10 WHITE ST - BUILDING INSPECTION (27)i
T Commonwealth
The Commo ea1h f t o Massachusetts q Department of Public Safety
�. Massachusetts State Building Code(780 CMR) 77pp
Building Permit Application for any Building other than a One-or Two-FanMODW&4 :A 1: 00
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
1
SECTION I LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
d CuA r Ji- o a 970 w as Cure /ftCt ,.
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descripti n of Pr posed Work:
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:U GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 A-4❑ A-5 ❑ I B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3 ❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA 0 IIIB ❑ 1 IV ❑ 1 VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
- i permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
$� 3 Gait trev� PP�1r�t> C-C.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
K6 ( A k,
Name(Print) No.and Street City/Town Zip
Pro erty wner C ct Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
applicable,the prop owner hereby a orizes n //
o. CPS 3(, C a b 72 o J 1r1 Oc 8a1
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
It building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 ne1al Contractor
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Name of Pe R sponsible for Construction / License No. and Type if Applicable
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'/S7�t-ree-ett Address � City/Town State Zip
Tele h �No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ p O U'C Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (FIVAC) $ Note:Minimum fee=$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ (r-D Q (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name ae
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
No. and Street City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 -Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
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Imagery Date: 6/6/2015 42°3119.12°^N 7q°52'57F23=
The Commonwealth of Massachusetts
s Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 0211 4-2 01 7
Ivww.nutss.gov/dia
INorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/GrganizatioiV[tidividual):Peterson Party Center
Address:36 Cabot Rd
City/State/Zip:Woburn,Ma Phone 9:781-729-4000
Are you an employer?Check the appropriate box: Type of project(required):
LE][am aemployer with 200 employees(ftdl and/orpart-time).• T ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $_ ❑ Remodeling
any capacity.[No workers'comp.insurance required:]
3.0[flm n homeowner doing all work myself. [No workers'comp.insurance required.]r
9. ❑Demolition
4.❑i am m e a hoeowr and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 1 I.[]Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. j 3 ❑Roof repairs
These sub-contractors have employees and have workers'comp.insurarml
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.DOtherTemporary Tent
152,§1(4).and we have no employees. [No workers'camp.insurance required.]
t'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
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 most attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
employees. I,.the sub-contracmrs have employees they must provide their workers`co np policy number. ,
I ant an employer that is providing workers'CWhal eresation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:A I M Mutual Ins Co
Policy#or Self-ins. Lic.#.WMZ8008006586 Expiration Date:10/9/16
Job Site Address: ,"C) &J/I r te fly City/State/Zip: Q Lf/W
Attach a copy of the workers compensation policy declaration-page-(shussing_the_policy.number mad-cx-piration-datey. -------- --
Failure to secure coverage as required under MGL c. 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 cer6 n nder t epa rt�nd penalties ofperjury that the information provided above ' trite //d correct
Signature: �' Date' 7 4 �y
Phone 9.1 781-729-4000
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#:
k
Aff Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
License: CS-060219 L
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I 1 1\ 4
Marl. Traina - ��
33 Hanford Road
Stoneham MA 02180
Expiration
Commissioner 04/27/2017
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ISSUED BY .- Date of Shipment 5
5 REGISTRATION v46
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NUMBER sr. INDUSTRIES INC_ 5/1 z/zoos 5
If Tent Identification
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MANUFACTURERS OF THE FINISHED 04617028 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
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5 657150
5 PETERSON PARTY CENTER INC 5
5 139 SWANTON ST
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5 WINCHESTER MA1890
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5 The articles described on this Certificate have been treated with a flame-retardant approved 5
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55 Serial # 5
5 8046016C(2) 1j
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5 a�a,0a TENT PRODUCTS DESCRIBED HEREIN 5
55 This is to certify that the materials described have been flame-retardant treated 5
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5 PETERSON PARTY CENTER INC 5
5 139 SWANTON ST 5
WINCHESTER MA1890 5
5 5
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5 Certification is hereby made that: 5
11 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 5 5
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