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1 WILLIAMS ST - BUILDING INSPECTION , GK, � i I o �2S `'� � � 'Che Commonwealth of�Iassachd��i.,�F�EC �$E�}A E�f���.� + Board of Duilding Regulations and Standards SALEhI �i�I Massachusetts State Building Code, 73QO�1�YiQ�$ H�,r � ��i1�l�1�r201! 4!; c nH Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Fmnily Dtivelling This Section Fa�Official Use Onl : ` k3uilding Permit Number. Date. plied5 I�. : . $ � . � Duilding OtTicial(Print Nvne). . �� Siqnalpre• ' . .� - . . Date � SECTION 1:SITE INFORN(ATIOPF � I.1 Property AJdress: LZ Assesson binp&Pnrcel�umben — 1 �.�.,`fl „� � S S � . 1 I.I a Is this an ncce ted street?yes no_ M1lap Number Parcel NumM:r � I.J 'Loning Informntion: I.d Property Dimenslonr � "Luning Dislrict Proposed Use Lot Ar��a(sy ft) Promage(It) � 1.5 Building Set6ncks(R) ' Fronl Yurd SiJe Ya'ds Rear Yard Reyuire� Provided Reyuired ProviJed Required Provided 1.6�Vnter Supply:(M.G.L c.40,§Sd) l.7 Flaod Zone Informatlon: I.8 Sewnge Disposnl System: � Zune: OuLside Flaod Zone7 Munici ol O On site dis sal s skm ❑ Public❑ Privare❑ — Check if es0 P P0 Y SECTION2: PROPERTY0IVNERSHIP!^ 2.1 O vner1�o(Recorj ` �� J � �7 U . ����`�y;o..- � a c41 v� J�C"v`" � t��1me(PrinQ Ciry,State,ZIP , ` ,' ;,,; 5-� 97B-�9S= yG)S � a . '7 i,J� l 5 No.and Strect Telephane Emml AdJnss SECT[ON 3: DESCRIPTIOIV OF PROPOSEU WORK3(check nll that npply) New Constructian O Esisting Building❑ Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition ❑ Demolition O AccessoryBlJg.❑ NumberofUnits Other 0 Specity: , �rief�escription of Proposed 1Vork=: � � � SECTION a: ESTIDIATED CONSTRUCTION COST3 Itcin Estimated Costs: Official Use Only Labor aud�larerials) I. 6uilJing � i. Building Permit Fee:$ fndicare ho�v fee is Jetermined: ❑Standard City/I'own Application Fea 2. Electrical � p Total Project Cost�(Item 6)x multiplier x 3. Plumbing 5 ?�?Qther Fers: S �/.I LisC �• vt� d.��Icch;mical (HVAC) 3 � 5. \lcchanical (Firz � Cotal All Fcas:3 Su ressiun) Check No. Check Amount: Cash�\mount: G. Tutal Project Cust: � �v,�,s ❑p;iid in Full ❑Outstanding Oalance Due: MA,�� s�� ��t � SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Dale List CSL Type (see below) Name of CSL Holder Type Description . No. ;mJ Sweat U I Unrestricted(Buildings up to 35,000 cu. Il. R Restricted 1&2 Family Dwelling ZIP M Masoray RC Rootin Coverin :City:fF:(un:vn,late, WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered [tome Improvement Contractor (NIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No. and Street Email address Ci /Town, State ZIP Tele hone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 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 Isitum a of the building permit. Signed Affidavit Attached? Yes .......... d No ........... ❑ SECTION 7a: OWNER AUTHORIZATION: TO BE COMPLETED WHENr OWNER'S AGENT OR CONTRACT OltAPPL1ES FOR BUILDING PERMIT' [, as Owner of the subject property, hereby authorize 4� ✓e—K 1 it tee t l' t9 act on my behalf, in all matters relative to work authorized by this building permit application. / US5 J J /5 Print Owner's Narne (Eledronic Signature) Date SECTION 7b: OWNE&t OR AUTHORIZED AGENT DECLARATION 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 acccuurrat/e-t/q the best of my knowledge and understanding. �' i / !v 4/. 