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10 WHITE ST - BUILDING INSPECTION (17) i4 i f J The Commonwealth of 1iv1ass.ichusetts Department of Public Safety i • •I' hlist-Ili titate]ill ildi Fig Co It,(7,41)C.\1 Ill Building Pernlit Application for any Building other than a One-or"I'wo-FamiIy Uwe IIil (This tier lion For Offi(ial Use 011ly) 8ti lding Permit Number' .._. __. Date Applied: ( _ fill ildiing Offic is - - SEC 110 N, 1: 11OCA I ION(Please indicate Gluck Y and Lut p fur locations for which a street address Is not oval _ . S'f _J4 N7 — — — RQ_4.wt 1 wr�lo _�U No, 'o. ,Ind Street CIII./folvn /ill Code None at Build ntg(if alrplirable) .. SECTION 2:PROPOSED WORK --------- ---......[Jiliun at MASenr Code used __. .. It New Construction chock here❑or dnrk all Ill al apply in the Iwo rows below lisistinl; Building ❑ Repair :11ter,Il ion Q :1Jdiliau❑ fLowlition O (Please fill uutand submit Appemlis l) Chaury;eol L'x. ❑ Ch,up;cafUccupaulry ❑ Other �perify'_ ,� jYj �' �' Arcbu11J1ng pl.uls and/or consl nlc tit n Ill s'wnen is being sit pplied:Is pe rt of th is permit appl ica tiun? 1'cs ❑ No ❑----- --- k all Independent Structural Enginerrin+ Peer Review reyuired� Yes ❑ No ❑ Thief Description of Proposed Nark:-, a o7 O l�� !PH'rAoie' Tv SECTION J:COMPLE"TE FIIIS SECTION IF EXISTING UUILDING UNUERGOINC RENOVATION, AUDITION,Olt CHANGE IN USE OR OCCUPANCY Check hero if,m Existing Building Investigation and Evaluation is enclosed (See 780CNIR.N) ❑ Existing Use Group(s): — Proposed Use Gnn4,(s):---_._—.___ SECTION S:BUILDING 11F,IGHT AND AREA Existing Proposed No.of Floors/Stories(indude basement levels)A Area Per Floor(sy. ft.) -fatal Area(sq. It.)and total Height(Ft.) SECTION 5: USE GROUP(Check asa licable) A: Assembly:it-1 ❑ A-_'❑ Nightclub ❑ ,\,) ❑ :\-1 ❑ :1-i❑ B: Business ❑ E: Educational ❑ P: Facto F-I ❑ 17❑ I1: Ili h Flaznrd 11.1 ❑ H-2❑ I hi Q 11-J❑ 11-5❑ 1: Institutional 1-1 ❑ 1-2❑ L)❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-1❑ RA ❑ .ti: .titurage SI Q S2 Q U. Utility❑ Special Use❑and ,lease dc,cnbe l+claw: tiperial L'sc SECTION 6:CONSI'RUCrlON INPIC(Check a-- a t licable) L\ Q IU ❑ IIA ❑ ... ill:\ ❑ RIB ❑ IV ❑ VA ❑ \'B Q SEC"I"ION 7:SITE INFORMA I'ION(refer to 780 C,\IR I I I.II for details on each item) lVa ter Supply: IIooJ Lone Information: Sewage Disposal: French Pennit- 17i'bns flemuval: --- Fublir ❑ Check it amtsidc I It /_one Cl InJi,,Ite municipal❑ A trcnc It cell not be I.keened Pkp",Il pile❑ Pm.Ih•❑ „r Indvnlil9 /one nnm sne,t stem ❑ mquir"'I Otto` Irr•ndl nr,per If% _ Iarnnit is one laved ❑ . Rai baud right-at-way: Ilarards Io Air..\'av igation: \',at .\pphv,il'la Q I Iv<Irwlnro r.rthin.urp,�rt.ypnaor h.irc,t1 Iv lhru rrt'ml.I, Iu(grlcd rr L „n.on1 It, Itud,l rnJu.ra1 Q )e, ❑ ar N'„Q 1 r,❑ \n Q . tiff IIO.N 9:CU.N II[N'I O'lh It IIFICA I-L•'UI'O(( L PAM Y IJilnu,.I (,"Ir (.a•l;n,ul,l.l Itiar rl(„n.11m lean' nl,ula,urtla ,ul lnr hl,,,,I. _ I)"t h,-bu drhnt;, •n Lou.m�Pru,Alor tit stem.' . . .. `Per of '-111,uIMIFm' I . SUIL,I ION '): VRO N I(I YOWN Fit Au I I MR I ZA,I[ON d Iry nl Vropvr elln p Nmne(Print) P-P No. ,jild Street City/Town /i prtIptvtY Owner Coma: Information: —-----— I"'It-PlIolle Telephone No. (C01) e.mailaddresi I file No. (business) U. 1it 1 ) Viv wrkt)N tit ViW � street Address city/ rms-it