10 WHITE ST - BUILDING INSPECTION (2) ,r 4
The Commonwealth of Massachusetts
�r Department of Public Safety
V Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
Q (flus Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available)
ncT
No.and Street City/Town Zip Code Name of Building (if applicable)
I� 16 SECTION 2:PROPOSED WORK
I� 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❑ Demolition ❑ (Please fill out anchsubmit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other Specify:
Are building plans unci/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? .. "Cl- Yes ❑ No ❑
Brief Description of Proposed Werk: ri' r'eG .�!_tlD�) 1 n a- w. Stiry_6
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:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
L Institutional I-1 13I-2❑ 1-3❑ I-4 ElM: 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 ❑ IIIB ❑ 1 IV ❑ 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 ❑
required❑ or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: FlIa,zards to Air Navigation: �tA Historic C��rninIs,ion Rev_ic�r.F'n_n�s_:
Not Applicable❑ tue 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
Ed ition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building cont�ain an Sprinkler System?: Special Stipulations:
ai
kt-4-L�0 \� p . v . g1IS -
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner 1
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the propertv owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑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 General Contractor n
Co Name
Name of Person Responsible for Cons r� 1 License No. and Type if Applicable
5 -31 63r-i -e- cp ux I.��e v'�tr ) 1 .A-4 o
Street Address U City/Town State Zip
RC1 3<�b l
Telephone No. business Tele hone No. cell a-mad .d ress
� (.
SECTION 11:1, MPGNSATION INSURANCE AITIDAVIT M.G.L,c.152.§ 25C(6))
r WGrk�rZi ttion nsurance Affidavit from the MA Department of Industrial Accident nust be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the i uance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
L Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor) _$
3. Plumbing $
=1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $
Enclose check payable to
6.Total Cost $ (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
7Zn rs true and accurate to the best of my knowledge and understanding.
Gwnf s�- '7 I -
Please prin andsign nam- Title Telephone No. Date
I�
Street Address City/Town State Zip Q
Municipal Inspector to fill out this section upon application approval: Ld-+" O f
Name Date
The Commonwealth pfMassachuseds
Depardnent oflndustrdalAccddents
I Congress Sheer,Suite 100
Boston,AM 02114-2017
www massgov/dia
WWorkers'Compensation Insurance Affidavit:Builders/ContractorsMiectricians/P)umbers.
TO BE FILM WITH TBE pERMTMG AUTHORITY.
Applicant Information Please Print LeObly
Name(Business/Organindloohaii ndual): V-1
C -
Address: (�-t'0G Ct V e r
City/State/Zip: 1 Phone#: C)1 3 la
Are you an empbyerr Cask the appropriate box:
1. I'm a employer with b
Type°tP7oject(required):
_etap Peer hill and/orpart_time).•
2.❑I am a sok proprietor or parmenhip and have on 7. ❑New construction
airy capacity [No workcs'" ermployea wodung forme m S. Remodelin
aomP•insurance raNvcd.J ❑ g
3.❑Iem a h�eownc doing all work myself.[No wodms'corny.insurance required.]1 9. ❑Demolition
4.❑I am a homeow�amd sill be hiring cootracmrs to conduct a0 wodc on my p+operty. I will 10❑Building addition
gimme that aU cOmidors eltherhave workers'compensation insurance or are sole 11. ElfxtiiCal
proprietors with no employes. ❑ repairs of additions
s. 7 am a 12.0Pllmtbing repave or additions
❑1 m contractor and I have hoed the subcontractors listed on the aaeehed sheet.
haw employees and have wrorkers'comp,fosurance.f 13.❑Roofrepairs
6.0 We are a cooperation and its of6cas have exercaed dads 8M ofexemption per MGL c 14.❑Other
152•§1(41 and we have no employees.[No workers'comp.insurance required.)
'Any applicant that docim box#1 must ako frill out the section bebw ah
t Homwxmers who submit this affidavit inch owing their workers'compensation policy mfommuon.
