167 FORT AVE - BUILDING INSPECTION (005) <7 15o3e $Z.S
The Commonwealth of Massachusetts 1p( REc I/w,
Board of Building Regulations and Standards PECTO,Tjyj�0
} t Massachusetts State Building Code, 780 CMR, 7"edition 1� OF SAL E VICES
" J S Rgyttsed Jumlury
Building Permit Application To Construct,Repair, Renovate Or Demolish a Ll.df83P08q
One-or Two-Family Dwelling 03
This Section For Official Use.Only
Sp Building Permit Number: Date Applied: ^�
V Signature:
I Building:Commissione/Inspector of Buildings Date
f� SECTION 1:SITE INFORMATION
U 1 1.1 Pr party Address (' �11 (0 VJ5 1.2 Assessors Map& Parcel Number
lP i'tlfLY�1 ]� e, SUS em , me
I:l a 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 R) Frontage(A)
` 1.5 Building Setbacks(R)From 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 O On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
=f l°t�A D WS l del a w l\ Av C I S al m. m Y�
Name(Print) - Address for Service:
.Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check an that apply)
New Construction❑ .Existing Building❑.. Owner-Occupied ❑ Repairs(s) q 1 Alteration(s) ❑ Addition ❑
Demolition 13 Accessory Bldg.O. Number of Units_, Other Specify: I:
Brief Description of Proposed Work=:
r ' 111
0 2DA D l
15
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Onty
-- Labor and Materials
I. Building I S ' t PAP I Do 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S - ❑Standard. Cityfrown Application Fee -
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S'
4. Mechanical (HVAQ S List:
5. Mechanical (Fire - S
Suppression)" Total All Fees: S -
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: S -f ❑paid in Full - 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ofCSL-holder List CSL Type(see below)
.'r - Description
.Address _ - U- Unrestricted(up to 15,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature- - " - - M - Masonry Only
RC Residential Routing Covering
Telephone - - WS-- Residential Window and Siding
-- - SF Residential Solid Fuel Burning Appliance Installation
D - Residential Demolition
5.2 Registered Home Improvement Contractor(HIC")
IIIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature - - Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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..........0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize Ylj' F dQPC to act on my behalf,in all matters
relative to work authorized by this building permit application.
(pIZzU�
Signature of Owner - Date- I
SECTION 7bs-OWNERr OR AUTHORIZED AGENT DECLARATION
Owner or Authorized Agent hereby declare
) � I ,as0 g Y
I t r ��� � �-�^rt G�.
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf,
lmlbc
Print Name 1
�2 15 _
Signature of Owner or Authorized Agent " _ Date
(Signed under the painsand.:penaltiesof 'u'
NOTES:
1. An Owner who-obtains a building permit to do his/her own work,oran owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will.Mal have.access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL).can be found"in`780 CMR Regulations I l0.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total Floors area(Sq. Ft.) (including garage,finished basement/attics,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'maybe substituted for"Total Project Cost"
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
l Congress Street,Suite 100
Boston,MA 02114-2017
www mass gov1,is
orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):The Event Co
Address:PO Box 419
City/State/Zip:Gloucester MA 01931 Phone M 978-283-4884
Are you an employer?Check the appropriate box: Type of project(required):
I.Q I am a employer with 20 employees(full and/or part-time).' 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance requireA.]
9. El Demolition
3.❑I.a homeowner doing all work myself.[No workers'comp.insurance required.]}
10❑Building addition
4.❑I sin a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole ME]Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.M 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-conuactors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.D OtherTents
152,§I(4),and we have no employees.[No workers'cow.insurance required.]
-Any applicant that checks box#1 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 mus{:.attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Tavelers
Policy#or Self-ins.Lic.#`.XEUB2186T50511 Expiration Date:1(/112/16 �[
Job Site Address:Sal" W i'I N)S t I U] rV f1 a A I' 6� City/State/Zip: J a 16l)) m tl
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pain w}d enaldes o 'ury that the information provided above true and correct
Simafore: // C, p Date:
Phone#:
.Official use only. Do not write in this area,to be completed by city or town official
City or Town: - Permit/License#
Issuing Authority(circle one): -
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -
Contact Person: Phone#:
The Event
Co.
P.O.Box a191s JOB CONTRACT
Gloucester, MA 01930
the event co. Voice: (978)283-4884
Fax: (978)283-4163
. .
INVOICE TO: DELIVERY ADDRESS:
Order Status: Confirmed Order
FestEvents Salem Willows Sales Person: Taylor Hedges
PO Box 460 167 Fort Hill Ave Last Updated:APR 11 15 1:19PM
Seabrook,NH 03874 Salem,MA
ATTENTION: Jude David JOB SITE: Salem Willows PO.
CUSTOMER#:
PHONE: (603)918-3385 Ext: ROOM: TERMS: 25/25/50
FAX: (603)474-5495 CONTACT:
EMAIL:jude@festeventsne.com PHONE: CELL:
ORDER DATE&TIME: Delivery DATE&TIME: Event Start DATE&TIME: DELIVERY VIA:
MAR 4 15 11'06AM JUL 7 15 JUL 10 15
Event End DATE&TIME: Pickup DATE&TIME: DATE&TIME: RETURN VIA:
JUL 12 15 JUL 13 15
JOB DESCRIPTION: Salem Seafood Festival 2015
EQUIPMENT
QTY I DESCRIPTION DUR UNIT$ EXTENDED DISC NET
Tents-Sidewall extra
1 10 X 10 Frame Tent 2.0 d 125.00 125.00 10% 112.50
For Check-In
No Sidewall
Staked
3 10 X 20 Marquee 2.0 d 225.00 675.00 10% 607.50
2 for Coke Booths, 1 to cover Stage
Sidewall for all sides
Coke Booth Tents weighted, Stage Tent staked
1 20 X 30 Frame Tent 4.0 d 400.00 400.00 10% 360.00
Seating Area
weighted
1 20x30 Frame tent-eco 2.0 d 400.00 400.00 10% 360.00
1 for Culinary Tent
Sidewall on 1 side of Culinary Tent only
Weighted
1 20 x 40 Pole Tent 2.0 d 440.00 440.00 10% 396.00
Beer Tent
Tables and Chairs
200 Black plastic chair with chrome frame 2.0 d 1.25 250.00 10% 225.00
chair installation additional .50 each
200 Solid Sidewall 2.0 d 1.25 250.00 10% 225.00
50 White plastic chair 2.0 d 1.25 62.50 10% 56.25
Chair installation extra .50 each
30 8' Banquet Table-Stacked 2.0 d 8.50 255.00 10% 229.50
Table installation extra 1.00 each
Tables and Chairs
2 8' Bartop Table 2.0 d 12.00 24.00 10% 21.60
Table installation extra
30 3' Round Table- Hightops 2.0 d 8.50 255.00 10% 229.50
Table installation extra
42" High
Accessories
24 350LB Ballast Block 2.0 d 20.00 480.00 10% 432.00
Quotation Updated on APR 11 15 at 1:19PM
. r
MISCELLANEOUS
QTY DESCRIPTION UNIT PRICE EXTENDED
1 Permits 125.00 125.00
EQUIPMENT TOTAL: $3,254.85
MISC TOTAL: $125.00
DEL & PICK-UP: $150.00
(MA State)TAX TOTAL: $ 203.42
GRAND TOTAL: $3,733.27
PAID TO DATE: $ 0.00
BALANCE: $ 3,733.27
Customer Signature
Customer Printed Name Date
Quotation Updated on APR 11 15 at 1:19PM