WILLOWS PARK - BUILDING INSPECTION I I ile C'onunonoealth ot•ibhusachuscas
Board of Building Regulations ;Ind Standards CI I'1' OF
Massachusetts State Building Cute. 790 C'M1IR Revi.wit thir'nil
Building Permit Application To Construct. Repair. Renovate Or Demolish a
Urrv-ur ruv-b'umih Umcllin.V
This Section Fur OI'f ' I Use Only
nd� Building Permit Number: _— U c Applied:
Building Onicial(Print Mune) S'ignaturc Uul
L ` SECTION I:SITE INFORMATION
JL 1 p 1WSdre7a..K 1.2 Assessors Slap S Parcel Numbers
I.1a is this an ales teed street?yes no Map Number Parcel Number
1.3 Zoning Information. 1.4 Property Dimensions:
Zoning District Imposed tJ:;v Lot Area IN 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.I.c. 40.154) 1.7 Flood Zone Inrormatlon: 1.3 Sewage Disposal System:
Ihtblic❑ Private❑ Zmta: _ Outside Flood-Zone? Municipal❑ On site disposal s)stem ❑
Check if ycsO
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
g',7v/' O�
NanJJ-e(Pri t) "� City.State.ZIP
X;1 Gi(JwS f ft2iL
Nu.and Street rclephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ speeiiy:
Oriet'Description of Proposed \Vork':
Met T/ 'rG'1✓$Z; Z
SECTION 4: ESTISUTED CONSTRUCTION COSTS
heal Estimated Costs: Official Use Only
I labor and Materials)
I. Building S I. Building Permit Fee: S Indicate how ree is determined:
_'. Fleetrical S ❑Standard Ciry.Tuwn Application Fee
❑Total Project C'ust'I item 61 x multiplier _..-- x
1 Plumbing S '. Other Fees: S_
1. \tecllmlical ill\ \t'I S List:.— '----
� 5 \lcchauic.tl IFve S —'
�u rd>s ion I anal .\II Fees: S_.._------
Check No. (heck .AmolmC C,I�h \momil:
Ibul I'rvsject Cost: i ®K _- — — _
lJ ❑ Pail in Full ❑OwsCmJing Ilal,tnee Due:
SF:( PION S: ('ONSI'RI C'fION SERVICES
re
Su � �� - - .l.)ami .t li lu15,11110 cu. ILI
y)'(�T li Rnlricl.J IRS P.ImilD,wllin
Cihifue n.Slate.Lll' ._—. . .-- .\I \lusun
RC RtMlin l'uverin
...—. N'S N'induw.iJ tiiJin
0/ 7lf l-�o0 2 SF Solid fuel I)uming.\pplianccs
I Insulation
fcic hums Fmuil addrel., D Demolition
5.2 Registered Home Improvement Cuntntctor(HIC)
IIIC Registration Nunthcr 1!gpinttiun Date
I IIC Compun) Name or I IIC Registrunt Nine
No. itd Street Email address
City/Town. State ZIP rcie hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 23C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this al7ldavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
M
my behalf,in all mutters relative work authorized by this building permit application.
Print Owner's Nine(ENctrumc 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.-
I'rinI D,I iWi or AuIhorired.\gene's Noma Ificctnntic Sign;mve) Date
NOTES:
I. .\n Owner whu ubtains a building permit to do his.her own wurk,or an owner who hires an unregistered vvntrnctur
(nut registered in the Hume Improvement CuntmcturlHIC) Program), will rrrr have access to the arbitration
program ur guaranty fund under M.G.L. c. 1 s?A. Other impurtant information on the HIC Program can be lilund at
11,,1", ;O, ",.I Information on the Cunstruction Supervisor License can be found at,,,, � nie•+ '�: , ,Ip•
2. U hen substantial Iwrk is planned,provide the int'urmadun below:
rota) flour area (ay. Q.) - I including garage, finished basement attics, decks or porch I
Gross iiv ing area 114. 11.1 __.... _—. . _ habitable ruum count _ .. ... . -
Vunrhnul'lireplaces .. - \unlherol'hedrounu . .