'Contractors that check this box must attached additionalheyAM short AD work and than hire otande conuwm must submit a nee•affidavit indicating such.
employees. If the sub<ontramors have `t'io6 the name of the subvDnbwms and state whether ca not those mulles bave
mplay"M they most provide their worlojr'CMW policy mumber.
lam an employer that as providing workers'eompmsadon insurancefor my employees Below is rkepaNcy andjob site
informadon. I S-►-_
Insurance Company Name:_ UPte, A 1—'S4�� tom' fj e �
Policy#Or Self-ins.Lic.M ti 1_ZYExpiration Date:
Job Site Address: 0 R)r City/Statemp: S,— k-0, rn ^ _
Attach a copy of the workers,compensation policy declaration page(ahowhr the fes/) a J
g policy number and expiration date).
Failure to secure Coverage as required under MGL c. 152,§25A is a criminal violation punishable by a Sae 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 h suf y cern the airs an�pen 'es ofperjury that a information provided above is true and eorrect.
Si store: (�)�
Date:
Phone M
O,�'fetai use on(Ic Do not write in tkis area,to be cooWWed by city or town o,�etal
City or Town Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cierk 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 spartments 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)nane(s),address(es)and phone number(s)along with thein 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 ewer their
self-insurance license number on the!EplMate 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 permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple perrnitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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 f rwre 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 cornmercial venture
(i.e.a dog license or permit to bun 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
7AYIO� 531 Broadway
(gj Haverhill, MA 01832_ 978-374-0136 Status: Reservation
—----- Contract#: 26812-1
TERMS AND CONDITIONS
1. INSPECTION. Customer acknowledges that Customer has had an opportunity to personally 14.COLLECTION COSTS. Customer agrees to pay all reasonable collection,attorney's and
inspect the equipment,and finds it suitable for Customer's needs and in good condition,and court fees and other expenses involved in the collection of the charges or enforcement of
that Customer understands its proper use. Customer further acknowledges Customers duty to Dealer's rights under this contract,
inspect the equipment prior to use and notify Dealer of any defects. IS.REPOSSESSION. Upon a failure to pay rent or other breach of this contract,Dealer may
2.REPLACEMENT OF MALFUNCTIONING EQUIPMENT. If the equipment becomes unsafe terminate this contract and take possession of and remove the goods from wherever they are,
or in disrepair as a result of normal use,Customer agrees to discontinue use and notify Dealer and Dealer and his agents shall not be liable for any claims for damage or trespass arising out
who will replace the equipment with similar equipment in good working order, if available. of the removal of the goods.
Dealer is not responsible for any incidental or consequential damages caused by delays or 16. INSPECTION OF TRAILER HITCH. Customer agrees to inspect the trailer coupling
otherwise. mechanism and safety chain before leaving Dealer's premises. Customer also agrees to
3.WARRANTIES. THERE ARE NO WARRANTIES OF MERCHANTABILITY OR FITNESS, inspect the equipment periodically(every 100 miles)and to maintain the coupling and chain In
EITHER EXPRESSED OR IMPLIED.THERE IS NO WARRANTY THAT THE EQUIPMENT IS a safe and secure condition.
SUITED FOR CUSTOMER'S INTENDED USE,ORTHAT IT IS FREE FROM DEFECTS. 17.SEVERABILITY. The previsions of this contract shall be severable se that the invalidity,
4.POSSESSIONITITLE. Dealer owns the Equipment,and title in and to all of it will remain unenforceability or waiver of any of the provisions shall not affect the remaining provisions.
Dealers at all times. Customer is entitled only to use and possess the Equipment for the 18. LOADING AND UNLOADING EQUIPMENT. Customer Is responsible for loading and
Rental Period;subject to the terms of this Contract.If Customer retains any of the Equipment unloading equipment. If Dealer's employees assist in loading or unloading the equipment,
beyond the agreed Term without Dealer's express written consent,Customer will be deemed Customer agrees to assume the risk of,and hold Dealer and/or its employees harmless for any
to have materially breached this Contract.Customer will not take,grant or permit the taking property damage or personal injuries,including damage and personal injuries attributable to
of any(and Customer hereby waives any and all)liens or other similar claims on any portion the negligence of Dealer.
of the Equipment,and Customer will take such actions as may be necessary,at Customer's 19.PROPERTY DAMAGE. Not responsible for any damage whatsoever as a result of on-the-
sole cost and expense,to ensure that any and all such liens are released as soon as possible. job deliveries or pick up by Dealer.
5. HOLD HARMLESSANDEMNITY. Customer assumes all risks associated with the 20. FEES, LICENSES, PERMITS, TAXES AND FINES. The Customer shall be solely
possession,use,transportation and storage of the Equipment.ACCORDINGLY,CUSTOMER responsible for payment of any fees,licenses,permits,taxes or fines,required by or resulting
HEREBY WAIVES ANY AND ALL LIENS AND CLAIMS ARISING FROM OR ASSOCIATED from the Customer's use or operation of the vehicle/equipment&Tents.
WITH, AND AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE DEALER 21.UNDERGROUND FACILITIES.Customer agrees to have all Underground Facilities,in the
FROM AND AGAINST,ANY AND ALL LIABILITIES,CLAIMS,DAMAGES,LOSSES,COSTS vicinity of the Equipment Installation,clearly marked prior to the arrival of Dealer's work crews.
AND EXPENSES(INCLUDING WITHOUT LIMITATION,ATTORNEYS'FEES,CLAIMS FOR Customer assumes full responsibility for damage to all Underground Facilities.To identify
BODILY INJURY(IES)(INCLUDING DEATH),PROPERTY DAMAGE,LOSS OF TIME AND! Underground Facilities,Customer must call one week prior to installation.
OR INCONVENIENCE) RESULTING FROM OR ARISING IN CONNECTION WITH SUCH 22. EQUIPMENT FAILURE. In the event any of the Equipment fails to start, breaks,
POSSESSION, USE,TRANSPORTATION AND/OR STORAGE, REGARDLESS OF THE malfunctions, becomes unsafe or is in need of maintenance or repair, Customer agrees to
CAUSE AND INCLUDING ANY INJURIES ANDIOR DAMAGES SUFFERED BY CUSTOMER, immediately discontinue use, notify Dealer, and if directed to do so, return the Equipment
CUSTOMER'S EMPLOYEES AND/OR ANYTHIRD PARTY(IES),EXCEPTTOTHE EXTENT to Dealer.Customer further agrees Customer will not repair or have anyone else repair any
DIRECTLY RESULTING FROM DEALER'S INTENTIONAL MISCONDUCT. Equipment.Failure to timely notify Dealer will result in Customer being charged for all Time
6.ASSIGNMENT AND SUBLETTING.Dealer may,at Dealer's sole option,assign all or any Out.
portion of Dealer's rights and/or remedies under this Contract without Customer's consent. 23.FUEL SURCHARGE.Equipment with gas(diesel engines must be returned full of fuel or
CUSTOMER MAY NOT ASSIGN CUSTOMER'S RIGHTS OR REMEDIES UNDER THIS Customer will be charged at the current Dealer's rate.
CONTRACT,NOR MAY CUSTOMER SUBLEASE OR LOAN ANY OF THE EQUIPMENT 24.SITE PREPARATION.If Dealer has agreed to deliver any Equipment,Customer agrees
TO ANY THIRD PARTY WITHOUT DEALER'S PRIOR WRITTEN CONSENT.ANY SUCH to have the Site clean and ready for the delivery and installation or dismantling and retrieval,
ATTEMPTED ASSIGNMENT OR SUBLEASE BY CUSTOMER WILL, AT DEALER'S and Customer agrees to pay an additional charge for any delay incurred,or additional labor
OPTION,BE DEEMED VOID AB IN/TIO. performed by Dealer resulting from Customer's failure to timely do so.
