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167 FORT AVE - BUILDING INSPECTION (03) nq The Commonwealth of Massachuse t -A ��: �� =i ! ,i" Department of Public Safety b AUG =5 \lassadnisctls Slate Building Gn!e(i tip C\IR) Building Permit Application for any Building other than a One-or tinily Dwelling 0 (This Section Fur Official Use Only) t I Building Permit Number. _ Ddle Applied: 1 Building Official: SLCTION 1:LOCATION(I'lease indicate Block�and Lot r:for locations for which a,tree taddress is not ayeilabI ((per FORT VE ML-J�j /1 0117() ILLGJNS Nu.and Stwet City/Town Zip Cmlc Nanteof Building(if applicable) SECTION 2:PROPOSED WORK Edition of\I:\State Code used_ If Ncry Construction check here❑or check all th.tt apply in;he Ileo rotes btdotr I Existing Building❑ I Repair❑ :\Ih•rebnn ❑ ( :\ddilimt Cl Denu>litinu ❑ (I'Irasc(ill nut and submit Appendix I) Change of Use ❑ 1 CltangeofoLcupancc ❑ IOther Specify: b Arc building pla n5 anJ(ur construction dt><untenls being e'upplied as part of this permit application? \es ❑ No Cl 1S.111❑xlepcndcnt Stn¢ht rat Enginrerin>;Peer Reeia+ ttqurteda _ Yes C� No ❑ Brief Dtscriplion of ProposediVoi:: LLX�rT �i �OR"'R j TCNE / 7/1 ?C!qn ANIS °L - �a0X3h) F:Y)1L a�Z tk<a �✓z.<.cT hA -n SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVA"CION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 C\IR 34) ❑ Existing Use Giymp(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement Icvels)&Area Per Floor(Sq.ft.) I Total Arca(sq.ft.)and Total I1eight(ft.) SECTION 5:USE GROUP(Check as app licable) A: Assembly A.t C A-2❑ Nightclub ❑ A-; O A40 A-i❑ I B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: If i h Hazard H-1❑ [1-2❑ H-3 ❑ H-1❑ H-S❑ 1: Institutional I-1❑ J-1❑ 1-}❑ (-1❑ M: Rfer<antile❑ R: Residential R-10 R-2❑ R.3❑ IZ-a❑ S: Storage 5-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: S'pecia!Use SECTION 6:CONSTRUCTION TYPE(Check as applicable) [A Cl IB ❑ IIA Cl IIB ❑ IIIA Cl DIB Cl IV ❑ I VA ❑ VIS ❑ SECTIO:.7:SITE INFORMATION(refer to 750 CNIR 111.0 for details un each iter) _ Nater Supply: Hood"Lune Information: Sewage Disposal: I'renclt['ermiC Debris Remo,al: Public❑ Cherk if nu Lside Hund Zone❑ • Indicate Ino nicipal❑ \Irtndt trill not be Licensed Uispnsal Site❑ ruyuired❑ur trench nr specify:__ Prnme❑ or indentih'lune: or on site system❑ I pcni nrt s cucluscd❑ Railroad rght-of-way: ardc to air N.wiytion: 4,; — I ❑ [I az Not \pplcablei,. . . illtinairpurtapproacltare.i? Is their reriesv rvvnp!oted? or Consent WBuild.•ndnacd❑ 1'cs❑ or Nu❑ , t'es❑ No ❑ t SECTIONS:CON-116NVr OF CBtcrIFIC.