10 WHITE ST - BUILDING INSPECTION (15) a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
\ y j Massachusetts State Building Code, 780 C'MR, 7"edition OF SALEM
y/ Res-deJJunuury
Building Permit Application To Construct, Repair. R ate Or Demolish a mil. zrR>Y
One-or Two-Family Dwell ' g
This Section For OIT sl Use O
Building Permit Number: to Applied:
Signature:
Building Cummissioner/Inspector of Bru din e
SECTION/11:SITE 1 ATLON
1.1/O erty AQdreps S secs Map& Parcel Numbers
I.1a Is this an acce ted street?yes no WNumber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(II) ^
1.5 Building Setbacks(11)
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:
Zone: _ Outside Flood Zone? -.
Public O Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
�jI Ownertof Record: / S,! S��
Q7R.e.cv-roc i���o^.,.:L t�i�e �yn•'/2 /U 2XI 7T�
me(Print) Address for Service:
s�
'Silgnature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(checks aH that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterotion(s) ❑ AdditionJ
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other VSpeciy: '-e%'7 7�_
Brief Description of Pro7sed Work=:
7`0 .�?e� 2 =Pc) Y 3 0
N^� T
imp t
SECTION 4: EST MATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
I. building IS I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical 1 S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S /
4. Mechanical (HVAC) S List: %L
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 6$- 13 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.Iyy1 Licensed Construction Supervlsor(CSL)
�� 1���) L License Number li.s uatiun )ate
Numr3e u1't"� ' a n e -/gym /jt,l� List CSL type(see below)_ L)
Z7 GC Gl C// v f Uescri ion
`
U Unrestricted u 00 to 75.0 Co.Ft.
R Restricted Ik2 FamilyDwelling
�Si °utum�-7 M M Only
RC Residential Roufin Coverin
I'eleplxme WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A (lance Installation
D Residential Demolition
rAddmu
ered Home Improvement Contrector(HIC)
y Name or HIC Registrant Name Registration Number
Expiration Date
gnaure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..........O No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subject property hereby
aurh LS rs-( 4 ,. a t,. _to act on my behalf,in all matters
relative to work authorized by this application. /
Si ureureofrMr Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, .//< A� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf. /
Print N
Signature of Owner or Authorized Agent Dat
Si under the sins and penalties of 'u
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 gig 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 790 CMR Regulations I I O.R6 and 110.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.) flabilable 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 _
J. "Total Project Square Footage"maybe substituted for"Tolal Project Cost"
, w t
o r nsu�u��s�fr��nLnLnrr Pd-[3j I IMPORTANT ®O C U M E N Tarr LPL LPdr3r3PLPL PLPL- PLPL Puy o
5 �ertif leave of Flange Resistance 5 u"� wpkk'
I,k. 5 r d3�4ia; A'�IS.�r
5 R
5 REGISTRATION ISSUED BY Date of Shipment 5
, r
5 APPLICATION v cur C��R 5112I2005 5
5 NUMBER = MIN I SI INc® rj
5 �pd�i EVANSVILLE, INDIANA 47725 Tent Identification 5
5 Elao.l ~ ��048'�'
�� °r MANUFACTURERS OF THE FINISHED S
5 TENT PRODUCTS DESCRIBED HEREIN 5
This is to certify that the materials described have been flame-retardant treated 5
55 (or are inherently noninflammable) and were supplied to:657150
5
5 PETERSON PARTY CENTER INC 5
5 139 SWANTON ST 5
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 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial # 90205000(2) 5
5 Description of item certified: 5
5 FIESTA TOP 20WX30 WHITE SNY VL 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 SNYDER MFG NEW PHILADELPHIA.OH Signed: I PEC�EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5
5 G
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-
' -- PUBLIC PROP-RERTY
DEPARTMENT
KI)I aER LEY DRISCOLL
MAYOR 120 WASHLNGTON STREET • SALEM,MASSACHCSE-rS01970
TEL:978-745-9595 ♦ FAX: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
1'
(Ij
Name (Business/Organizanon/lndividual): e es a 1111 r -
Address. `/� ''
City/State/Zip:LU//7C/ 0s ��/4 Phone #: 7 22 2~
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employec_with_o7 -_� 4. 0-1-am a general contractor and I _T6.-Q-New-construction.._. -
- . have hired the sub-contractors —
employee�full and/oi part=tirtie)'. - t 7, ❑ Remodeling
2.El I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
o workers' comp. insurance 5. ❑ We are a corporation and its
re P 10.❑ Electrical repairs or additions
required.] officers have exercised then
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no _ 12.E❑fRoof repairs
insurance required.] t employees. [No workers' 13.E Other/__z Pl'rf�• T"
comp. insurance required.]
*Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information-
t liomeowners 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 of the sub-contractors and their workers'comp.policy information.
fain art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /!��
Insurance Company Name: . ,t 1 " Z_
Policy#or Self-ins.Lic. #:/IL C_ V3,6e/ 6 Expiration Date: A)
Job Site Address: _Q `�t S City/State/Zip: SkI r17
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 i
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.
