10 WHITE ST - BUILDING INSPECTION (23) IThe Commonwealth of Massachuscus
Board of Building Regulations and StandardsTa *iddONSIM
f
Massachusetts State Building Code. 780 CMR, 7'h edition
i� TT BuildingDept
Building Permit Application Td Construct. Repair. Renovate Or DemoOn r 7tro-Fomif�Ossr!ling
is Sectio or Official Use Only
Building Permit r: Date Applied:
Signature:
Building Commissioner/Inspoidir of Buildings Date
SECTION 1: SITE INFORMATION
rDis
g21:// 1.2 Assessors Map& Parcel Numbers
epted street?yes_ no Map Number Parcel Number
rmation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
"(Print)
ly: (M.G. c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
ivate O Zone: _ Outside if Floo
Zone? Municipal O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
eeord:
Ne orC o.c/ I Sf
Address for Service:
73'- 7`,10-2Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other d Specify % fr7
Brief Description of Proposed Work':
eC"- Q- 30 xcecp x: O M .z a
O✓f o A 607 ar-1_� /o
1 J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
RPlumbing .
S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
l S ❑Total Project Cost'(Item 6)x multiplier x
g S 2. Other Fees: S
ical IHVAC) S List:
cal (Fire Sn Total All Fees: SCheck No. Check Amount: Cash Amount:6 ota roject Cost: Sam ❑ Paid in Full 11 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL) � �9 7
kL crn.e Number puw an Date
..v'4me of aNH tied` � / �/ /4/n'� Lit CSL Type(we below) Cad
5� lit T �h T Description
A ss S .� U Unrestricted u to 35,000 Cu. Ft.
R Restricted 1&2 FamilyDwelhn
Signature M Masonry Only
RC Residential Roofin Covering
Telephone ;RC
Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.
Signet!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 r A-s ,,i cta4-,-i (-�ki 4e< to act on my behalf,in all matters
rela ive to work authorized by this bZilding permit application.
7_2-2^/O
Si nature of Owner Date
SECTION 7/b:OWNER' OR AUTHORIZED AGENT DECLARATION
rthat
:stateme�nftmsand
f h,ri GP�'C ,as Owner or Authorized Agent hereby declare information on the foregoing application are true and accurate, to the best of my knowledge andr2I S
7 d O
Signature of Owner or Authorized Agent Dat
Si ned under the ams and penalties of perjury)
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 W 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 110.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below: -
Total floors area(Sq. FL) (including garage, finished basement/anics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decksi porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage" may be subsbluted for 'Total Project Cost"
O cPu��Prt�lJ?nPrl�J�cPfcflrScPcP�bPrJ��PcPJ?n�l�Pcfl IMPORTANT DOCUMENT
5 5 ,�eri_�e3:.
5 5 r.
5 5 �R
5 VCertifirartt of ,f lee Rot'5ta na S ' 151
ISSUED BY 5
5 REGISTERED u��,. G Date of Manufacture 5 1 .
i 5 APPLICATION Q HORi CJ
s
5 NUMBER IN PRIES INC. 5 f
EVANSVILLE, INDIANA 47711 Order Number 5 t
5
5 F131.4E 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
55 (or are inherently noninflammable),and were supplied to:
657150
PETERSON PARTY CENTER INC 5 55 139 SWANSON ST
5 C5
5 WINCHESTERMA 01890 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 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, ULC 109. 5
5 -The method of the FR chemical application is: 55
5 Serial : 8109100(1) f�
5� Description of item certified: 5
5 CENT MATE 30W X 60 VL W W
5 _ Flame Retardant Process Used Will Not Be Removed By 5 f
5 Washing And Is Effective For The Life Of The Fabrics
5 IOHN 130YI-E STATESVILLE NC Signed: t . zJZ C5
L� Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. L
O cnrJ��PcPcPcPcPcP�PoP�P�n�P�ncPcPcPcPcP�P�PcncPcPcP�ncP�PoPcn�PcPcPrPcPcP�ncP�PcPcPcPoPc.noP�Pr:P�nrJ��P�P�PrJ�nu�cP�ncP�PcP�nc.ncPcP�P�Pc.rar.PcPcP�PcPbP�PcPcP�ncPcP�P�P�PcPol
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@rPJ�P��1?c �Jc.�nfnl��rPrJ�cPr�r1IMP® TeoNT D®C TMENT
5 Certificate of Flare lsesist�apee
ISSUED BY a dry:
Date of Shipment 5 REGISTRATION5
3 APPLICATION o °`s �� 5/12/2 05
5
NUMBER NDUS7RIE ING® s.. 5
5 fC f
EVANSVILLE, INIDIANA 47725 Tent Identification
fj '� Mr pr 04048575 + ft<
S r]ao l MANUFACTURERS OF THE FINISHED 5K.
