63 JEFFERSON AVE - BUILDING INSPECTION (7) FlIe Commonwealth of M;ssachu sells
�. isy Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 C NIR SALLM
L'�" Krrisc.l ILu• 'll
Building Permit Application 'ro Construct, Repair. Renovate Or Demolish a
(Arc- or Two-Fainil.V Divelthif
This Section For Offs lal Use Ot
Building Permit Number: Da App)e
Iluilding Official(Print Nzunc) j. -Sigrmtu t
ate
SECTION 1: SITE I RN
1.1 Property Address: 1.2 Asses rs Slap& Parcel Numbers
63 AM 4r, i JuC
1.1a Is this an accepted street?yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/Doing District Propsedteo h Lot 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:( . I.c.40.§Sq) 1.7 Fload Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if ycs❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
dt'2 QQYwrr_L
N;une(Print) City.State,LIP
No.and Strcet Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied 07 Repairsls) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other .Specify: TeSv>Tn.
Brief Description of Proposed Work: -t- a A R,-b DUE ��, lam L .eti u L
%doh . TN.Jteu.. Oi.1 /U,2rf /L�.ywrA Io 30
SECTION 4: ESTIAIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Libor and .Materials) Official Use Only
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S Cl Standard City/Town Application Fee
1, Plumbing $
O Total Project Cost'(Item 6)x multiplier _ _' x
— -----
_. Other Fees: S
4. \lechanical IIIVAC) S List:-
5 \fccltanical (Fire S .__ --_ --'— ---- --- '
.Su pressionl Tot:d :\ll Fees:
n. Turol Project Cost: 5 CbDO/ ('heck No. _-_('heck Amount: _ --_-- C,uh:\nu unn: - .
❑Paid in Full ❑Outstanding Bahmee Doc;
SECTION 5: CONS"I-RUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Numhcr ---- --- I wiration Date
------
I.im CSI. fN Pe lscc belo% 1
— -1\pe Description
No. and Street ---------- --
U t timAricled I Ihlildin gs tio to 15.000 ea. 11.)
_ R Restricted 1l2 Famil M%ellin g
C i tcifown.Slate, IF M Masan
RC Boutin C'overin
A". R'indaw;md Siding
SF Solid fuel Burning Appliances
I Insulation
ICle hone IInad address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
'rE7ov— /IeiC7rA L. IIIC Registration Number INpiration Data
I IIC C'ompan) Name or IIIC Registrant Name
(3 ptE A(R
No. and Street o3 Is Email address
.VEWror� .vN 603-68.'t'��S
City/Town,State,ZIP 'relc hone
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 .......... ❑ 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 Na ne(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.
Print 0wncr's or:\uthorircd Agent's Nanw(Ficctrunic.Signature) Date
NOTES:
1. .\n O\vner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(H IC) Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. I I'_A. Other important information on the HIC Program can be found at
It\I,\ n�.r.. �;!1 • i.l information on the Construction Supervisor License can be found at yl>\,s.nia.< >o\ ,loi
2. when subslantial\vork is planned, pro%ode the information below:
Total flour area(sy. R.) _ (including garage, finished basement attics.decks or porch)
Gross living area I sq. Il.) --_ ---- . Habitable room count -
Number offircplaces___. ..._ Number of bedrooms
Nanther of bathrooms \umber of half haths
_ . . -
I\pe of heating s)stem \anther of decks, porches
f\Pe of Coo l 1116 j\Ste Ill _ _ - l'I1clUrid .. - _ -_(1PC❑
1. "total PfJleel tilhlarl` I'JUinge"Ill;l\ he substlluted for-fotal Project Cost'
IMPORTANT D O C U M E NTH'`P�' '`�'`PJ'`�'r1'rl'`f'`PcP`P`PrJ� o
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5 Cerdfleate of Flange 1Resistapee 5
ISSUED BY Date of Ship 5
5 REGISTRATION mentF os/osloa 5
5 APPLICATION ° _ CII1IIR® 5
NUMBER r NDUSTRIE mc.