5-AM J Print Owner's 6r Authorized Agent's Name (Electronic Signature) ate NOTES: I . An Owner who obtains a building permit to Jo his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program); will not have access to the arbitration program or guaranty fund under NI.G.L. c. 142A. Other important information on the H[C Program can be found at +v+v+v mass eov:'oct Information on the Construction Supervisor License can be found at www.ntass.eo+-'Jns 2. When substantial work is planned, provide the information below: 'total floor area (sq. R.) 's .(including garage, finished basementlattics, decks or porch) Gross living area (sq. 11.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'type of heating system Number of decks/ porches rypeofcoolingsystem Enclosed Open 1. " rotal Project Square Footage' may be substituted for "Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIMTTING AUTHORITY. Applicant Information L Please PrintLegibly Name (Business/Organization/Individual): /�Ile„`ue, 7 %�iiii 4e-( u(PN. � — LT ieK �c o/ 1&t - Address: 300 L z -Li e ff t t2 City/State/Zip: Phone #: %79`5_3 S _S 0�5 Are you an employer? Check the appropriate box: Type of project (required): I. ERI'ant a employer with employees (full and/or part-time).* 7. F-1 New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in g. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.n I am a homeowner doingall work myself. t y [No workers' comp. insurance required.] 4.R I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 EJ Building addition ensure that all contractors either have workers' compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5.F-] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have employees and have workers' camp. insurance.[ 14. U6ther Tu2 n 6.E] We are a corporation and its officers have exercised their right of exemption per MGL C. 152, §l(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information. I 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 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. I am an employer that is providing workers' compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: vri G �L 46L e r ` C tg :ZK e>e/rre u ce (fl? Policy # Or Self -ins. Lii�c. #:('_Li L rS %% '�Q - "j `; S - oo Expiration Date: ,9 �q Job Site Address: I L[% , i 4 VC, 5 City/State/Zip: SA [ e w I A4 I cf 70 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 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 certify and the above is true and correct. 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permitAicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia uerliTICa „( �£! Date Manufactured 03/24/2010 ?410" 4 AZTEC TENTS 2665 COLUMBIA ST TORRANCE, CA 90503 (800)228-3687 es I S la 1 14.oe PAGE: 2 This is to certify that the materials described below have been flame retardant treated (or are inherently flame retardant). Allied Financial Solutions 7103 Turfway Rd Ste.306 Florence, KY 41042 Events for Rent 464 Lowell Street Peabody, MA 01960 - - _irertifidati-osis hereby made that the articles described below hereof are made from a flame-retardant fabric or material registered and approved by the n California State Fire Marshal for such use. The fabric has been tested and passes NFPA 701 Large Scale. See chart