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SALEM WILLOWS PARK - BUILDING INSPECTION (2) PC.L''rSLl qc% ;�1 the Commonwealth of Massachusetts j Board of Building Regulations and Standards CITY 7 J Massachusetts State Building Code, 780 C'MR, 7'"edition OF SALFM yr Revised danuarl- Building Permit Application To Construcl, Repair, Renovate Or Demolish a /. 200 One-or rwo-Fumily Dwelling This Section For Oftcial Use Only Building Permit Number: Date Applied: Signature: _ .5 2SA Building Commsssio er/Inspector of Buildings Date SECTION 1:SITE INFORMATION I.1 Pro erty Addr dk e 1.2 Assessors Map Parcel Numbers S,e �'ws P 1.la Is this an accepted street?yes no Map Number Porcel Number 1J Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arm(sq 11) Frontage(11) 1.3 Building Setbacks(It) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal!System: Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposals stem O Check if es0 y SECTION 2: PROPERTY OWNERSHIP' 2.1 ner'of Recp(� C/�V of .J gle"'/ Name(Print) Address for Service: r Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) O Addition O Demolition O 1 Accessory Bldg.O 1 Number of Unit_ Other or Speciry: OQ Brief Degcription of Propos d�ork-: c� Rn SECTION 4: ESTIMATEb CONSTRUCTION COSTS Item Estimated Costs: I011ic)al Use Only Labor and Materials I. Building I S 1. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S O Standard City/Town Application Fee O Total Project Costa(Item 6)x multiplier x J. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Str ression Total All Fees:$ r Check No.__Check Amount: Cash Amount:_ 6. Total Project Cost: S ldcIT) 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES F5.1molek Licensed Construction Supervisor 1CSL) / a/na License Number lix ralfu/n Vale N;a of List C'SL-type lice below) sue,— fO u G( I1GrY1 f Description U Unresuicted u to JS,000 Cu.Ft. R Restricted Ik2 Family Ihvellin Signarurc M M Only 7 t' 722—ym-�Y-0 RC Residential Itoolms Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Bumin A liance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) I IIC Company Name or HIC Registrant Name Registration Number t Address - Expiration Date Signature Tclephune SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 152. 2SC(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 ..........O No...........O 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 all matters relative to work authorized by this building permit application. Sianaturcofowner Date SECTION 7b::OWNEW OR AUTHORIZED AGENT DECLARATION I, e IO eks(/)') /G�&& 6q � ,as Owner or Authorized Agent hereby declare that the statements and information an the foregoing application are we and accurate,to the best of my knowledge and behalf - Prim� / Signature of Owner or Authorized Agent Date Si under the ains and rallies of 'u NOTES: I. 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,gf have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL►can be found in 790 CMR Regulations I I O.R6 and I I O.RS,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 healing system Number of decks/porches Type of cooling system Enclosed Open ). "Total Project Square Footage"may he substituted for"Total Project Cost" .a to x°fit' 11t1+ 111t'O , il i n M. M d 10�v Wo t,oyyy I ir 5� aa J'j.r, I g! ;z tC I ,", I, If t,S, Nr,it 7i Wl;j,P..."l:j if if It if ROOM YW it mg "Pula Uf Lfif PH M III I onte";-, q, Ill 6L iii, p ,!f P�M Er i 14 VION ,oft; k; :L V YY ii if I V J!it T -V Tit," 11, it