7.ASSUMPTION OF RISK.Customer acknowledges that the possession,.use,transportation 25. INSURANCE. If any of the Equipment is to be used for a commercial purpose or is
and/or storage of the Equipment may give rise to the risk of personal injury and/or property otherwise designated as"Customer Insured"on Page 1, Customer agrees to maintain (a)
damage.CUSTOMER VOLUNTARILY ASSUMES ALL SUCH RISK AND RELEASES AND property damage and casualty insurance on an "all risks" basis for the full replacement
DISCHARGES DEALER ANDTHE EQUIPMENT FROM ANY AND ALL LIENS,LIABILITIES cost of the Equipment (including without limitation, all risks of loss or damage covered by
AND CLAIMS ARISING IN CONNECTION WITH THE SAME, INCLUDING, WITHOUT the standard extended coverage endorsement) with such deductibles, if any, as may be
LIMITATION, ANY AND ALL CLAIMS ARISING FROM OR IN CONNECTION WITH acceptable to Dealer in Dealer's discretion;and of commercial general liability insurance with
DEALER'S NEGLIGENCE(OTHERTHAN DEALER'S INTENTIONAL MISCONDUCT). minimum limits of$1,000,000 per occurrence.Such insurance shall cover all operations and
8. PROHIBITED USES. Use of the equipment in the following circumstances is prohibited, contractual obligations,as well as any and all damage or liability arising in connection with
and constitutes a breach of this contract. (a)Use for illegal purpose or in illegal manner.(b) the handling, transportation, maintenance, operation, use or possession of the Equipment
Use when the equipment is in bad repair or is unsafe.(c)Improper,unintended use or misuse. during the Term.and shall name Dealer as an additional insured and loss payee on a"closed
(d) Use by anyone other than Customer or his employees,without Dealer's written permission, clause"basis.All such insurance shall be primary,without any self-insured retention,and shall
(e) Use at any location other than the address furnished Dealer without Dealer's written waive subrogation against Dealer.Customer agrees to provide to Dealer copies of the proper
permission. (Does not apply to mobile equipment.) endorsements for the above coverages specifying that they will not be cancelled during the
9.ASSIGNMENTS, SUBLEASES AND LOANS OF EQUIPMENT. Dealer may assign his Term.Any insurance Dealer carries will be deemed to be in excess of Customer's insurance,
rights under this contract without Customer's consent,but will remain bound by all obligations 26.DAMAGE WAIVER. It Customer pays the damage waiver charge (DWC)as specified,
herein. Customer may not sublease or loan the equipment without Dealer's written permission. subject to the limitations and exclusions below, Dealer agrees to modify the terms of this
Any purported assignment by Customer is void. contract and relieve Customer of liability for accidental damage to the rented items) on
10.TIME OF RETURN. Customer's right to possession terminates on the expiration of the this contract, and for loss due to fire,windstorm, upset and riot. Dealer excludes from the
rental period ("Due In"date&time)and retention of possession after this time constitutes a waiver,however,any loss or damage due to theft,burglary,collision,misuse or abuse,theft
material breach of this contract. Time is the essence of this contract. Any extension must be by conversion,intentional damage,mysterious disappearance or any loss due to Customer's
mutually agreed upon in writing. failure to care for the rental items) as a prudent person would his/her own property, such
11. LATE RETURN. Customer agrees to return the rented goods during Dealer's regular as proper lubrication. In addition. if the items) rented is a truck, Customer is not relieved
store hours,upon expiration of the rental period("Due In"date&time). Customer agrees that of liability of accidental damage for the truck container(box)caused by striking a stationary
if the rented goods are held beyond the expiration of the rental period("Due In"date&time) object. If any such loss tends to indicate a crime may have been committed,a further condition
as designated in the contract,the daily rate as indicated on the contract shall be the agreed of this waiver is that Customer must file a report to the proper law enforcement authorities and
contractual rate for the entire period,notwithstanding any lesser periodic rate. furnish Dealer copy. In addition,if Customer has insurance for the toss or damage,Customer
12,DAMAGED, DIRTY, OR LOST EQUIPMENT. Customer agrees to pay for any damage shall exercise,and shall empower Dealer to exercise,all Customer's rights to obtain recovery
to or loss of the goods,as an insurer, regardless of cause,except reasonable wear and tear, under insurance,shall cooperate with Dealer to obtain recovery and all insurance proceeds
while the goods are out of the possession of the Dealer. Customer also agrees to pay a shall be given or assigned to Dealer.
