WILLOWS PARK - BUILDING INSPECTION (003) The Commonwealth of Massachusetts
d �y Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7`h edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kvo lbdwa
One-or Two-Funrilc Duelling
This Section For Official Use Only
Building Permit N mb : Date Applied:
Signature: _
Buddi CommissionW�Oect f Buildings Date
SECTION 1: SITE INFORMATION
t.1 Property Addresrn� 1.2 Assessors Map& Parcel Numbers
10rn`
G4/I45 If> 1l
1.1 a Is this an accepted street'?yes no Map Number Parcel Number
1 1.3 Zoning Information: 1 1.4 Property Dimensions;
Zoning District Proposed Use Lot Arca(sq fl} Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 gQwnei of Record; +
Name(Print) Address for Service:
Signature Telephonic
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work=:
et.-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building ; 00 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
). Plumbing 5 2. Other Fees: S /ryfj �
4. Mechanical (HVAC) S List: � {--
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S
0paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL)
'
�ft7e _ ift-s/T License Number Expiration Date
N,�rnc of L-Hylyier I ^ List CSL Type(see below)�0 Ll7 C�iyv� S
Address , Type Description
re wKS !3v 2y
V1113C0l$"7{, U Unrestricted(up to 35,000 Cu. Ft.)
�fp � r R Restricted I&1 Family Dwelling
Masonry Only
RC Residential Roofing Covering
Telep WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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.
Signed Affidavit Attached? Yes ...........n' No........... ❑
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 not 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 I I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for"Total Project Cost"
L:IIenuF: TDS L , C
ACORU CERTIFICATE OF LIABILITY INSURANCE 04/02/09 )NY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Rental Specialties ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P,Q.Box 53310 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
C1
Irvine, CA 92619 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
$00 854-3298 INSURERS AFFORDING COVERAGE
INSUREp INSURER A: St Paul Fire and Marine Insurance Co
aystate Electronics Inc. INSURER B Travelers Indemnity Company of CT
DBA: Bayskate Tent&party INSURER C,
150 Lorum Street
Tewksbury,MA 01876 -INSURER D. -- — --------
INSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE 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, TFIF 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,
INSRTYPE OF INSURANCE-�--'-- —'� POLICY EFFECTIVE POLICY EXPIRALIMITS
TION -_--^--' --
POLICY NUMBER D T M D TE O
A GENERAL.LIABILITY CF
KK00221462 04/01/09 04/01110 EACH OCCURRENCE _ $1 000X00
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Aeyonofire) $100,000
-I CLAIMSMADE IX OCCUR MEDEXP mnL-_.person}_ $5,000 A
PERSONALS ADV INJURY_ 51.000,000 -_-
GENERA,..AGGREGATE $2, 00
,00
GE_N'L AGG REGATE LIM ITAPPLIES PE R: PRODUCTS=COMP/OP AGO $1,000,000
X POLICY1_1 PRO- —�JFC1 LOC
AUTOMOBILE ABILITY
-AUTOMOBILE COMBINED SINGLE LIMIT IS
ANY AUTO (Ea tr cident)
ALL OWNED AUTOS
— BODILY INJURY $
SCHEDULED ALI NIS (Per person)
HIRED AUTOS
-- BODILY INJURY $
NON-OWNED AUTOS (Per accident)
-- ----.....—.-.�--_--..- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUfOOMY-EAACCIDENT_ $ ______
___ ANY AUTO EA ACC _ $
OTHER THAN
AUTO ONLY: AGG $
EXCESS LIABILITY_ EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE
DepuCnBLE ------- $ --�-
RETENTION $ --�_--$ - -_
B WORKERS COMPENSATION AND XEUB5899Y49709 01/31109 01131110 )( WC STATU- OTH-
IDRY.LIMITS_ ER_
EMPLOYER$'LIABILITY
E.L.EACH ACCIDENT $1,000_,000
E_L.MSEASE-EAEMPLOVEE $1,000,000___
_. ..�..
EL.DISEASE-POLICY LIMIT $1,000,000
OTHER
DESCRIPTION OF OPERATIONSlLOCATIONBIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
This certificate is issued as a matter of proof only."Except 10 days
notice of cancellation for non-payment
CERTIFICATE HOLDER ADDmONALINSUREDLINSURERLETTER: _ CANCELLATION
SHOULD ANYOF THE AROVE DESCRIBED POUCIESBE CANCELLED BEFORE THE EXPIRATION
Andover Country Club and DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TOMNL30'DAYSWRITTEN
C.A.Investment Trust NOTICETOTHE CERTIFICATE HOLDERNAMED TOTHE LEFT,BUTFMLIJRE TODOSOSHALL
Canterbury Street IMPOSE NO OBLIGATION OR LIABILITYOF ANYKIND UPON THE INSURERJTS AGENTS OR
Andover, MA 01810 REPRESENTATIVES.