5 Tent Identification 5
5 rf M'yg�F EVANSVILLE, INDIANA 47725 03851234 5
5 P121.q M MANUFACTURERS OF THE FINISHED
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5 76556 5
5 APEX TENT RENTAL 5
5 7 COTEVILLE RD 5
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LONDONDERRY NH 03053 5
5 r
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5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. Icy
5 Serial # 80250()0(1)
5 C5
5 Description of item IgR1if1ft5kANDABLE TOI'30Wx30 LSD
5 WHITE V NYL
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55 Flame Retardant Process Used Will Not Be Removed By 5
:Washing And Is Effective For The Life Of The Fabric 5
5 JOHN BOYLE STATESVILLE NC Signed: / 5+
ESPECIAL EVENTS DIVISION•ANCHOR INDUSTRIES INC. 5
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5 CertlfleatC Of Flan-e ARCsistapee_._ 5
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5 REGISTRATION v 08/03/045APPLICATION V.mqp. 5
NUMBER Tent Identification 5
5 EVANSVILLE, INDIANA 47725
03916744
MANUFACTURERS OF THE FINISHED
5 rizl,4 E 5
5 TENT PRODUCTS DESCRIBED HEREIN
SThis is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5 76556 5
5 APEX TENT RENTAL
S7 COTEVILLE RD 5
5 LONDONDERRY NH 03053 5
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5
5 5
5 5
5Certification
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The articles described on this Certificate have been treated with a flame-retardant approved 5
55 chemical and that the application of said chemical was done in conformance with California 5
Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPA[ 84, ULC 109. 5
5 Serial # 8025300(4)
5 _ 5
5 Description of item certified: 5+
ME, FIESTA EXPANDABLE.MIDDLE 5
30WXIO WHITE VINYL 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
Ma JOHN BOYLE STATESVILLE NC signed:
5
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` Date ofacture
5 REGISTRATION f M
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5 NUMBER s Nousraies i c.® 5
EVANSVILLE, INDIANA 47725 Order Number 5 38i123 5
5 F12L4 �� eM* °T MANUFACTURERS OF THE FINISHED rJJ
5 TENT PRODUCTS DESCRIBED HEREIN
5 This is to certify that the materials described have been flame-retardant treated 5
(or are inherently noninflammable) and were supplied to: 5
5 76556 5
APEX TENT RENTAL 5
5 7 COTEVILLE RD 5
5 LONDONDERRY NH 03053 5
5 . E
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial # S
5 8106200(8) 5
5 Description of item certified: (5
WALL 610 X 22'LAP&SNAP 2 5
4ukU1E_V1DW- 5
5
Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric (5
5 cw,r _ Signed: so ✓/ "` -` 7
lOLIN13CLYLE-STATESYIL
TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5
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5 Certif icate of Flame Resistapee 5
5 REGISTRATION ISSUED BY rA
5 �� Date of ;Yftpcture S
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NUMBERU"J USTRIES INC,® rj
EVANSVILLE, INDIANA 47725 Order
rd r Number c5
5 FI2I.a EM* 84
MANUFACTURERS OF THE FINISHED 5
TENT PRODUCTS DESCRIBED HEREIN 5 55 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
76556
5 APEX TENT RENTAL 5
5 7 COTEVILLE RD 5
5 LONDONDERRY NH03053 T
51
5 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 The method of the FIR chemical application is: 5
5 Serial # 0j
5 5
sozs000 of 5 5 5 Description of item certified: Cj 5
FIESTA EXPANDABLE TOP 20WX20
5 Fti-Y.I 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 5 Washing And Is Effective For The Life Of 'The Fabric 5
JO++N BCt�S7 A�FxSYt66E NC 5Signed •1J —a Q 5: � 5
tj TENT DEPARTMENT.ANCHOR INDUSTRIES INC.
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