\1'E OF OCCUI'A:NCY F lmmo of Cudc' Use Group(s): . _._ h'po of tun+Inr<tiuir _ ._ Ouupent fro,Ilvuc hoes the lrnddhng antlanl an Sprin;.!er Sysh•m?: Special Stipulations' __�._ ______— 1 pYULEV 1 SEC'IIONv: i'IZOI'ERl'YOWNERAU'Tf101iIZ:YrION Niunu and:\JJmes of Property Urcncr G M �l 11 L�L-0 I,J S j•' k ;Name(I'mit /� Nn.and Street (� � Cit1'J fonrn Zip �J OF c�r [l ^ p X � I'rupcnt�Oorno�C5lftaet Ll�telaho°: •V l M I\ \ C —:_ itli' Mephnne No.(business) 'foicphone No. (all) c-:nail address It applicable,the properly owner heretic authorizes Name Stroot Address City'/Town Stala Zip t-0,10011 fhe property mvner s behalf,in Al matters rel ltiv•to work aII I bvthL'bUdIlilll,1 permitopplicatioll. SECTION 10:CONSTRUCFiON CONTROL(Please fill out Appendix 2) I (if bulldwg is less than 352W a:.ft'If\•ndnsed s mcc and/or not under Constmction Control 0m,cherk hen 0 nod ski rSetYivn 10.1Registered P`rofvss�siona/l,Responsible for Cunstruction Control '1 .�-3..fa0� 11Vr�7�.S�A(DACr7Fnf \'nun(R•ytstrant) Fcle hone No. a-mail address 1 utratiun 'umber nfrac�✓)«�1yE �, tm)✓ A Rel., Sheet Address City/Town State Zip Discipline Espiretiun Date 1 110.2 General Contractor SES}COAST ff 925/V77C Cauapanv Name INHUNFAw IVarve of Person •spnnsible for Construction Licinu? mid Tvpe if Applicable 15Ai E: PLOW H 03ff05f Street Address Cit Rracn � ➢/ ip 6H-aa 36 — /Ua2 ®r c'Sta�teZSS at4 Tele hone No.(business) Telephone No.(cell L mail address SECTION 11: T.'S_r i:Upb SS.\I lO', It.I It Fit y\`.l I M.G-L.e,152- 25C 6 A llorkets'Compensation Insunmcc.Vhdavit from the MA Duperhnent of Industri.t Aaidenfs moat be completed and s,.bmitted a.ith this application. Failure to provide this affidavit will result in fliv denial of the Issuance of the buildung permit. Is a si Inca:l tfidevit submitted with chis a r licelion? Yes Cl No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Coils:(Labor 1 and.\laterials) I Total Construction Cost(from item 6)=S I. 0uiid ung ) y —� Building Permit Pere=Total Constnalion Costs (Insert here 2.Electrical $ appropriate municipal Lector)—$ _ � 4. Vlundrini, $ i,.Me ll,ulkal (flVAC) 5 V,rla:\li'm mll fee=5 (contact nnmicipalio, 5.}Icde.wieal (Other) S \ Endow dr,:k payeblc to o.'fatal Cost ti U (contact!nunicipality)and write check number here— SECTION ere -_ SECTION 13:SIGNATURE OF BUILDING PERMIT A PPLICANT - - Bc rrdcring nay name brlow,I hcrrbv attest under the peins and penalties of perjure that all of the information a otainod io 111.1 application is true,md accurate to the best of III),know!ad,e and understanding. Uu �NLU� of III), Plo�ase Vrinl am sign name Fi ole 'frlephune Nn. ]a r• I titlwt Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: 61 "`w y \`_ Name Doe CITY OF S:iLEAi %LASSACHUSETTS BI:LLOING DEP.t RT\LENT •i3'S:Elft`;' tie kV NSHL4GTON STREET, ]�FLOOR TEL (978) 745-7795 r-Ax(9 78) 740-984.6 !U>IBERLEY DRISCOLL �Li'fO t DHOIUS STTI&R-R—E DIRECTOR OF PCBL(c