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167 FORT AVE - BUILDING INSPECTION r . Gl< 321► Z ZS�° -� The Commonwealth of Massachusetts Department of Public Safety Ylassachusetts State Building Code(780 CMR) -Fami ly Dwelling BuildingPermit Application for any Building ldmg other than a One-orCwo 1 (This Section For Official Use Only) Building Permit Number. Date Applied: Building Offi6al: SECTION 1:LOCATION(Please indicate Block#and Lot 4 for locations for which a street address is not available) t�RFR1 �N1 - Fll2T bl F \ No.and Street City/Town Zip Code Name of Building(if applicable} SECTION 2•PROPOSED WORK Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ I Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of OaupancY ❑ Other ❑ Spccify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ .. v Yes ❑ No ❑ - oral En•ineerin•Per Rcvice•requirul. Is an[ndependent5tnnt b � _ � �3CX � Brief Description of Proposed Work: �� .� 3 �Y �•� I 1 �() c � SECTION 3:COhIPLETE THIS 5ECTIOli IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Chak here if un Existing Building Investigation and Evaluation is enclosed(See 780 C\IR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)anal Total Height(ft.) SECTION S:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A3 ❑ A-1❑ A-3❑ B: Business Cl E: Educational ❑ F: Facto f-I ❑ P2❑ H: Hi h E[azard H=t❑ H--I❑ H-3 ❑ 1{—F❑ H-5❑ Institutional I-1❑ I-2❑ [-3❑ 114❑ bl: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R�❑ S: Storage S-t ElS-2❑ U: Utility❑ Special Use❑and please describe below: Special Use SECTION fi:CONSTRUCTION'CYPE(Check as applicable) IA ❑ [B ❑ ILV ❑ IIB ❑ iIIA ❑ [fill ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CJlii Ill.o for details on each item) Trench PermitFDDebrisRemoval: WaterSupply: Flood Zone❑tformation: Sewage Disposal: A trench wilt not besposal Site❑Public❑ Check if outside Flood Zone❑ Indicatemunicipal❑ required❑or trench Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \I\I lrvp:ri{�,•gnr :i,m I:p.;icm I'ronv.: , Not applicable❑ Is Structure within airport approach area? Is their review completed? or Consent�o Budd enclosed❑ \'es.❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OE CERTIFICATE OF OCCUPANCY n Editioof Code:____Use Gmup(s): rvpeof Constructinn: Occupant Load per Fluor..____. Does the building contain an Sprinkler Systems?:(___$Pedal Stipulations:._ lot i S SECTION 9: P12OPER"rY OLVNER AUTEIOIUZATION Naas and Address of Property Owner Name,(print) No.and Street City/Town Zip XProperty Owner Contact Information: ` "title Telephone Nu.(business) Telephone No. (cell) retail address It applicable,the property owner hereby authorizes Name Street Address City/Town State Zip h1 ad on the ro er onvner s behalf,in all matters relative to work authorized bV this building emnit a p tlication, SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,000 cu.ft of enclosed s ace and or not under Constniction Control then check here❑and ski Section'M.I 10.1 Registered Professional Responsible for Construction Control I F0, UA'LIAtiE L -33�Z-.3 'i� C i 6fi yA(665W111V0P r� Nam•(Re is ran[) - Telephone Nu. e-mail address r Registration i umber ;1 1�Q 111f.i[ l PLftt�ibV/ - �S Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 5 R{rI k .-T fAMT I�r�y17rt C Company Name xW�ITNFy wAukf (�) IA Nance of Person Responsible for Construction License and Type if Applicable 5 C 1 UK All 91 M ST:'vd -NW S- Street Address City/Town _ State Zip �i 2 -i-4 u 'In'f-L, a.(,ftlrr,I)s-ffcnt3 .Corr, Telephone No. business Telephone No. cell c-mail address SECTION 11:W0HF.I(RS'C MlPlf\SMI[o\ HN;\Vl'I' M.G.