\umherofhathraums \'umberol'half haths _
I')pe of heating s)rlem \'umher ofdccks- porches
I (lien
"I'od,ll 'rUie�l ti1111;1fe I',h q.lge 111;1\ he ,IlhQll tiled tUf ,l',d.11 Project ('ll,l" �
The Commonwealth of Massachusetts , Print Form
Department of Industrial Accidents
Office of Investigations
kwil I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
state Tent
Nan7e (Business/Organization/Individual):Ba y
Address: 150 Lorum Street
City/State/Zip:Tewksbury, MA 01876 Phone 4:978-851-2002
Are you an employer? Check the appropriate box:.,, , Type of project(required):
1.21 1 am a employer with 20 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors -
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12 ❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name orthe sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:St Paul
Policy#or Self-ins. Lic. #XNUB5899Y49712 Expiration Date:1-31-13
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ceril under Jhe emas and enalties oLgerLury that the information provided above is true and correct.
Sinnature 61 Date (P 2�,
Phone 4:978-851-2002
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
' 2012 tdorfh Shore Cancer
WALK Salem Willows Park. e
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Invoice # 118861
Balystate Tent & Party EVENT INFORMATION
150 Lorum Street BAYSTATE 6/24/12
Tewksbury, MA 01876 TIME OUT Sat 9AM
(978) 851-2002
RETURN 6/24/12
BILL TO TIME IN Sun aft 12PM
North Shore Medical Center Willows Park
Development Office Salem, Ma
81 Highland Ave
Salem, MA 01970
PHONE# 978-825-6116
ORDER DATE PAYMENT AMOUNT REP ALT. PHONE# 978-335-3316
6/24/12 Net 30 Days Rose VM EVENT DAY Sunda
CITY 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
20 10 X 10 Ultra White Festival Frame Tent(vendor) 1 120.00 2,400.00
2 8'x 20' Solid Wall 1 20.00 40.00
2 of THE WALLS ARE FOR ONE SIDE EACH OF THE 20X20
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
150 Chairs Samsonite Bone/Neutral 1 1.00 150.00
70 8'Banquet Table 1 8.00 560.00
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 -1,250.00 -1,250.00
meet rose 9AM on the 23th
2 Permits TBD 0.00
Payments/Credits $0.00 Subtotal $5,105.00
Sales Tax (5.0%) $0.00
Total $5,105.00
Cllernq:4155" 7608
ACORD. CERTIFICATE OF LIABILITY INSURANCE °OVIO/2012ATE "
04/7 012 01 2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER71FICATE 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(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the wrtiflcate holder k an ADDITIONAL INSURED,the posicy(les)must be endorsed.N SUBROGATION IS WANED,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 endorsemerd(s).
PRODUCER MVICT
USI Rental Specialties E ---
Na EId:800 8543298
P.O. Box 53310 Ii4kllftll.
Irvine, CA 92619
800 854-3298 BL4U 8 AFFORDING COVERAGE NAIL i
INSURER A:St Paul Fire&Marine Insurance 24767
wwaEo IJSURER8,Phoenix Insurance Company 25623
Baystate Electronics Inc.DBA: Baystate Tent&Party INSURER c.
150 Lorum Street MSURER D:F:
Tewksbury, MA 01876 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 CONDITION OF 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.
