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FOREST RIVER PARK - BUILDING INSPECTION 14— I S S O RECO L StiRY 1GEs The Commonwealth of Massachusetts Department of Public Safety'�t``,1,,'1 p .2 A 2q ® Massachusetts State Building Code(7801&JR E? 2 Building Permit Application for any Building other than a One-or Two-Family Dwelling ('Phis Section For Official Use Only) Building Permit Number: Date.Applied: Building Official: SECTION to LOCATION(Please indicate.Block,#and Lot#for locations for whic a street address is not available) QRecll fRl✓ie-2 Ank ja6m 1114 f164 eeK Ui Aq No.and Street City/Town Zip Code , Name of Building(if app cable) 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❑ 1 Alteration ❑ 1 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 Description of Proposed Work: 70 �Ree� c> 30 x3o eMnoaca . 7e v11 9a� iY v s r P w o✓e,/ mn 9 ar- ( i -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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H 1 ElH-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: - ISECTION 6:CONSTRUCTION..TYPE(Check as applicable) ' IA ❑ IB ❑ IIA ❑ I18 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ r'' „SECTION 7:SITE INFORMATION:(refer to.780 CMR 111.0 for details on each item) Water Supply: Flood Zone Inform Trench Permit: Debris Removal:ation: Sewage Disposal: Licensed Disposal Site El ❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards 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: SECTION 9i�PROPERTY OWNER AUTHORIZATION i'' Name nd Address of Property Owner of So�etr 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 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) If buildingis less than 35,060 cu:ft:of enclosed s ace and or not under Construction Control then check here 0 and skip Section Al 10.1Registered 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 - R S avl G K 4V il Co�m ny Name 0G01f9 CS Name of Person esponsible for Construction / License No. and Type if Applicable 3b CG&off �?cP 610 huit rl A14- 0 reel Street Address City/Town State Zip Telephone No.(business) Telephone No, cell e-mail address SECTION11:WORKEW COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.:15Z..§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❑ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ (j(Tp Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ O-ZrD (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 appl' atio/n is true and accurate to the best of�y k9pwledge and understanding. GFZIC OAS 6!t %FI- 70- as /f 3� Plee pm d gn name - Title lephone No. ate Street Address City/Town // State Zip Municipal Inspector to filPout this section upon application approval: Name. Date 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) IMPORTANT DOCUMENT Certificate of Flame l§sistance ISSUED BY Date Shipment 05/07/1/13 FA444.2Registration Number f,'a.MICKORB USTRIES INC. Sales Order# -V-� 15153463 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: PETERSON PARTY CENTER INC 36 CABOT RD WOBURN, MA 01801 GXSTER CA(��DyQ N 7 F RE'CP� Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial # 8046015C (2) Description of item certified: NAVI-TRAC LITE HIP END 30WX15 #702 FERRARI BLOCKOUT 1030510A Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric 702 FERRARI MFG FRANCE �L% Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC IMPORTANT DOCUMENT Certificate of Flame Resistance ISSUED BY Date Shipment 05/07/1/13 Registration Number P"�4.mcmone FA444.2 49M INDUSTRIES INC. Sales Order# 15153463 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: PETERSON PARTY CENTER INC 36 CABOT RD WOBURN, MA 01801 G%5T h�OF CAt/,p��O �Q Z F RerP� Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial# 8046015C (2) Description of item certified: NAVI-TRAC LITE HIP END 30WX15 #702 FERRARI BLOCKOUT 1030510A Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric 702 FERRARI MFG FRANCE Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC The Commonwealth of Hassaehusetts Department of Industrial Accidents Office ofltivestigations 1 Congress Street, Suite 100 Boston, D111 02114-2017 rurvrv.rnasc.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PETERSON PARTY CENTER Address:36 CABOT RD City/State/Zip:WOBURN,MA 01801 Phone#:781-729-4000 Are You an emtloyer' Checl. Elie apliropri tut, bor. Type of project(required)' I.A I am a employer with 200 4. ❑ I am a general contractor and I �. ❑ New construction employees (full and/or part-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached shect. i. ❑Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity emplovees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.,' required.] 5. ❑ We are it corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, yx 1(4), and we have no ❑ TEMP. TENT employees. [No workers' 13. Other _ comp. insurance required.] 'Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new n aidzvit indicating such. �Contrnciors thus check this box nwst at ached an additional sheet showing the name of the sub-contractors and state whether or not those cmi ties have anplbyees ii lnG inn-u.01rt'aiu,rn IieVc 2n5pi yCc>.Iilty nM1Jm Ih JV'JC uie`' w�rn�b'eirTp.Bulgy 11Jt556ll'. t rnu am employer that is providing rva'kers'coapensatiai insurance fiir my employees. Below is the policy and job site information. Insurance Company Name:AIM MUTUAL INS CO Policy#or Self'-ills. Lic. #:WMZ8006586 Expiration Date:10/9114 Job Site Address: �O/Z<St I?(dlR �'2K City/State/Zip: `6e/—M Attach it 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 the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine Of up to$250.00 a clay against the violator, Be advised that copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify under the pains and penalties ofperitury that the infuriation provided above is true and correct. Si,nature: Aga l/lilGu— Date: Phone #: 781-729-4000 Official use only. Do not write in this area, to be completed by airy 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 S. Plumbing Inspector 6. Other -- l contact-pe sou Phone#: -- ] t aco CERTIFICATE OF LIABILITY INSURANCE DATE'MMIDD" Y' 10/1/2013 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(ies) 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 endorsement(s). PRODUCER CONTACT Michael Bonacorso NAME: Bonacorso Insurance Agency, Inc. PHONEXU. (781)273-3200 FAX No: (081)273-0600 83 Cambridge Street AIL ADDRESS:mike@bonacorsoins.com P.O. BOX 1502 INSURERS AFFORDING COVERAGE NAICk Burlington MA 01803 INSURERAAcadia Insurance Com an INSURED INSURERa C N A Insurance Co. Peterson Party Center, Inc. INSURERCAIM Mutual Insurance Co. 36 Cabot Road INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:2013 Master 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. INSR TYPE OF INSURANCE ADDLS SR POLICY EFF POLICY EXP LIMITS LTR VO POLICY NUMBER MMIDDIYYVV MMIDDGYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,0p0,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ORENT D PREMISES RENT rtence $ 100,000 A CLAIMS-MADE OCCUR X X PA 5061026 10 10/9/2013 10/9/2014 VIED EXP(Any one person) $ 10,000 PERSONAL B ADV INJURY $ 1,000,0 0 C GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP ADS $ 2,000,000 POLICY X PRO- LOG $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED X X 5113173 10 10/9/2013 10/9/2014 BODILY INJURY(Par aaidanl) S AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Uninsured motonsl BI split limit $ X UMBRELLA LIAB X OCCUR X EACH OCCURRENCE S 10,000,000 B EXCESS UAB CLAIMS-MADE AGGREGATE $ 10,000,000 CEO I X I RETENTION$ 10,00 5085496458 30/9/2013 0/9/2014 $ C WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT S 1,000,000 OFDCERIMEMSER EXCLUDED? NIA (Mandatory In NH) Z8006586 10/9/2013 10/9/2014 E.L.DISEASE-EA EMPLOYE $ 1 000 000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 ppp ppp DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION \ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE_ Michael J. Bonacorso ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. IN9n25nn,nns on rl.o nrtnan mod i--- „ s�� ,�d ass-sbhu setts - De03rnnent o' Pub[tc Smfct Bomrd of Buddlog Racula;lons and 5!andnrds Ln C tLl 21 CS-0-0 60299 11ARIk TRAI.NA ' :r 33 H=LYFORI7 RD yy. .x _ Stonehwn NIA 02180 °J.� �� r, sd ' fXCila?IOn Commissioner 0412712015 Office oflousamer SffursS Busincst lte„nleiian § TOME IMPROVEMENT CONTRACTOR pt oglstrailon _tFi9922 Type: w ,�Exp 'o BN78 vOtS Individual p',gRK R TRIANA MARK IRAINi 3l RANFORO RD. SrONEHAM,MA 02180, llndereecretary^ License or registr,^.tion v'nlid for individul use only before the expiration date, if found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,>1.1 02116 - __ 'rot valid withUut tinnnw rc