0000 WASHINGTON SQUARE SOUTH SALEM COMMON BPA-14-47 The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY OF
Ij Massachusetts State Building Code, 730 CL`vIR SALE[
Revised Alar 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
[his Sect oriFbrOffi Use0til
Building Permit Numbbr: Da Appli
Building Official(Print Name): ignaturd: Dnte
SECTION I:SITE7NF0
1.1 Property Adriress: 1.2 Assess rap& Parcel Numbers
Ci�41P_vh (_P�vYl1.,A
l.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if es❑ Municipal O On site disposal system
SECTIONZ, PROPERTVOWNERSFIIP '.:
2.1 O n to cor
Name(Print City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORW'(check air that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑L.v Number ofUnita Other ❑ Specify:
Brief Description of Proposed \Vorkt: 6K 18W r5 — 6 La i 1 l ervr 20 X C)
lbw ODlat��1 �Q S4-t- m �Trtaeh esS 2 Jp�7 LrPv_
SECTION4: ESTINUTED-CONSTRUCTIONCOSTS-
item Estimated Costs: OfRdal Use Only..
Labor and Materials
I. Building S I. Building Permit Fee:S' rndicate how fee is determined:
2. Electrical $ ❑Standard.dly/PownApplicationFee,.`
O'rotal Project Cost(Item 6)x multiplier x
J. Plumbing i 2- Other Teas 5
t. M-Chaniail (IIVAQ S List:
i. ,Mechanical (Firo $
ink irCsi m) _ Ibtal All Fees: S_
Chock Yo. Check rluwunt: C;ish ;\uwunt:
n 1'ntal Project ('u:Ci❑ --
I .ti�l n Pull 0 Outst:uulimg Ihd:uua Uuo:
SEcrION 5: CONSTRUCTION SERVICES
5.1 Constructiun Supervisor License(CSL)
License Number Expiration Date
Name of CSL I loldcr List CSL'Type(see below)
Type Description
No. and Street U Unrestricted JBuildings uo to 35,000 cu. 11.
R Restricted IBt2 Fami[Z Dwelling
City/rown, State,ZIP IM %lasonr
RC Roaring Covert"
WS Windownnd$idin
SF Solid Fuel Burning e\ppliances
I Insulation
Pula hone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date'
I IIC Company Name or IIIC Registrant Nune
No.and Street Email address
City/Town State 'LIP Tele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 157.§ 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......•••••0
SECTION In: OWNER AUTHORIZATION TO BE CONIP ETED WHEN
OWNERIS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 7h: 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
containe " this application its tru•and accurate to the best of my knowledge and understanding.
l7 � GGtL /-4t/ld� 20/
Print Ownur's or r\utlturi�ud:\gent's Nanta(Elatruntu Stgnahtru) /Dete
NOTES:
1. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
progr:un or guaranty timd under AI.G.L. c. 142A. Other important information on the HIC Program can be found at
w w w m:us.tarv%oca Information on the Construction Supervisor License can be found at wtwv.utass..�v_�IL
? \vhen substanti;d work is planned,provide the information below:
__.___ —(including garlge, tinished basemendattics,decks or porch)
Total fluor area(sq. lt.)
t iro;; living❑rea Oki tt.l Number o room count _
Number,tf fireplaces.. ___----_— Number of budraoms -- ----------- ___--
4umherufbathnnnns .- ----__---- Number ofhaltibaths .-
- --
P,lw of heetim!iy,lent
_.. ---
I%l,e of cooling a;y.tei -_ Fndased. --- pen - -
t. "I',,Lil l'nq:�:t �quI.1:o I.i11a" m.tq he Mil'utln:d f,,r "1'.,cil PII,icrll_o-��--- .
CITY OF&U-Ems MASSACHUSETTS
BUILDING DEPARTNfENT
• + 120 WASHIINGTON STREET,3'D FLOOR
TEL (973)745-9595
F.ix(978) 740.9846
KI,(ggarY DRISCOLL
MAYORTHoNw ST.Pmm
DIRECCOR OF PUBLIC PROPERTY/BUILDIING CONLWISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Naillc(Busiixsr.Orgtnizationdindividual):�'��� INC
Address:..!�4 11 A 7>0RGLi_e�,
City/State/Zip: S f 4__e11 d W L O Z_CJ�6Phone#: 27/ — L/65 — / 5/" a 9
Are you an employer?Check the.appropriate box: 'Type of project(required):
1.0 I am a employer with 4. 0 I am a general contractor and I 6,
employees(full and/or part-time).* have hired the sub- onttactors ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees- These sub-contractors have 8. ❑ Demolition
working,forme in any capacity. workers'camp.insurance. 9, Building addition
(No workers'comp.insurance 5.A We area corporation and ild '
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c..152,¢1(4):and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.0 Other,
comp.insurance required.)
-Any appllc:un that checks box ill must also fill out the section below showing thou wakua'wmpniwion policy information.
f I hamowncrs who submit this affidavit indicating they are doing all work and then him wiside contractors must submit a new alndavit indicating such.
=Contmcu s that chuck this box most attached an aklitiwul,heel showing the rates of the subamntnsson uuf theirwohant'comp,policy information.
f um an employer that Is pravlding workers'compensaton htsurance far my employees:- Below Is the pol/cy and Jab slier
informadom
Insurance Company Name:
Policy#or Self-its.Lic. #: Expiration Date: '
Job Site Address: City/StatrJZip:
,lttacb 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 c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. 13e 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 certify under the puins and penoldes ofirerjuty that the beformalfon provided above is true urid correct.
Si¢nnnlre' Date'
Phone#:
OJJlcial use only. Do not write in Idis urea,to be completed by city or town oJJIcIaL
City or'Cown: PermiuLlcense# _
Issuing Authority(circle one):
1. Board of Wallis 2. Building Department J.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.O t her
Contact Person: Phone#:
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ISSUED BY:
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EUREKAI TENTS / a div. of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest �.5 CA4,,
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Tent Products Described Herein �-
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DEALEkNAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading MA 01864
STATE2IP:
This is to certify that the products herein have been manufactured from material inherently flame
retardant as here after specified by the material supplier.
Certification is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code, NFPA-701, Underwriters Laboratory of Canada(ULC-8109-M87), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 20' Traditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture June 09, 2006 - Serial#009744
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSO UTD ORS INC.
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EUREKA! TENTS / a div, of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902 •
Manufacturers of the Finest STgR
Tent Products Described Herein
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DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading MA 01864
STATEIZIP:
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This is to certify that the products herein have been manufactured from material inherently flame
retardant as here after specified by the material supplier.
Certification Is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code, NFPA-701, Underwriters Laboratory of Canada(ULC-S109-M87), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C-43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 30' Traditional Party Canopy—WBo solid white 13 oz. vinyl
Date of manufacture March 27, 2007 - Serial #V007114
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSDIIUTD ORS INC.
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EUREKA[ TENTS/a SUED
ofnson Outdoors Inc. `JohBY.
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B►NGHAMTON, NEW YORK 13902 �l
Manufacturers of the Finest T
-� of CA4T?nfProdUCtS Described Herein
.. 9�F•sae M�"'OP ��/
DEALER NAME: Kids Stuff Amusements LLC ReTp�
ADDRESS: 8 Cobblers Lane
CITY: North Reading
STaTE21a: MA 01864
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This Is t0 certify that the products herein have been manufactured from material inherently flame
retardant as here after specified by the material supplier.
Certification is hereby made that: The articles described on this certificate have been manufactured with
an approved flame retardant chemical that was tested and passed the following codes: California State Fire
Marshal Code,NFPA-701, Underwriters Laboratory of Canada(ULC-S109487), and have been tested in
accordance with the Federal Test Method Specifications and meet or exceed the Military Flame
Specifications of MIL-C-43006G and hence superseded by A-A-55308.
Description of item certified: 20' x 30' Trtditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture March 27,.2007 - Serial#V0071227
Flame Retardant Process liked Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSO UTD RS INC.
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On the Salem Common
Saturday - July 20th 1 Oam to 8pm
Sunday - July 21 st 1 Oam to 6pm
H
Saturday, July 20 Sunday, July 21
10:00 am CultureFest Opens 10:00 am CultureFest Opens
11:30 am National Anthem t K 11:30 am National Anthem
by Michelle Brooks Thompson by Amy Moquin&Katelyn Silva
f 11:40 am Drumming With A31) { Drumming led 6yMamadou Diop
i led by Mamadou Diop 12:00pm Julio Bare
12:00 pm Be Imagine.. . featuring : ' Dommiran/Caribbean Music
tv the Sparx, Woof',Anonymous _ , 1:15 pm High Hopes Band 70's Reggae
1:30 pm Sisters in Dance - - • - 2:30 pm Gumbo Diablo
Middle Eastern Belly Dancing •
W3:00 pm Khalilah Pan-Amedana Music
= Roots Reggae 3:15 pm Parade and Pinata-FamilyEvent
V 4:00 m Parade and Pinata 3:45 pm Hipshot Band
N P R&B/Jau with Vocals and Homs
Famrly Event 5:00 pm Imojah and the Skylight Band
4:45 pm Kah N I Band 4 Roots/Reggae
Roots Reggae 6:00 pm End of Day
6:30 pm King-I
Reggae MC's for Both Days
8:00 pm End of Day Q j• • • Conquest Creative Media
t • - Art of Black Dance&Music,Inc.
KIDS EVENTS Pinata, Parade, Face Painting, Henna, Moon Bounce, Pony Rides, Karate Demo & More
I Visit over 50 Craft and Food Vendors reoresentin all the arts and different cultures p'
IWITHSP,EcKL-GUEST;PAP,A ALE�,NIANG
25TV SENECoAl 1(VEST IF,RICA Sponsored by MD, Inc.
IRON®
African Development.through Drum and,Dance
E.
Mastery Bank For more Information: www.salemculturefest.com