wSRADM Lie
LrR TYPE OF INSURANCE INSR WVQ POLICY NUMBER YAMM I UNITS
A GENERAL UASILM ZPP10N373431247 1/201204/01/201 EACH OCCURRENCE s1000000
X COMMERCIAL GENERAL LIASILRY MR10.11T5.D Pfe s 10O OOO
cLaM MADE OX OCCUR MEDEXP jAnyone roan $5000
PERSONAL&ADV INJURY f 1 000 B00
GENERAL AGGREGATE s2,000,000
GE :'GREGATE LIMIT APPLIES PER: PRODUCTS.COMPIUP AGG f2000000
X POLICY PRO- LOC f
,eCTAUTOMOBILE UABILITY MNNED SINGLE LIMIT
n11,
My AUTO BODILY INJURY(FW Parson) f
ALL OWNED SCHEDULED BODILY INJURY(Per ao .ol) IIAUTOS AUTOS
HIRED AUTOS NON-OWNED PROPERTY GE f
AUTOS
f
A X UMBRELLAUAB X OCCUR ZUP10N811451247 01/201204101/201 EACH OCCURRENCE $1000000
fEXCESS LU1B CLAIMSMgDE AGGREGATE f1 000 000
DED X RETENTION 1g000 f
BWOR�S COMPENSATION XNUB589OY49712 11311201201/31/201 X WC STATU- OTH.
EMPLOYERS'LIASIUTY PROPRIETOR/PARTNERIEXECVTIVE Y/N E.L EACH ACCIDENT $1000000
ICERlMEMBER EXCLUDED? a NIArwata In NH) E.L.DISEASE-EA EMPLOYEE $1000000
n YYes.� IPTI ON OF O GESCiPrIO OF OPERATIONS OaIow E.L.DISEASE-POLICY LIMIT f1 DDD DOD
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(A itch ACORD 101,AddidanW R*amk.achs&lo,a,Rsn spay Is ngldnd)
Boston Childrens Museum and CBRE Facilities Management that are required by written contract are named as
additional insured/additional protected person or organization for general liability.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIPA17ON DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORUEE�D REPRESENTATIVE
01988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
JLCT111T7auT11177A - AYl .lr-
cerfifu*- : of i rYce
T
�v�d �•ERt REGISTERED
ISSUED BY Date treated or -
•� APPLICATION manufactured
�•y� i CONCERN No, Academy Tent & Canvas
5035 Gifford Ave. 03/17/03
f R ET PP 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 111A 01876
Certification Is hereby made that:(Check "a"or "b")
(a) The articles described below thls 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.
Name of 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
NFPA701.96.
Trade name of flame resistant fabric or material used ...............VIIHYL....... Reg. 419;01
The Flame Retardant Process Used ..Will.Not...Be Removed by Washing
(will or will not)
David Bradley By Tom Shapiro - President
Name of Applicator or Production Superintendent Title
�, OhDITA� Citp of Agsalrm' AmoarbugCM6
a
•.
� Office of tlJe (fitp Couttri!
Citp 3ball
COUNCILLORS-AT-LARGE JERRY L. RYAN WARD.COUNCILLORS
PRESIDENT
2011 2011
THOMAS H.FUREY CHERYL A.LAPOINTE ROBERT K.MCCARTHY
JOAN B.LOVELY CITY CLERK MICHAEL SOSNOWSKI
STEVEN A.PINTO JEAN M.PELLETIER
ARTHUR C.SARGENT III JERRY L. RYAN
JOHN H. RONAN
PAULC.PREVEY
JOSEPH A.O'KEEFE, SR.
Ms. Roselyn Fisher
Special Events Associate
North Shore Medical Center
81 Highland Avenue
Salem, MA 01970
Dear Ms. Fisher:
At a regular meeting of the Salem City Council, held in the Council Chamber on
Thursday, September 8,201.1 the City Council voted to approve your request to hold a Cancer
Walk on Sunday,June 24,2012 starting at 5:00 A.M. and the 5K road race beginning at 7:30
A.M. The use of the Salem Willows the day before and the use of the Salem Commons on
Sunday must be approved by the Park and Recreation Department. The use of tents must be
approved by the Fire Department. Please make sure that loud speakers are not used early in the
morning:
Yours truly,
CHERYL A. LAPOINTE
CITY CLERK
Cc: Police Chief
Police Traffic
Watch Commander
Chief Fire Dept.
DPW Director
Health Agent
Planning
Director of Park, Recreation& Comm. Services
SALEM CITY HALL • 93 WASHINGTON STREET • SALEM, MA 01.970-3592 •WWW,SALEM.COM