HomeMy WebLinkAboutBuilding Permit # 4/28/2015Permit NO:
Date Issued:
TOWN OF ORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
PROPERTY OWNER
Print 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Hstoric District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
D New Building
D Addition
Alteration
0 One family
0 Two or more family
No. of units:
0 Industrial
D Commercial
D Repair, replacement
D Demolition
D Assessory Bldg
D Others:
0 Other
0 Septic 0 Well
0 Water/Sewer
0 Floodplain D Wetlands
D Watershed District
7".
11 C IY"-)01'e
DESCRIPTION OF WORK TO BE PERFORMED:
a 4., (c:-71,7
431
Identification Pleas Type or Print Clearly)
OWNER: Name: "7-66.,./77 cf Phone:
Address:
CONTRACTOR Name:
Address 3
Phone:
Supervisor's ConstructionLicense:
Horne Improvement License
e"' ihz,n
(..)/
E)(p. Date:
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.
FEE: $ //c(
Receipt No.: I" -
Total Project Cost: $/er?)-r)
Check No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor /7614, ktec-flet,
Plans Submitted Plans Waived Certified Piot Plan Stamped Plans
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Name of Applicator of Flame...Resistant Finish
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The.Life Of The Fabric
Description of item certified:
CENTURY MATE EXPANDABLE END
40WX20 SNYDER WHITE VINYL
Serial #
8108985 (2)
ANCHOR INDUSTRIES INC.
E
Tent Identification
04618268
Date of Shipment
5/12/2008
0
P LEPLP
r_Pr_PEPLIEP r_PLPE_P LICIPLIO Ea-
El
The Cornmonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
iviv)v.inass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
PFTERSON PARTY CENTER
Name (Business/Organization/Individual):
Address: 36 CABOT RD
City/State/Zip: WOBURN, MA 01801
P 781-729-4000
Are you an employer?
LL
2. 1-1
3. LI
I am a employer with 200
employees (full and/or part-time).*
I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
I am a homeowner doing all work.
myself. [No workers' comp.
insurance required.] . t
Check the appropriate box:
4. E I am a general contractor and
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.t
5. r 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.]
Type of project (required):
6. 11 New construction
7. Remodeling
8, Demolition
9 P Building addition
loP Electrical repairs or additions
lip Plumbing repairs or additions
12. Roof repairs
13,T otherTEMP, TENT
*Any applicant that checks box #1 must also fl out the section below showing their workers' compensatio i policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IContractors 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-coutractors have employees, they must provide their workers' romp. policy number.
lain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:A IM MUTUAL INS CO
Policy # or Self -ins. Lie. #: WMZ8006586 Expiration Date: 1 °/9/15
Job Site Address: 423
4) 01L' '41-7) T
4(,)
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 81,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 8250.00 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.
City/State/Zip: /
I do hereby certifY under the pains q/id penalties of peljug that the inforinationpiovided above is true and correct.
/ /4,12
Sienature:
Phone #: 781-729-4000
Date:
2
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, Electrical Inspector 5. Plumbing Inspector
6. Other
'ontact Person: Phone #:
A C�� �CERTIFICATE OF LIABILITY INSURANCE
DATE(hlh1/DDnYYY)
9/28/2014
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
Bonacorso Insurance Agency, Inc.
10 Cedar Street
Unit # 32
Woburn MA 01801
CONTACT Michael Bonacorso
NAME:
PAC (781) 937 32Q0 FAX No): (7 Fa)927-3202(No Bull:
E-6tAIL michael@bonac0rs0ins.com
�ADORESS:
INSURER(S) AFFORDING COVERAGE
NAIL #
INsuRERA:Acadia Insurance Co.
INSURED
PETERSON PARTY CENTER INC.
TABLE TOPPERS OF NEWTON
36 Cabot Road
Woburn MA 01801
INSURERa:AIM Mutual Insurance Co.
INSURERC:
INSURER D :
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER:2014 Master Certificate
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
INSR
SUER
WVD
POLICY NUMBER
POLICY EFF
(MM/OD/YYYY)
POLICY EXP
(MMlDD/YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
CPA5061026-12
10/9/2014
10/9/2015
EACH OCCURRENCE
S 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
S 2SO, OOO
MED EXP (Any one person)
$ 5,000
CLAIMS -MADE X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X PRO- I I LOC
JEO_T
'A
AUTOMOBILE
—
y
LIABILITY
ANY AUTO
ALL OWNED
X
-
X
SCHEDULED
AUTOS
NON-Of/NED
AUTOS
2IAA 5063173 12
10/9/2014
10/9/2015
COMBINED SINGLE LIMIT
(Ea accident)
S 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
S
PROPERTY DAMAGE
iPer accident)
UM/UIM
s 1,000,000
A
X
UMBRELLA LIAB
EXCESS LIAR
X
OCCUR
CLAIMS -MADE
TED
10/9/2014
10/9/2015
EACH OCCURRENCE
$ 10, 000, 000
AGGREGATE
$ 10, 000, 000
S
DED
RETENTIONS
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH}
If yes, describe under
DESCRIPTION OF OPERATIONS below
YIN
N
N/A
iMZ8008006586
10/9/2014
10/9/2015
X, WC STATU- I OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT
S 1,000,000
E.L. DISEASE - EAEMPLOYEE
S 1,000,000
$ 1,000,000
EL, DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS / 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)
W R025 ranirot rtt
1988-2010 ACORD CORPORATION. All rights reserved.
Th,, ArnRn n„ e% n,,,1 h- -,n nro rar,ic+orc,l ,n,rl,o e f ArnOn
Massachusetts -- Department of Public Safety
:,iard of Wuding Regulations and Standards
TAP
Uskatwi
License: CS-060219
w
k
Mark Traina
33 Hanford Road
Stoneham MA 0A80
-44
')41.1000
P A
k
Commissioner
Expiration
04/27/2017