WILLOWS PARK - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
I JJJ t Board of Building Regulations and Standards CITY
,n OF SALEM
Massachusetts State Building Code, 780 CMR, 7 edition
Revised Junuun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :f/fhY
�JV
,l ftf-or Two-Fumily Dwelling.
This Sectign For Offtc'al'Ose Only
Building Permit er: I _ to Applied:
Signature: l
Ruilitir447"ormilissionert I specter of Buildings - Date
SECTION 1:SITE INFORMATION
1.1 Property ress:Add 1.2 Assessors Map& Parcel Numbers
G✓IL�OtyZit
I.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 11) Frontage(11)
1.5 Building Setbacks(R)
From 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:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert or Record:
Name(Print) Address for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ AdditioJE3
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work,-
e� T-S r- N lv�t wHz
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Citylrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:E
�.� Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S �� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) A
-72�jV T License Number Expiration Date
/�� List C'SL Type(see below)
/S—D ,LO r("V IM S /
T Uexri ion
Address U (lnrctaricteJ I---W lz. Cu. V.
R Restricted 182 Famil Uwellin
Sign to M M Onl
RC Residential Roolin Coverin
I"dephone WS Residential Window and SiJin
SF Residential Solid Fuel Bumin A liame Installatiun
c Q D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration tote
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 ..........0 No...........O
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.
Sianature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
r yr [ 77
1 YJ v��/) T ,ras-9wner'oT Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behal�fP
Av10 k,rvl�')\�
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and Penalties of 'u
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 WJ have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
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
). "Total Project Square Footage"maybe substituted for"Total Project Cost"
110602
BAYSTATE 6/20/10
6/20/10
North Shore Medical Center Willows Park
Development Office Salem, Ma
81 Highland Ave
Salem, MA 01970
978-825-6116
978-335-3316
6/20/10 Net 30 Days Rose DK Sunday
QTY DESCRIPTION DAYS RATE AMOUNT
2 20 X 20 Ultra White Festival Frame Tent(Reg Photo) 1 275.00 550.00
1 30 x 30 Quicktrack Ultra White Tent 1 650.00 650.00
7 Leg Extensions 1 12.00 84.00
16 10 X 10 Ultra White Festival Frame Tent(vendor) 1 120.00 1,920.00
2 8'x 20' Solid Wall I 20.00 40.00
24 4'x 4' Stage Platform W/Adj Leg(24xl6x2) 1 32.00 768.00
14 Stage Rails 1 0.00 0.00
1 Adjustable Stairs 6 Step w/rails 1 45,00 45.00
170 Chairs Samsonite Bone/Neutral 1 1.00 170.00
150 8' Banquet Table 1 8.00 1,200.00
30 Chrome Stanchions 1 8.00 240.00
2 4x8 Riser 1 64.00 128.00
3 Yellow Rope 1 0.00 0.00
Labor @ 12 Hours 900.00 900.00
Bring 6 milk crates
Discount -900.00 -900.00
MEET ROSE loam 19th
Payments/Credits $0.00
$5,795.00
$0.00
$5,795.00
�� ��c
�-(� H--
M
Sb� �s
Client#:415544 ' 7608
Jr,OBQ.e CERTIFICATE OF LIABILITY, INSURANCE oaiis/io°'"'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Rental Specialties ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 53310 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Irvine, CA 92619
800 854-3298 INSURERS AFFORDING COVERAGE
INSURED INSURER A: St Paul Fire and Marine Insurance Co
Baystate Electronics Inc. INSURER B: Travelers Indemnity Company of CT
DBA: Baystate Tent&Party -
150 Lorum Street INSURER C:
INSURER D:
Tewksbury, MA 01876 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
A GENERAL LIABILITY CK00221462 04/01/10 04/01/11 EACH OCCURRENCE $1 OOO OOO '
X COMMERCIALGENERALLIABILIT' FIRE DAMAGE(My one fire) $100000
CLAIMS MADE FxI OCCUR MED EXP(Any one person) $$000
PERSONAL B ADV INJURY $1 OOO O00
GENERAL AGGREGATE $2 OOO OOO '
GEN'L AGGREGATE LIM ITAPPLIES PER: PRODUCTS -COMP/OPAGG $1 ODOOOO
X POLICY PRO- LOC
JECT
AUTOMOBILE LIABILITY
' COMBINED SINGLE LIMIT $
ANY AUTO - (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-0WNED AUTOS - (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
E
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND XEUB5899Y49710 01/31/10 01/31/11 X WCSTATU- DEH-
EYPLOYERS'LIABILITY E.L.EACH ACCIDENT E1 OOO 000
E.L.DISEASE-EA EMPLOYEE $1 000,000
E]
E.L.DISEASE -POLICY LIMIT S1 000.ON
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
This certificate is Issued as a matter of proof only. `Except 10 days
notice of cancellation for non-payment.
,
I
I
;tom; t t rtl�ttttri�r
i
-
y utM F REGISTERED Date trea!rE c, {
o O ISSUED BY
APPLICATION manufactmeG
Academy Tent 8 Canvas
CONCERN No. 5035 Gifford Ave.
e I 03/17/03 '
F�19.O1I Los P.!Iceles,.CA 90C`° I�
j (322) 277-8368
This is to certify that the materials described below hereof have 7:ecn flame retardant
treated(or are inherently nonflammable). �
FOR BAY
STATE PARTY RENTALS ADDRESS. 1487 MAIN STREET I
— - - --
TEWKSBURY STATE MA 01876 a
CITY _ — — — ---
' Certification is hereby made that: (Check f'a"or "b')
((a) The articles described t;elew this ccr.;icate have bc-entreated writ ame-retarre: a chemical ,
�1 , • J approved and regisle!cc c by the Sty I-ire Marshal and that the aFI '-�llon of selc c!-emical ;_ t
a
was done in conformance with the Ial+s of the Stale o1 Californiaa the Rules a a: riegula
lions of the State Fite I.4arshal. �l
{ Name of chemical used. ............... .......................................... ........
111 Method of application ................. ............... ................... .....
� (b) The articles described I c ow hereof ate made from a flame-reslsta :ihnc or ma ,_r aI regis-
—� lered.and approved by '.hc Slate Fire Marshal for such use; Fabric I- : been lesk c ,and passes
VINYL F419.01 l l
-I Trade name of flame-rrsisianl fabric or material used .......... ...__........_. Reg. :'e l
The Flame Retardant. Process Used ..�'`'!!..' .:.....Be Rerneved by Washing
(will or..i6 nut) I
;i 1-
David GiadIey By Tom Shapiro 1 nt
`i Nanw 0:Appt�cat0, o, p.oducoon auf , ondt!n1