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0000 WASHINGTON SQUARE SOUTH SALEM COMMON - BPA-15-306 CS IR 'fhe Commonwealth of MassachusetTECEIVED CITY of � Board of Building Regulations a"fffIN3t HAL SERVICES SALEM �(t / Massachusetts State Building Code, 780 CMR Revised blur 2011 Building Permit Application To Construct, RepairZjKf tA%ez)1 DAokVhZO One-or Tivo-Fmnily Dwelling This Section For Official Use Only ' Building Permit Number: Date Applic oQ -71 r �(\ Building Othcial(Printtune). Signature Date \� I SECTION 1:SITE INFORMATION 1.1,Prnperty Address, 1.2 Assessors Map di Parcel Numbers �� 141�t ✓I l g�Y ✓Yl CN\ 1 I.I a 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 it) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required - Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTIONI: PROPERTY OWNERSHIP,' 2.�A r\ofRecor�� R7 a(Print) 'C. City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Cl Repairs(s) Cl 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of 'ts Other ❑ Specity: Brief Description of Py)posed Work-: 'iVcli" e-0` LAILI VK` r L SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S Cl Total Project Costs(Item 6)x multiplier x 3. Plumbing $ P Qther Fees: S 4.Mechanical (FIVAC) S List: 5. Mechanical (Fire $ Total All fees:S Su ressiun) Check No._Check Amount: Cash Amount:_ 6.'rut:d Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: �� 0014nd(' SECTION 5: CONSTRUCTION SERVICES 5.1 C`on'struuctiio'nnSupervisor License(C(/gL) �✓� 7 S , �'t"T� T 1 r ," �- / License Number Expiration Date N:mte0CS older t , List CSL'fype(see below) . No. id Street J Type Description . O`G� 0 U Un Restrict Duildin tip to 35,000 cu. It. 0 R Restricted I&2 Famil Dwelling City/'rosvn,State,ZIP M Masonry RC Roofin Covcrin WS Window and Siding �a SF Solid Fuel Burning Appliances -/ I Insulation Tole hone Enwil address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§2$C(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 Isluance of the building permit. Signed Affidavit Attached? Yes..........0 No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO EIRCOMPLETED.WHEN:' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT` I,a Owner o the sub' ct p operty,he by authorize 19 t n my ehalf,i all atters rely veto w uthorized by this building permit application. ( '41r t Ow is ame( ec nic ' mu ) Date — SECTION 7b:OWNER'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 Owner's or Authorized Agent's Name(Electronic Signature) Dale NOTES: I. 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 Home Improvement Contractor(HIC) Program);will nut have access to the arbitration program or guaranty fund under 1M.G.L.c. 142A.Other important information on the HIC Program can be found at ivww mass.env'oea Information on the Construction Supervisor License can be found at www.nias� . 2. When substantial work is planned,provide the information below: 'total floor area(sq. 11.) 9 (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'type of lieating system Number of decks/porches 'type of cooling system Enclosed Open J. "Total Project Square Footage"may be substituted i'or"'rural Project Cost" Client#:415W BAYSTTEN ACORDTM CERTIFICATE OF LIABILITY INSURANCE °410612016) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT USI Rental Specialties HONE FAX 1616 Smith Road,Suite D 888 489-7165 (ac,No,Eztl: (AIC,No):888 489-7105 Temperance, MI 48182 E-MAIL 888 489-7165 ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# INSURER A:St Paul Fire and Marine Ins Co 24767 INSURED INSURER B:Travelers Indemnity Company 25682 Baystate Electronics Inc. DBA: Baystate Tent&Party INSURERC: 150 Lorum Street Tewksbury, MA 01876 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) A GENERAL LIABILITY ZPPlON373431547 04/01/2015 04/01/2016 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE $100,000 PREMISES Ea occurrence) CLAIMS-MADE 91OCCUR MED EXP(Any one person) $5,000 PERSONAL B ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 GE PRODUCTS-COMPIOP AGG s2,000,000 X WC PRO- LOC $ V JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODI LY INJU RV(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ (Per accident) A X UMBRELLA LIAB X OCCUR ZUPION811451547 04101/2015 04/01/2016 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 X RETENTION$$10,000 $ OED B WORKERS COMPENSATION XEUB5899Y49715 01/31/2015 01/31/201 WC STATU- OTHER AND EMPLOYERS'LIABILITY YIN X TORY LIMITS ANY PROPRIETORIPARTNERIEXECUTIVE FFICERIMEMBER EXCLUDED? N NIA E.L.EACH ACCIDENT $1,000,000 i (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 if yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below $1,000,000 A Inland Marine ZIM13N038831547 04/01/2015 04/01/201 Equipment Floater Limit: $900,000 Wind/Hail Deduct Deduct: $10,000 1e/a/$10,00n minimum DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AdtlitlonaI Remarks Schetlule,it more space is requiretl) This certificate is issued as a matter of proof only for the named insured. Certificate should not be changed or altered. If a specific name should be needed contact Insured