3 FORT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
/r Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised Mar 2011
0 Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family ravelling
Chic Section For Official Usa Op
Building Permit Numberr, Date lie
Building Official(Print Name) :, Signature; Data
v e SECTION(:SITE INFORMATION.
1.1 Property Addresr L2 Assessors Map Br Parcel Numbers
� :�rtaluoo✓ l2l-z
1.1a 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 ft) Frontage(it)
1.5 Building Setbacks(ft)
Front 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:
Public❑ Private❑ Zone: _ Outside Flood Zane? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 1., PROPERTI��OWNERSHIPL .:
2twnertofEtccord:
�'A-ACM f O/7Li � ,Syt'�r?dYl
Name(Print) City,State,ZIP
No,and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOUD3VOW(check all that apply
New Construction ❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed%Vorkr:
`G,ecil/ 7—L?VTS Q r" CXorilce YL /ry
OX /d Jd
a-X go SECTION 4: ESTINIATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only-..
Labor and Nfaterials
1. Building g I..Building Permit Feer 3' In iicate how fee is determined:.
2. 6leotriatl CI Standard.City/CotvnApplication Fee'
$ 13'CotalProjectCost(Item.6)smultiplier x
3. Plumbing S ?. Other Fees: S
1. Mechanie.d (I IV:\C) S List:
. Mechanical (Piro S
Snp ressio 1) Cotal All Fees::S_
n Check No. Check Amount: Cash Auwun :.t
6 1'afal Project ('nst: S ,. --
t/ b d � ❑ Paid in Pill ❑Outstanding Ilulance I)ue:
SECTIONS: CONs'rRUCTION SERVICES
5.1 Cj57
clion Stgtervisor Licctue(CSL)
� fif77-,�ly Licenst Number Gcpiratiuu Date
List CSL Type(see below)
Lo v vvl ST A1 -1'n"U
Description
No. and Street
T d/'.Z / stricted(Buildings u el 35,000 cu. If.)
�b icted 1.4t?pamil DwcllinCity/roan, State, ZIP nrn Cuverinow Fuel Burning Appliances
TelpTtiun
I'de hung I Email address D I Demolition
5.2 Registered Home Improvement Contractor(FIIC)
HIC Registration Number Expiration Date
I IIC Company Name of NIC Registrant Name
No.and Street Email address
City/Town,State ZIP Pele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.1 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.
Signed Affidavit Attached? Yes .......... No...........❑
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 ail matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dnte
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.
Print Owner's or Authorized:\gent's Name(Electronic 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
(nut registered in the Honle Improvement Contractor(HIC) Program),will nit have access to the arbitration
Program or guaranty rind under M.G.L. c. 142A. Other important information an the FIIC Program can be round at
oww.m;u..euv;;xa Deformation on the Construction Supervisor License can be Found at ww•tv.m;ts .�'uy�.JL
2. When substantial work is planned,provide the information below:
Total floor area(,it. It.) _(including gcrage, finished hasement/attics,decks or porch)
tiro;; living area(s(l. It.) -._ habitable room count —
Nund+er of tireplacc.i.-__------ Number of bedrooms _-__—_--
Nunther of bathroom, Nnutber of hAt,,baills _.—_—
rypu Of N:uiug syatetn - - ----- _-- Number of deck„ porclics _—__--
\peoreaoling ;y;leut Eindoicd --. u)pen --
� t. "I',+t.d I'nq;a Squ.ua I�not.i,a" in.ay he ;ub;nuit. l f;+r"rM.il I'ruitd l'o<t'
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
f_ 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Hanle (Business/Organization/Individual):
Baystate Tent
Address:150 Lorum Street
City/State/Zip:Tewksbury, MA 01876 Phone #:978-851-2002
Are you an employer?Check the appropriate box: Type of project(required):
I.❑✓ I am a employer with 20 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 9. ❑ Building addition
[No workers' comp. insurance comp. insumnce.t
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 81 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 ofthe 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 insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:St Paul
Policy#or Self-ins. Lic.#:XEUB5899Y49713 Expiration Date:1-31-2014
Job Site Address:IVl aO S �/9Y lL City/State/Zip: 5''filz 7 N A-
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 certa under the gatns and enalties o Hug that the information provided above is true and correct.
avid Knight o9 ro.°,Kg, ma�, 9,��n .......
mature o3oswixiis wou Date
Phone#:978-851-2002
Offrcial 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#:
Certificate of ,Frame Req;i!6tonce
�m REGISTERED TENTS
APPLICATION 2665 COL Date treated or
COLUMBIA ST manufadurad
CONCERN NO. TORRANCE,CA 90503
CAL COMB F419.01 (800)228-3687 - O7�ZOO8
This is to certify that the materials described below hereof have been Name retardant treated(or are inherently nonflammable).
FOR 'r
BAY STATE APRTY RENTALS a° 0
150 LORUM STREET Y�
TEWKSBURY, MA 01876
ATTN: DAVE KNIGHT .,.°
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 applicationof said chemical was done in confor-
mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Nameof chemical used............................................Chem. Reg. No. ........................
( Meathod of application ................................................................................................
(b) The articles described below hereof are made from a flame-resistant fabric or material registered and
approved be the State Fire Marshal for such use; Fabric has been tested and passes NFPA701-96. ,
Trade name of flame-resistant fabric or material used..'+"'r"•re°ra°rm . Reg. No.......E.?1&9±......
The Flame Retardant Process Used ....... Be Removed by Washing
(will or will not)
David Bradley Chuck Miller - President
Name of Appliwtora Protluction Superimentlent Tpe -"'>
' Invoice # 121536
Paysiate Tent & Party EVENT INFORMATION
150 Lorum Street BAYSTATE 6/23/13
Tewksbury, MA 01876 TIME OUT Sat after 9A...
(978) 851-2002
RETURN 6/23/13
BILL TO
TIME IN Sund Aft N...
North Shore Medical Center Willows Park
Development Office Salem, Ma
81 Highland Ave
Salem, MA 01970
Meg Wright 978-825-6232
PH ONE# 978-825-6116
ORDER DATE PAYMENT AMOUNT REP ALT. PHONE# 978-335-3316
6/23/13 Net 30 Days Rose VM EVENT DAY Sunday 5PM
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(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
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 Q 12 Hours 900.00 900.00
Bring 6 milk crates
Discount -1,495.00 -1,495.00
2 Permits TBD 0.00
Payments/Credits $0.00 Subtotal $4,920.00
Sales Tax (5.0%) $0.00
Total $4,920.00
I
V kky of < ielm, 1 tr II OC tt
er
a)3 � I
LNt� ng /
P.v,ULI t_.:�'ei_ .iCi.ilY E+. LC'v E-L''( ;i;'z�P�C UPK:IE
23'% LaIt f:`r'L ZV 3
xRR,Jt:" „I'..?'(a.Fki<
ARTMJR . ..'-rGEN'T ai :IFRRY I R"YAN
.JCSH.H.
PAIR C. PREVE:Y
.16SEPH A.0 ','_-'EFL.SR.
September 13, 2012
Ms. Roselyn Fisher j
Special Events Associate
North Shore Medical Center
81 Highland Avenue
Salem, MA 01970
Dear Ms. Fisher:
At a regular meeting of the Salem City Council, held in the Council Chamber on
Thursday, September 18, 2012 the City Council voted to approve your request to hold the North
Shore Cancer Walk and use of city streets on Sunday,June 23, 2012 and the road race and use of
city streets on Saturday, June 22,2012. The course to be used must be approved by the Salem
Police Department and the use of the Salem Common needs to be approved by the Park and
Recreation Department.
Yours truly,
j
CHERYL A. LAPOINTE
CITY CLERK
Cc: Police Chief
Police Traffic
Watch Commander
Chief Fire Dept.
DPS Director
Health Agent
Planning
Director of Park, Recreation& Comm. Services
Special Projects Coordinator
S,ALEM, UTY HALL-93 Wt1SHINIGM)N S"!lREET a SnLOO, MA,0197C-35)9 -',A'vVW.SALE M.CO(`.:1
U ' 2013 North Shore Cancer
WALK Salem Willows Park � �;
V,
REST a7 o I<w
ROOMS„
° W s
Recycling t t$ a
Tent
1—BftTable sRefresltments '-
br ;,(3)fd xtOkS
2chains iVcrth('casi
-, pSerania+d�¢y� Tt tK
t,a eft`tablas
Whole Foods 2,C�iairs '
10 x to,
Tent 44os nutonar
4=8 it table; r
2 chairs
'GE et x
® Cranney
10'xabt TrucK
t te:'
2 cha ble
s
North shore-1 '
Ban ie�t..: 0
W.
.ft
DUNKS �.
�r.
Team Photos
PR
-. Volunteer Check IN
20'Tent 91, -
20 x
w backing
3-h fttabla;=
10 chakii risers Flrsi Aid: .�,
__� 10 z10 Tent A,
i Sfttable Ambulance
4 Chairs -
WALK RegisfranQn)-. —
20 x 20'Tent- Tribute Boulisl
w backing= Megnetl CC tent
7 BRtab1¢s � 10'xtP Tmt
20 Charts 2-8fttables
d Chairs,
WALK Wear
-..__ to•xtrcretn
1 KW�) 2 3 ft tables
i :2 Chairs3-
k
Acura
AStarage s
3"h�ta��w
104
_ to xto Tent ,a 104.9 FN
l sa s+gs:- Eastam Dank Salem Erve I i 8fttabhi'
Re ki" 2 Chile
ttab
'tJ t aft tabio to10'Tent iV xtO',Ten[1
' 8 hairs' T t t-8 fttable, J tlfttable;
t ea l nl° HINT Udnks.
2chainl 1chalss Br ngin9lheir'
40,
own tcnt
BAC I TUV Electric Danversbank
say �..ID'x 10 Tent : Ins al a 10 xt0'Tent _ .
xa a nN �- 2 8ft febie 1PxtO Tent t sfttaCle
�' d chars t 8 ft table;' _
2ch lrs-
. . 2ehans:� a ® m ® Bur WALK
`�^., inish Line
•` Needs Elea
e^
Living Proof "�� 1-20 amp Circuit
®� 7-B RTable2 C
I
CITY OF SALEM, MASSACHUSETTS
PARK, RECREATION&COMMUNITY SERVICES
5 BROAD STREET,POST OFFICE BOX 465
SALEM,MASSACHUSETTS 01970
TEL. (978) 744-0180 OR(978) 744-0924
F1n1BIfR1A;%'DRISCOLL FAZ (978) 744-7225
MAYOR KPARTANEN@Szu X N1.00a1
KARIiN PAR ANP.N
DIRFC101t
June 4, 2013
Dear Rose Fisher,
The North Shore Medical Center has permission to use Salem Willows/Salem Common on June 23,
2013 for the North Shore Cancer Walk.
If you have any questions or concerns, please contact me at (978) 744-0180, ext. 20 or
tshort@salem.com.
Thank you,
Tim Short
Recreation Supervisor