HomeMy WebLinkAboutBuilding Permit # 4/26/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 1 4 261- %i Date Received /24//(
Date Issued:
IMPORTANT: Applicant must comple
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
C Others:
/t/�i ��
❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Phone: 7%'-- 7Zc- -3c)a
OWNER: Name:
Identification - Please Type or Print Clearly
BR- ors fie, fo 64,
Address: Moe oe AT Pc) AJD 12_61z ;
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Address:/ (/h4,r, /�rJ �°� M//is /V' e.3449 Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
! Aid user , /t A
Phone: o3-3V-4769
Total Project Cost: $ l� m?
Check No.:
FEE:$ —
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NOTE: Persons contracting with egistered contractors do not have access to the guaranty fund
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Date Manufactured
1/8/2014
AZTEC TENTS
2865 COLUMBIA ST
TORRANCE, CA 90503
(800) 228-3687
This is to certify that the materials described below have been flame retardant
reeled (or are inherently flame retardant).
Christian Party Rentals
18 Clinton Drive
Hollis, NH 03049
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,
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing
Title of Applicator or Production superintendent
P
Invoice Number: 0202537-IN
Customer P.O.:
Customer Number: CHR030
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Date Manufactured
1/8/2014
This is to certify that the materials described
AZTEC TENTS
2665 COLUMBIA ST
TORRANCE, CA 90503
(800) 228-3687
below have been flame retardant
treated (or are inherently flame retardant).
Christian Party Rentals
18 Clinton Drive
Hollis, NH 03049
'114'
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Page:
Invoice Number 0202537-IN
Customer P.O.:
Customer Number: CHR030
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,
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing
Tido of Applicator" or Prooloolion Supelintondent
ITEM CODE
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UNIT ORDERED PRODUCED
Z31 8T1 00E040B/0 #100x40 2pc Series 2000
TP UW
#0Id Style to match
previous orders#
Includes Jumper Ropes
Only
Blackout White
(Tie Downs Not Included w/
Top)
Z39900430 5/8Polydac CP Jumper 45"
Z318Z001801310 *100x20 End S2000 TPLA
UW
w/ New Plates Includes
Jumper Ropes Only
Blackout White
(Tie Downs Not Included WI
Top)
Z31E00190E3/0 100x20 End 52000 TPGR
UW
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Jumper Ropes Only
Blackout White
(Tie Downs Not Included wl
Top)
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Date Manufactured
1/8/2014
AZTEC TENTS
2965 COLUMBIA ST
TORRANCE, CA 90503
(800) 228-3087
This is to certify that the materials described below have been flame retardant
treated(orarB inherently flame retardant),
Christian Party Rentals
18 Clinton Drive
Hollis, NH 03049 e,„ P0414104 ttef5000
.ftost,traitIR ibi44450
pv.. feen boo (100 / VilOn
Yri"Zeg. F=Lila ' - 66A
Certification is hereby made that the articles described below hereof are made Tn Vaniqo 6oL6gbd f 12.1.01
from a flame-retardant fabric oi material registered and approved by the 6s vinat0a 64110
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flame -resistant fabric or material used and additionally referenced on the label of
the fabric panel,
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing
Two of Appficetor of Production Supetintenelent
41,1,410110,
Invoice Number: 0202537-IN
Customer P.O.:
Customer Number: CHRQ30
Mr/A
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citosfsos
ITEM CODE
'gator or „Production Superintendent
ITEM DESCRIPTION
NIT ORDERED PRODUCED
1'1
'1 101
23181100E0408/0 #10Ux40 2pc Series 2000
TP UW
#Old Style to match
previous orders#
Includes Jumper Ropes
Only
Blockout White
(Tie Downs Not Included w/
Top)
Z39900430 5/8" Polydac CP Jumper 45EACH 2 2
2318200180B/0 `100x20 End 52000 TPLA EACH 1 1
UW
w/ New Plates Includes
Jumper Ropes Only
Blockout White
(rie Downs Not Included w/
Top)
72182.00190B/0 *10040 End S2000 TPGR
uw
w/ New Plates Includes
Jumper Ropes Only
Blockout White
(Tie Downs Not Included w/
Top)
/
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Date Manufactured
1/8/2014
This is to certify that the materials
treated (or are inherently flame ret
Christian Party Rentals
18 Clinton Drive
Hollis, NH 03049
Invoice Number:
Customer
Customer Number: CHR430
AZTEC TENTS
2665 COLUMBIA ST
TORRANCE, CA 90503
(800) 228-3887
described below have been flame retardant
ardent).