reasonable cleaning charge for equipment returned dirty. Accrued rental charges cannot be 27. WAIVER OF JURY TRIAL. Each party waives its right to a jury trial of any claim or
applied against the purchase or cost of repair of damaged,lost or stolen goods. Equipment cause of action based on or arising out of this agreement or the subject matter hereof. This
lost,stolen or damaged beyond repair will be paid for at its current list price.The cost of repairs waiver pertains to all disputes that may relate to the subject matter hereof,including,without
will be borne by Customer,whether performed by Dealer,or,at Dealer's option,by others. limitation,contract,tort,breach of duty,and all other common law and statutory claims,and will
13.TIME OF PAYMENT. Accounts are due and payable at the termination of the rental period. not be subject to any exceptions. Each party(A)understands that this is a waiver of important
A carrying charge of 1.5%per month(ANNUAL RATE OF 18%)will be charged on all overdue legal rights and(B)acknowledges that he/she/it has had a reasonable opportunity to discuss
accounts. this waiver and its effects with legal counsel. Accordingly,each party knowingly,voluntarily,
irrevocably and unconditionally waives its jury trial rights.
A LARGER FONT COPY OFTHESE TERMS AND CONDITIONS IS AVAILABLE UPON REQUEST.
th 2013 by Business Forms by fn-A-Bind,Inc.,All Rights Reserved.(12603) Unauthorized reproduction and/or redistribution strictly prohibited.
531 Broadway
g17AOR RENTAL® Haverhill, MA 01832
_- 978-374-0136
TERMS AND CONDITIONS
1. INSPECTION. Customer acknowledges that Customer has had an opportunity to personally 14.COLLECTION COSTS. Customer agrees to pay all reasonable collection,attorney's and
inspect the equipment,and finds it suitable for Customer's needs and in good condition,and court fees and other expenses involved in the collection of the charges or enforcement of
that Customer understands its proper use. Customer further acknowledges Customers duty to Dealer's rights under this contract. g
inspect the equipment prior to use and notify Dealer of any defects. 15.REPOSSESSION. Upon a failure to pay rent or other breach of this contract,Dealer may
2.REPLACEMENT OF MALFUNCTIONING EQUIPMENT. If the equipment becomes unsafe terminate this contract and take possession of and remove the goods from wherever they are,
or in disrepair as a result of normal use,Customer agrees to discontinue use and notify Dealer and Dealer and his agents shall not be liable for any claims for damage or trespass arising out
who will replace the equipment with similar equipment in good working order, if available, of the removal of the goods.
Dealer is not responsible for any incidental or consequential damages caused by delays or 16. INSPECTION OF TRAILER HITCH. Customer agrees to inspect the trailer coupling
otherwise, mechanism and safety chain before leaving Dealer's premises. Customer also agrees to
3.WARRANTIES. THERE ARE NO WARRANTIES OF MERCHANTABILITY OR FITNESS, inspect the equipment periodically(every 100 miles)and to maintain the coupling and chain in
EITHER EXPRESSED OR IMPLIED.THERE IS NO WARRANTYTHATTHE EQUIPMENT IS a safe and secure condition.
SUITED FOR CUSTOMER'S INTENDED USE.OR THAT IT IS FREE FROM DEFECTS. 17.SEVERABILITY. The provisions of this contract shall be severable so that the invalidity,
4.POSSESSION/TITLE. Dealer awns the Equipment,and title in and to all of it will remain unenforceability or waiver of any of the provisions shall not affect the remaining provisions.
Dealer's at all times. Customer is entitled only to use and possess the Equipment for the 18. LOADING AND UNLOADING EQUIPMENT. Customer is responsible for loading and
Rental Period;subject to the terms of this Contract.If Customer retains any of the Equipment unloading equipment. If Dealer's employees assist in loading or unloading the equipment,
beyond the agreed Term without Dealer's express written consent,Customer will be deemed Customer agrees to assume the risk of,and hold Dealer and/or its employees harmless for any
to have materially breached this Contract.Customer will not take,grant or permit the taking property damage or personal injuries, Including damage and personal injuries attributable to
of any(and Customer hereby waives any and all)liens or other similar claims on any portion the negligence of Dealer. -
of the Equipment,and Customer will take such actions as may be necessary, at Customer's 19.PROPERTY DAMAGE. Not responsible for any damage whatsoever as a result of on-the-
sole cost and expense,to ensure that any and all such liens are released as soon as possible. job deliveries or pick up by Dealer.
