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HomeMy WebLinkAboutBuilding Permit # 6/16/2015Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION /616)-K Date Received IMPORTANT: Applicant must complete all items on this page LOCATION 76 PROPERTY OWNER 76.A.1 MAP PARCEL: c di St-- Print ZONING DISTRICT: 100 Year Structure yes Historic District yes Machine Shop Village yes no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential DIslew Building LI Addition LI Alteration 11 One family 111 Two or more family No. of units: Li Li Industrial Commercial LI Repair, replacement CI Demolition LI LI Assessory Bldg Other VOthers: ,161911 0 0 0001 0 . 011001011,0';',10gprip 10f14)i, nu-nv ,F11.000"101g, ..00TUJI ,'", **gip 'Ihrt1 24'0,'"",r1 rrNte,rorp, rarrrrr. 1111:11111,1,1,11,1,1,1,1,1,1,1,1,1,1 , 0101111„2,1000„rp,',',;h„"",,„ run911111111113p1,1,1,11110.111.40N 11111111,)%d,.; 1A0 r '01A11,;rf 1,1'6")1110,,09v)11.;,11,11110 DESCRIPTION OF WORK TO BE PERFORMED: c,9 Identification - Please Type o OWNER: Name: 76 tv,i OfAle a Address: Sfr SEEYI ipZ i? ar7 Print Clearly Phone: Contractor Name: ?e' eRsrn Email: Address: 3(0 Qeof-- Supervisor's Construction License: Home Improvement License: Phone: '7 7.4.9 - /W3 a- (.74 Exp. Date: 9 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. Total Project Cost: $ FEE: $ 34, Check No.: ,,t? 7'7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 7.9vapowA ,rwif ovii 46' "we/Pi ignature—ore gem, wrier, ai/ ,v ,,444 V" wap., /WWI grg 4g6".61.1.1)ii atur econtraCTOOP co a) Cl) 0 O CD 0 Z • ▪ O cn -o "0 O O cfl C CD —1 v • o CO CO . y • O C N I Cl)CD � Z 0 0 O ▪ CD a 0 so NO103dSNl 9Nl01lf18 m cn Cn 0 cn O to Cn m 70 m Cl) a) 0 Cl) VIOLATION of the Zoning or Building Regulations Voids this Permit. o 0 -a o cn o =_" • cD - o Cc> a 0 oo-rt51'- er o_ 0 �- 0 CO n CD U) C cD 'a o-) ', S' o co CL N O Aa Fir, m CD -0 o < ca 67.5 oo�' D `D cn fa. o • su m CL CO sl CD �D • cD o 0 .- o co a O 0 �rt cD cn m o pan o} uolsspied set' CT y .LVHl S31II12130 SIHI CL Peterson Party Center, Inc. 36 Cabot Road Woburn, MA 01801 Tel: (781) 729-4000 Tent: (781) 503-2144 Fax: (781) 729-4999 www.petersonpartycenter.com BILL TO: Special Event Equipment and Tent Rental CATERING WITH DISTINCTION 27 DRY DOCK AVENUE BOSTON MA 02210 PROPOSAL, 565993 REVISION#: 3 DAY: SATURDAY DATE OF USE: 06-20-15 TIME OF USE: 3:00 PM 1 DAY RENTAL SHIP TO: GAIL (978) 682-7072 STEVENS ESTATE a OSGOOD HILL 723 OSGOOD STREET NORTH ANDOVER MA GET DEL. & PICK UP TIMES PROPOSAL DATE TELEPHONE.FAY 05-20-15 (617) 345-4200 (617) 345-4230 ORDERED BY, PHONE ANDREW (617) 345-4200 DELIVERY DAY & INSTR FRI PICK UP DAY & INSTR MON /SUN WE ARE PLEASED TO QUOTE THE RENTAL OF THE FOLLOWING: 1 MINIMUM TENT RENTAL 1 20' X 30' SERVICE TENT 1 6' X 10' CANOPY 1 GENERAL ILLUMINATION- 4- 25' STRINGS GLOBE 1 APPROXIMATE PERMIT FEES* (FIRE/BUILDING ONLY)* 1 MARK AREA FOR DIG SAFE ??? (TBD) 1 TRANSPORTATION AND SITE LABOR* MATT E/M'D ANDREW 6/2 Payment to be as follows: $550.00 DEPOSIT DUE AT SIGNING - BALANCE COD 'r eptdtuue of.9rDpo.✓ 1 - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Deposits are not refundable or transferable unless otherwise specified. Sub -rental of equipment to others without authorization is prohibited. d NOTE: This proposal mnv Be withdrawn bL •s if.ot accepted by: 05-25-15 Authorized Signature: Date of Acceptance: Customer Signature: 1,250.00 0.00 0.00 95.00 0.00 100.00 1,250.00 0.00 0.00 95.00 0.00 100.00 SUB -TOTAL: 1,445.00 SALES TAX: 78.13 LABOR: 0.00 DEL/PU FEE: 0.00 DAMAGE $ 0.00 WAIVER: TOTAL: $ 1,523.13 MATTHEW BOUDREAU Please sign and return one copy of this proposal with On Monday, September 15th, Peterson Party Center will be implementing a non-refundable 5% Damage Waiver. This fee will be assessed on the subtotal of the entire order excluding Sale Items and Tent Equipment. This fee will protect you from charges due to accidental breakage and minor losses of rented items. osit. .10PL LrPE_PLIE rPrr_Pr_PrPLPLIPrPrPEPLIMPLEPE r IEPLOPLPrPc1P�rJPcPrJPr�r_PEPLPr_r_PL PE_PL PL PLEPLPLLPL PP1'r�EPE_ J�ESEPLLPLI PEIERI 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 SNYDER MFG NEW PHILADELPHIA.OH a -90 —I0 93 CD0P:F) 5Pt 0 w 6. tD ® m- (.n 7 0. 