PROPERTY/BCLIDiNG COS6fiSStONER LV'urkers' Crrtnpensation insurance :\ftiditvita Builders/Contractors/Electricians/Plumber, Applicant Infnnnatill" {� /� c �� Please Print l egihly Ntai11CR[/J (HminnvOrGnl:a;iaml:nlivvir/nl'lii_SfrgA,�l/AlIN1 Address: m Cityt5tatci"lip:�LA-IS7()W Nt" U3Xi(+t Phone;t:�j �g2 2bC/g� :ktc,,nu in employer?Check the appropriate box- 'type Of project(required): 1.2I)am a employer•wit1h 1. Q 1 am a general contractor and 1 6. Q T'ctVconswctian Jmplaycos(full and/or pan-tim<).° bare hind Iha sub-mmractors 2 ❑ lama sole proprietor or partner- listed an the attached sF.ect.1 '. ❑Remodeling .nip and have no employees These sub-contractors have S. Q Demolition wo.kirg.for me in any capacity. workers'comp. insurance. 9. El Building addition (\o worker'camp.msurnct 5. We are a carpamtion and iu .—'Electrical r: quircd.) ofticers hove extreiscd they 10LJ Pairs or additions 3.❑ i ant a homeowner doing all work richt of cxrmnliun ptr MGL I i.(]Plumbing rcpuia or additions ntyaelf.(No workers'cenno c. 152,§1(4),and we havt no 12.0 Roof repairs t insuraneerequired.)t employees.(No workers' ry ,� I comp.in.suarq T rcquircdJ 13.E u`her i�dyt_1 •nny applir:e,n ave d:c.ks bor el tour i,u till un a rasion hluw;huniug;hcir uorken'wmpenv npofiry uaurmmim. 'Il.,mcnwr�.n who,ul:mil tArt arFrL-,vit indiurine they m d°Inp ell.roh and;hen hire omsv!e centmcrors mmt axhmn a�cw aIDdavit intliaina such. r'nmmcmn thm,heck Shia boa mist vud.al an nJdaiurui What showing n'x aaec Nthe;ub-c^.evumn anJ ihcir workers'comp.policy mf,rm son. /um un enrpluymr rhuf is providing n•arkers'rronrprusu{cn i+r.rumncr for my exrplo}•ers. Qe/ury h'lGr po/fey tardJuB si!e Insurance Cnn+pany,\'arae144 IK-t.( L-U. -- Piney 4 or Sc'f-ios.Lic.7: Job Site Address: 11L9 7 ! -09T 4(; L CityiSta!e/Zip: L//i/�/� .\(tach a copy of the worfters'compensation policy declaration page(showing the policy number and expiration darn). Failure to secure cuvertge as required under Section 25.1 oi'.MGL c. 152 can lead to the imposition of criminal penalties of a r.rc up to S1,5UUJJ0 a.^.Lor ore-year i:nprisnnmem as well as cieil penalties in the Ibnn ofa STOP IVORK ORDER u:;d a line cr up to 5?i()00 a day against the violator. I3<mlviaed that a copy uClhis e!ateT,ent may lee funvardrd to d:c Oflico of ln•:r.nyviens uf:he MA for insurance co,crngc vcri!,unon. I(to hdreby terrify//111/111.10/,t'1171,sa•nod penolaar of perjuy tlm•t rhr it aurn+udwr pruvideQJ 1 hu yr r:c true oud corre,t Officrul u"rrn ly. Do not write to rh ie'ureu,to he completed 5y city ur town r/JiriuL i City nr Tutvn:___-___ _-_ Purmib'Lkcnse.tl ih.r uing Aul!writy(circle one): —_ -- _— — L nnard of licuhh L.6uiid ln�Ocp.trhncnt t,Cityffmau Cie r;; 7. I:!ceh'iral ln+pn'tur S. Pitt mhiug lusprcror L.Other ... P;mne : ) CITY OF S,gE;Nf) tiL1SSACRUSETTS E7CnDL\G DEP.l3l*.NZNT 1?0CV.t3HLNGTON ST11ET 3 ��e�,..1=• m FLOOR T.L (978) 745-9595 K11t3EU-FY DRISCOLL F•tX(978) I-W-984.5 tLRYO;t I�iOSLtiST.PIE.RI28 DIRECTOR OF?GOLiC PROPERTY/BCIZ.pLyG CO\pn55rONER Construction Debris !Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixd2 edition ofthe State Building Code, 780 CbfR section ( l 1.5 Dcbris, mid die provisions of AML c 40, S 54; Building permit e this work shall be— is issued with the condition that the debris resulting from Itt• slsn.�. disposed of in a properly licensed waste disposal facility as defined by NICL c The debris will be transported by: y JF_AMAST IFntr keN1ArLS (name ut hauler) The dab s will be disposed of in SE�FC.QA�r �(T��l1r7z7-r P (fal nC of f.ln!ify) >5_Cn11D-w ��_ Avg ➢� AYSRVIIVH (address of rac31ip/1 �: teU // fJUOtItl11( —� SEACO.1 OP ID:EB `a�oizo CERTIFICATE OF LIABILITY INSURANCE DATE(MMR)DIYYYY) 04129!2016 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 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(ies)must be endorsed. If SUBROGATION IS WAIVED,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 endorsement(s). PRODUCER CONTACT Foundation Insurance Group Inc NAME: Joe Pottllast PO Box 6326 PHDxE ACxy-EXt(:703.527-8780 ac xo:703532.8300 Falls Church,VA 22040 -UMC Joe Potthast ADDRESS: _ INSURERSAFFORDING COVERAGE NNCtl INSURERA:AXIS Insurance Company 37273 INSURED Seacoast Tent Rentals,Inc. 5 ChadwickAvenue INSURER e:AmTrust North America . Plaistow,NH 03865 INSURERC: INSURERO: INSURERS' 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 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. IN*R rypE OFINSURANCE UB IF IOLICY NUMBER MMS YEFF VfYYYINMI�p YYXYY umns A X COMMERCIALGENERALLIABILITY EACH OCCURRENCE S 1,000,00 CLAa1S-MADE LX I,OCCUR ,AISENH001 05/01/2016105/01/2017pREMISE6 Ea ercel 5 100,000 MED EXP(Myq a PD..) S 5,0110 J( EPLI I I PERSONAL a ADV INJURY S 1,000,0 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,00 X I ]LOC u jE� F PRODUCTS COMPRJP AOG s6 2, 00C OTHEREPLI Sq (AUTOMOBILE LMBRITY I I IBII ED SINGLE LIMB 6.1 IS 'J ANY AUTO BODILY INJURY(Pv person) $ ALLOWNED SCHEDULED AUTOSAUTOS AUTOS BODILY INJURY(Par accNOMI 5 HIRED AUTOS I WN?OWNED PROPERTY— S Pe s UMBRELLA Me I OCCUR EXCESS LB1B I I EACH OCCURRENCE S CLAIMSHMDE AGGREGATE S ED RETENTIONS I I S WORKERS COMPENSATION AND EMPLOYERS'uABILITY VIN I X STATUTE ERTM B ANY PROPRIFORNARTMER/EXEClI1VE ❑ C0826126 06/01/2016 05l01/1017 E.L EACH ACCIDENT $ 1,000'0 OF E"EEMBER EXCLUDED? NIA 00 IMyeelMatorym NH) ELL.DISEASE-EA EMPLOYEES 1,600,000 DESCRIPTION DOFF OPERATIONS W. TEL.DISEASE POLICY L0.IR $ 1,OOD,OO DESCMPTWN OF OPERATIONS I LOCATONSI VEHICLES (ACORO 101,AtltlUbntl RMnnMs SchoEuk,mey W amcxetl II mwo apxo Is reAutreQl CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional Services ' 120 Washington St,3rd Floor AUTHORIZED REPRESENTATIVE Salem,MA 01970 yy O-- - I P'� _ ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD City of Safem, Massachusetts Fire Depa7 mens GMl.NS d>` 48 Lu%ayerte Syzzt David'!V. Cody 01570-9695 c:,f Tc!