to right for trade name of +?, flame -resistant fabric or material used and additionally referenced on the label of the fabric panel. INV NUMBER: 0179791 P.O. NUMBER: CUSTOMER NO: EVEN019 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING David Bradley Name of Applicator or Production Superintendent General Manager- Manufacturing Title of Applicator or Production Superintendent ITEMS MANUFACTURED TYPE PRODUCED ***8x20 Grand Panorama Wall- 15oz UW S 25 Qty 4 P5 Window per wall Lap and Snap "Indiana Style" Bmm Bmin MW\ Fpi.Oa hliPomla Crcne. 1dm-Tee !: :a, 16, lEoz Fa19.01 1.nt Fatln6 1ti,/IN. 1570.02 OAF =17", .,I I2%9 F-593.01 ORF OAF F-59t.OJ e.a�.wy a.90 vaysaleen w.r F-41a.o1 Fenn sot F-444.01 Ferta. hEym2ft N2 F-44408 MWIpz Tatlu6 ITA. uner 1.50001 Ic rttn. .0.11 on r 5 01 S,/ ., W G,,n 1140.01 Mr evade >mio 5B0 F-1zi.n2 Tr Vama9e Bp Ti4` F-121.10 Ttl vamape Va�puaN wemon P-06901 Ttl Vantage Wetllen/Cnawline F-069.01 Versntla9 0urasxm ov673, B35I5 F-530.01 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING David Bradley Name of Applicator or Production Superintendent General Manager- Manufacturing Title of Applicator or Production Superintendent ITEMS MANUFACTURED TYPE PRODUCED ***8x20 Grand Panorama Wall- 15oz UW S 25 Qty 4 P5 Window per wall Lap and Snap "Indiana Style" I.C.ertifirate of Mame Regf5tance PAGE: 2 Date Manufactured AZTEC TENTS 12/18/2012 2665 COLUMBIA ST TORRANCE, CA 90503 (8001228-3687 This is to certify that the materials described below have been flame retardant treated (or are inherently flame retardant). Events For Rent 464 Lowell St. Peabody, MA 01960 Certification is hereby made that the articles described below hereof are made from a flame-retardant fabric or material registered and approved by the California State Fire Marshal for such use. The fabric has been tested and passes NFPA 701 Large Scale. See chart to right for trade name of flame -resistant fabric or material used and additionally referenced on the label of the fabric panel. INV NUMBER: 0196833 P.O. NUMBER: CUSTOMER NO: EVEN019 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING David Bradley Name of Applicator or Production Superintendent General Manager- Manufacturing Title of Applicator or Production Superintendent ITEMS MANUFACTURED TYPE PRODUCED 30x3OxO8 IT Lite SYS Frame -Hip S 1 System track frame w/ IT Lite Legs, Pins, Stakes, Baseplates, and Tie Dawn Ratchets 30x10x08IT Lite SYS Frame -Mid S 5 System track frame w/ IT Lite Legs, Pins, Stakes, Baseplates, and Tie Down Ratchets_-- y Brvin M1kSM1 F222.02 C,111wPN Comb. Wm Tex 11. 14, 16. 1. F-919.01 c.r. 111-1 c1N: Yry' te9•; 209x 1-510.02 OAF clear "1" 161, / 24e F-593.01 0Fr OAF 759 .ox ErnusNejy Expo O... ... uner '.mc, Rnn' Pre rtminl 702 4e A0 rwursruans __ a,o-m. uo. WCTnc. ne(d em:[/V11.n F-505.01 sr"a' 1.11 so.n 1,10,01 TI V,n'e Flmnst Soon 1-368.05 , Vente9e Prtro 1. s-13..02 Tn Var.,e 6"" 1a2110 Tn Vanmge an,r.,0 w,nl F-.901 Trr V,nte" Weblon/Coeztllne '.901 V'ce .9 Ournswn el6>3, s1s15 F530-01 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING David Bradley Name of Applicator or Production Superintendent General Manager- Manufacturing Title of Applicator or Production Superintendent ITEMS MANUFACTURED TYPE PRODUCED 30x3OxO8 IT Lite SYS Frame -Hip S 1 System track frame w/ IT Lite