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,
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing
TiOe of Applicator or ProduCtIOn Superintenclem
ITEM CODE
0202537-IN
riearn of Applicator or Production Superintendent
ITEM DESCRIPTION
UNIT ORDERED
PRODUCED
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Z318T100E0406/0 #100x40 2pc Series 2000
TP UW
#01c1 Style to match
previous orders#
Includes Jumper Ropes
Only
Blockout White
(Tie Downs Not included w/
Top)
Z39900430 5/8" PolydEIC CP Jumper 45'
Z318Z00180B/0 *100x20 End S2000 TPLA
UW
w/ New Plates Includes
Jumper Ropes Only
Blockout White
(Tie Downs Not Included w/
Top)
Z318Z00190B/O 100x20 End 32000 TPOR
UW
WI New Plates Includes
Jumper Ropes Only
Blockout White
(Tie Downs Not Included w/
Top)
EACH
EACH
EACH
EACH
2
2
1
Continued
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 PERMITTING AUTHORITY.
Applicant Information
Name (Business/Organization/Individual): Christian Delivery & Chair Service, Inc. / Christian Party Rental
Address: 18 Clinton Drive
City/State/Zip: Hollis, NH 03049
Phone #: 603-883-5326
Are you an employer? Check the appropriate box:
1.1: I am a employer with 25 employees (full and/or part-time).*
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.01 am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees5 .
1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet
These sub -contractors have employees and have workers' comp. insurance.t
We are a corporation and its officers have exercised their right of exemption per MGL C.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Please Print Legibly
Type of project (required):
7. 1:1 New construction
8. Li Remodeling
9. El Demolition
10 0 Building addition
11.0 Electrical repairs or additions
12.0 Plumbing repairs or additions
13.D Roof repairs
14. D Other TENTS
*Any applicant that checks box 14 I must also fill out the section below showing their workers' compensatio policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 for my employees. Below is the policy and job site
information.
Insurance Company Name: NH Motor Transport Association
Policy # or Self -ins. Lic. #: P000749NHMTA2016 Expiration Date: 01-01-2017
Job Site Address: // 6 0 (4-tegi /9///76/ /2d City/State/Zip:
• /V ' A/WI/Pr PO III SY!'
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 undeiji
Signature:
Phone #603-883-53 6
:
ties of perjur y :pat the information provided above is true and correct.
Zyl
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. Cityr Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact Person:
�
/^
"°W "°~°`°`"" ==" `°°°°~""` =^,^""°°
TUM
{
puBox 3898
Concord, wxm302-x890
(603)224-7337
n
F U
THIS CERTIFICATE 0ISSUED AGA 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 ORPRODUCER, AND THE CERTIFICATE HOLDER.
This is to certify that:
Christian Delivery & Chair Service Inc. DBA
Christian Party Rental
18C|inhon Drive
Hollis, NHU2U48
Cortificmto#: 1
Is, at the issue date mthis certificate, insured below. The insurance afforded bythe listed policy(ies) is
subject to all their terms, exclusions and conditions and mnot altered by any requirement, term mcondition mother document with respect mwhich this
certificate may be issued.
COVERAGE AFFORDED UNDER wmLAW opTHE FOLLOWING STATE: wx
TYPE OF POLICY
EXP DATE
Continuous*
Extended
Policy Term
POLICY NUMBER
LIMIT OF LIABILITY
Workers' Compensation
ADDITIONAL COMMENTS:
09/01/2016-01/01/2017
Bodily Injury By Accident
Bodily Injury by Disease Policy Limit
Bodily Injury by Disease Each Person
'If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date.
NOTICE OF CANCELLATION: (Not applicableunless anumber of days is entered below.) Before the stated expiration date, the company will not
cancel or reduce the insurance afforded under the above policies until at least 30 days. Notice of such cancellation has been mailed to:
Christian Delivery & Chair Service Inc.
dboChristian Party Rental
18 Clinton Street
Hollis, NHU5O49
NHMOTOR TRANSPORT ASSOCIATION SELF-INSURANCE GROUP TRUST
Concord, NH
Authorized Representative
��24-7337
O3/2o/2O1O
Phone Number Date Issued