directly. CERTIFICATE HOLDER CANCELLATION EVIDENCE ONLY PROOF OF COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DO NOT ALTER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NOT TO BE CHANGED OR ALTERED ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S14814116/M14758838 AXLJG COUNCILLORS-AT-LARGE ARTHUR C. SARGENT, III WAR PRESIDENT 2015 THOMAS H.FUREY CHERYL A. LAPOINTE ROSE WILLIAM H.LEGAULT CITY CLERK HEA ELAINE F.MILO T( ARTHUR C.SARGENT,III pA J( E JOSEF January 8, 2015 Mr. F. Joshua Claudio Director of Development HAWC 27 Congress Street, Suite 204 Salem,MA 01970 Dear Mr. Claudio: At a regular meeting of the Salem City Council,held in the Council Chamber Thursday, January 8, 2015, the City Council voted to approve your request to hold� Walk for HAWC and use of city streets on Sunday,April 26, 2015 beginning at 12:Um P.M. Yours trul0q11 y, 0��I? CHERYL A. LAPOINTE CITY CLERK cc: Police Chief Lt. Preczewski - Police Traffic Lt. Brian Gilligan Watch Commander Fire Chief DPS Director Health Agent Planning Park&Recreation Director Special Projects Coordinator SALEM CITY HALL • 93 WASHINGTON STREET•SALEM, MA 01970-3592•WWW.SALEM.M LCL. ty/8) t%'-V1t5VUA(Y/S) /'W-VYL4 KthtBERLEY DRIScoLL FAX 978 744-7225 MAYOR KpART NENQSALEM.COM K AREN PARTANEN DrRECCOR PARK APPLICATION Name of Applicant:F. Joshua Claudio Organization:Healing Abuse Working for Chanjw (HAWC) Address:_27 Congress St.#204 Salem,MA 01970 Telephone Number:978-744-2299 x 314, mail:joshuac@,hawcdv.org Park Requesting:_Salem Common Date(s)requested: Sunday April 26,2015 Time(s): 8:00am to 4:00pm Number ofattendees anticipated: 800n000 Describe event and schedule in detail.Use additional pages if necessary: _The 23rd Annaal Walk for 1L4WC. Setup for the Walk will begin at 8:00am and tM walk will kick off at noon.There will be tables for registration,T-Shirts,infonnatioM for our Sponsors. Two tents will be barreled. Kelly's Roast Beef will provide food a1iiiiiiii the Walk. There will be a DJ, family entertainment and children's activities. ri ®Need electricity(Willows Shell or Common Gazebo) YES Check each amenity your event will want to provide: Tent _X—Portable sanitation units _X Food preparation/service Vendors—Items to be sold:_It will depend on who is a sponsor RReturn complete applic ion vih pnt ,ment to:Parks&Recreation,5 Broad St.,Salem,MA 01= Signahue i Date: Irl f ll� DIRECTOR'S APPROVAL Date: If applicable Park and Recreation Commission approval: Comments: II Certittro.te of jr1ame Rem'!9tance !� REGISTERED AZTEC TENTS Date treated or APPLICATION CONCERN NO. 2665 COLUMBIA ST manufactured TORRANCE, CA90503 ' CAL COMB F-419.01 (800)228.3687 0712008 This is to ceridy that the materials described below hereof have been flame retardant treated(or are inherently nonflammable). FOR BAY STATE APRTY RENTALS 150 LORUM STREET +s TEWKSBURY, MA 01876 ATTN: DAVE KNIGHT f>> 9 � ET 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 �t and registered by the Slate Fire Marshal and that the appficationof said chemical was done in confor. or- mance 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. ........................ Meathodof application................................................................................................ ,, (b) The articles described below hereof are made from a flame-resistant fabric or material registered and approved be the State Fire Marshal for such use; Fabric has been tested and passes NFPA701-96. Trade name of flame-resistant fabric or material used../ambmfetlFebrk .Reg.No.......F:!!&R+ The Flame Retardant Process Used Be Removed b Washing (will or will not) •••• Y g David Bradley Chuck Miller - President Name MApplirator ar Proeutlion SupennleMeN Tine > I �g�c Cif of SaCen chusetts { -Fire De; 'Irtment 0,L `l ette street ay 'Davrd7N Cy�fy Salem tiCassatfiur�tts01970-3595 CA�f t ire Preven ion Fel.973 i44 I23 979 744 699¢ Bureau dcody@salemeom j �dX 9- S f-'4646 978" 74� t*ti<*t*ttic*t*tt**:F iFkttt*ktt***;Ft*ikx*tttt2"t***:Fie*i4**tt�ic£-F*t**tt.''e>Fttt*�***.tic*ttti*.*'tt9ctzt*3 APPLICATION/P-ERMIT TO. ERECT TENTAGE OVER 120 SQUARE FEET IN THE CITY OF SALEM!ACCORDING TO THE MASSAOHITSETTS PIRE PREVENTION REGULATION 527=CMR 1900, AND THE SALEFI FIRE CODE, ART. I! 20 ict&*t*t*t t9ct***t*ttXt**tttttt*t**F&ttt ttttttt****ttxttttt:*tttttxitt iFtttt*tXtt*ttiF.itiictt ttt.:F'. 1, FEE $Bp:00 ' 1 .p C-HECK APP-LICANT_ ADDRESS �?_7� CITY STATE _ ZIP._�IPHONE � /W LOCATION OF TENTAGE: OWNER OF PROPERTY_C L+ _ A7DRESS - - ZIPe PHONE; ' _— INSTALLER/RENTAL CO. OF TENTAGE �CPHONE ADDRESS-- IJV V S CITY: �/r _ STATt;_ ZZP INDICATE WITH REFERENCE TO PROPERTY LINES AND OTHER_ BUILDINGS THE LOCATION O'F I THE TENTAGE ON THE BACK OF THIS FORP1 MATERIAL USED_ I. 1 (� L MANUFACTURES SIZE OF TENTAGE: > { .- NAME OF TESTING AGENCY AGENCY APPROVAL NUMBER g11,UI .CERTIFICATE OF FLAME RESISTANCE - -- CONDITIONS,ONDIT OF APPROVAL OTHER THAN L` AS PER FIRE PREVENTION REGULATION SALEM BUILDING DEPARTMENT PERMIT NUNbER! DATE OF ISSUE y u. i6 S.ITE INSP,,ECTION DATE J lS EXPYRATION DATE y Z1_ I APPROVED BR C TITLE: WtLL FORM ?QB (Rev. 8/99) 80B