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the' uance of the building permit. Is a signed Affidavit submitted with this a lication? Yes•Ef No Cl SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=S 1. Building -S Building Permit Fee=Total Construction Cost x_(Inserthem 2.Electrical 5 appropriate municipal factor)=S 1.Plumbing $ "I.Mechanical (HVAC) S Note:,Hnirn um fcL=$ (contact municipality) 5.\dechanical (Other) S Enclose check pavablc to fi.Total Cost 5 C j ,�l5 (contact municipality)and write check number lure SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 13v entering my name belor.•.I hereby attest under the pains and penalties of perjury that all of the information contained in 0nis application is true and accurate to the best of my knowledge and understanding. _ LL Please print and sign panne 'Pule Telephone No. Date 9troet Address - City/Town State Gip Municipal Inspector to fill out this section upon application approval: t I_ Nontc Dah: 30� CITY CIF SuEm, %LkssC\CHUSETTS BUILDLNG DEPAMLENT 130 WASHLYGTODI ST:tE&T, 3'FLOOR -ILL(978) 745-9595 F.v<(978) 740-984,S (U1iBF1iLEY DR.ISCOLL A.L�Yo:2 TI-toac�.ssr.Pll=uts DIRECCOR OF PusLic PROPERTY/aUMOLYG CUNWISSIOYER Construction Debris Disposal Affidavit (required for all demolition and renovatioa work) In accordance with the sixth edition of the State Building Code, 730 C&IR section 111.5 Debris,mid the provisions of IMGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting From this work shall be disposed of in a properly licensed waste disposal facility as defined by,LIGL c I 1 I, S 150A. The debris will be transported by: y l (name of hauler) The debris will be disposed of in -__-- (name of ra"Ity) -----(aJdressW rrileihty) si,rtarure ufpermit applicant ,• CITY OFS.ILE�I, l'I1SS:ICHL'SETTS s y,,, Bi:ILDI\G DEPARTMENT 4,i ;��1�) 110 WASHINGTON STREET,3m FLOOR / TEL (978) 745-9595 =� F.AC(978) 740-9946 KI\IBERI-EY DRISCOLL THOh,iAS STTIEMS NPLYOR DIRECTOR OF PI BLIC PROPERTY/BUILDING CO\NISSIO\ER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Ptumbers Applicant Informatinre Please Print Legibly V.Inti:(nusine.s.Organ i>ation,'In,livi<:ual): Address: F) �•FYR17W u, �Y111 City/Statelzip:?J J1 ZIA _NN 6t,�glnC" Phone u: 603- 3;Z 34bi? \rc an employer?Check the appropriate box: Type of project(required): I. I am a employer with I o 4. ❑ I am a general contractor and 1 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,' El Remodeling ,hip and have no employees These sub-contractors have li. ❑ Demolition workers'coo .insurance. working for me in any capacity. P 9. ❑Building addition tco workcn comp.insurance 5. ❑ We are a corporation and its officers have exercised their to.[] Electrical repairs or additions required.] of ).❑ 1 am a homeowner doing all wodr right of exeulption per MGL I I.❑plumbing repairs or additions myself.[No workers'comp. c. 152, S 1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' i 3.tJ'tnher_J" {.h.i i comp.insurance required.] -Any appticmt due chtwks hum 91 must also flu uW the secCun chow showing their waders'compensidon poll y mLumaqun. t I this affirLivit indicating they aredoing all wak and then hire oubWecuntract mot submit a new afrdavit indioriny such. $lna,wona W het check this bus mint anaehed an:ddw.noi shwa showing the mare of the ob.coraracion and their workers'camp.policy inrormmfon. 1 or,:an employer that is providing workers'compensaton insurance for my employees. Below is the policy and fob site information. ^\ Insurance Com !V party Name:' r^,,, 'Q.\A "T ._ C'✓T� 1''+.itC` ?A to Policy i4or SclGita.l1Lic..1ti: �IU�. (�r•LtO4Z 41,._ Expiration Dale: J A h lob Site Address: City/Slate/Zip:4 .