/do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature //j�L �/fG ` Date•
Phone#' 7
..'a.-,-r. .-. t _ _._be co-nip
eieh�-by eht4
y �Ojficial use'onfy. Do nat wale in this area, to be completed by erty or town oJrelaL �J
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
-ontaetPerson• _ — Phone#:
CERTIFICATE OF LIABILITY INSURANCE DATE(MM DDl1'1'W)
to/s/zolo
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,Cortaro Policies may require an endorsement. A sLaterneol on this certificate does not confer rights to the
certificate holder in lieu of such endorse m ent(s).
raooucl[a NAME.
T
NAME: Michaei Elonacor so N
Bonacorso Insurance Agency, Inc. PLONE (781)273-3200 Fax
/AIC,No,Exq. INC,rvo): ITeTI>T3-ceoo
83 Cambridge Street ADDRE mike@bonacorsoins.com
ADDRESS'
P-O. Box 1502 PRODUCER 00003879
CUSTOMER ID F.
.BVrlington MA 01803 INSURENS)AFFORDING COVERAGE
INSURED -' NAIC k
INSURER ARepublic Franklin Ins. Co'.
INSURER B:Tra Voters Indemnity
Peterson Party Center, Inc. INSURERCHart-ford Insurance Co.
139 Swanton Streeet
INSURER D'
NSURERE:
Winchester MA01890 INSURERS
COVERAGES CERTIFICATE NUMBER-2010 MASTER REVISION NUMBER:THIS iS TO CERTIFY-THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 7HE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VNi1CH 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- 'IDOL SUBft; _
� LTR TYPE OF INSURANCE i IN ft NNp I ' POUCY EFF�POLICY E%P -- - - --- - -
PODCY NUMBER MMlDO1YYYY MM/t1D/YYYY OMITS
GENERAL LIABIIJTY I �
_EACH OCCURRENCE 5 11000,000
X COMMERCt4L GENERAL LIABILITY DEEMISET(E..,D- .. --'
- - - PRE_M_ISES(Eao¢uuence) 5 500,000
A _ CLAIMS MADEX.I OCCUR X X OPP 4361629 110/9/2010, ¢0/9/2011 MEOEXP(Anyone Perron) 5 10,000
- - PERSONAL&AW INJURY 5 110001000
GENERIC AGGREGATE S 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER
---_ .--, PRODUCTS C_0MP/OPAGG S 2,000,000
POLICY XJIECT LOC -_-- _- - -
5
-AUTOMOBILE UAEIUTY COMBINED SINGLE LIMO 5 1,000,000
ANY AUTO _(Ea oi0
B _.ALL ONMED AUTOS X X I A 929GR836 I10/9/2030 110/9/2011 .BCOILYINJURY(Pw,,a n) :5
X :SCHEOULEOAUTOS BODILY INJURY(Peraoddent):S
X HIRED AUTOS PROPERTY DAMAGE _-
j (Peracddm0 $
_X.I NON-OWNED AUTOS UrWe8leored_otod5 RI SPIO S 1,000,000
Unsure&motorist Bl SPln haut S 1,000,000
X BMBRELIA UAB OCCUR :EACH OCCURRENCE 5 5,000,000
EXCESS CAD 'CLAIMS-MADE. - -
.. .. .__. ..... _..__ r AGGREGATE
AGGAT
_. _ .- .. . .. ._5 5,000,000
DEDUCTIBLE - I.
A ,RETENTION b X X iIMB 4361631 110/9/2010 p0/9/2011 - ---
S
A WORKERSCOMPENSAl : NC STATU- .OTH-'
ANO EMPLOYERS'WBILrtY YIN , X:TDRYIIMITS i.. ..:-ER..; ...._ _ .... . .
ANY PROPRIETORIPARRIEILE IECUTIVE EL EACH ACCIDENT S
'(Mandatory In INA,EMBEED9 a�,NIA' HC 4361630 10/9/2010-I0/9/2011 --- -- - -_._500 000
Dyyes desalbe OF OPERATIONS
C E-L.DISEASE CA EMPLOYEE S_ _ 500i 000
DESCRIPTION t loafr Uelo« L� E.L.DISEASE-POLICY LIMIT:S 500,00
C Equipment Floater Yc i X frO BE DETERIDNED O/9/2030 0/9/2011
'Leased and Rented Equip:
5 100,000 Until
DESCRIPTIONOFOPERATONSILOCATIONSIVEHICLES (Af bACORDtot,Addltlonal RemarksSchedule,Mmoreapace Ismqutmdl
Evidence of Coverage.
CERTIFICATE HOLDER CANCELLATION -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Michael .7. Bonacorso
Y
ACORD 25(2009109) (D1988-2009 ACORD CORPORATION. All rights reserved.
INS026 aDome) The ACORD name and logo are registered marks of ACORD I.
'-' �la:.;t< hu.rit. - Dcp:n'tntcni of Pulrlir `:rfi-i�
Board nl Building flr_ulation. :ntd Cturd:u'rl.
Construction Supervisor License
License CS 60219
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
f Expiration: 4/27/2013
nuniisxi.carer Trb': 13389
t