SALEM WILLOWS - BUILDING INSPECTION (3) ~ The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards SAL 1 M
\4i Massachusetts State Building Code, 780 CMR Revised Mar 011
Building Permit Application To Construct, Repair, Renovate O Demolish a
One-or Two-Fancily Dvelling
This Section For Official Use Only
Building Permit Number: - Date Applied: �u
Building Official(Print Nume) Sign a Date
SECTION 1: SITE INFORMATION
L1 Pr�oPart/y AJJress: // CSurL�r t'�'elaC' 1.2 Assessors Map& areal Numbers
J4 !�✓mac Wr
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L 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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
sln
N;mie(Print) / City,State,ZIP
S Ieµ uxltocuS C2c6zr ECIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑- Specify:
Brief Desc iption of Proposed Work'': (f�l- u0 »�- 3n�K50' (2,i.a.4 `- y5'reu.kcDo , c..
7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical $
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �J
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $ 'Total All Fees: $
Suppression) '
e/' _\ Check No. Check Amount: Cash Amount:
6. Total Project Cost: S SJ 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ul'C'SL IioWer
List CSL"fype(see below)
No.and Street Type Description
U Unrestricted(Buildings no to 35,000 Co. It.)
Cuy/fu R Restricted Fanal Dwelling
ten,Slate,ZIP I&2;MJ
Covering
and Sidinel Burning Appliances
n
felt hone Email addresson
5.2 Re istered Home Improvement Contractor(HIC)
Je 4S �C�Z IIIC'Registration Number Expiration Date
I-IIC'Company Name or I IIC Registrant Nmne
No. and Sue et q
6KPI, Email address
Py'1T) l`f b O 7�S5-Sb S
City/Town. Stifte,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION 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 IssuartH 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
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 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 Otsner s or Authorized Agents Name(I:c-ironic S i Mate
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142.q.Other important information on the HIC Program can be found at
}ygss_. SSLLs ^ov_oca Information on the Construction Supervisor License can be found at wastv.nciss. V: ,Jps
?. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basemenUattics, decks or ponh)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed___Open
3. "Total Project Square Footage"may be substituted for, Project Cost"
Events For Rent Status: Reservation Page 1 of 2
464 Lowell Street 978-535-5035 phone Contract M 216489
Peabody, MA 01960 978-535-4561 fax Event Date: Fri 613/2011 8:OOAM
www.eventsforrent.com
Operator: KEITH R.
Customer# 9283
FIDELCO 860243. 8 860769-0567
103 OLD IRON ORE RD
Bloomfield, CT 06002
Qty Key Items Rented Part# Status Event End Date Price
1 1900400 TENT FRAME 30X50 1900400 Reserved 6/6/2011 5:00PM $955.00
25 180012000 TABLE BANQUET 30X96 180012000 Reserved 6/6/2011 5:OOPM $200.00
TABLES MUST BE PROTECTED FROM WEATHER AT ALL TIMES
TABLES RETURNED DAMAGED ARE SUBJECT TO REPAIR COSTS
PLEASE DO NOT STAPLE INTO TABLES FOR THE SAFETY OF OUR CLIENTS AND
STAFF
100 060020000 CHAIR SAM FLDG WHITE 060020000 Reserved 6/6/2011 5:OOPM $160.00
TO MAINTAIN QUALITY,PLEASE REFRAIN FROM APPLYING STICKER-LIKE
MATERIALS OR OTHER SUBSTANCES TO CHAIRS
Qty Key Items Sold Part# Status Each Price
1 650025000 LABOR CHARGE 650025000 Selling $200.00 $200.00
1 650025000 PERMIT FEES 650025000 Selling $150.00 $150.00
1 101970 DELIVERY&P/U SALEM,MA Delivery $50.00 $50.00
DELIVERY AND PICKUP
Delivery Date: Fri 6/3/11 Contact: DON ARMELL
Pickup Date: Mon 6/6/11 Phone: 617 959-0489
Company: SALEM WILLOWS
Address: SOCCER FIELD ; Salem, MA 01970
SET UP IS ON SALEM WILLOWS SOCCER FIELD
TIME WILL BE COORDINATED W/DON ARMELL
DELIVERY IS TO SALEM WILLOWS SOCCER FIELD
SET UP WILL BE COMPLETED BY 11:OOAM
EVENT IS ON SATURDAY 6/4/11 1:30 -6:30PM
PICKUP WILL BE ON SATURDAY 6/4/11 AFTER 6:30PM
*** CUSTOMER IS RESPONSIBLE FOR GETTING DIGSAFE TICKET#, (888) DIG-SAFE ***
EFR WILL OBTAIN BUILDING AND FIRE PERMITS ***
***ORDER WAS PLACED BY: JAN ADAMS CELL#860-830-2282***
' NON-REFUNDABLE RESERVATION FEE WAS CHARGED TO CARD#'"'"'**"*"5340 EX 03/13***
*** BALANCE WILL GO ON CARD BEFORE DELIVERY***
***ANY ADDITIONAL ITEMS WILL BE CHARGED TO CARD ***
NAME ON CARD:
JULIE GAMBLE
FIDELCO
SAME BILLING ADDRESS
Reservation fees are non-refundable
Printed on 5/25/2011 7:45:22 am Modification#4
Software by Point-cf-Rental Systems WWW.POINT-OF-RENTAL.COM c:\por,Reports\Contract-Params.rpt
Contrpct fl: 216489 FIDELCO Events For Rent Page 2 of 2
Payments made on this contract:
Rental/Sale Paid $700.00 on 21-Apr-2011 8:43 am Credit Card Visa xxxx-xxxx-xxxx-5340 Auth:094887
Total Paid $700.00
1 agree to pay the above amount according to the card issuer agreement. SIGNATURE:
RENTAL CONTRACT Rental: $1,315.00
'This is a contract.The back of this contract contains important terms&conditions including lessor's disclaimer from all liability
for injury or damage&details of customers obligations. These terms and conditions are a part of this CONTRACT! Damage Waiver: $0.00
`If equipment does not function property notify lessor within 30 minutes of occurrence or no refund or allowance will be made.