I 4, Wr, _�jijzj Nil I C,it W�z,,1,11 if) NQP * id jot t"I, Tr I Certificate of Flame Resistance 5 5 REGISTRATION ISSUED BY 5 5 APPLICATION Date of Shipment 5 �®® 5/12/2005 5 NUMBER = NoY�as3'in® JJ EVANSVILLE, INDIANA 47725 Tent Identification 5 MANUFACTURERS OF THE FINISHED 04048,75 S �j TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certifythat the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to:657150 5 5 PETERSON PARTY CENTER INC S 139 SWANTON ST 5 5 WINCHESTER MA 1890 5 5 5 5 5 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 5 chemical and that the application of said chemical was done in conformance with California 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 5 Serial # 810910I (I) 5 5 5 Description of item certified: 5 5 CENTURY MATE 30WX60 SNYDER WHITE VINYL 16o7 5 Flame Retardant Process Used Will Not Be Removed By 5 C5 Washing And Is Effective For The Life Of The Fabric 5 5 sNVDER narc NEW I HaADr_L I-uA off Signed: �u 5 (/ ` SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. rj n� r Pr On�r ns��ns�srnrsdL3rE: �u�u��Cnu_n�n��n�nu�uu�nsrss� 10 The Commonwealth of Alassachascas Depai onent of I/Idttstrial Accidents h' Office of III vestigations 600 I1"ashington Sweet �i yasmtt, MA 0-7111 noorv./itass.0v1dia \1 orkers' Coutpensation Insurance Affidat'it: Builders/Couhactors/Glcctriciaus/Plumbers Applicant Infortitation Plense Print Lcaiblt M111lC ([3u>incss'Oreanizetwn/Individual): yUAn � K Addiess:__J�2 �4bc�f City/Statz'Zip: W ( nC h125-flPIK t 177/9 Phone r: 7 — 7a9- Ya o o Are you an employer? Check the appropriate Vox: Type of project (required): - I.�i I am a employer with O O 4. ❑ 1 am a oeneral contractor and I _ em loyzes full and/or ) 6. ❑ New construction p ( pa -time have hirzd he sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t y. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition sorkinS for me L•t any capacity, workers' comp. insurancz. 9. ❑ Building addition [No v.orken' comp. insurance 5. ❑ Pre are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all v,ork right of exemption per MGL I I.❑ Plumbing repairs or additions Myself. [No workers' comp. c. 152, §I(4), and xs e have no 12.❑ Roof repairs I irsurancc required.] r employees. [Nov%orkers' 3 r-7;gyp /�n P m� cop. insurance rquired_j � .[ Ode. te .anpL _nt chat ch s'coX I MLSi 2110 fill ost et.,section below shov.in (heir poli •m 10=_ ion. t Hon'eo nea 'ro sub.-f t this a(`i^ sit in heat n tliev are dotos all war and then hire autsidc cor.t actors rust Sob 7,4t a new af-adad(ird-caLr sein. :Ccnt._.uon that chec' this box nus,attached an additional sheet snowing the n_„e o:the sua<ontracton sand t'-,r u'crke s ec,--.p polici in;orriaucc. I inn an eu:ployer that is providii porkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: U O 1]C- Lt-1 Pohry -or Self-iris. Lic. Vxu C (/3 ro/G 3 o Expiration Date: Job Site Address: q/p/n & r�/pC</S Ci v/State/Zip:_; Attach a copy of the workers' compensation policy declaration page(showin,the policy number anti 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 51,500.00 andior ohm-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 ce-�rrtttiiif�j under the pains/anted penalties of perjury that the information provided above is I c and correct- Sicnature .�/l/.�ifil� -!