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HomeMy WebLinkAboutBuilding Permit # 6/16/2015Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH AN lOVER APPLICATION FOR PLAN EXAMINATION Date Received I ORTANT: Applicant must complete all items on this page LOCATION 20 PROPERTY OWNER MAP PARCEL: Prin 100 Year Structure yes no ZONING DISTRICT: Historic District yes no Machine Shop Village yes, no Print TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential W.New Building 111 Addition CI Alteration 0 One family 111 Two or more family No. of units: CI Industrial El Commercial 0 Repair, replacement CI Demolition 111 Assessory Bldg El Others: kr Other WY , ( w Opp nariaMP ''IYI 4r('Imi 'HP/ q //' DESCRIPTION OF WORK TO BE PERFORMED: ReC 71- ec c.) C.) 7narei.iy R0 e ov, 41entification Plase Type or Print Clearly OWNER: Name: 1k tf-e b, Ce Address: 3 0 'H""Rd Rc 74 Cohtractor Name: e fe Email: Address: 3 r a 7‘' c Lio E;L) rk, 6/14"" Of Supervisor's Construction License: (5 (4, 0 zi4 7 Exp.. Date: Home Improvement License: /6, Exp. Date: 1,44k TR a •hone: Yez-x-, 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: $ 5-Or FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund '.1irgittregfn "AVM"' Ap11111, r" ,,,,wmpop01117 CD a Z 'p O � s . CO ✓ O 0 CD �D O co co Q O C CD CD 0 0 CAn ' Z3• 0 Cl) V 0 cn 'y O 0 CD 0 e-M CD CD 3 Cl)• CD cn 0 0 CD 2 O CD woo o.1 palm 2IO103dSNI ONlaline VIOLATION of the Zoning or Building Regulations Voids this Permit. o can CD fDa•0 c ' Q 0 rt C o a -. -0 O 0 .+ C. N lD • a 0 %N 0 , O a1 0 St C0'� CD mD • CD -O o < ca Fi7 St- O "' • CD 0 DCD w o.o = o < y 00. 0 O CO '< CD a1 'o O • 0• � CD • O ▪ O CQ � ra O 0 :' C EP 1 tD E Eir 0 3 o N 716 O • Oi, • u D C -0 I now U) CD V1' o' O CD CD 0 IVHl S3Id112130 SIHI Party Center, Inc 6 + ubot Road Woburn, MA 01801 1;. (781) 729=40 781) 5032144 729,4999 ATION; W!� -ORt_MG-SAFE. Rt'AT ON AND SITE You are au, PROPOS REVISION DATE-0 I :TIME OF DAYREI' UB-TO \ The C,olmnomPealth! of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 lvlt1v.rnass.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. I am a employer with 200 4. employees (full and/or part-time). 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. LJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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. 7. S. 9. 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13, OtherTEMP. TENT I I New construction Remodeling Demolition Building addition *Any applicant that checks box #1 must also fill out the section below showing their workers' compensatio policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a ffidavit indicating such. =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 :employee.. If rite sub cunn.actors hew_ employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for imp 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: 36 Expiration Date:10/9/15 City/State/Zip: /7 le/ gr^ e'^-1 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 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. I do hereby certify under the pains and penalties of pediuy that the information provided above is true and correct. Phone #: 781-729-4000 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 #: A ccoRti9 CE TIFICATE F I ABILITY 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 (11C No Extt: (781) 937-3200 FAX (AIC, Not: (781)937-3202 E-MAIL michael@bonacorsoins.com ADDRESS: INSURER(S1 AFFORDING COVERAGE NAIC # INsuRERAAcadia 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 : 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 LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY __(MMIDD/YYYYUMMIDD/YYYYL PA5061026-12 10/9/2014 10/9/2015 EACH OCCURRENCE S 1,000,000 PREMaENTED PREMI ESESST(RENTED occurrence) S 250,000 MED EXP (Any one person) S 5,000 CLAIMS -MADE X OCCUR PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE —1 POLICY X LIMIT APPLIES RT- PER: LOC PRODUCTS - COMP/OP AGG S 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) S 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE (Per accident) $ UM/UIM $ 1,000,000 A X UMBRELLA LIAB EXCESS LIAB X O OCCUR CLAIMS -MADE BD 10/9/2014 J.0/9/2015 EACH OCCURRENCE $ 10, 000, 000 AGGREGATE $ 10, 000, 000 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 Y / N N N/A 4Z8008006586 10/9/2014 10/9/2015 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 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) IN5(195 rwninns� m © 1988-2010 ACORD CORPORATION. All rights reserved. Th,s. AC(1Rtl onrf Inn, n, , roniefmnart n,,rke of AC(lOrl achusetts.Dep of (lidding Rer! m License: CS-060219 2x G p Mark Traina 33 Hanford Road \ Stoneham MA (2!8 ( ;ornmis, entofPublic Safety ns and Standards I / Ex ration 04 27 2017 ( DIFOJUrdierr ErcalElPcifflicl PLEJTY T3JUIPATO?rPrJPLPrJEP -1T-2E JOOPLPEESEPLEEPJVEFEIMPOPLPEIOETO PLEUFOOJEIPLLPfrJcJVi�.rrJ�_ _ �m 513 5 5 5 I S3IbLSf14NI UGH3NV :pag�g,uao weal jo uoRduosea 0 1 0 0 v 6 CD F wm0m �a . 0 5 c ' o a< 0 CD 56' 5, cry (8 al ® 0 5 fla �S q0 �0 4W id. rD lJi ld�' F1) a et) < FD c3 o a p Z a 71 CD 5 o 8 T Es. D) 0 e o CD o to CD C Ci fp -I+ -0 ® 0 0681,0 b'W :131S2H3NIM 0 eDO -0 0.) 5 DCn � O Z{ Z O-a z> co 732. -I CD rn 3 2 rn 0 Cr Z (iy n a wzr F6' U m 3 CD a CD CD CD a TENT PRO* CTS DESCRIBED HEREIN Su2af13VMINVII�I ®3 SIN] F bV `211IASINIV SZLLt7 VNll A 3fSSI uol;eo!p Uapl lual luawdiy8 Jo ajea El112 FOSOPLEPL rJPLEPLOPESE PLIEPLEPLIDEIPPL rJr. frJggEPLPL P�PLPLPEP ESIES PLEPLEPLEPr�rJEE_PL r UPrJUr PLEIEPLEFfferJ f1