'RESERVATION FEES are NON-REFUNDABLE if cancelled. Sales: $350.00
'ALL rental items should be considered USED unless otherwise noted.
'ALL deliveries are strictly TAILGATE deliveries unless otherwise arranged. Delivery Charge: $50.00
'EFR is not responsible for and will not secure rental items in/on customer vehicle upon pickup of items-customer is responsible
for securing items to his/her vehicle for safe transport to&from Events For Rent. Misc.Charges: $0.00
'Unless declined,I agree to the Damage Waiver charges for the rental items for which Damage Waiver is offered. D.W.C.is
offered on only selected items. Subtotal: $1,715.00
'Events For Rent reserves the right to apply appropriate charges to Master Card,
Visa,Discover or American Express for late,lost or damaged items.
'Upon receiving rental items,I acknowledge receipt in good order of the items rented. Massachusetts
'1 certify that I have read and agree to all terms of this contract. $82.19
6.25%:
TOTAL: $1,797.19
SIGNATURE: PAID: $700.00
FIDELCO AMOUNT DUE: $1,097.19
Printed on 5/25/2011 7:45:22 am Modification#4
Software by Point-of-Rentel Systems WWW.POINT-OF-RENTAL.COM c:\por\Repons\Contrad-Parems.rpt
1 M PO RTANT DOCUMENT'
5 Cert�if ieate of 'Flame Resistance 5
ee 5
ISSUED BY Date of Shipment
5 5 REGISTRATION CNORa 5/13/2008 5
NUMBER f INDUSTRIES INC. 5
5 , Tent Identification 5
EVANSVILLE, INDIANA 47725 5
MANUFACTURERS OF THE FINISHED 04629478
5 F-12t l0 TENT PRODUCTS DESCRIBED HEREIN 555
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to:293200
5
5 NORTH SHORE RENTAL INC c5
5 DBA EVENTS FOR RENT S
5 464 LOWELL ST 5
150 5
W PEABODY MA 19602741
5
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, CPA184, ULC 109. 5
5 Serial # 5
5 8025300(5)
5 Description of Item certified: 5
5 FIESTA EXPANDABLE MIDDLE
5 30WXIO WHITE VINYL 5
5 Flame Retardant Process Used Will Not Be Removed By 5
55 Washing And Is Effective For The Life Of The Fabric
JOHN BOYLE STATESVILLE NC Signed:
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
cPr P�PrJ��PrJ cfcPc c r rcrc Pc PrP�P�J@PPcPPr
000jale EggJ@PlP:: j:iggj:PJI : EirL PJPlJPPMJ� � �JP O
MUM
(�
ertif catr ]of if lame E t t �tce
ISSUED BY Date of Manufacture
REGISTERED �{(�' y ANCHOR INDUSTRIES INC. 4n4i97
APPLICATION �y17� L EVANSVILLE.INDIANA 47711 Order Number
NUMBER (���o
MANUFACTURERS OF THE FINISHED
F12L4 TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have boeen flame-retardant treated
(or are inherently noninflammable) and were supplied
PAUL W. GRILLO CO. 43728
464 LOWELL ST.
PEABODY
MA 01960
Certification is hereby made that:
The articles described this application of said chemical was tficate have been treated Idonefin conformance
approved chemical and that
app
at the app
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109
The method of the FR chemical application is:
y
Serial tt: 8025300 (0003)
Description of item certified:
FI EXP MID 30W X 10 VL W W wb
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Name of Applicator 01 Flame Resistant F RTM inish TENT AENT—ANCHOR INDUSTRIES INC. ,,
s
C�EE'tifiCtttE of lameResistance
ISSUED BY Date of Manufacture
REGISTERED ,Q ('r
APPLICATION ¢¢Q��QQ(���� ANCHOR INDUSTRIES INC. ai2a�97
NUMBER 1�pf�1 EVANSVILLE,INDIANA 47711
66''��!! !~ Order Number
MANUFACTURERS OF THE FINISHED
FI2L4 TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated
(or are inherently noninflammable) and were supplied to:
PAUL W. GRILLO CO. #3728
464 LOWELL ST.
PEABODY MA 01960
Certification is hereby made that:
The articles described on this Certificate have been treated with aflame-retardant
approved chemical and that the application of said chemical was done in conformance
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109 mi
The method of the FR chemical application is:
1 Serial#: 8025000 (0001)
Description of item certified:
p
FI EXP TOP 30W X 30 VL W W `
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Signed: ��,N, 6G p...�t.,
Name of Applicator of Flame Resistant Finish TENT=? AI RTMENT—ANCHOR INDUSTRIES INC. mti
f11 �j
v s r
.A .. .. .. .. b.. ..\ ..