/C�Aii.e_ Date: e7 Z _ Phonc - worn Official use Duly. Do fiat rerite in this area, to be completed by city or[own official City or Town: Permit'License - Issuing Authority (circle one): I. L'oard of Health 2. Building Ucpartment 3. Cit}/1 oxen Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other t� Contact Person: Phone -: P;rrr fill nl '01 I'ulrlir .ilrr � lirraril rrl liuilrlin_ ION,;rrrrl d.1�.1 '-on,truchon C up_-r.r5or Licence_ license: cs 602i9 ".. STOf�EHAt��, MA 02130tat Expiration: 4/27/2013 Tr 13369 A & CERTIFICATE OF LIABILITY INSURANCE DATE Ir.R.IIDO1YYrr) 10/q/2011 THIS CERTIFICATE IS ISSUED AS A MATTE R OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE BELO'-V. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BET CERTIFICATE HOLDER. THIS CERTI9IGATE bOES NOT AFFIRMATIVELY OR' NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES , REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 4'dEEN THE ISSUING INSURER(S) AU iII THI IMPORTANT: 11 the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS W D AIVG , subject Ic the terms and conditions of the policy,certain policies may require an endorsement, A Statement on this certificate does not Confer rights ID the certi',icale holder in lieu of such eladorsemont(s). PROOVCEF CONTACT NAME. Michael Bonacorso Bonacorso Insurance Agency, Inc. PHONE ---------- - - . - _ . m I„ E.,1. (761)273-3200 FAX o. nsllz:;-ua;. 83 Cambridge Street E-r.AIL .mike06onacorsoins.com P.O. Box 1502 ADORESs. C NSURER(S)AFFORD G COVER'GE :AI < Burlington MA 01803 ---- -- _ _ __ INSURED ulsuRERAReoublic FrakJju Ins Co — INSURER©:Travelers Cas L Sur of Ill inio__Peterson Party Center, Inc. INSURER C Utica National Insurance C . __139 Swanton Street c InsURER D:T ravel e rs Casualty and Surety - INSURER E -- Winchester _ t1-, 01890 INSURER F: COVERAGES CERTIFICATE NUMBER:2011 M_Z.STEER REVISION NUMBER: THIS IS TO CER=1 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 W'HiCH THIS CERTIFICATESIGNS 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.POLICI E5.LIMITS SHOVvi4 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - N DR $D LTR TYPE OFINSURANCE pOUCV NUM1IBER M11.�DDMIYY MCrD NI l LIMITS GENERAL LIABILJtt LICY UP EACH OCCURRENCE 1,000,000 X �-COMMERCIAL GENERAL DABILITY DAMA ETO RENTED -- PREMISES Ea occurrence S 50,000 A. CLAIMS-MADE 1z OCCUR X X PP4361629 10/9/201'1 10/9/2012 MEEDEXP(Anyoneperson) S 10,000 PERSONALa ADV INJURY S 1,000,000 GENERAL AGGRG_AT '_ n0C,000 G rGR=_G>TE LIMIT APPLIES PER: PRODUCTS-CDs rC C _ 7.;� }. GLICY� LG- AU TOSIOOILE UASIUJ k LDMOIIJE0 61NCL-UCJT fca acodc- r y000_EOCD' B 'NY AU-. � BODI LY INJURY(Per persar-I $ ALL ONmED SCHEDULED LJ AUTOS X AUTOS X X ^-9296R936-11-SEL 10/9/2011 10/9/2012 BODILY INJURY "-----"— X HIRED AUTOS NON-0'ANED -- PROPERTY pAMgGEacdde.q -5 __— X AUTOS _ Pe�arsidenl S UACHOCCURRENCE d URRE split llml S 1,000,000 X UMERS LIAR OCCUR X X EACH OCCURRENCE S 10,000,000 G EXCESS lJAB CLAIh19-MApE AGGREGATE 5 10,000,000 DEB RETENTIONS 4361631 0/9/2011 0/9/2012 S D WORKERS COMPENSATON WCSTATU OTH�I AND EMPLOYERS'UABIU Y 1 Y X X T c 51 AIYY PROPP.IETORPARTNER/E%ECUTIVE '-- OFFICERlEMBEREXCLUDED'+ N❑ NIA EL.EACH ACCIDENT 5 500 G`0 IMand,l In NH) C 4361630 10/9/2011 10/9/2012 EL DISEASE-EA EMRLOIEES If ze X.Gesmbe under 500 LOGO DESCRIPTION OF OP ERATIOI below EL.DISEASE-POLICY LIMIT S 500 — DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (A c00 F RD 101,Additional Remarks Schedrle,H more space Is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED III ACCORDANCE WITH THE AUTHORIZED REPRESENTArIVE j III tdichael J. Bonacorso ACORD 25(2010J05) ©1988-2010 ACORD CORPORATION. All rights reserve;:. INS025,vn,o:o ni Th. Arnon