�
TENT PRODUCTS DESCRIBED HEREIN y
5 This is to certify that the materials described have been flame-retardant treated 5 ryj, ti �
5 (or are inherently noninflammable) and were supplied to: 5
5
5 657150
5 s ,
PETERSON PARTY CENTER I,NC +;v
5 139 SWANTON ST 5 t ;
WINCHESTER MA 1890 5
55 5
5
5
5 5
5 i �
I 1i rin
5 Certification is hereby made that:
5 - The articles described on this Certificate have been treated with a flame-retardant approved
5 chemical and that the application of said chemical was done in conformance with California 5 i
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 + o r
5 Serial # 8025500E(2) 5
5 Description of item certified:
5
5 FIESTA TOP 20wX30 WHITE SNY V1_ 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The// Fabric 5
SNYDER NI PG NEW PI-I I LA DE Signed:
5 5
5 (j ' SPECIAL EVENTS DIVISION•ANCHOR INDUSTRIES INC. 5
j!P�fcPcPrJPLtPLPL PcPcPcPEll 1; !1cPt1 1 1:1 1;!:: 1 2L rJ"tPr-pc- PLrJcFruL PcPcPrSrJ�rPtPrJ�r- PcPLi-c3 P�PtPrJ�rJprJ'r3r3aLlL!II:; tPrJ�tPrJ�r?1cPcPrScP cP
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o
�l:t>�::iltll�CCI� - [)CIIJ.:'ifil�ni (Ii. pui)llc \a[ct\
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c [3crlyd (of Buildin, Rc�uiatinn. and Standard>
Construction Supervisor License
License: CS 60219
Restricted to: 00
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
Jam- �yf Expiration:. 4/27/2011
(lnnnli>sioucr Tr#: 14425
Client#: 635556 PETERPAR2
ACORD- CERTIFICATE OF LIABILITY INSURANCE 13/10MpD Y)
Pao°uceR 41G/10
THIS CERTIFICATE IS ISSUED AS Al., I ER OF INFORMATION
US] Ins Sery of MA, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O Box 920444 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Needham, MA 02492
ALTER THE COVERAGE AFFORDED DY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
wsuaED Peterson Party Center Inc wsURERA: Hanover Insurance Company 22292
139 Swanton St INSURERS Liberty Mutual Insurance Company 23043
Winchester, MA 01890 INSUR_ERC
INSURER D:
SURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSRI TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY-EXPIRATION
GATE MIA ODNY DATE MMIDDIYY LIMITS
A GENERAL LIABILITY DATE
10/09/09 10/09/10 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S300000
euIMS MADE ❑X CCCUR M=D EXP(Any one person) s5 000
PERSONAL 6 ADV INJURY E1 000 000
GENERAL AGGREGATE s2 000 OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E2 OOO 000
POLICY r X PRO-
JECT X LOC
A AUTOMOBILE LIABILITY AMN6398554 10/09/09 10/09/10
COMBINED SINGLE LIMIT
tXNON-0WNEDAUTOS
AUTO (Ea accident) $1,000,000
WNED AUTOS
DULEDAUTOS BODILY INJURY $
(Per Person)
DAUTOS
- BODILY INJURY E
(Per ae denl)
PROPERTY DAMAGE
(Per ecadent) E
GARAGE LIABILITY AUTO ONLY-EAACCIDENT E
ANYAUTO
OTHERTHAN EA ACC S
AUTO ONLY: AGG E
A EXCESSAIMBRELLA LIABILITY UHN6482021 1O/09/09 10/09/10 EACH OCCURRENCE E5000000
X OCCUR CLAIMS MADE AGGREGATE ES 000 000
S
DEDUCTIBLE "
=000
RETENTION ENOnB - _B WORKERS EMPLOYRS'UABNSATION ANDWC2Z11259617029 10/09/09 10/09/10 X ---We STATU- OTH-
EMPLOYERS'LIABILRYANY PROPRIETOR/ ARTNERJEXECUTIVE E.L.EACH ACCIDENT OFFICERMIEMBER EXCLUDED'! E.L.DISEASE-EA EMPLOYEE EL.DISEASE-POLICY LIMIT
OTHER
___PIPT"N OF OPERATIONF I r OCATInus 1 VEHICLES I"Cl USIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
.
ACORD 25(2001/08) 1 Of 2 #S4312552IM4063373 BJECG ID ACORD CORPORATION 1988
The Contar oil)vealth Of Massachusetts
Depar7metrt Oflndustrial Accidents
office of Investigations
ICI �i- I
600'1,'ashili ton Street
Boston
-'� wlvrvanass.gon/ilia
Workers' Compensation Lrsuran
A > >licant Information ec Affidavit: Builders/Contractors/Electricians/Plurnbcrs
Please Print Legibly
Name (Business/Organization/Individual): 11111
Address:
City/State/Zip: �h o Phoney:
Arc You an employer? Check the appropriate box:
[2.
. I am a employer wither --p 4. ❑ I am a general contractor and I d>Pe of project(required):
cmployees (full and/orpart-time), have hired the sub-contactors 6. ❑ New construction
❑ 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
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.' 9. ❑ Building adcition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs oi additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] ' c..-152, §1(4), and we have no 12.❑ Roof repairs
r 13.® Other GFt'IA. C�
cmployees. [Ao workers' �_
comp. insurar.cc required.] I
^:\ny applicant chat checks box 81 must also all out the section beiowshowing their workers'compensation policy information.
r Homeowners who submit this alydavit 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp
.policy number.
t our an eirrptoper that is providia rvo.kers'compea.catimr insurance for any employees. Below is the policv and job site --
information
Insurance Company.Name: 1Z.,
Policy#or Self-ins. Lie. I 141AC- Z// Q(o p
�/ Expiration Date:
Job Site Address�Q ((J`J l City/State/Zip: 6 ��
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 die 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
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.
I do hereby certi ,and r the pains and penahies ofpeijurJ�that the infornuaioit provided 4abo is true cord correct.
Si a ure:
Date:
Phone#:
I
ficial use onlr. Do rr01 wrire in this area, to be completed by till-or town offic•inl
ty or Town: 1 crmil/License #
uing Authority(circle one):
Board oCHcalth 2. Building Department 3. Cihlfown Clerk 4. Llectrical Inspector 5. Phunbing Inspf ctor
Other
Contact Person: _.. Phone p: