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HomeMy WebLinkAboutBuilding Permit # 8/19/2015Permit No#: Date Issued: ?5 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received MPORTANT: Applicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential II New Building 0 Addition 0 Alteration 0 One family 0 Two or more family No. of units: 0 Industrial El Commercial 0 Repair, replacement 0 Demolition 0 Assessory 0 Other Bldg Lii,o,thers: ....., all, ,,,,,,' "1' ") 0,0 P17401141t1k Crigar ' RWIS ,(„rl , ,, ,,..4,yt moosomplogy vvt e s e tooyvtotex to st, c o , DESCRIPTION OF WORK TO BE PERFORMED: 1,10% I/ et z-ie wet er,r/ e7it'' el/241 7L fee,474.1 141 /// bC eibe2v.14 4///// Identification - Please Type or Print Clearly OWNER: Name: Me.re-ifv)eick:- Phone: cr Address: A)0,0C1/0- 0/601V3:- e Itt! mgrahobmot COMM " ARCUITECTIElsIGINEER ///t 1)( el 6-e) I_ / cJ Address: iery Phone: 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: $ c2, Z2Zie,,2 Check No.: NOTE: FEE: $ Receipt No.: kl Persons contracting with unregistered contractors do not have access to the guaranty fund ll'AT/77A7P7 WW,T-777,07"7 ,7? Plans Submitted _ Plans Waived Certified Plot Plan _ Stamped Plans TYPE,6F SEWERAGE DISPOSAL Ppblic Sewer — Tanning/Massage/Body Art _ Swimming Pools ❑ Well — Tobacco Sales — Food Packaging/Sales ❑ Private (septic tank, etc. — Permanent Dumpster on Site _ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on f;/9-C Signature COMMENTS w ryi, 6,4) idez ark,66o/ezeid,./ IEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street N• N n O O z CD 0 Z y O N a CI tDCD tD O CD ® U CD CO CD ( N Z r CD CD O CD 210103dSNI 9NI011f18 Cl) C!2 VIOLATION of the Zoning or Building Regulations Voids this Permit. oa$® can = < CD =c CD Q: o o oo o 2: a- (n ?; (T,• 0 0 se 0. Fl 'us ccr, -a. o c �� 0 �(n.a CD MS 0 0 (a o -,, oP. a CD �� o a09- - ro CD S 0 0 0 CD cU) CD 0 0 rt O CO 0 co (D c� cn cn 54 0 oo � rt D0 o c' cu o' o � 0 paia o} uolss!waad seq lb'Hl S313112130 SIHM Lot I Aca' Inno Cent hyolcat Plant Baseball Field Softball Field Sport's Medicine d Health ANDQ. E'R, MA 0'1845 4 OAlA f4,W U. 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Sales Order # F-140.01 SO-614935 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: Date of Shipment 4/10/2015 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial # 8150200 (2) Description of item certified: CENTURY END 40W X 20 HOLE SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric a4/4 SNYDER MANUFACTURING INC, PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC IMPORTANT DOCUMENT Certificate of EYame Wcsi stance Date of Shipment ISSUED BY 4/10/2015 Registration Number CHoR INDUSTRIES INC. Sales Order # F-140.01 SO-614935 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial # 8150300 (2) Description of item certified: CENTURY END 40W X 20 LOOP SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric ag/), SNYDER MANUFACTURING INC, PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC Registration Number F-140.01 IMPORTANT DOCUMENT Certificate of Elame &sistance ISSUED BY CHOR. ,4ftINDUSTRIES INC. Date of Shipment 4/7/2015 Sales Order # SO-614929 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial # 8150100 (4) Description of item certified: CENTURY MIDDLE 40WX20 SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MANUFACTURING INC, PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC Registration Number F-140.01 IMPORTANT DOCUMENT Certfficate of Flame P sistance ISSUED BY CHOR ‘,...41111INDUSTRIES INC. EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: Date of Shipment 4/7/2015 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA Sales Order # SO-614929 Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial # 8150100 (4) Description of item certified: CENTURY MIDDLE 40WX20 SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MANUFACTURING INC. PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC Registration Number F-140.01 IMPORTANT DOCUMENT Certificate of Flame &sistance ISSUED BY CHOR ,v.....41MINDUSTRIES INC. EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: Date of Shipment 4/7/2015 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA Sales Order # SO-614929 Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial # 8150100 (4) Description of item certified: CENTURY MIDDLE 40WX20 SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric a4 SNYDER MANUFACTURING INC PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC 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 Please Print Legibly Name (Business/Organization/Individual): Christian Delivery & Chair Service, Inc. DBA Christian Party Rental Address: 18 Clinton Drive City/State/Zip: Hoiiis, New Hampshire 03049 Phone #:603-883-5326 Are you an employer? Check the appropriate box: 1.0 1 am a employer with 40 employees (full and/or part-time).* 2.0 lam a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] .0l 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 employees. 5.0 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.t 6.0 We we a euipoiui u l ujid Its offiecls have exercised of exemption pcl 1v1UL e. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ® Remodeling 9. ❑ Demolition 10 ® Building addition ! 1.0 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.E Roof repairs 14. r1Other TENTS *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: New Hampshire Motor Transit Association Y"•'J Policy # or Self -ins. Lic. #: P000749NHMTA2015 Expiration Date: 01-01-2016 Job Site Address:, ,,�� 74':09/47/P4. 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 City/State/Zip: /V' 4#'?d ori/c:�� 41% 6'1/r °Y+. I do hereby certi fy under the pains and penalties of perju hat the information provided above is true and correct Signature: Phone #: 603-883-532u Date: Official use only. Do not write in this area, to be completed by city or town official. Ciiy or Town: Pet-Hai/License I 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 #: AC C RTIFICAT IMF LIA = ILITY IN UNC DATE (MM/DD/YYYY) 8/29/2014 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 THE ROWLEY AGENCY INC. 139 Loudon Road P.O. Box 511 Concord NH 03302-0511 INSURED Christian Delivery & Chair Service, Inc, dba Christian Party Rental 18 Clinton Drive Hollis NH 03049 CONTACT Rhonda Noble NAME: PHONE (603)224-2562 Ipp./C. No, ExtZ ADDRESS: rnoble@ rowleyagency . corn INSURER(S) AFFORDING COVERAGE FAX (603)224-0012 (A/C, No): INSURER A :Hanover Insurance Company INSURER B : NAIC # INSURER C : INSURER D : INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER:14/15 - • 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 ADM INSR SUER WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY zaV084436307 9/1/2014 9/1/2015 EACH OCCURRENCE $ 1, 000 , 000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100, 000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES JEt° X PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED X x SCHEDULED AUTOS( NON -OWNED AUTOS ABV071690907 9/1/2014 9/1/2015 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 $ BODILY INJURY (Per person) BODILYINJURY (Per ) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UHVOB4436507 9/1/2014 9/1/2015 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 DED X RETENT ON $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under Y / N N/A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Covering operations of insured during the policy period. CANCELLATION "For Informational Purposes Only" 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 Rhonda Noble/RLN ACORD 25 (2010/05) INS025 0nlnn5\ Ill © 1988-2010 ACORD CORPORATION. All rights reserved. Tha ar•.non name and Innn arc raniatarcri marlra of Ar:f1121-1