54 TURNER ST - BUILDING INSPECTION (4) tl �� G;7
Cny-OFSALEM ---
PUBLIC PROPERTY
DEPARTMENT
KI\MF-RLEY DR151'ULL
MAYOR 120 WAsiimamN hkrmeT•&v.LK\1AsuCxLstj-ts 01970
Tu.,978-745-959S 0 FNc;978.740-98"
APPLICATION FOR THE REPAIR,RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: oust ad' S105'h Building:
Property Address:
Property is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land Name: ayst Oc �GUf`j Cs g
Address:
�y -7�f,&1-7Qa
Telephone: 7zl9" D 94/
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New o?oz�O
Brief Description of Proposed Work:
-O %MWvf Q So ' xI-lo
017 7 P_ ryl .
07
Mail Permit to: Gt
I
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Confolrp.to Law? As stos?
AmNileeft Name r�//
Address and Phone 3 Swam 7d$—
Mechanic's Name
�I'/rlol,-rs se, liJ7fl OB'So
Address and Phone
Construction Supervisors License# ploOa HIC Registration#
Estimated Cost of Projed$_2acrCl � Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional$5.00 Is added as an
Administrative charge.
Make sure that all fields 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
specifications. Signed under penally of perjury X
Date U 7
I
of
N
� o
C6
a3
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 060219
Birthdate: 04/27/1954
Expires: 04/27/2007 Tr. no: 9737.0
Restricted: 00
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
Commissioner
�� ��' o J 'u���J���rPLPDL��JJ��PLPLr -L rjIMPORTANT ®OLUMENTOPI -�
Certif ieaw of 'Flame Resistapee
ISSUED 5
REGISTRATION Date of Shipment 5
APPLICATIO NUMBER N v 's CN�IRw enoizoos 5
INDUSTRIE INC
EVANSVILLE, INDIANA 47725 Tent Identification 5
7 ° MANUFACTURERS OF THE FINISHED 04263446
j h140.1 TENT PRODUCTS DESCRIBED HEREIN S
This is to certify that the materials described have been flame-retardant treated 5
U (or are inherently noninflammable) and were supplied to: 5
_j 657150
5 1, CENTER INC
39 SWANTON ST 5
SWINCHESTER MA01890 5
5 5
T
U
Certification is hereby made that: 5
The articles described on this Certificate have been treated with a flame-retardant approved 5
71 chemical and that the application of said chemical was done in conformance with California 5
21 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
jSerial # 8150701 (t) 5
j Description of item certified: 5,7 CENTURY LOOP END 50WX20 WHfFE 5
5 SNYDER BLOCKOUT SINGLE POLE T
5S Flame Retardant Process Used Will Not Be Removed By 5
` Washing And Is Effective For The Life Of/ The Fabric n (5
5 2441Dco nnr6 NEW PUTT"DrL6H1d'Qw Signed:
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. CO
O r��PcPcPrJ�r�rJrJ�rSrJrJrPcPcPcPr�rPrJ�rJ�rJ�rJ�rJ�rJ�cPrJ�cPrJ@.nr�cPrJPPcPrJ�r�rJ�rJ�cPcPrJ�rJ�r.PrJ�cPcPcPr�rJ�cPcPr.Pcl�rlrJ�cPrJ�rJ�rJ�rJ�rJ�r�cPrJ@PrJ�r�cPcPrJ�r�r�cJ�cP O
��rn����rr3�I-JP Fr1PNJ , "1 M P O RTA NT D O C U M E N T��'�uu��r.nJ�������'
Certif ieate of Flan?e Resistanee 5
ISSUED BY REGISTRATION Date of Shipment C S
APPLICATION is
riN�RW5/10/2006
NUMBER SSSIRIE 15 EVANSVILLE, INDIANA 47725 Tent Identification J
0 F140.1 MANUFACTURERS OF THE FINISHED 04263446 r,
2 TENT PRODUCTS DESCRIBED HEREIN 5
j This is to certify that the materials described have been flame-retardant treated 5
j (or are inherently noninflammable) and were supplied to: 5
657150 S
PETERSON PARTY CENTER INC
5 139 SWANTON ST 5
5 WINCHESTER MA 01890 5
5
5
nj
Certification is hereby made that: 5
