54 TURNER ST - BUILDING INSPECTION (3) 1 Ili
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MPFCI1aF]PWR W A IPERIW?BEING GRANTkD
J� CITY OF_SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remd, Odsll,,Siding. Construct Dad*, Shed, Pool,
PLEASE FILL OIIT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCEUM
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accortLip•to the following
specifications:// /./ l
Owner's Name o S c- of se/le4 6& /-ey
Address 3 Phone Sy 7uen e- gr (?i 2 1 9W 0 Q9/
Architect's Name
Address d Phone D / n
Mechanics Name I e7�2 Sriv\ Pbwt /v
Address & Phone /3 g_ rJg� Sf fc)11?de51,1L(7r 1 7,7 S- 4/0Dr-o
Whd is sn purpm it buNdYp? /riG DO/CCt Q Y ���
MOWN a buYdrlp? K a dwNwq,for how miry aw&n?
WIN bukbV codwm to uw? Ambaft?
E�rlrr.a Cad City uc«w r sta. 0
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Sig ddure of Applicant
SKINED UNDER THE PENALTY'
DESWUPTION OF WORK TO BE OWE OF PENURY
MAIL PERMIT
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No. Xal 06
APPLICATION FOR
PE OW TO
36)1\-45- To,-t—
LOCATION
PERMIT GRANTED
19
INWECTOA OF BUILDINGS
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Certificate ieat�e of �lan�e 1�esistanee � 5
0 r ( p 5 REGISTRATION ` ISSUED BY Date of Manufacture 3 5
hx, J 7 5 APPLICATION RICH91111 R 05imo2 5
i• 5 NUMBER 3'
r INDUSTRIE INC
EVANSVILLE, INDIANA 47725 Order Number 5
351412 5
J -i 5 FIa0.1 E MANUFACTURERS OFTHE FINISHED 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
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Ala. 5
This is to certify that the materials described have been flame-retardant treated q:. 5 h5 (or are inherently noninflammable) and were supplied to: 2
PETERSON PARTY CENTER INC 4 n 5
139 SWANSON ST
5 WINCHESTER MA01890 5 {
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Certification is he eby made that:
5
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i 5 The articles described on this Certificate have been treated with aflame-retardant approved 5
> 5 chemical and that the application of said chemical was done in conformance with California 5
ri ; jl 5 Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
1
Y 5 serial # 8109005(1) 5
5 Description of item certified: 5
CENT MATE30W X 45 SNY W W f
du� ,•�I� r.T • 57
Flame Retardant Process Used Will Not Be Removed By " 5
r �I Washing And Is Effective For The Life Of The Fabric 5
YM T C�1 SNYDER MFG NEW PHILADELPHIA.OH 5
p S Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC t 1` 5
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 060219
Birthdate: 04/27/1954
91 Expires: 04/27/2007 Tr. no: 9737.0
Restricted: 00
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180 Commissioner
3 The Commonwealth of Massachusetts
_ Department of Industrial Accidents
O>fce aflnuestW26017s
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600 Washington Street, Th Floor
Boston, hfass. 02111
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\\'orkers' Conyx'nsation Insurance Affidavit: Building/Plumbing/ISlectrical Coniraclors
A ilicant formation:
TleascTRl--
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aci�irc„ /39 S• � �r�' ----
--tin• GV lhGflfS . �
work sift location(lull address __
I am a homeowner perfomiim all wor myscll_ I r Ijut l ypc J�j Ncw C.ouatruU inn❑Rcmodci
I am a sole Inert leior and have no one working many capacity- ❑ Building Addition
I am an employer providing workers' compensation for my employees working on this job-
company name: PF7-f7ZS6/y
Address 7
ci n- bu/^Je Alf 57-£2We
in.n caner ni. nolicr;;
�� I ❑rr :: sole ri"pi ino;.geucr:d coutTaco iI o! Ins Inco"Elul(rinb onC ami h:.rc hrrO IhgmmIT:+cb n6 h_. r )—. :
the hdlo,,ing workers' conipcnsation pohcc,:
eons any name
address:
city- phone 9-
insurance m. Tic H
company name:
address:
city phone to
insatanceco. t" N
Failure to secure coverage as required under Section 25A of MCL M can lead to the Imposition of Criminal penalties of a But up to S1,500.00 and/or
one years'impriseummt as well as civil penalties to the form of a STOP WORK ORDER and a fine of SI00.00 a day against me, f understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
f do hereby aceerrfify under thee p--a' and penalf s of perjury that the information provided above is true and correct
Signature alz4 W—e �4�/0 Date
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Print name Phone# 7FI-7, '' yDDZ�
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official use only do not write in this area to be completed by city or town official
city or town: permiUlicense t! ❑DD�epanmefl'ent❑ _❑check if immediate respnse is required ❑ ce❑ entcontact person: phone p; ❑
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