54 TURNER ST - BUILDING INSPECTION (7) n..
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JdSA�EC1�F1 J IIQR D AMG GRANTED Ii
CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whiahaver apply) Roof, Reroof, Install Slding, Construct Deck, Shad, Pool
Repair/Replace, Other.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROl
TO THE INSPECTOR OF BUILDINGS.
The undersigned hereby applles for a pomk to build according to the folW**q
specifications:
Owner's Name -V,5u d f gzosj
Address A Phone S'4/ sT,, s.Qzf-.4$1 (?7,?) 7W— yf9z.
Architect's Name
Address & Phone ( t
Mechanics Name 66A17F�
AN-r^wa7'0� 47
Address & Phone 104 (7?! 1 7a9- o
;A 5
What b In pupoaa et buN4n0? gig ,,Z", 77a r�
mdwdm
d M~ F a dwalYlp,for how manly bmmm?
VM bulft=Won b law?
t dh"coat. � '�._My Lkow m N A atri/Ja.LEa/arm p &S' d Zo Z/I
Saar Iapro�aae
c;2-� Lie.
Signature of Applicant
I C1 vo SIGNED UNDER THE 10111111
DESCRIPTION OF WORK TO BE DONE OF PERJURY
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MAIL PERMIT TO; d/E- 81 &,o4 —
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APPLICATION FOR
PERMIT TO
LOCATION
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PERMIT GRANTED °
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APP OVO ,
INSPECTOR OF BUILDINGS
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 060219
Birthdate: 04/27/1954
Expires: 04/27/2005 Tr. no: 9542
Restricted: 00
MARK TRAINA
33 HANFORD RD
STON EHAM, MA 02180
Administrator
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The Commonwealth of Massachusetts
- - l Department of Industrial Accidents
0lOce011MV19al/oas
600 Washington Street
Boston, Mass. 01111
Workers' Compensation Insurance Affidavit
ten 1C� prma ---t_ east eC1 _
name
lontion
city nhone N
0 I am a homeowner performing all work myself.
0 1 am a sole proprietor and have no one working in any capacity
1 am an employer providing workers' compensation for my employees working on this job.
tompauynaptc•
address: /3/f .1'/ytlNyan/ .fT
ciry: /L i I' 4 IvidO phone N: 780 7,24-
insurance eo. �• �' � ' vplicyM 70/U i�/G O /ZuL L_
(] 1 am a sole proprietor, general contractor,or homeowner(circie one) and have hired the contractors Iisteo below who have
the following workers' compensation polices:
company name:
sddresr
city: 2hone N-
insslrsnce co. policy N
company name:
Address,
city' phone N
1
insurance ca. y0licrN
ailo
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to SIS00.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fint of S100.00 a day against mc. t underhand that a
copy of this statement may be forwarded to the Ocrice of investigations of the DIA for coverage veriftotion.
,s
/do hereby certify under she pains and penalties of perjury that the information provided above is true and correct
Signature (ZZ4il.G Date 'ram/' %rr7
Print nam /-e M 2)),,m-f a/�j— Phone 0 %� — iXII b L->
official use only do not wnte in this arcs to be completed by city or town official
city or town: permitiliccm7N_ rl Building Dcpartmcnt
7 Licensing Board
O check if immedisle response rs required OSdcetmen's Office .�
0Hc2lth Dcpartmcnt
contact pcmon: phone N; rlothcr t3
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I M P O R T A N T D O C U M EL N T '1uPLn��tPLPuPLtsuas�:r��c'JL
� 5
Certifi�ta�te of if lame Re.i5tanre� .�
5
� ISSUED BY 5
% +' 5 REGISTERED uu,. Date of Manufacture
APPLICATION CIH®fI;® 5
r , NUMBER ri irvousTRIES wc. 5.
EVANSVILLE, INDIANA 47711 Order Number 5 �-
wwa r.
5 F12L4 MANUFACTURERS OF THE FINISHED r
TENT PRODUCTS DESCRIBED HEREIN' 5
This is to certify that the materials described have been flame-retardant treated 5
F" 5 (or are inherently noninflammable) and were supplied to:657150
5
: c5 5
{� PETERSON PARTY CENTER INC C5�
5 139 SWANSON S 5
ilt' S
WINCHESTER MA 01890 5
5 Certification is hereby made that: 5
'® _5 The articles described on this Certificate have been treated with a flame-retardant ;approved 5 '
�x 5 chemical and that the application of said chemical was done in conformance with California Fire 5
Marshal Code, equal to exceeds NFPA 701, CPA[ 84, ULC 109.
li 5 The method of the FIR chemical application is: 5
SSerial #: 5
F" S 8109100 fu
r 5S Description of item certified:
was 5 CENT MATE 30W X 60 VL W W
5 _ Flame Retardant Process Used Will Not Be Removed By 5
K� Y: 5 Washing And Is Effective For The Life Of The Fabric 5
I tIV •y - L tOFIN BOYLE STATESVILLE NC Signed: _2�
Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5
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