The articles described on this Certificate have been treated with a flame-retardant approved 5
U chemical and that the application of said chemical was done in conformance with California 5
Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
jSerial k 8150701 (1) 5
nj
5
;_j Description of item certified: S
CENTURY LOOP END 50WX20 WHITE
5 SNYDER BLOCKOUT SINGLE POLE S
5 Flame Retardant Process Used Will Not Be Removed By 5
5 ` Washing And Is Effective For The Life Of The Fabric
� / 5
5 SN4:DrR Mo Gn1€WPNI6nD€6PH1n,Ow Signed:
S Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
O cPrPcPcPcPrJ�cPrJ�rPrJ�rPrPrPrJ�rPrlrPrl�PrJ�rJ�[PrPrPrPrPrPrJ�rJ�rJ�rJ�rPrPrPrlcPrPrPrPrPcPrPrPrJ�cPcPrPrPrPrJ�cJ�rPrPrP[J�tlrPcl�rJ�rJ�rnrPr�cPrPrPrP[Pr FL3Q PQPrP 1 0
g .ifxflYEccfks w- - +y v iSr+ i .a
ommonwealtlt o S hlf e1 r a�
ro Depat7inent of Indus ttur7Aidenfs: � --
_ J Office Offinvestt ations
.. TI 'i JJ - J
600 !i'ds mgton tree —
I:1�jr Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organiiahoi0ndividuap: - e/ G S07 6 '��W_
V.
3
C t Stat e/Z p:�jJ�i7G�/PJ G!� y/!s� Phone =..._-
-... _
Are you anyemployer? Check the appropriate box: � - - Type of project (reywr ed): .��
1.M-1 am a employer with_ 4. ❑ I am a general contractor avid I 6. ❑ New.construction
employees(full and/or pan-lime).` have hired the sub-contractors
_2_0_I am asole prgprietor_orpattner-_
listed on the attached sheet t 7, ❑ Remodeling
- -
---ship-and have no employees These .b.contractors7tave 8-❑'Demdlitioff -
working for mein any czPecily workers' comp. insurance. 9. ❑ Building addition -
[No workers' comp. insuM;: ❑ We arc a corporation and its
required.) officers have exercised their
10.❑ Ell cu ic. I ;,pairs of additions
I am a homeowner do: .. .71:_ right of exemption per h9GL 1 l.❑ i'i _ S or additions
myself. [No workers' comb.. . c. 152, §1(4) and sbe have no 12.❑ P.nul ire
insurance required.) ' employees. [No workers'
- -- ]3. Othu ��1ny �ryy
i [ comp. insurance 'regtiired] - - - --� ,
:;nplicanl that checks box=1 r. <ccrion below showing their workers'compensation policy information.
,v :mowners who subma thik aff'..' arc doing all work and then hire outside eonvacto6 a must submit u .. m, wing such.
:Contractors that check this box nor.: :e.�:Iduniunal sheet showing the name of the suhcontamors and their workers',trim.policy information.
I anz an employer that is prnridin,, win kcrs'compensation insurance for my employees. Belau is the pahcf and job site "
information. (//�/�� �,�/ > l per_ �/
Insm'ance Company Namc:_ -� 117AI- ��( r A sJ I'� .
Policy #or Self-ins. Lic. y lO �7ozlo� Expiration Date: /D 7
ob Site Address: 5 U��/�� City/State/Zip:
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 ofMGL c. 152 can lead to the imposition of Criminal penalties of 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 5250.00 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.
do hereby certify u er the pains and penalt s of erJu' 11i" the o 'zahon provided above is true and correct.
. � trse.anly Do not yrae to this ea,to-� Je7� �.�� uuiL r. r�r"
i; ate. : � � °,_ :".3 r � 'r--• -•�»-t �'" �. �€�'-..a �
' Tsstiing Authority(c one). "' - -..•
]. Board of Iicalth Building Department _Ctty/fown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6 .Other -
JL i aef.,Persim:
- « 4.