AUT ORIZREPRESENTATIVE
ACORD 25-S(7197)1 of 2 #S3368393/M3368392 LRGJG o ACORD CORPORATION 1988
41 Vii.M3 kY i P
Ceair* of , one i tac re
Ec,. ERF REGISTERED
ISSUED BY "�� Date treated or
F APPLICATION Academy Tent &Canvas manufactured
CONCERN No. 5035 Gifford Ave.
12/11/02
e ReTPe F-a19.o Los Angeles, CA 90058
(323) 27778368
This Is to certify that the materials described below hereof have been flame retardant
treated (or are Inherently nonflammable).
FOR BAYSTATF PARTY RENTALS l' ADDRESS 1487 MAIN RTRF.FT
CITY TEWKSBURY i ' STATE MA -
Certification is hereby made thAt:`(Check."a"or.'b")
F-1(a) The articles described below this certificate have been treated wl%a flame-retardant chemical
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.
Name of chemical used............................................................. Chem.Reg. No. ........................
Methodof application. ............................................+......................................................................
(b) The articles described below hereof are made from a flame-resistant fabric or material regis-
tered and approved by the State FIeelMarshal for such use; Fabric has been tested and passes
NFPA701-96.
The Flame flame-resistant
instant fabric or material used ....................r}Nyi.,.... Reg. ttn419,01•....
Retardant a
Process Used :.` /i!I....�t.. .Be Removed by Washing
(will or will not)
David Bradley By _ Tom Shapiro -President
Name of Applicator or Production Superintendent Title
11111111111111111111 ut-i
M +•�
a' -
CITY OF S.�ENl, ANSSACHL-SE'TTS
0L'II.DLNG DEPAR'fytENT
120 WASHINGTON STREET, 3'a FLOOR
TEY.. (978) 745-9595
F.kx(978) 740-9846
KI,,BERLEY DRISCOLL
THOMAS ST.PIERRS
MAYOR DIR£CrOR OF PuSLIC PROPERTY/BL'QDLNG CO.%L%aSSIONER
Workers' Compensation insurance AMdavit: BuilderslContractorslElectricianslPiumbers
A lienor Information
Please Print Legibly
Valve tljusin.�s.OrganintiominaJiwdual):
Address: � U ^th 1
City/Statc/Zip: e i��-.� Phonek: 76-4�i - 2-00-2-
Are you mployer?Cheek the appropriate boar Type of project(required):
1.at am a employer with /ID 4. 0 1 am a general contractor and 1 6. CJ New construction
employees(full and/or part-time).' have hired the sub-contractors
I am a sok proprietor or partner- luted on the attached sheet : C] ReRemodeling2.El ship and have no employees These sub-contractors have S. C) Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and in 10 Q Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.C]Plumbing repairs or additions
myself(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. (No workers' 13❑Other
comp.m trance required.]
'Any applicant that chocks bot rt must alw no out the section below showing ibeir wortm'compeneativa policy infumtanm
'I LaneuwMa who submit this affidavit indicting they are doing all wort and than hire Omida connneton must sutxnif a naw affidavit indicting such,
t'.mtrs'+an that check this boa muvt annclsed an 3d1 itkwW had showing the name of the aub.conttacwrr and their we*='comp.policy infornunw.
I am as employer that it providing workers'Compensadon lwsarance for my employee% Below Is the polley and Job rite
information 57
Insurance Company Name: \/ ��t q
Policy Al or Self-ins. Lic.M: �C U ! \� L d + Expiration Date- 1 Y �✓ k
lob Site Address: Cityistatelzip:
,\[tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
i
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil Penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day againsl the violator. Ile edvi.sed that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do here cern under th a s and p allies of perjury that the informadon provided above is true and Correct
Ci.n. t rr —Date:
Phone�
OJfcial use✓sly. no[tot write in this area, to be r✓mpleted by city or town official
i
City or Tuwn: __. PermitIlAcense
Issuing authority (circle one):
i L Huard of Health 2, AuildinL Department J.City(fown Clerk 4. Electrical inspector 5. Plumbing Impeetor
6. Other
i
Courser Person: _ __. __. _ Phone p:
P