WILLOWS PARK - BUILDING INSPECTION (4) 9� the Commonwealth of Massachusetts
m7, CI"1'1'OF
'i Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Re1,),ed llur ' 11
L; W
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Ott]
Building Permit Number: Date Applied:
i
Building Official(Print Nine) Signature D
SECTION I:SITE INFORMATION
1.1 Property Addres : 1.2 Assessors Map& arcel No e
ll L� 1 0 � �ARIs
I.I a Is this an accepted street?yes no Map Number 'arcc] mbe.r
p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required provided
L6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s stem ❑
Public❑ Private ClCheck if ycsO p p
SECTION2: PROPERTY OWNERSHIP'
1 nett of Record:
i �i �tJic�+�T/�YSUII� i i IFw K u2 i�A of s� �
Name(Print) City.State,ZIP
I TO l oktLM S7 qZo, dez�a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify:
Brief Description of Proposed
1 N L( CAI �� a i an a-fir)
CAMAT`rA
P �ll 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(L.abor and Materials)
1. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3 Plumbing S 2. Other Fees: S
4-Mechanical 0iVAC) S List:
5, Mechanical fPire S Total All Fees: S
Su iressionl
Check No. Check Amount: Cash :\nxnmt:
i 6. Total Project Cost: 5 (ZD),O DO 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Na �-.J--C��l-� _ Licansc Ntn»btr p.xpiralion Date
Name
ne o(CSI. I luldcr
List CSL F'pe(see below) _
No. :mJ Street Type Description
D Unrestricted 35,000 cu. It.)
Urydl own.State.ZIP -- R Restricted I&' Fm»il Dteellin
M hlasunr
RC Roulin Cuverin
W'S Window and Sidin
SF Solid fuel 13uming Appliances
_ I Insulation
cic hone I'rnail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name I IIC Registration Number Fapiratiun Date
No.and Street
Email address
Ci /Town, State,ZIP Telephone
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 Issuance of the building permit.
F
ned Affidavit Attached? Yes .......... 0 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property,hereby authorize
,y aha ,in all n tters relative to work authorized by this building permit application.
P t Owner's Name(Elect is 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner s or Authorized Agent's Name(Llectrunic 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 Home Improvement Contractor(HIC) Program),will ran!have access to the arbitration
program or guaranty fund under M.G.L. c. Ia2A.Other important information on the HIC Program can be Found at
wt�rt.i)7c.I.s.Srip oc( Information on the Construction Supervisor License can be found at �t-trrr.net;;.� m 1lp_
-- -
_' When substantial work is planned, provide the information below:
Total fluor area(sq. ft.) _(including garage, finished basentent'attics,decks or porch)
Gross living area(sq. ft.J __ Habitable room Count
'Number of lireplaces -_- Number of bedrooms
Number of bathrooms
--------------- Number of half'baths
1)pe of heating Sfl ym Nste --------------------
umber ul decks porches
l)peofaurlinsystent — ------
- ----__ ------- -- Enclosed --- -------Open
-focal Project Square Footage-may be sttbstimted for-r„tat Project cost-
113269
BAYSTATE 6/26/11
6/26/11
North Shore Medical Center Willows Park
Development Office Salem, Ma
81 Highland Ave
Salem, MA 01970
978-825-6116
978-335-3316
6/26/11 Net 30 Days Rose VM 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
24 10 X 10 Ultra White Festival Frame Tent(vendor) 1 120.00 2,880.00
4 8'x 20'Solid Wall 1 20.00 80.00
2 of THE WALLS ARE FOR ONE SIDE EACH OF THE 20X20 THE OTHER
TWO WALLS ARE FOR 1 - 1OX10
24 4'x 4' Stage Platform W/Adj Leg(24xI6x2) 1 32.00 768.00
14 Stage Rails 1 0.00 0.00
I Adjustable Stairs 6 Step w/rails 1 45.00 45.00
170 Chairs Samsonite Bone/Neutral 1 1.00 170.00
75 8'Banquet Table 1 8.00 600.00
10 Chrome Stanchions 1 8.00 80.00
2 4x8 Riser 1 64.00 128.00
3 Yellow Rope 1 0.00 0.00
Labor 3 @ 12 Hours 900.00 900.00
Bring 6 milk crates
Discount -1,495.00 -1,495.00
meet rose I OAM on the 25th
2 Permits 60231 $60 60232 $30 90.00 180.00
The balance for the second check will be$920.00. Those are for the add ons.
Payments/Credits $0.00
$5,620.00
$0.00
$5,620.00
k w eRF REGISTERED ISSUED BY
Date treated or
s APPLICATION manufactured
Academy Tent & Canvas
y e z CONCERN No. 5035 Gifford Ave. 03/17/03
9Me ET °e F419.01 Los Angeles, CA 90058
(323) 277-8368
This is to certify that the materials described below hereof have been flame retardant
treated(or are Inherently nonflammable).
FOR BAYSTATE PARTY RENTALS ADDRESS 1487 MAIN STREET
CITY TEWKSBURY _ STATE MA 01876
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 and registered by the State Fire Marshal and that the application of said chemical
was done in conformance with the laws of the State of California and the Rules and Regula-
tions of the State Fire Marshal.
Nameof chemical used............................................................. Chem. Reg. No. ........................
Methodof application.....................................................................................................................
(b) The articles described below hereof are made from a flame-resistant fabric or material regis-
tered and approved by the State Fire Marshal for such use; Fabric has been tested and passes
N FPA701-96. F
Trade name of flame-resistant fabric or material used ................................... Reg. tTo419:01
The Flame Retardant Process Used ... !!lNot...Be Removed by Washing
(will or wilt not)
David Bradley By Tom Shapiro - President
Name of Applicator or Production Superintendent Title
4
wientp: 4'J544 /buiS
DATE(MM/DDIYYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE 04119/2011
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
I CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to
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certificate holder In lieu of such endorsement(s). CONTACT
PRODUCER NAME:
USI Rental Specialties P"A/C NE 800 854-3298INC.No: 9497909222
L Ext
P.O. Box 53310 ADDRESS:
Irvine, CA 92619 IFRO
CUSTOMER ID 0:
800 854-3298 INSURER S)AFFORDING COVERAGE NAIL 0
INSURED INSURER A:St Paul Fire& Marine Insurance 24767
Baystate Electronics Inc. INSURERS,Travelers Indemnity Co of CT 25682
DBA: Baystate Tent& Party INSURERC:
150 Lorum Street msuRERD:
Tewksbury, MA 01876 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS ISTO 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ri POLICY EFF POLICY EXP LIMITS
L TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYV
A GENERAL LIABILITY CK00223544 4/01/2011 04/01/201 EACH OCCURRENCEDAMAGE
$1 OOO OOO
X COMMERCIALGENERAL LIABILITY PREMISES Ea occurrence $100,000
CLAIMS-MADE IXOCCUR MEDEXP(My one person) $5,000
PERSONAL B ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GENL AGGREGATE LIMIT APPLIES PER: 7
- PRODUCTS-COMP/OP AGG $2,000,000
JECT
X POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
SCHEDULED AUTOS - PROPERTY DAMAGE $
MIRED AUTOS (Peraccidem)
NON-OWNED AUTOS
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
b
DEDUCTIBLE
RETENTION
B WORKERS COMPENSATION XNUB5899Y49711 1/31/2011 01/31/201 X WCSTLA, OTH-
AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? FJN� NIA E.L.DISEASE-EA EMPLOYEE $1,000,000
(Mandabry in NMI
I/yes,describe under E.L.DISEASE-POLICY LIMIT $1,000000
DESCRIPTION OF OPERATIONS helow
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace is required)
This certificate is Issued as a matter of proof only.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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