State Zi Name p III ant I'll tilts pro sera owner's 11,41,11f, M•111 matters rt.1,Itivv it)work authorized by this 111111dillil permit l SECTION 10:CONS I KUL I ION CONTROL(please fill out Appendix 2) If I'tifl,lillit is ICSS than 35JDoll Cu.it.of enclosed space and/lIr not under Construction control then check here 0 ana 41,41 9vttioll 111.11 lo.1 Registered Professional Responsible for Construction Control Naille(Registrant) [*e1cphone No, e-mail address Registration Number ,411eet Address City/Town State Zip Discipline r\Viration Date GL eral contractor L!S C ,a,ltp.tny N ime Nasileof I" kit esponsab furCt,listruction Liicnse No and Type'If APPficable ­stat, --Zip, Servo Address City/Town roophone No. business relephone No. cull) e-mail address SEL 1UN11; 1 1, VAI',VmI AI11 ,� II M.G.L.c152, ZS C(6)) A Workers'CoCompensationIlls' ce Affidavit from the MA Department of Industrial Accident mum bect)[111:1 112teki and Submitted with this,tpplication. Failure to provide this affidav it will result in file denial of the issuance of the building permit. Is a iialled Affidavit submitted with this applicotion? Yes E3 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Mid Materials) Item and Costs: (Labor total Construction Cost(it(,"' [tell'(1) - I. Building 13 BLI[Iklillg Permit Ftv-Total Construction Ct)st x ([itself here 1 Electrical 5 Ippropriatt?111111116PAl 1`1100f) t. 111tillibill), ) — Note \lillillltllll fee -5-- (Tennant munieip•dily), — 1. \ICdI,IIIik.II (IivAQ 11, (Other) I S I-licit,se div,k payable to Cost 1 1-1 9 e_tl C-b (CoIllatt IllUllik 1[1,114%)and I,rite,Ilk-%k number lice s Ec r 10 N 13:S I G NA I U It E OF BUILDING VE IC\I IT A 11 11 L I CA N r Ite I penalties of I,,-rjtlry 111.1t.111 It life lillormatlon"'lit'lilwd it, this ontormi; IIIN.. muteI liercl,v ittust under flit-p,1111s,111, i trUVAIld 111 Ur.ItV to the N'St 'If MN I'll"" ., e,md understanding. � /. 1 HIV h-k-i'llotiv \I, D.tto Pic,i,e privint 'l 4b,11 11.1111t. Ao- "I"') WdWli III*, Vo%,if %1,1,litipal Insli"tur to fill out this Qltit'll "W"I appliiation approval: v Nmiu, o u�rsr�rlrs�nrsrsr�r�r�rsrsrsrsrsr�rs�n�nrPrnrsrsrlrs�ti IMPORTANT DOCUMENT ?r'uclr�r�r�rsrscPr�u�u�r�rsur�uu�uu�r�u�r�urlrs o 5 Q'L,ertift,eate of flame Rem'5tanre C5 5 REGISTERED ulrF Date of Manufacture 5 5 APPLICATION NOR® C� NUMBER ¢ 03129/00 Cj a t INDUSTRIES INC. EVANSVILLE, INDIANA 47711 Order Number 5 5 F121.4 7 a� QF 312748 5 5 5 c MANUFACTURERS OF THE FINISHED 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:657150 5 5 PETERSON PARTY CENTER INC 5 �5 139 SWANSON ST ICj 5 WINCHESTER MA01890 5 55 Certification is hereby made that: 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 Fire 5 5 Marshal Code, equal to exceeds NFPA 701, CPAI 84, UL,C 109. 5 5 The method of the FR chemical application is: 5 Serial #: 8023300(4) 5 Description of item certified: 5 5 - E EXP Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 „i .IOHN BOYLE STATESVILLENC Signed: Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5L �° CPC I�LI�CPLI�CPCPCPCJ�CP[J�[FafJ�LFC I�LFOCP[P[PCP[PCPCP[P[_I411 31�L1 :111 F! ll:! Ell C1[PPZP[P[PCP[PClaLI�CPCPLI�CPCJ�CP[P[IBC I@I�[lC l@PC FCPLI�CPCP[PLI�LI�[Pc 1�CPLl�C IBC I�CP[PC I�LI�LI�CP[PCPCP[@PCP I i o nErs,r n�MIPLPL PLPLnLPs�J I M P® RTA NT D O C U M [E N