5. HOLD HARMLESSANDEMNITY. Customer assumes all risks associated with the 20. FEES, LICENSES, PERMITS,TAXES AND FINES. The Customer shall be solely
possession,use,transportation and storage of the Equipment.ACCORDINGLY,CUSTOMER responsible for payment of any fees,licenses,permits,taxes or fines,required by or resulting
HEREBY WAIVES ANY AND ALL LIENS AND CLAIMS ARISING FROM OR ASSOCIATED from the Customer's use or operation of the vehicleiequipment&Tents.
WITH, AND AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE DEALER 21.UNDERGROUND FACILITIES.Customer agrees to have all Underground Facilities,in the
FROM AND AGAINST,ANY AND ALL LIABILITIES,CLAIMS,DAMAGES,LOSSES,COSTS vicinity of the Equipment installation,clearly marked prior to the arrival of Dealer's work crews.
AND EXPENSES(INCLUDING WITHOUT LIMITATION,ATTORNEYS'FEES,CLAIMS FOR Customer assumes full responsibility for damage to all Underground Facilities.To identify
BODILY INJURY(IES)(INCLUDING DEATH),PROPERTY DAMAGE,LOSS OFTIME AND/ Underground Facilities,Customer must call one week prior to installation.
OR INCONVENIENCE) RESULTING FROM OR ARISING IN CONNECTION WITH SUCH 22. EQUIPMENT FAILURE. In the event any of the Equipment fails to start, breaks.
POSSESSION. USE,TRANSPORTATION AND/OR STORAGE, REGARDLESS OF THE malfunctions, becomes unsafe or is in need of maintenance or repair, Customer agrees to
CAUSE AND INCLUDING ANY INJURIES AND/OR DAMAGES SUFFERED BY CUSTOMER, immediately discontinue use, notify Dealer, and if directed to do so, return the Equipment
CUSTOMER'S EMPLOYEES AND/OR ANYTHIRD PARTY(IES),EXCEPTTOTHE EXTENT to Dealer.Customer further agrees Customer will not repair or have anyone else repair any
DIRECTLY RESULTING FROM DEALER'S INTENTIONAL MISCONDUCT. Equipment.Failure to timely notify Dealer will result in Customer being charged for all Time
6.ASSIGNMENT AND SUBLETTING.Dealer may,at Dealer's sole option,assign all or any Out.
portion of Dealer's rights andror remedies under this Contract without Customer's consent. 23.FUEL SURCHARGE.Equipment with gasidiesel engines must be returned full of fuel or
CUSTOMER MAY NOT ASSIGN CUSTOMER'S RIGHTS OR REMEDIES UNDER THIS Customer will be charged at the current Dealer's rate.
CONTRACT, NOR MAY CUSTOMER SUBLEASE OR LOAN ANY OF THE EQUIPMENT 24,SITE PREPARATION.If Dealer has agreed to deliver any Equipment,Customer agrees
TO ANY THIRD PARTY WITHOUT DEALER'S PRIOR WRITTEN CONSENT.ANY SUCH to have the Site clean and ready for the delivery and installation or dismantling and retrieval,
ATTEMPTED ASSIGNMENT OR SUBLEASE BY CUSTOMER WILL, AT DEALER'S and Customer agrees to pay an additional charge for any delay incurred,or additional labor
OPTION,BE DEEMEDVOID AS INITIO. performed by Dealer resulting from Customer's failure to timely do so.
7.ASSUMPTION OF RISK.Customer acknowledges that the possession,use,transportation 25. INSURANCE. If any of the Equipment is to be used for a commercial purpose or is
and/or storage of the Equipment may give rise to the risk of personal injury and/or properly otherwise designated as "Customer Insured"on Page 1. Customer agrees to maintain (a)
damage.CUSTOMER VOLUNTARILY ASSUMES ALL SUCH RISK AND RELEASES AND property damage and casualty insurance on so "all risks" basis for the full replacement
DISCHARGES DEALER ANDTHE EQUIPMENT FROM ANY AND ALL LIENS,LIABILITIES cost of the Equipment (including without limitation, all risks of loss or damage covered by
AND CLAIMS ARISING IN CONNECTION WITH THE SAME, INCLUDING, WITHOUT the standard extended coverage endorsement) with such deductibles, if any as may be
LIMITATION, ANY AND ALL CLAIMS ARISING FROM OR IN CONNECTION WITH acceptable to Dealer in Dealer's discretion;and(b)commercial general liability insurance with
DEALER'S NEGLIGENCE(OTHERTHAN DEALER'S INTENTIONAL MISCONDUCT). minimum limits of 51,000,000 per occurrence.Such insurance shall cover all operations and
8.PROHIBITED USES. Use of the equipment in the following circumstances is prohibited, contractual obligations, as well as any and all damage or liability arising in connection with
and constitutes a breach of this contract. (a)Use for illegal purpose or in illegal manner.(b) the handling, transportation, maintenance, operation, use or possession of the Equipment
Use when the equipment is in bad repair or is unsafe.of Improper,unintended use or misuse. during the Term,and shall name Dealer as an additional insured and loss payee on a°closed
(d) Use by anyone other than Customer or his employees,without Dealer's written permission. clause"basis.All such insurance shall be primary,without any self-insured retention,and shall
(e) Use at any location other than the address furnished Dealer without Dealers written waive subrogation against Dealer.Customer agrees to provide to Dealer copies of the proper
permission. (Does not apply to mobile equipment.) endorsements for the above coverages specifying that they will not be cancelled during the
9.ASSIGNMENTS, SUBLEASES AND LOANS OF EQUIPMENT. Dealer may assign his Term.Any insurance Dealer carries will be deemed to be in excess of Customer's insurance.
rights under this contract without Customer's consent,but will remain bound by all obligations 26.DAMAGE WAIVER. If Customer pays the damage waiver charge (DWC) as specified,
herein. Customer may not sublease or loan the equipment without Dealer's written permission. subject to the limitations and exclusions below, Dealer agrees to modify the terms of this
Any purported assignment by Customer is void. contract and relieve Customer of liability for accidental damage to the rented item(s) on
10.TIME OF RETURN. Customer's right to possession terminates on the expiration of the this contract, and for loss due to fire,windstorm, upset and riot. Dealer excludes from the
rental period("Due In"date&time)and retention of possession after this time constitutes a waiver,however,any loss or damage due to theft,burglary,collision, misuse or abuse,theft
material breach of this contract. Time is the essence of this contract. Any extension must be by conversion,intentional damage,mysterious disappearance or any loss due to Customer's
mutually agreed upon In writing. failure to care for the rental items) as a prudent person would his/her own property, such
11. LATE RETURN. Customer agrees to return the rented goods during Dealer's regular as proper lubrication. In addition,if the item(s) rented is a truck, Customer is not relieved
store hours,upon expiration of the rental period("Due In"date&time). Customer agrees that of liability of accidental damage for the truck container(box)caused by striking a stationary
if the rented goods are held beyond the expiration of the rental period(')Due In"date&time) object. If any such loss tends to Indicate a crime may have been committed,a further condition
as designated in the contract,the daily rate as indicated on the contract shall be the agreed of this waiver is that Customer must file a report to the proper law enforcement authorities and
contractual rate for the entire period,notwithstanding any lesser periodic rate. furnish Dealer a copy. In addition,if Customer has Insurance for the loss or damage,Customer
12.DAMAGED,DIRTY. OR LOST EQUIPMENT. Customer agrees to pay for any damage shall exercise,and shall empower Dealer to exercise,all Customer's rights to obtain recovery
to or loss of the goods,as an insurer.regardless of cause,except reasonable wear and tear, under insurance,shall cooperate with Dealer to obtain recovery and all insurance proceeds
while the goods are out of the possession of the Dealer. Customer also agrees to pay a shall be given or assigned to Dealer
reasonable cleaning charge for equipment returned dirty. Accrued rental charges cannot be 27. WAIVER OF JURY TRIAL. Each party waives its right to a jury trial of any claim or
applied against the purchase or cost of repair of damaged, lost or stolen goods. Equipment cause of action based on or arising out of this agreement or the subject matter hereof. This
lost,stolen or damaged beyond repairwill be paid for at its current list price.The cost of repairs waiver pertains to all disputes that may relate to the subject matter hereof,including,without
will be borne by Customer,whether performed by Dealer,or,at Dealers option,by others. limitation,contract,tort,breach of duty,and all othercommon law and statutory claims,and will
13.TIME OF PAYMENT. Accounts are due and payable at the termination of the rental period. not be subject to any exceptions. Each party(A)understands that this is a waiver of important
A carrying charge of 1,5%per month(ANNUAL RATE OF 18%)will be charged on all overdue legal rights and(B)acknowledges that he/she/it has had a reasonable opportunity to discuss
accounts. this waiver and its effects with legal counsel. Accordingly,each party knowingly,voluntarily,
irrevocably anis unconditionally waives its jury trial rights.
A LARGER FONT COPY OF THESE TERMS AND CONDITIONS IS AVAILABLE UPON REQUEST.
02013 by Business Forms by It--A-Bind,Inc.,All Rights Reserved.(12603) Unauthorized reproduction ani redistribution strictly prohibited.
C cof itw Of u tr
GT�R Date treated or
C G R, o REGISTERED ISSUED BY
4_ APPLICATION Academy Tent & Canvas manufactured
t' CONCERN No.
c ' �d �=2 5035 Gifford Ave. 10/23/03
e
T>¢� NFPA�O Los Angeles, CA 90058
RF
I� (323) 277-8368
� This is to certify that the materials described below hereof have been (fame retardant
treated(or are inherently nonflammable).
FOR TAYLOR RENTAL ADDRESS 831 BROADWAY
CITY HAVERHII.L STATE MA O1R3�
Certification is hereby made that: (Check "a"or "b")
(a} The articles described below this certificate have been treated with a flame-retardant chemical
( L_J approved and registered by the State Fire Marshal and that the application of said chemical
was done in conformance with the laws of the State of California and the Rules and Regula-
tions of the State Fire Marshal
Nameof chemical used............................................................. Chem. Reg. No. ........................
Methodof application...........................................................................................................I.........
A(b) The articles described below hereof are made from a flame-resistant fabric or material regis-
j] tered and approved by the State Fire Marshal for such use; Fabric has been tested and passes
NFPA701-96.
f Trade name of flame-resistant fabric or material used ...................;D YL.... Reg. K;�FP,A:i01--
The dame Retardant Process Used ..v'tt!ltf"t.... Be Removed by Washing
i tvai or wits not,
e
David Bradley By Tom Shapiro - President
me of Applicator or Production Superintendent title
Na �!
1
THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING
1 EA. 40' X 100' X 8' CANOPY
CONTROL NO.
CUSTOMER ORDER NO.
CUSTOMER INVOICE NO.
YARDS OR QUANTITY
COLOR
STYLE
DATE PROCESSED --_
ALL MATERIALS ARE CERTIFIED BY THE CALIFORNIA STATE FIRE
MARSHALL AND MEET THE REQUIREMENTS OF THE NFPA 701 AND UL214***
07Y OF SALEM, MASSACHMETP
BLnDMDJIPAFrrr
IMWA9mwMS9R>an',3'DA0 t
7ffi.(978 7�5-9595.
$YMBERIZYDIRLSMII,
FA8(47i�7449846
MAYOR 7ssSzP
Dnmcmit crFURUC /BUMDM0 CMM
Construction Debris Disposa/AffidWit
(required for all demolition and.renovation workj
In acwrdanm with the sixth edition of the State Building Code, 780 CMR, SeCUOn 111.5 Debris,
and the provisions of MGL coo,S 54; Building Permit 0 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A
The debris will be transported by: /
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date