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HomeMy WebLinkAboutBuilding Permit # 4/19/2016Permit No#:, Date Issued: LOCATION PROPERTY OWNER l'Or.7 4)-5 Print UILD G ERMT T WN F ORT A 00VE APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page eLbs- cv,(,,\„),A do 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes, no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 Addition 0 Alteration II One family 0 Two or more family No. of units: 0 Industrial 0 Commercial 0 Repair, replacement 0 Demolition CI Assessory Bldg 0 Others: —,wgettecV7W -,6 Other °41 lo ' 4'44441 viA er e mow gigir °r11 II 101i \I' il,) iii0 0 )311!1 it VINO 14 i; ' 1) DESCRIPTION -V (•(\k' ci 60' x OWNER: Name: Address: Identification - Please Type or Print Clearly Phone: Contractor Name: • k-t, -, Phone: cl 2S-- c3 .- I 2 D 0 'D... Email: 10 -, )c .. Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 0 (2 C) FEE: $ Total Project Cost: $ Check No.: Receipt No.: ) ) e", NOTE: Persons contracting with unregistered contractors do not have access tithe guar nty fund Signature igli rnWifiTICAVA-7/1' '!Sig 44fiJFVWW a co CD CD O c.� A > cce O CD CO �D O CD O 03 C oCi bC CC CD H. y O A. 'a n 00 CD 3 0 naapo./palpl 210103dSNI ONIa1Ifl VIOLATION of the Zoning or Building Regulations Voids this Permit. 0 0-P o CD CD,� O n 5 O. `O O l/! '6' O 0 Q W �D N Cl) CI: a) FA Q. O N. O O � • CD CD o o 6 (O O o N Z CD o a CD 0 0 49- CL 0 ca N O = �D 9.� W .i O r U) O - N Cl) �Oi- C) O CO g ooSt co cn 'a "g C N Mt o 0 no CD "0 0 = rt 62) Q. pan of uolssRuied set (O cn 0 IVH. S3Id112130 SIHI f:4 CID oec51 WATER TECHNOLOGIES 815 Chestnut Street a North Andover, MA ® 01845-6098 6 Tel. (978) 688-1811 • Fax: (978) 794-1848 April 7, 2016 To Whom it May Concern, This letter is to confirm that Watts Water Technologies gives permission to Bay State Tent to erect a 60" x 120" tent on our property at 815 Chestnut Street, in North Andover, MA. Regards, Michael Gaulin Marketing Communications Manager Watts Water Technologies, Inc. Innovative Water Solutions Since 1874 /ACOR®® `� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 4/1/2016 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 Ileu of such endorsement(s). PRODUCER Merrimack Valley Insurance Agency Inc 655 Boston Road, Suite 1A Billerica MA 01821 CONTACT Darlene . Villaras NAME:. PHO No,ExU: (978) 667-2541 No): (970)671-4514 E-MAIL ADDRESS: dvillaras@mvin8.com INSURER(S) AFFORDING COVERAGE . NAIC # INSURER AmTrust North America, Inc. 15954 INSURED Baystate Electronics Inc 150 Lorum Street Tewksbury MA 01876 .. INSURER B :The Hartford INSURERC: INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:CL164102412 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 ADDL INSp SUBR WVp POLICY NUMBER POLICY EFF IMMIDDIYYYY) POLICY EXP (MMIDD/YYYY) LIMITS B COMMERCIAL GENERAL LIABILITY 08VUNOx2387 4/1/2016 4/1/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE ESORENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO - JT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE — LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ _AUTOS SCHEDULED AUTOS NON -OWNED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE 08HHUOX2389 EACH OCCURRENCE $ AGGREGATE $ 1,000,000 DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WWC3188209 1/31/2016 1/31/2017 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E);PIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A Lucacio/DVILLA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(20141O4) The ACORD name and logo are registered marks of ACORD INS025 (2014011 ertifttate a REGISTERED APPLICATION CONCERN NO. CAL COMB F-419.01 tame ike515tante AZTEC TENTS 2665 COLUMBIA ST TORRANCE, CA 90503 (800)228-3687 Date treated or manufactured 07%2008 This is to certify that the materials described below hereof have been flame retardant treated (or are inherently nonflammable). FOR BAY STATE APRTY RENTALS 150 LORUM STREET TEWKSBURY, MA 01876 ATTN: DAVE KNIGHT Certification is hereby made that: (check "a" or "b") The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the applicationof said chemical was done in confor- mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used Chem. Reg. No. Meathod of application (b) The articles described below hereof are made from a flame -resistant fabric or material registered and approved be the State Fire Marshal for such use; Fabric has been tested and passes NFPA701.96. Trade name of flame -resistant fabric or material used..lamf^tfedfabrc . Reg. No. T-4/30( The Flame Retardant Process Used WILL NOT (win or will not) Be Removed by Washing David Bradley Chuck Miller - President Name of Applealor or Prndodun Supenolnodent 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: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Business/Organization Name: 9 c •'t C -c E l.e. C kr o ,r (S Address: 1 b d Lc-- u w‘ City/State/Zip: 'Tew 5 inA 0 /' 7GPhone #: Are you an employer? Check the appropriate box: 1.13 I am a employer with or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Please Print Legibly 9 -j _ VS-1- 2,00d Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. 0 Entertainment 10. ❑ Manufacturing 11.1=1 Health Care 12. 17.1 Other R tvti'C t *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance formyemployees. Below is the policy information. Insurance Company Name: A Y"\ l rt..)S 4• N Or t V� (-1mt.c : COL , I 0,C Insurer's Address: SUlkr:OC f1vtY‘Ut C. . 1� n, City/State/Zip: Cu.vt\,v,.A t. Policy # or Self -ins. Lic. # 093 V V N 'K 2. 3 as- employees (full and/ Expiration Date: Attach a 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 $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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. II! 7 I do hereby certify, un4er t to pains and penalties of perjury that the information provided above is true and correct. A IJ Signature: Phone #: 171/ 972- c s1- a00a Date: '145d I L, 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia