FOREST RIVER PARK - BPA 13-69 /,46, t� 33 e3
I'lie C'onunonweallh of M:us:lchuseus
y; Board of Building Regulations and Standards CITY OF
'r blassaclutselts State Building Code, 790 C NIR SALEM
Building Permit Application To C•onstrua, Repair, Renovate Or Demolish a
Me-or rwo-Alum& Utre//i r•kr
This Section For Olr••a1 Use Onl
Building Permit Number. D e A lied:
Budding Otliciul(Print N;une) Signature OweSECTION 1: SITE INFORAIATION
l.yroperty 27
1.3 Assessors Map& Parcel Numbers
I.la Is This an accepted street? •es no bhrp Number Parcel Number
I.J Zaning Information: 1.4 Property Dimensions:
Loning District Proposed Use Lot Arco(sy 11) Fmnlaga(R)
1.3 Building Setbacks(II)
Front Yurd Side Yards Rear Yard
Required Provided Required Provided y Provided
Required
1.6 Water Supply:(M.G.I.c,40,§54) 1.7 Flood Zone Information: 1.3 Sewa`e Disposal System:
Ihrbllc O Private O �L�4 Zone: _ Outside Flood Zone?
Check if ns0 Municipal Cl On site disposals)stem O
2.1 Owner'of 5ECTION2. PROPERTY OWNERSHIP'
ory�
N;une(11611) City.State,ZIP
Nu.and Street felephune tmuil Addn:ss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O E.risting Building O Owner•Occupied O Repoirs(s) ❑ Alteratlon(a) ❑ Addition ❑
Demulilion O Accessory Bldg. p Number of Units_ Other O Specily:
Brief Description of Proposed Work":
TAP �T
SECTION 4: ESTI;AIATED CONSTRUCTION COSTS
(tcm Estintaled Costs:
11-ibur:Ind Materials) 0111c1a1 Use Only
I. Building $ I. Building permit Fee: S Indicate how Ire is determined:
'. Electrical S O Standard City!Tussn Application Fee
11'Iunihing S O Total Project Cost'l Item 6)x multiplier -
_. Ocher Fees. S_
J. Nlech.utical ill\ W) S List:
Vecltunic.tl IfIry '...._ . . .
i tiu +reisiunl S (alai .\Il Fecs: S
I'mal Project Cnsi: S Check \u. _...-_Check Anuaru: _ _.. _ .Caih \m a nc
13 P.iid in Full 0 Oulsculding Bai•uuc Due:
("r M 1*4 SFR%'I(
kpiration Mile
r
Lq Holder ==--Z'
PC Dvicriplion
slrvCt (I I lnresnidcJ
"R11,111 in its up it, 3S.1100
at ILI
R Is. I mw) I)%%eI1i11g
%I % aSA-11
RC Kixflill Co%crin
window ind sidill
SF solid Furl homing Appliances
Institution
1 111.11,�.Jdrvm— I)l'de hourOrnloliliun
Improvement c untraclor M—)
.4.2 Registered Ilume Impir ---
IIIC Ilegillrition Number I%\P1r11i1v1)W19
FIT C-11111pin) ilidle or 111C Flegi.strunt Nuitio Firail address
No. and Street
'cane none .
ci n-own, state ZIP 25C(6))
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152
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 Arlidavit Attached? yes.......... E3 No...........
SECTION IM ONIVNERAUTI
—`--'jOJU7ATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
u rized by this liul�diinv permit application.
to acelaphalf,in all 7cLtters relative to work a,
on my oi
Print ON1113cir—'ss NLwhe(EI% ii flgnuiuro)—
M�SECTION 7b:OWNERW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
aimed i application is true and accurate to the best or my knowledge and understanding.
contained
,this Opp �5- zlp(—Z
. III* — ') note
Print omicr'i,r N 1111or JA iNitinvii. - roni0iiinalklm
Non&
1, An Owner who obtains
a�building permit to. ao.i;ls her awn work,or an owner who hires an unregistcrrd contractor
(not registered in the Hanle Improvement Contractor(1-110 Program),will no have access to the arbitration
or guar;tlity fund under M.G.L. c. 142A. Other important infurmation on the HIC Program can be found at
ip'rogra 11 1 Information on the Construction Supen-isor License can be round at
2. T%�hen substantial\%urk is planned,provide the nibrination below: decks or rordii
(iliclug g;1rage. finished basement.111i".
rotai floor area 1'4- Habitable room countGrois 11% S4. it.) Nt,111her ot'hedroxims
Number ol 11.111,hathl
orhathroomi Number of d%xks, Pord'"
I pc 1wating SN'loll Olwn
pc of�oollllg '%itoli
joial llroivG t Square ed t1or *l'otal llrojc6l 01,t"
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DATE: 7/9/2012
CERTIFICATE OF INSURANCE - --- ---- -- ----,----- ---�
CERTIFICATE NUMBER:!20120629084472
i
Entertainment&Sports Insurance
0 New Nort s de Drive,Suite 640perts(ESIX) NO RIGHTS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
56 I AMEND,EXTENDOOR ALTERS HE COVERAGE AFFORDED BYE T
HE POLICIES S BELOW.
