOnyt
use only. Do not write in this area, to be completed by city or town official
Town: Permit/License#
Authority(circle one):
of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Person:
Phone#:
Certificate of fflame Req;iOtance PAGE. z
Date Manufactured AZTEC TENTS '
12/18/2012 2665 COLUMBIA ST INV NUMBER: 0196833
TORRANCE, CA 90503 P.O. NUMBER:
.8001228-3687 CUSTOMER NO: EVEN019
This is to certify that the materials described below have been flame retardant
treated (or are inherently flame retardant).
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Certification is herebymade that the articles described below hereof are made T"Oentg YD1a 50° F RI.Oz ^ws
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from a flame-retardant fabric or material registered and approved by the Tn V.M.,e Vanynam We61m F.p59.D1
California State Fire Marshal for such use. The fabric has been tested and T"VaMao• W(blm/r°an°na F-ob9.o1 "�°a+
` ! passes NFPA 701 Large Scale. See chart to right for trade name of
flame-resistant fabric or material used and additionally referenced on the label
of the fabric panel. o
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager-Manufacturing
` Name of Applicator or Production Superintendent Title of Applicator or Production Superintendent
ITEMS MANUFACTURED TYPE PRODUCED
30x3OxO8IT Lite SYS Frame-Hip S 1
System track frame w/IT Lite Legs,
Pins, Stakes, Baseplates, and
Tie Down Ratchets
30x10x08 1T Lite SYS Frame-Mid S 5
System track frame w/IT Lite Legs,
Pins, Stakes, Baseplates, and
Tie Down Ratchets - --- - '-'—
e i ica e of Flame esis ancePAGE: 2
Date Manufactured AZTEC TENTS
03/24/2010 2665 COLUMBIA ST INV NUMBER: 0179791
TORRANCE, CA 90503 P.O. NUMBER:
I8001 228-3687 CUSTOMER NO: EVEN019
This is to certify that the materials described below have been flame retardant
treated (or are inherently flame retardant).
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7103 Turil Rd Ste.306 464 Lowell Street
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from a flame-retardant fabric or material registered and approved by the TA°aMa°e °e^9"ira w�tm F.°°901
California State Fire Marshal for such use. The fabric has been tested and
passes NFPA 701 Large Scale. See chart to right for trade name of °"zP°� a' n B16T'a'S'S F.55°.UI
^-'.. flame-resistant fabric or material used and additionally referenced on the label
of the fabric panel.
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager-Manufacturing
Name of Applicator or Production Superintendent Title of Applicator or Production Superintendentto
ITEMS MANUFACTURED TYPE PRODUCED
***8x20 Grand Panorama wall- 15oz UW S 25
Qty 4 P5 Window per wall
Lap and Snap "Indiana Style"
01/20/2015 0:50 AN FAX 603 964 1484 ALI-ECIAN-r NQVT CORP In 0001/0001
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CERTIFICATE OF LIABILITY INSURANCE 0112 0/2 01 5
THIS CERTIFICATE IS ISSUED AS A!MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATPJELY OR NEOATI:rELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S) AUTHOR2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the cortmeste holder is an ADDITIONAL 117SURED,the Polley(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the Policy.certain Policies may require an endorsement. A statement on this vediTirate does not 00nfar rights to the
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Rye,NH 03870-ODD
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CERTIFICATE HOLDER CANCELLATION
North Strove Rental,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLIGYES BE CANCELLED BEFORE i
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1
dba:Events for Bent ACCORDANCE YAM THE POLICY PROVISIONS.
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Peabody,MA 01980 !
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Arne 2A r20141011 The ACORD name and loge are registered marks of ACORD