37 WASHINGTON SQ SOUTH - BUILDING INSPECTION zS C,1< 1 s- /
a� The Commonwealth or Massachusetts
's 's Board of Building Regulations and St RECEIVED CI'rY OF
Q ' CTIONAL SERVICES SALEM
Massachusetts State Building Code, 78 M Revised filar 2011
Building Permit Application To Construct, Repair, Reno ��Dim'pli¢(s41 29
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Dale
SECTION I:SITE INFORMATION
1. P petty Address: 1.2 Assessors Map& Parcel Numbers
�2/f}�2 .n r 14 S� SBGt7M �5— D679
1.1a Is this an accepted street?yes_ no Map Number Pwccl Number
1.3 Zoning Information: L4 Property Dimensions:
Loning District Proposed Use I..ot Area(sq tt) Frontage(It)
- 1.5 Building Setbacks(ft)
Front Yard Side Yids 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'?Check it'yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow rI :f Record:
Name(Print) �� p--�� City,Stale,ZIP
No.and Strcot lblephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owne�crUnits
❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Numb Other ❑ Specily:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how ice is determined:
7. Electrical $ ❑Standard City/town Application Fee
❑Total Project Cost'(Item 6)s multiplier_ x
3. Plumbing $ 2. Other Fees:
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire _
Su ression) $ 'total All Fees: $
Check No. Check Amount: _Cash Amount:__
6. Total Pro
ject Cost: $ �3d�r 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nmnc of CSL Holder
r . ty In List CSL"type(see below)
No.and Street Type Description
IJ Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted l&2 F�E Dwellin
City/Powu,State,ZIP M Mason
ry
RC Itoofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
R 3 D1 r n e. + 24 Rt a r • G�LaN?Ary 1IIC Registration Number Expiration Date
I IIC Co,_mj�any Name or I IIC Registrmtt Name
No. d�trL / m a O / ��� Email address
Ci[ /Town, State,ZIP 'I Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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...........❑
.y
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 Name(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
con . ed in this ap>�ati is[rued accurate to the best of my knowledge and understanding.
Print Owner's or Aut u ired Agent's N:une(Electronic Signature) Date
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 Flome Improvement Contractor(FIIC) Program),will not have access to the arbitration
program or guaranty fund under N.G.L. c. I42A.Other important information on the HIC Program can be found at
www.nrass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count_
Number of fireplaces____ Number of bedrooms
Number of bathrooms _ Number of halt/baths
Type of healing system _ Number of decks/porches_
"Type of cooling system—. -- Enclosed _Open . _--
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Don Goldman
Executive Director
PO Box 4452 / Salem,MA 01970
Phone: (978)306-3142 Sr
Cell: (781)405-1909OOon,
Email: r!on.goldman@a3dinc.org °n0anunW
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On the Salem Common For More Info: WWW.Salemcult -refest.com
Arts/Crafts and Food Vendors/Family Entertainment/Live Music/Children's Activities&More
Saturday, July 19th 10am to OP
Sunday, July 20th IOam to 6pm
Saturday July 19 / Main Stage o Sunday July 20 / Main Stage Program
MC: De Ama Battle, Founder/President I fi* Co-MCs: Holly Harris,Educator&Sat Night Host atWUMB
De Ama Battle,Founder/President ABDM
11:15 am-11:45 am A313 Drumming 11:15 am-11:45 am A3113 Drumming
led by Mamadou led by Mamadou
11:45 am-12:00 pm National Anthem m
sung by Maria Chaves A
11:45 am-12:00 pm National Anthem
sung by Martine Bernard
12:00 pm-12:30 pm Sisters In Dance 12:00 pm-1:15 pm Hipshot
(Belly Dancing) (High Energy Horns/Singi1, �,
1:45 pm-2:30 pm Greg Coles w. 2:00 pm-3:00 pm Julio Bare
(Dance) (Dominican/Caribbean)
3:30 pm-5:00 pm Hot Like Fire 4:00 pm-5:30 pm Hills&Valleys Roots
(Reggae) Reggae Band(Reggae)
6:00 pm-7:30 pm Michael Gabriel �— v Children's Program Schedule
(Reggae) 1:15 pm-1:35 pm The Dragon Within
Children's Program Schedule (Karate Demonstration)
12:45 m-1:15 m Joe Hayes 1:35 pm-2:00 pm Salem Police K9 Demonstration
p P y 3:15 m-3:45 m Peter Stewart(Special Guest
(Native American Storytelling) P P ( P )
1:15 pm-1:45 pm Siren of the Circle (Children's Music)
(Hoola Hoop Demonstration) AM,Inc.
baly Children's Events African Development through Drum and Dance
In the'Irs A Small World"Kids Section t aft It$SPONSORStr ill1 0ppon
10:00 am-4:00 pm Moon Bounce/Children's Face adsutr sr BEVERLY
Painting/Henna/Assorted International Games e � � Am�m� d^B�"� ,
11:00 am-2:00 pm Pony Rides ^ p
11:00 am-2:00 pm Macaroni Kids-Crafts OEastem Bank SalemFive cJ�a�ert
(Each Day: Parade around the Common,followed with a Difiata party "�� "`"
i7rr£CAMEI'LEPIF72 Kid er0 nca
Saturday 3:15-3:30 Sunday 3:45 4:00 � ��Ra u rw g p,i....
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EUREKA! TENTS/a div. of Johnson Outdoors Inc. `C '1
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest �.ST�R
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DEALER NAME:JQds Stuff Amusements LLC
ADDRESS.. 8 Cobblers Lane
CITY: North Reading STATEIZIP: MA 01864
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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-C43006G and hence superseded by A-A-55308.
Descdptionofdem ce&fied.. 20' x 30' Traditional Party Canopy—W130 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,J0AWS011kTD10R1 INC.
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ISSUED BY:
EUREKA! TENTS/a div. of Johnson Outdoors Inc.
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest ;5 eRF
Tent Products-Described-Herein C?
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DEALER NAME: Kids Stuff Amusements LLC
ADDRESS. 8 Cobblers Lane
CITY, North Reading STATEOP. MA 01864
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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.
Descnption otdem 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 QD ORS INC.
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EUREKA! TENTS/a div. of Johnson Outdoors Inc. r
BINGHAMTON, NEW YORK 13902
Manufacturers of the Finest ;ELF
- — - -- Tent-Products-Described_Herein ��'=°
DEALER NAME: Kids Stuff Amusements LLC
ADDRESS: 8 Cobblers Lane
CITY: North Reading STATE/ZIP: MA 01864
O ♦ O
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-C43006G and hence superseded by A A-55308.
Description ofdem certified: 20' x 20' Traditional Party Canopy—WBO solid white 13 oz. vinyl
Date of manufacture June 09, 2006 - Serial#009823
Flame Retardant Process Used Will Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
TENT DEPARTMENT,JOHNSO D ORS INC.