� Atlanta,Georgia 30328
-: Phone:678-324-3300 Fax:678-324-3303
NAMED INSURED: !!INSURERS AFFORDING COVERAGE:
USA Triathlon Bill Burnett - - INSURER A: AXIS Insurance Company(NAIC#37273)
5825 Delmonico Drive
Colorado Springs,Colorado 80919-2401
!EVENT INFORMATION:
'Witch City Triathlon(7/28/2012-7/29/2012)
POLICY/COVERAGE INFORMATION:
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.
INS TYPE OF INSURANCE: !POLICY NUMBER(S):, EFFECTIVE: EXPIRES: ;LIMITS:
A GENERAL LIABILITY
C----- AXGL04100260-11 .12/112011 12/l/2012
X COMMERCIAL GENERAL12:01 AM :12:01 AM GENERAL AGGREGATE(Applies Per Event) $2 000,000
LIABILITY EACH OCCURRENCE $1,000,000
X Occurrence DAMAGE TO RENTED PREMISES(Each Occ.) $1,000,000
X Participant Legal Liability
MEDICAL EXPENSE(Any one person) EXCLUDED
PERSONAL&ADV INJURY $1,000,000
PRODUCTS-COMP/OP AGG $2,000,000
-DESCRIPTION OF OPEATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS:
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The certificate holder is an additional insured,as required by written contract or written agreement,but only for liability arising out of the negligence of the named insured,
but only with respect to the USAT sanctioned or approved event specified on this certificate.
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CERTIFICATE HOLDER:
HOLDER: _ j NOTICE OF CANCELLATION:
City of Salem I Should any of the above described policies be cancelled before the expiration date thereof,
93 Washington Street I notice will be delivered in accordance with the policy provisions.
Salem, 01970
!AUTHORIZED REPRESENTATIVE
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d
DATE: 7/9/2012
CERTIFICATE OF INSURANCE
CERTIFICATE NUMBER:',20120629084446
;AGENCY:
Entertainment&Sports Insurance eXperts(ESIX) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
5660 New Northside Drive,Suite 640 _ NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT
Atlanta,Georgia 30328 AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Phone:678-324-3300 Fax 678-324-3303
:NAMED INSURED: INSURERS AFFORDING COVERAGE:
USA Triathlon Bill Burnett INSURER A: AXIS Insurance Company(NAIC#37273)
5825 Delmonico Drive
Colorado Springs,Colorado 80919-2401 -
i
EVENT INFORMATION:
Witch City Triathlon(7/28/2012-712912012)
'POLICY/COVERAGE INFORMATION:
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 j
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.
INS I TYPE OF INSURANCE: POLICY NUMBER(S): EFFECTIVE: ! EXPIRES: LIMITS: J
A !GENERAL LIABILITY
r—�--- -iAXGL04100260-11 12/1/2611 12/1/2012
X COMMERCIAL GENERAL GENERAL AGGREGATE(Applies Per Event) $2 000,000
LIABILITY I12:01 AM I 12:01 AM
EACH OCCURRENCE $1,000,000
X Occurrence ! I
j DAMAGE TO RENTED PREMISES(Each Occ.) $1,000,000
X Participant Legal Liability
— MEDICAL EXPENSE(Any one person) EXCLUDED
i
! PERSONAL&ADV INJURY $1,000,000 �i,
PRODUCTS-COMP/OP AGG $2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS: j
Evidence of Coverage Only as respects to the USA Triathlon sanctioned or approved event specified on this certificate.
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Coverage applies to USA Triathlon, its race directors, event owners, regions,clubs,official sponsors,committee members,race officials,volunteers, lifeguards and race,
participants,but only while functioning or performing on behalf of USAT in a USAT sanctioned or approved event.
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CERTIFICATE HOLDER: NOTICE OF CANCELLATION: i
YMCA Salem Should any of the above described policies be cancelled before the expiration date thereof,
One Sewall St notice will be delivered in accordance with the policy provisions.
Salem, 01970 AUTHORIZED REPRESENTATIVE:
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Certificate of jflalne 3kototance
......... .
REGISTERED WLi04 4 Date
FABRIC �}� -
NUMBER
Ti7PTEC PRODUCTS, ELC
1073 Neety Forty Road.
•,.� .�* 5 ffa Laurens, SC 29360 U6 z3i9Rl
Thls is to certify that the materials described
are inherently flame retardant.
Name_. TILA D L APPLETON INC
145 COMMERICAL ST
Addrow
City VYNN MA D1905
-Stale Zip -----
Cerlification is hereby »marde than.
j The articles described are approved and registered by the State Fire Marsha; .arid that
Me fabric is in conformance with the laws of trhe State of Calitornta and the Rules and Flegulatiorrs of the
'. State Fire Marshal. Fabric has been tested and passes W-P,A701-99, ULG2i'4, MVSS302.
Method of Application, The Flame Reetarcdertey of tN4 Fabric is Inher�¢t at9r�(��r�anent_
PARTY' 20K30 SLACKCUT WI�ITE
GlosoripEran of item c+�flifiac�;�_.��_.,��,,
The Flame Retardant Process Used WILL NOT Be Removed By Washing,.
TOPTEC PRODUCTS, LLC.
MODEL TTIR20-4coon
�ta�+ Ln� [` z�3.6v3e
Now of SERIAL N_