-94-.9-744-1235 "irz Przv<r. bn 97&744-6990 Fax 97S-i 45-4645 L�OLr7 di.^.�m.toM -?FLT_CP.TIDN/PERPIIT TC ERECT TENTAGE OVER 120 SOUAR_ FEET IN 7t,E CITY OF SALEM ACCOUDNC- 10 THE `fASSAC USZTTS FIRE PREVENT-1011 3EGuLAT ICi7 527-CPiR 19.00+ AND THE SATE`; FIRE CODE ART. i' 20 FEE $30.00 CHECK ADDRESS: CTTt': STATE: ZIP: PHONE: LOCATION OF TENTAGE:f 0+vNEF-1 OF PROPERTY,-�*�'''�11-- iaD�iR_SS' CITY: STATE: ZT_P• PHONE INSTALLER/'ENTAL CO. OF TEHT?.GE: SgA60ASI ALDRESS:L5ep TFN �2UZT�jP:_ AI TPl : 035�3� INDICATE 'w+TTii REFERENCE TO PROHRITY LINES AID OT-HEF. KILDTNGS TF.E LOCATION OF THE TENTACE ON TOE BACK OF THIS FOR!-f: +aTEFIA USED: U1NO ._,�,;�,F�.c-uREa:JaNCttnQ irvD��sfi2-�F� SIZE of TENTAGE: 2 - 3Dx 30 l -2-0 x ;vr`T;E OF TESTING ..GE:iCY: J6NN 5Lt` f— _ p�{OZ 5585 a._ NU :-. �,4CERTTFTC2.T' OF FT--IE RESLST4P2C-:_`72 Q�LL(7 CONDITIONS OF APPROVAL OTHER TuzN AS PER FTFE PREVENTION REGULAT:ON: �-- _ SA.LE'! Eli ILD-ING DEPART9'EHT PERYT T DATE OF ISSUE: SITE TNSPECTTGN DATE: Erp T_R2.TIOiv' E-kTE: A-PVROVEFD Bim: TITLE: .. =0R:4 tG'B (Ree. 8199) SOB , 7 C3• LjitrNC x+eiEF Ai L 1E ."Ran. , is fent rnees #h� arnmab # y re ` rC1t5 a P 84 hoprio lfray b qV ► teft� r► in cent�t wi h any flame source�� e;applta�tto � `y, er n�sbtstan eP#atk+e= entjicroal . thear sF �efi es-Ane t the , e teistan#PT a . G#Uri U } ftt t4Strie. -4k ' -b ntry.,00 trt C t rt s ss ' o uRKEgm@999999 M I M PO RTANT DOCUMENT o 5 Certificate of Plane Resistapee 5 SREGISTRATION ISSUED BY 5 APPLICATION v ' y C��Q�a Date of 05a�u04acture 5 5 NUMBER a woSsrRiE3 wc. C5 5 fr EVANSVILLE, INDIANA 47725 Order Number 5 17140.1 38129 IT MANUFACTURERS OF THE FINISHED 1 5 TENT PRODUCTS DESCRIBED HEREIN S 5 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 716965 5 5 SEACOAST TENT RENTAL 5 S 5 CHADWICK AVE PLAISTOW NH 03865 51 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, CPAI 84, ULC 109. S 5 The method of the FR chemical application is: 5 5 Serial# 5 S 8108801 (2) 5 0aDescription of item certified: 5 5 CENTURY MATE 20WX40 SNYDER rL] ame Retardant Process Used ll Not Be FI Washing And Is Effective For The Life Of The Fabrrii By 77� r5� 5 5 SNYDER MFC:NEW PHIL ADE PHIAOH Signed: S TENT DEPARTMENT•ANCHOR INDUSTRIES INC. 5 O r1e!@fc1"OcPr�cPrJ'Or.PrJ�cPcPrJ�rJ�r.!'OcPr��cPrncPrJ�rJ'OctctcPcPcPcPcPrlOcPcfrJ�rJrJr.PcPrPr�cPc!'� rJ�rJ@PrfrlO�rJ��Pt:PcfOrJ'OrJ��cPr�rPr�rPrS�PrJ"rSr�rJ"cJ'7cPcP�Prlc � '