Legs, Pins, Stakes, Baseplates, and Tie Dawn Ratchets 30x10x08IT Lite SYS Frame -Mid S 5 System track frame w/ IT Lite Legs, Pins, Stakes, Baseplates, and Tie Down Ratchets_-- NORTH -4 OP ID: ES '4`� CERTIFICATE OF LIABILITY INSURANCE DA04/10/201YY) 04/10/2015 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(les) 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 endorsemen s . PRODUCER DPS Insurance Group, Inc. 500 Granite Ave., Suite Milton, MA 02186 P Sullivan NT CT Elizabeth Saville COSME- a"/cNNaE.e:617.4795600 %c N,; 617479-0761 gLiSaville@dpsinsurancegroup.com ADDaEss: ESaville@dpsinsulancegroup.com INSURER(S) AFFORDING COVERAGE NAICB RNT-CLOO104364 INSURER A: Nova Casualty 04/0112016 INSURED North Shore Rental Inc. Chris Leblanc INSURER B: MED EXP (Any one person) $ 10,00 464 Lowell St. INSURERC: INSURER D: Peabody, MA 01960 INSURER E; $ INSURER F: AUTOMOBILE X COVERAGES CERTIFICATE NUMBER: 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. LSR TYPE OF INSURANCE D AOLPOLICY POUCY NUMBER EFF MMIDDIYYYY CY EXP MMIODIYYYY LIMBS A X COMMERCUILGENERAL LIABILITY CLAIM -MADE X OCCUR RNT-CLOO104364 04/01/2015 04/0112016 EACHOCCURRENCE $ 1,000,00 PREMISES Eaomrrence$ 300,00 MED EXP (Any one person) $ 10,00 PERSONALS ADV INJURY $ 1,000,00 GEN'L AGGREGATE UMIT APPLIES PER: POLICY❑PRQ LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG S 2,000,00 $ AANY AUTOMOBILE X LIABILITY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS X AUTOS RNT-MH-0010007-1 04101/2015 04101/2016 COMBINED SINGLE UMIT $ 1,000,00 Ea aWdent BODILY INJURY(Pe-mmn) $ eM ( I BODILY INJURY Peracdtl$ PR PERTY DAMAGE Per acadent $ A X UMBRELLA LUIS EXCESS LIAR X OCCUR CLAIMS -MADE RNT-UM-0010271-1 0410112015 04/0112016 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 DED I X I RETENTION$ 10,000 $ WOR,LERSCOMPENSAnON AND EMPLOYERS' LUIBIUTY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEWMEMBER EXCLUDED? ❑NIA (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS belma PER TIF STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ A Equipment Floater NT- CL 0010436-1 04101/2015 0410112016 Equipment 800,000 DESCRIPTIONOFOPERAnONSILOCAMONSIv ELES (ACORD 101, Addrional Remada Schedule, may be attachmi I mom pave lareguired) Rental of Goods ANDOVER Andover Country Club 60 Canterbury St Andover, MA 01810 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ALTHORIZEDAREPRESENTATIVE �/� 4REjIe -� riahts reserved ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD n{ MIul,C-91-1 oda ®};4cT @'iC O c e[a�i`�8 f eiF�,r.«wivvc i1flUz±jY� _ - ..�.. a HiFnA184FFfara a.e±aLY Bata "' .^.uArE'C :1T5 UPw +n]m :CATE HOLDEN TWI$ THlS �F- -r FMATF a 'cV AS {4. M!'`.rEq A sr qtr rm dlTFo T]]c GpYERAbr- AFY-OK N-0 by iHF P' i'jC.iES CERT±c TF j}uz: R{ri'i AFF!RF ene i`d£LY LSx�@{^ ^!£I?LCO(vS rtr�;i ,;r_w��tA4T Sxtv`e£�a —E """ G MSLYwiFSj. n4i•y�a,: = 8ELGmi, 'FH!$ MR 'M,- GATE 4. .._SUPMJN F REPRE-ftNTATWE Q;s c YVYIXER. ANC/the Q.EN.TiiM JCS to HGLULn - i- ImMeho .: mra 3Yth!ef :h r PORTANT' It the tP?IlR_fit' hQkWr i5 2n A65ttitKiNkL IwSLi FttU eie rdiiCy�icai ,� s•.eEe.^`" nn 74'q a tfifttsYe m'Gs3 t]o3..L..._Y fig. W u:G' the tenv> Amu condluan� 0+ ti{e policy, Q€r ;t pokixs 1„«]v......n�r__- - ` YnCGnd CIMr _'feG .Ai'. a1311t P.Sif z�BE!1?t <i : `v _ ROD Lataye4e fid. FYe. Nt; ost: