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MEMORIAL DR - BUILDING INSPECTION What is the current use of the Building? Material of Building? It dwelling.how many units? Will the Building Conform to Law? Asbestos? Architects Name erc-e �eK4 1 C e�c to the Address and Phone MedumiWs Name Address and Phone Construction Supervisors License 0 HIC Registratlon 0 Estimated Cost of Projed 3 Permit Fee Calculsdon Permit Foe S Estimated Cost X$7J$1000 Residential Estimated Cost Xill/i1000Cammerda4----- An Additional $5.00 Is added as an Administrative charge. Make sure that all flelds are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated s PecRations. Signed under penalty of perjury DateIZZ �I f s LC6 ,�- 96 --_ Crry-OF- PUBLIC PROPERTY DEPARTMENT ! �rAYde 130 WAUdH=W 3MM SK ..... AsaAaaset'1s 01970 7O-M74&""H M-14a."M APPLICATION FOR THE REPAIR. RENOYATION. CONSTRUCTION D&MOLITION,OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location NamK L'� �. v e ' Buildlrlg: P� �le uc o r:� � l�✓ � - - Property in located In a.Conservation Area Y/N Hista to Obbid YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: — Address: Telephone: &0 COMPLETE THIS SECTION FOR WORK IN EXIMIT110 BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Nov Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: bro Le aQ©w e �lo7D -- -Mail Permit to: - - I CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT :sIMURUY DRI%a A.L MAY(* Ir.WAAHMILiro[.S7Rrx7 4 SnlFr4,Mns,nun.u:l-i�0197'J Trt:97S-743-9595 4 FAX:978.740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Leeibly Name tausitic%VOrgattizationtlndivtthml): C P IC e vC fCc ( P vf�v VI C Address' ll J Ca /Vf S¢ City/3tarcizip: 91/5-11honehl: Are yo a employer?Check the appropriate box: 'type of project(required): t. 1 am a employer with 4. ❑ I am a general contractor and I ❑ 6. New construction employees full and/or art-tine .' have hired the sub-contractors ( P ) 2.❑ I am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling ship and have no employees These sub-contractors have a. ❑Demolition working for me in any capacity. - workers' comp. insurance. q, ❑ Building addition f No workers'comp. insurance 5. ❑ We are a corporation and its requirud.) I officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. (No workers'comp. C. 152.§1(4).and we have no 12.❑ Roof repairs insurance required.j t employees.[A'o workers' 13.❑Other comp. insurance required.] -Ail)applicara nw chicks boa ea moat also lilt out the section below showing astir wurkai conrpensalion pulicy infumutiun. '1lotrwownen who suhmil this arflelavit indicating they ate doing all work anti then hbe omride con rxton moat.uhm4 a new affidavil indicain8 such. :Cortlmusn that c4vk this box most attached an addilional.fleet showing the nature or the aubcomractots and their workan•comp.policy information. fain list employer that Is providing workers'compensaflon hisarancejor iffy employees. Below is the pulicy and job site information. // .tt t Insurance Company Name: Lnff�Lrneseipk �g/kl. I__ Policy is or SelGins. Lie.#: wC DDD `l7• —OCo \ Expiration Date: Of �os Job Site Addresc:6U1..,P N Oft¢ City/Slate/tip: 54 fe 04 I (�� /�f970 Attach a copy of the workers' comiiensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A uf.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 5250.00 a day against the violator. Ile advis:d that a copy of this statement may be forwarded to the Office of lavc,ngatiuni ul'thc DIA for insurance Covcragu verification. l do hereby certify ander li Was art p/ennyis//licir ujperjary that fire injormatton provide t. �yd above is true and correct. Sig rare• L•,/�i�/a7 PIll�v a: 9 ?g_ 9a -SGGo Ofe fal use only. Do not write in dds area,to be ronipleted by city or town aJJie iuL City or Town: __. Permitt1.1cense Issuing Authority(circle one): I. Iloard of health I. Building Department J.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Of her Contact Person: -- - — Phone q: Information and Instructions Massachusetts General Laws chapter 152 requires all employers tto the dserviceor er ' compensation any cotheir ttract ofloye Pursuant to this statute,an employee is defined as"...every person express or implied,oral or written.- An employer is defined as"an individual,partnership,association.corporation or other legal entity,or aay two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver"trustee of an individual.partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein.or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL chapter 152. $25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chapter 152,§25C(7)states"publiceither the work until am nwealth nor any of ptable evidence of it pliti cl w�he rnsmu"I enter into any contract for the performance u requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the•affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the pormitilicense number which will be used as a reference number. in addition,an applicant that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address'the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 1'hc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Me*Of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-49M ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia O rrud3 L3 PrJ�cnuL3IcPrJ@PucPrJ�rJ�c M PO RTANT DOCUMENT 5 Certificate of qFla Resistances 5 REGISTRATION t ISSUED BY 5 APPLICATION Q �T�" A/� A Date of Manufacture �J 55 NUMBER s it *�u+o�sHe3 Pa 05/08/03 55 5 EVANSVILLE, INDIANA 47725 Order Number S 5 FI2I.a E ° MANUFACTURERS OFTHE FINISHED 368094 S 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 .This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 5 692825 S 5 RICE RENTAL CENTER 5 5 TAYLOR RENTAL CENTER#14978-4 5 5 115 CABOT STREET 5 5 BEVERLY MA 019155108 5 El! 5 C, 5 R Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant'approved S chemical and that the application of said chemical was done in conformance with California 5 5 Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 S The method of the FR chemical application is: 5 Serial # 8025000(1) 5 Description of item cert TOP Sow X 30 VL w w 5 5 05 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 IOHNBOYLE STATESVILLENC Signed: _.Z� g ,. 5 5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5 t7 �[P[f@PtP[P[P[P[PcPcP[J�[PtP[P[P[P[P[ItP[P[P[PrP[P[P[J�[P[PtP[PcP[P[P[PtP[J�cPcP[P[P[P [P[P[P[P[P[PcP[P[P[PtP[P[P[P[Pr P[P[P[9ff P[P[J�cP[PtP[P[P[P 4, ° 7""'1 M PO RTA NT DOCUMENT o s Certif irate 6f Flame Resistance 5 SREGISTRATION t ISSUED BY 5 S APPLICATION Q /C�uHo tRf Date of Manufacture 5 5 NUMBER = INDUSTRIES INC° 05/08103 l5 5 EVANSVILLE, INDIANA 47725 Order Number r5 5 5 FI21.a MANUFACTURERS OFTHE FINISHED 368094 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 5 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 5 ss2825 5 S RICE RENTAL CENTER 5 5 TAYLOR RENTAL CENTER#14978-4 5 5 115 CABOT STREET S 5 BEVERLY MA 019155108 5 5 5 'a 5 5 . ' Certification is hereby made that: 5 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California 5 5 Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 5 The method of the FR chemical application is: 5 5 Serial # 8025300(f) 5 Description of item certjgM M D 30W X 10 VL W W 5 5 � 5 5 Flame Retardant Process Used Will Not Be Removed By 5 S Washing And Is Effective For The Life Of The Fabric 5 5 JOHN BOYL.E STATFSVILLE NC 5 � 9 �R Name of Applicator of Flame Resistant Finish Si ned: S TENT DEPARTMENT-ANCHOR INDUSTRIES INC. r5j O rJ�rJ�cPrJ@P�PrJrJ�cPrJrPcPcP�PrJcPrncPrPrJ�rJ�rJ�cPrPrJ@PcPcPcPcPrJ�rPrJ�cP�PcPrPrlrsrJ�cPcP cPcP�PrJ�rJ�cPcPrJ@fcPrJ�rJ�cP�P�PrJ�rJ��PrJ@PrJ@PrP�PcPrJ@PrJ�rJ� n�������u�u�u��nu��n�sE30- M01 I M P O R T A N T D O C U M E N T 0055005;ar-pnupt_n-goom�s�nu��nu�su��upc o 5 5 Cutlf IfatP Of ,f tamp Rpg5taurp 5 5 REGISTERED ISSUED BY5 5 5 APPLICATION o- Date of Manufacture 5 NUMBER Z!IMIN ES INC. 2/26/99 CJ 5 5 F121 .4 � EVANSVILLE, INDIANA 47711 Order Number 5 5 5 5 ET MANUFACTURERS 216154 MANUFACTURERS OF THE FINISHED 5 5 TENT PRODUCTS DESCRIBED HEREIN rj CC55 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 f3 RICE RENTAL CENTER 5 rj TAYLOR RENTAL CENTER 5 5 115 CABOT STREET S 5 BEVERLY MA 019155108 5 5 Certification is hereby made that: 5 S5 The articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California Fire 5 Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 5 The method of the FR chemical application is: �5 5 Serial #: 8105960 (0004) I5 55 Description of item certified: TENT WAL 6-10 X 30 VL W W 3/CA 5 5 5 5 5 Flame Retardant Process Used Will Not Be Removed By 5 Washing And Is Effective For The Life Of The Fabric 5E-::: TATESVILLE, NC Signed: 5 5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5 (cP[PC I@P[P[IJCP[PCI�[PCPC I1PCPC FCPCJ�CPCI�CPCJ�fJLI�[P[P[PCPC I@QP[PCPCP[P[P[PCP[I�CPLI@ NINON�CPCPC I�CPCPC I�CPC I�CP[PClfJ�[PfJ@I�CP[PCP[I@P[(CPC I�[P[Imo[fU�CPCPCP[PCP[I@PC I@PC I� �J ° `n`n`n�`n`n�'u�'�'�'u�'�'�'�'J I M PO RTANT DOCUMENT�����'�'�'����MpLpr o 5 Certif icate ` -of Fian?e Resistance 5 5 5 REGISTRATION ISSUED BY S 5 APPLICATION sCH Ili. Date n0f3Shipment S 5 NUMBER �7o 1Houst E99 5 /05 EVANSVILLE, INDIANA 47725 Tent Identification 5 Ftzt.a MANUFACTURERS OF THE FINISHED 04033875 5 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated S (or are inherently noninflammable) and were supplied to:692825 5 5 RICE RENTAL CENTER 5 TAYLOR RENTAL CENTER#149784 5 5 115 CABOT STREET 5 5 BEVERLY MA 019155108 5 5 5 5 5 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 chemical and that the application of said chemical w 5 pp as done In conformance with California 5 55 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. S �] Serial # 8105660(6) S SDescription of item certified: S 5 WALL 6'10 X 20'W2 CATHEDRAL WINDOWS WHITE VINYL 5 5 Flame Retardant Process Used Will Not Be Removed By 5 S Washing And Is Effective For The Life Of The Fabric S 5 5 JOHN BOYLE STATESVILLE NC ?Signed: ,Inl 5 SPECIAL EVENfS DIVISION-ANCHOR INDUSTRIES INC. e O rJrPrPrPrJ�rJ�cPrJ�rJ'rJ�rJ�cPcPrPcPcPcPrPrJ�rJ�cPrJ�cPrJ�cPt.PcPcPrJ�cPcPcPcPcPrJ�PrJ�rJ�cPr.PcPcPrJ@PrJcPcPcPrJ�rJ�i:.PrJ�rJ�rJ�rJ@PcPU�rJ@PrJ@PrJ��.PcP�PrJ�r.PcPrJ�rJ�cPrJ� O