0O CD m ® 0 CD ocr® I X 0 93' <en CL 0 CD C to a. Iv CD o. - ticp • C CD CD CD Ti CD. m IM ®® 0) • 3 0 DI c) o 5 v 33 CD Description of item certified: cn CD (sz) DOI0 8OS 068I- VW 2121S2HONIM - qi � c��n . CD cnm Dcn uo 714 z o � z 7 z > . cn z 3 -I l� n Z Z c ®D a� • 0" —1rn BCD CD ® �-—1 ® • W rn ▪ ®� rncP DJ M Z® CD CD CD CD CD 0 >m 5-� 5 5 c�`� 5 "—I ® - 5Ct3 5555 uoi;eoifltuapi ;uab CD W N 013 (T CD TE PrPalcr_ P�r�r_PE.PL PEPr_PrJPr_J�rPPPrPcSOPEPc EPc_ Pr P rrPr.PEZIO_PLEPLOePrEOPEDEEPr_PLEIrPrPEPrPEPEPLIDOPrPL PLOPEDLEff r 0 E .ntPr�JP�PF-J - PL��rPr�r._1�LPOPLIEYJr.r.. Pr Pr�c_Fi rritYcl�r�r20J Prr Pcrdi ��rlillT2P - c_ar ci-3r�cPrJc, r rr�cP Cl 5 5 5.0w ral `1 rp_ir: LI 5 5 5 S -, G C Name of Serial It -, CO w= z,(D�; a/ 0 �� z 2FR Applicator of Flame Resistant Finish name Retardant Prsc e Washing And is E e of item certified: FIESTA TOP 20W) V L # 1023970A (I I'( co M 0g. cr ul n_ c l _, !ss Used �i 1ILi Not Be Re r ve For The Life Of M ANCH Zz CD 0 s--f m f ei r1 -0 0 ri 1 -- Ti y7 m _ a -- — _ _ 0 .. ! ri L s'"=' 1 u 0 FEzi J = , i DR INDUSTRIES INC. �B� °ved ! Fabric 4 J . . .5.0 a o. P®® �< 6 a Tent Identification IFt2634-!6 Date of Shipment 5/ 10/2006 5 5 17 5 E, E cliE Pcial7C -] — IL' r PCPCPrit Ll FED_ ZEJ"7 PCIJ�CPC�LI�CPC ±1 fp pP r�Pr r- rr_j] I^GA-3 I L�C ap riiCPCPC PCJ^J citLI�LICPrCJr[I] � g License: CS-060219 gm Mark Traina 33Han$r Road Stoneham MA 0118 )epartmentofPublic Samty Rding Regulations and Standar a«Qna %m£A or 111, NO % Expiration 04 27 2017 A Rf CERTIFICATE OF LIABILITY INSURANCE DATE 9/28/2014YY) 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: PHONE (781) 937-3200 FAX (781)937-3202 1 I ., No xtl; (AlC. No): E-MAIL michael@bonacorsoins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INsuRERA:Acadia Insurance Co. INSURED PETERSON PARTY CENTER INC. TABLE TOPPERS OF NEWTON 36 Cabot Road Woburn , MA 01801 INSURER B AIM Mutual Insurance Co . INSURER C : INSURER D : INSURERE: 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. IFF LTR A GENERAL X TYPE OF INSURANCE LIABILITY COMMERCIAL GENERAL LIABILITY IN R WVD POLICY NUMBER _.._.. PA5061026-12 EY MMIDD/YYY _.. 10/9/2014 POLICY EXP M MIDDIYYYY 0/9/2015 LIMITS EACH OCCURRENCE $ 1,000, 000 PRa RENTED PREEMMI ESESS Eaoccunence $ 250, 000 CLAIMS -MADE X OCCUR MEDEXP(Any one person) S 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE S 2, 000,000 GEN'L AGGREGATE POLICY X LIMIT APPLES PRO PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED X X SCHEDULED AUTOS NON -OWNED AUTOS IAA 5063173 12 10/9/2014 10/9/2015 COMBINED SINGLE LIMIT Ea accident 5 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident) S U,I/UIM S 1,000,000 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE BD 10/9/2014 I0/9/2015 EACH OCCURRENCE 5 10, 000, 000 AGGREGATE $ 10, 000, 000 DED RETENTIONS B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE ER EXCLUDED? OFFICER/MEM(Mandatory (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N/A 42dZ8008006586 10/9/2014 0/9/2015 X WC STATU- TORY LIMIT OTH- ER E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYE; $ 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / 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) INSO2S nninnee m © 1988-2010 ACORD CORPORATION. All rights reserved. Tho AC C8PIl servo ,nd In,.n nen ronie4orod n-,nrkc of Arr-wrl The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 lvinp.inass.gov/dia 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 employer? Check the appropriate box: 1. 3. I am a employer with 200 4. 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.] 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.? 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. I New construction 7. I I Remodeling 8. I I Demolition 9. I I Building addition 10. Electrical repairs or additions 11, Plumbing repairs or additions 12.-1 Roof repairs 13. OtherTEMP, TENT *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation 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. I -Contractors 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. Ii the soh -contractors hove employees, they must provide their workers' comp. policy number. Join an employer that is providing workers' compensation insurance for Illy employees. Below is the policy and job site information. Insurance Company Name:A I M MUTUAL INS CO Policy # or Self -ins, Lic. #: WMZ8006586 Job Site Address: %'d3 Expiration Date: 10/9115 City/State/Zip: vek 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 S 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 clay 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Phone /I: 781-729-4000 Date: 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 Contact Person: Phone #: