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167 FORT AVE - BUILDING INSPECTION (2) 2S SO 3� 1 The Commonwealth of MassachusettYSPE CTFUW` Board of Building Regulations and Standards CITY OF ALEM WMassachusetts State Building Code,780 C .� __ (( �6 JUN 15 A �HedMa,Mar 2011 lV Building Permit Application To Construct, Repair,Renovate Or Demolish'a g' One-or Two-Family Dwelling This Section For Official Use.only Building Permit Number. Date Appl' $ntlding Ofcial(Print Name) : .Signature - Dal SECTION I-SITE INFORMA's WN 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L l a Is this an accepted street?yeses no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record• N Ct(AS 6_0 f"e . f a tea, 5 c( le . , new o l 9 7� Name(Print P(-City,State,ZIP Ir�f�yirk 6Ac ��axg_t_e L 'srs. t ci!843r6r�i31 Sla�s��r�ner+nert No.and Street Telephone Email Ad ss SECTION 3:DESCRIPTION OF PROPOSED WORIO(ohe&all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other jk Specify: Brief Description of Proposed World: lIIn .erne /nI'' F �f a : /pn �< crA Sc,lemIU 'IIp�y rnn rd Ll #to W B �O'L2R C/r) is- a,C!rS�Ti 1 —t (� � r.� —� w SECTION 4:ESTII1fATED C NSTRUCTION COSTS Se e fit�t" (o ', Q Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 1. Buildmi Permit Fee:$ Indicate how fee is determined; 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ . 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total AN Fees:$ - - Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due. C421Uti Lk F , o - to Z► � S U S FN J s , SECTION 5: CONTRUCTIOA SERVICES i 5 Constrru�cttio�n rSuperviss�or License(CSL) G;{ '} -'"(u�'. :./L �,l � �J ' License Number Expiration Date Name of ttL Hol er /�T x � r List CSL Type(see below) No StreeUS V /�_ ` Type DesrnPtion:: _.' / 1"1 U Unrestricted(Buildingsu to 35 000 cu.ft. 1. R I Restricted 1&2 Family Dwelling City/Town,State,ZIP JM I Masonry RC I Roofing Covering WS I Window and Siding ��jr �cl 6 �l ad SF Solid Fuel Burning Appliances I Insulation Tele hone Emaidress D Demolition ion Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLGI-a 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. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR$UIL ING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic 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 contain n this application i true and accurate to the best of my knowledge and understanding. =G//1 Z 6/1 Print Owner's or Authorized gent s Name(Electronic Signature) ate NOTES.- 1. 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at xvxvw.mass. oa v;'oca Information on the Construction Supervisor License can be found at www.mass. ov/dRs 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 133422 BAYSTATE 6/26/16 Sat @ 9AM 6/26/16 Sun aft 12PM North Shore Medical Center Salem Willows Park Development Office 167 Fort Avenue 81 Highland Ave Salem, Ma 01970 Salem, MA 01970 978-825-6116 978-335-3316 Sunday ^< 20 X 20 Ultra White Festival Frame Tent(Reg Photo) 1 295.00 590.00 1 30 x 30 Quicktrack Ultra White Tent 1 750.00 750.00 7 Leg Extensions 1 12.00 84.00 24 10 X 10 Ultra White Festival Frame Tent(vendor) 1 129.00 3,096.00 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(24x16x2) 1 32.00 768.00 14 Stage Rails 1 0.00 0.00 1 Adjustable Stairs 6 Step w/rails 1 45.00 45.00 125 BLACK-Samsonite Folding Chairs 1 1.00 125.00 60 8'Banquet Table 1 8.50 510.00 20 Chrome Stanchions I 8.00 160.00 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 -379.00 -379.00 meet Rose 9AM 978-335-3316 Payments/Credits Page 1 133422 BAYSTATE 6/26/16 Sat @ 9AM 6/26/16 Sun aft 12PM North Shore Medical Center Salem Willows Park Development Office 167 Fort Avenue 81 Highland Ave Salem, Ma 01970 Salem, MA 01970 978-825-6116 978-335-3316 Sunday Cust Obtaining Own Permits. Payments/Credits -$6,775.50 $6,817.00 $0.00 $41.50 Page 2 10X10 MAIN STAGE-24'x16' 30x3OTENT FOOD 10 x 10 GENERAL }IOOD 10X10 ELECTRIC FOOD 1OX10 Crosby 30X10 Vendor 2 SOUND GUY FOOD aglc 1OX10 OWN TENT? a� �ruc Crosby Vendor 1 Spaud © OWN 1OX10 TENT FOODS i0><i0 Injury aeon ntion 20X20 TENT <WITH BACKING ONE i0xio 1OX10 ORAL SIDE--TEAM PHOTOS r FIRST AID a� � no I % i0xio REIKI 20X20 TENT 10X10 MASS *WITH BACKING UP .y.. ONE SIDE—WALK Amerioris C ii Rl:rlrTRATIr1N 10X10 0 TRIBUTE T U E WALL BOOKS �a o 1OX10 WALK WEAR 10X10 1OX10 10X10 10X10 10X10 10X10 CLUB NS EAST D Bath SALEM 104.9 TENT Bank BANK B Cance 5 BANK HINT H 20- DD table Gli ` �_ 1OX10 1OX10 1OX10 10X10 R CK' xt] KIDS A.SURG ELEC PEOPLE 0 ACTIVE INS BANK o