�,fAM MA 0030 Attach a copy of the worhers'compensation policy declaration page(showing the policy number and expiration date). Failum to secure coverage as required under Section 25A ofIclGL e. 132 can lead to the imposition oreriminal penalties of line up to S1,500A0 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up m SZa0.00 a Jay agauu[the vwlamr. I3e advised that a copy of this statement may be forwarded to the Office of Investigations of the 0 1 A for insurance coverage verilicalion. /do 1wreby certify mr r fire pains and penallie.s of perjury that the ntfurmution provided above is true tried correct Sicn-mire' I'hore,�: VIr:J L• OD l r F,c only. Du eras wrim ire rho.+'grrq to be eonryfr[edby city ar soon nffiriut p PermitfLiccnic ylhurity(circle one):f health 2.Building I)cp:wtrnent 3.Cityffown Clerk A. Electrical faspector 5. plumbing 6upector..._rsons___—__.___ ___,_� Phnne fF:_..___, - i n Massachusetts .City o�,SaCem, , I }"ire Department ��rnris� 46 Lafayette Street rc David Cody Salem,-Massar-husetts 01970-3693 Tzre Pre-,tendon Chief Tel 978-744-123 . Bureau 978-744-6990 F X 978-745-4646 978-745-7777 dcody@safem.com APPLICATION/PERMIT TO ERECT TENTAGE OVER 120 SQUARE FEET IN THE CITY OF SALEM ACCORDING TO THE MASSACHUSETTS FIRE PREVENTION REGULATION 527—CMR 19.00, AND THE SALEM FIRE CODE, ART. 'v' 20 FEE $30.00 CHECK APPLICANT: ADDRESS: CITY: ii y �STATE: ZIP: PHONE: LOCATION OF TENTAGE: 1p�' ( OIL f 1Va-- ` OWNER OF PROPERTY ADDRESS: CITY: STATE: ZIP: ;�,� PHONE: 1� INSTALLER/RENTTAL��ppCO. OF TENTAGE:�a rj"(AA'� NT �i�V.� PHONE:bB'�p �'22Cjp�j,',o ADDRESS: Cj L!'�fl����,� AyF CITY: � A-1 c,!p STATE: N -__ ZIP: V JDGJ INDICATE WITH REFERENCE TO PROPERTY LINES AND OTHER BUILDINGS THE LOCATION OF THE TENTAGE ON THE SACK OF THIS FORM: E MATERIAL USED: VINA - MANUFACTURER: SIZE OF TENTAGE: Z ' 6)( ;0 NAME OF TESTING AGENCY: -1 0402.--s85 AGENCY APPROVAL NUMBER: 2,t ; CERTIFICATE OF FLAME RESISTANCE: CONDITIONS OF APPROVAL OTHER THAN AS PER FIRE PREVENTION REGULATION: ` 0 SALEM BUILDING DEPARTMENT PERMIT NUMBER: DATE OF ISSUE: SITE INSPECTION DATE: EXPIRATION DATE- � a APPROVED BR: TITLE: FORM M (Rev. 8/99) .r 80B p a e r1LE,N[, Lti(:15S:iCHL'SE"I"I'S ' BL"tLONG DEPAR"I1LENT I]O W.UHLNGTON STIEET, 3-Roott T-L (973) 745 9595 K mBERLEY DRISCOLL F•tr(97� 7-t0 9845 (L1Y0.'L THOSL�S ST.PiZRiLq DIRECL Oit OF PULIC PROPERTY/aU(l ODIG CO\L%((SS[ONEZ Construction Debris Disposal affidavit (required for all demolition and renovation work) In accordance with the sixth edition Of the State Building Code, 730 CPAR section 11 (.5 Debris, and the provisions of b1GL c 40, 8 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by,b(GL O 111, S 150A. The debris will be transported by: l (name oniawer) The debris will be disposed of in.: (name uF F'.lulity) 0c Al Biter? N f o3Sb�- (:ddmss oYriiulity) . Si�nJ(U(C ufpC(mit fit" Jilt — .._.�. 2 — NE �� w _ 2 tA R ' .. .. 1fj . N� SOURCES AWAY FROM THIS"TEwr FAB�tC.`r This tent meets the flatnmabiity requirements of.CPAI-84, The fabric may burn if left in continuQus,—. _ contact with any flame source, The'applicatiolI any foreign substance to the tent fabric may render the flame-resistant properties ineffective. Y Manufacturer: 5un1'o Industrie s ' Manufacturer Code number: !-c5PST Country of Origin: China rr s u w ?, y N. , z Sial j _ SEACO-1 OP ID: LW ,a►coRo CERTIFICATE.CIF LIABILITY INSURANCE D07/27AM /2015 I O7nn2o1 s 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 endorsements. PRODUCER NAMEACT Joe Potthast - Foundation Insurance Group Inc PHONE FAx PO Box 6326INC.NP El:703527-8780 ac Na: 703532$300 Falls Church,VA 22040 E-MAIL ADDRESS: Joe Potthast INSUR S AFFORDING COVERAGE NAICY INSURER A:AXIS Insurance Company 37273 INSURED Seacoast Tent Rentals,Inc. INSURER 8:AmTrust North America Attn: Jim Whitney INSURERC: 5 Chadwick Avenue Plaistow, NH 03865 INSURER D: NSURER E: NSURERF: 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. INSR I TYPE OF INSURANCE POLICY NUMBER MMNCOYEFF NIMLICY EXP LINKS T A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE FK OCCUR X AISENH001-00815-01 05/01/2015 07/26/2016 PREMISES fEa occurrence $ 100,00 MED EXP Any one person) $ -6,00 PERSONAL$.ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY❑jEC LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTNONI-OWNED PROPERTY DAMAGE $ HIRED AUTOS H AUTOS Per accident $ UMBRELLA LUIS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ i $ WORKERS COMPENSATION X ER STATUTE ERH AND EMPLOYERS L ABINJTY B ANY PROPRIETORIPARTNER/ ECUTIVE YIN WC0826226 06/01/2015 05101/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERNEMBER EXCLUDED? FINIA (Mandatary in NH) E.L DISEASE-EA EMPLOYEE $ 1,000,00 Iles,describe under DESCRIPTION OF OPERATIONS be. E.L.DISEASE-POLICY LIMIT $ 1,000,00 A Equipment Floater AlSENHOOI-00815-01 06/01/2016 07126/2015 Blkt Egmt Blanket DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be atiaehed N more apace Is required) Equipment Rental City of Salem Inspectional Services are listed as Additional Insured in regards to General Liability per written contract. 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 AUTOO,,,,����R¢��.E�DREPRESENfATNE Salem, MA 01970 1MI$Jke— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD I o rn�nJ���s�r�ns�n�rJJsrsssss��s�n �rl IMPORTANT DOCUMENT s'�' r1u�r n�n�n�nrsORn�ns�ns�nss�n�r� o 5 5 5 5 (fi t�f 1�r}� of lamrQl�� tt 5 S catif ttate o L �UED BY Date o 5 f Manufacture 5 5 REGISTERED 7r21/99 ® 5 5 APPLICATION wousTaies me 5 NUMBER ` Order Number 5 EVANSVILLE, INDIANA 47711 230048 5 F121.4 5 � `" � 5 t MANUFACTURERS OF THE FINISHED 5 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 5 (or are inherently noninflammable) and were supplied to: 5 5 5 5 SEACOAST TENT RENTAL 5 5 v 5. E 5 5 CHADWICK A 5 5 PLAISTOW 50 NH 03865 5 5 5 5 Certification is hereby made that: ated roved 5 The articles described onl this Certificate have been tre ication of said them cal was done n conformance w with California Fire 5 chemical and that the application S 5 Marshal Code, equal to exceeds NFP O SPAT 84, ULC109. 5 The method of the FR chemical application (0002) 5 C� Serial # 8108900 5 5 p CENTURY MATE 30W X 30 VL W W 5 Description of item certified: 5 5 _ 5 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 i ne d: ✓� -- 5 s 9 5 T£NT DE{°ART#AENT—ANCHOR iNDUSTRtES INC. -5 5 Name of Applicator of Flame Resistant Finish p t:PrJ"rSrJ�rnrlcPcP�cfc-fr��PcPcPcPrJ�cPrJ�cPcPrJ�r?�rSrSrlr.PcPcPcPrlr1'r.Pr�rSrJ�r.PcicPrlr.Pc.nr�rJ�r�r.PrScPcPrScfc.fcPrJ�rSc.1�rJCPrS�Pr r�r����rlcPcPr.Pr�rlrlr�r.roPrs C7 pOCU MEI\IT'�' �` s�n�sssss IMPORTANT 5 o nm a rag ncPclr nrsr nrlcncPcntPrJ� ��sist� 5 n♦ ,of flame 5 5 Date of Shipment Ce V' icat� ISSUED 5 04111105 � C 5 REGISTRATION v i UMBER 1 YPINIDpEg�® 7entldentification 5 APPLICATION s 5 1- C�U2i56i EVANSVILLE, tND1ANA 47725 5 MANUFACTURERS OF THE FINISHED 5 ptzl a TENT PRODUCTS DESCRIBED HEREIN } certify that the materials described have been flame-retardant treated This is to ce Y and were supplied to: I 5 (or are inherently noninflammable) 5 5 716E68 S SEACOAST TENT RENTAL S 5 GHADWICK AVE 5 _pLAISTOW NH 03863 5 5 5 c5� 5 5 at: ame-retardant approved 5 5 h i et of 5 b Mad ted with 5 Certification is hereby 5 The articles described on this Certificate have been treated Ca for S ical and that the application of said . asseswas oNFPA 701f99, CPAI 84,ULC California 5 Schem 5 5 Fire Marshal Code. All fabric has been tested and p 5 5 irGo7.t�c n> S _ 5 Serial # 5 Description'of item�ceStif�i TOP 2oO x4ewx;Txvrar.. C Be 5 Flame Retardant Proces Ve Fodr The Life Of The Will N FabricBy 5 Washing And is Effe ctl I 5 Ston� A 5 �p}P 6CYLf. S'I'A ESViC.t.EN SPECIAL EVENTS DIVISION• NCHDHINDUST8IESINC. r1cP�rJ�rJ�cP—P r.f'�f'c''r.PrJ-{J�rPcPcPcPtPrPrPcPcPcPrPr.fcPcPrPcnrP�r-rPrPcPcPcPrPrPrPrPcPcPcPcPrPrPr�c..frPrlcPrPcPcn p cPr.t'cf'cPrPcPcPrs'cPrlrPrPcP�PcP�r.fcP