T�d-d-�dud r_p gsgn�d�d-dd� a INCertificate of Flare csiscc 5REGISTRATION ISSUED BY Date of Shipment 5APPLICATION Q o ��®�® 06/08/04 5 NUMBER 5Tent Identification Sir EVANSVILLE, INDIANA 47725 5 �'r a��° MANUFACTURERS OF THE FINISHED osssozs4 5 S FI2I.d e TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 55 (or are inherently noninflammable) and were supplied to: 5 657150 5 5 PETERSON PARTY CENTER INC 5 5 139 SWANSON ST 5 5 5 WINCHESTER MA01890 5 5 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.Serial 5 5 55 Serial # 8023000(2) 5 5 55 Description of item certified: 5 5 FIESTA EXPANDABLE TOP 20WX20 5 5 WHITE VINYL 75 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 -, 5 IOHN BOYLB S"PATESVILLE NC Signed 5 " SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5 � d'0[Pr�[PclOd�[Pd@Pr�[PrPr1 T[P[Pd@PrP[P[Pd�[P[PcP[Pd�[P[Pd�d@Pd�[P[P[PrPcP[PrJ��P[Pd�d"r.P[P[Pd�rJ@Pr��P[Pd'�PcP�POP[PrPOP[Pd�r�dd@Pr�cPcPr�cfdd� O k� CERTIFICATE OF LIABILITY INSURANCE DATE(FIM1VOO YYY) 10/19/2012 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_NOLCONSTITUTE-A CONTRACT_BETWEEN_THE ASSUING_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 endorsement(s). ZOOUCER - NAtiITACT Michael Bonacorso 'onacorso Insurance Agency, Inc. PHONE (781)273-3200 nlc Ne: (781)273-0E00 3 Cambridge Street aooae ,mike(bonacors oin s.com ).C. BOX 1502 INSURERS AFFORDING COVERAGE HAIG9 .urlington MA 01803 INSURERA:Acadia Insurance Com an SURER MSURERS:C N A Insurance Co. Peterson Party Center, Inc. INSURER.AIM Mutual Insurance Co. 6 Cabot Road INSURER D� INSURER E'. bburn. MA 01801 INSURER F: OVERAGES 6 CERTIFICATE NUMBER:2012 Master 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. .R TYPE OF INSURANCE ADOL SUER - POLICY EFF POLICY EXP LIMITS R - p POLICY NUMBER M.%1DDNYYYI IMMICDFYYYYI 7GENER L.LIABIUTY EACH OCCURRENCE 5 1,000,000 COMMERCIAL GENERAL LIABILITY PRE al E..MAUL I U HEN urencal S 100,000 k CLAIMS-MADE . 00CUR X $ CPA 5061026 10 10/9/2012 10/9/2013 HIED EXP(Any one person) 5 10,000 j PERSONAL 3AOVINJURY 3 1,000,000 GENERAL AGGREGATE $ 2, 000,000 GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COMPIOP AGG 5 2,000,000 POLICY X PF' FI LOC s AUTOMOBILE LIABILITY - COMrciden SINGLE L@AIT a 1 OOO 000 Q ANY AlJiO BODILY INJURY(Per person) 5 ALL OkbNED y, SCHEDULED X .� N.AA 50631"13 10 10/9/20i2 10/9/2013 BODILY INJURY Per T XH Ri05AUTOS � NG.1 CIrNEJ (Par.c RTV,DAb1AGE S I Uninsured motorusl BI sol,fim11 e UMBRELLA LIAR X DCCUR X - EACH OCCURRENCE 3 10,000,000 EXCESS LIAR CLAIM$-MADE AGGREGATE o 10,000,000 0'O_IX I RETENTION; 1C,000I 085496452 10/9/2012 10/9/2013 S ST VC TU- WORKERS COMPENSATION V . A ANO EMPLOYERS LIABILITY YI N TS OTH- ANY FROPRIETORIPARTNERIEXECUTIVE E. EACH ACCIDENT $ 1,000,000 OFFICERIMEMSER EtCLUDEO? NIA WMZ8006586 10/9/2012 0/9/2013 (Mandator)in N41 E.L.DISEASE-EA SrAcLOYEI5 1,000,000 If, describe un.er DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E 1 000,000 ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ADDED 101,Additional Remarks Schedule,If more space is required) :ERTIFICATE 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 J. Bonacorso CORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. 4S025(201005).0; The ACORD name and logo are registered marks of ACORD t"S Adassachuse.s - Department of Public Safety �—� Board of Building Regulations and Standards Con ructi-m Supeni>or - - - ---- lic_nse: CS-060219 ,,L4RK TR-AES .' 33 ILAYF ORD RE y ; Stoneham ,LA 02130 ill; �� ��� >r ie" Ezpl raflon Commissioner 04/27/2015 -. H..r •1- H,IP OV--.IAE 1T CO- RAC - `- cc. - ,.,;n: _ •U is i'di]��: bil T.—' J 1 ..a iG.[• ` .. .. - l Il yl I IJ"n" nr re:fSi rnliuu vniiJ for Indii idul bulgy,rc the ccpira Cron tlnlc- II fqund i'ctur 11". DlCice of CV�'s miser A l lislr< mid Gncincvy IL'^ula ti:,u III I'arlc I'I;rza -tiuitc �1%II I;us ion_ALA n'1 U, ' 11u1 slid •.-ifhuul Si •naln rc... The Commonwealth of Mas'sachnsetts _ Department ofIndastriaf Accidents fe Office of firvestigations jk�, 600 lVnshirtgtmt Street Boston, .41f1 02111 ivww.toass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le=ibly NalTle(��siness.rOrganintionilndi vidua q: e e S vr-) Aa44 ren fK Address: 3(, r4 w4 R,( - City/State/Zip: `7 fY } /DUI Phone#: �7 7c2 J- 5,/0 O CU Are i.ou an employer?Check the appropriate box: Type of project(required): . am a general contractor and I I.CZ [ am a employer with a CR7 4 ❑ 1 � 6. New construction employees(full andlui part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition wotkm employees and have workers' g for me in any capacity. 9. ❑ Building addition [No workers' comp. insurance comp insurance.• requited] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am it homeora tier doing all work officer. hale exercised their I I.❑ Plumbing retain or additions nry«If [No vI olkcis comp- right of exemption per MGL 12.❑ Roof repairs insurance required.]': e. IS2, §1(4),and we have no employees. [Noworkers' comp. insurance required.] 'tAry a pp l ica tit that check hs n l ncimt I tilloutthe-enmu be low:'h<oin,their wukei. nmputslad on pi)l icy tNormat ion. -Io mote tars wlto.ubnut thiv in idavit indicating dial are-doing all work and then hire,t utaide contractor c,,et subanat a nca aflld .-'it indicating such. 'C:ontrattor,<that check this be, must unachea an additi on at'Ica shotvim-the name otthc snh-al nrr,,,nrs acid state,hether le"not.hone entities have tutplopeas. It the ,,b-,onTrtcbtb have tmpbyces,an,' must provide their ""Il s ceu.P_pal icy num her. !not an employer that is providin Workers'compensation in.curan ce,lor nth employees. Belo,is the policy and job site injoratation. Insurance Company Police 4; or Sell=ins. Lic. 4:6lt�2 O 0-C7('�03��� Expiration Date: Job Sicc .Address: t d _ City/State/Zip: (y'�f�__ Attach a copy of the workers' compensation policy declaration page(show licy(showing the po number and expiration date). Failure to secure coverage as required under Section 25A ofb1GL c. 1152 can lead to the imposition of criminal penalties of a Fine up to S 1.500.00 and/or one-year imprisonment,as well as civil pcnitlties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that it copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certily�plains r�ies ofperiurr that the mJor nation provided above is true and correct. r Si nauuc [)are Phone:L Official rise only. Do not write in this area, to he completed l)v city or town official. Cite or Town: Permit/License# Issuing,Authority (circle one): 1. Board of Health 2. Building Deparhuent 3. City/"town Cert. 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ Phone#: PAGE 3 OF 4