10 WHITE ST - BUILDING INSPECTION (10) I:\
Z to 7 9 77 �tZ S
-File Commonwealth of tMassachusetts
Department of Public Safety
\Llewl 11"sellstiL11cBuildinJ;C01le(7,411LMR)
I It'iIJing Permit Application for any Building other than a One-or'llvo-Family Dwelling
(I his tied it For Official Use lhdv)
Ruildiul;I'cnuit Number .._, ___ ___ Date \I+l,lied: _ _ Iluildiug Offii ial: _sa.III'ON 1: LOCATION(Please indicate Mock 9 and I ut p fur local UIS for which.1 street address is not available)
""-1 --Sr. Sc _/f�9..- -.._U/y 20- �✓frlQ?r14 t�4L<_ Q2rntr
No.,Ind Street CdV/Fo,vll Zi 1 Curie
f Name of Building(if applicddu)
SECTION 2: PROPOSFD WORK
Fditiun of MA SI,llr Code used _...._. If New Construe tion clink here❑or,heck all 111•a,lpph in the tico rows below
F\isling ]full,[lig❑ Repair❑ :\Iteration ❑ Addilian❑ Ucundilion ❑ (Please Jill uutand wbmit.\pprnd ix I)
Change of Use ❑ Change at Occupancy ❑ Other Specify:._Le,/1� _O a ehf
Are loulding plans and/or roiulruclion docunacnlS being Supplied as part of IhiS pcntlit application? Yes ❑ No ❑ ,
Is un Independent SlnlduraI Engineering Peer Review required?
Yc�v ❑ No ❑
thief Description oI Proposed Work:,__.—_
SECTION):COMPLETE I'IIIS SLCI'ION IF EXISTING BUILDING UNUHRGOING RENOVATION,,\UUI'1-ION,OR
CFL\NGE IN USE OR OCCUPANCY
Check hero if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR.4) ❑
E\j.0ng L'se GrouP(S): ._—__._ _ Proposed USe Group(s):
SECTION 4;BUILDING IIF.IGIIT AND AREA
Existing Proposed
No.of Floors/Stories(indude basement IC1'CIS)4 Area Per Flour(ski.ft.)
I'ot.d Area(sq. ft.),unF romi Height(ft)
(lL O
SECTION is USE GROUP(Check as applicable)
A; Assembly:l-I ❑ A-_2❑ ,-Nightclub ❑ A•) ❑ A-1❑ A-i ❑
❑ B: Business ❑
G: Educalimnal
I': Facto F-I ❑ F_'❑ I1: Ili IfHalard FI-I ❑ H-2❑ I[-.I ❑ 11-4❑ 14-3❑
I: Institutional I-I ❑ I-?❑ 1-1❑ 1-a❑ �D I: Mercantile❑ It: ItvsidenNal R-I❑ R-'_❑ R-.1❑ R-a ❑
S: storage 5•1 ClS-_❑ U: Utilit ❑ S
pe Y dal Use❑.Ind plcese Jcsrribe hcluw:
Sperial C'sc
SECTION 6:CONS rRUCEION IYPE(('heck as a 1 livable)
I:\ ❑ Ill ❑ II,\ ❑ JIB IIIA ❑ fill) ❑ IV ❑ V;\ ❑ \'B ❑
— SIrl, MIN 7: SITE. LV PUR�L11'ION(refer to 740 C.\IR I I t.0 fur details on v,leh item)
water Supply: Flood lone Information: Selvage Visposalr French I'Lrmit: I A4ris I(enuw al:
Public Cl I-It,-,Is d oulmdc Ilnrd Lour❑ had it.]le nunl it jimI Cl .\ lrem II is III lol be I i'vowd hi,pas:ll<ile❑
I'rll.uo❑ nr indentill /nnr . _ urnn,or,s,lrnl0 naluirod ❑or trench ut yekif%
p.•ranit i,on,Invad ❑
If aiIn LlJ right-ufway; llaiarls tu.\ir,V,wigalion: _
V'nl.AI,I,hra bar Cl Is Inn nor I,(thin .Ilrpol't appme,II,I rr,l.' la their I,x I, ,v,rmplrlr,l
I., Mudd,mlo.,rJ ❑ 1 Ir,❑ ::r Nu❑ 1 ❑ \' ❑
SFC IIO.N v. ( ON I I.NI uILIIt IilA \I1;OF O(C LPAN( Y
I Jllu•II I (:'dr l.,•l;n:uhl,l I l po„I C::n.ou,hro t u up.ml : .I,I per l 1,,,,r —_..__
114,0, Ihr hIIJJIn :•nla In an � vinAlrr ti,.trin� - -
1:
-- SI:(:I[ON+r: PROPER I OW N FR ,\U I I IOI(IZ,YI-ION
�` Illll Illd \d,I,s of 'rol+ 1'IN'Omi�r/ I y/� ale!)l /�/'/////A{ /')
IJR C2Q- ozne_ Lovc/�Rarna �O ��
Nannc(I riot) Ll1 No.clad titrcrl City/ rown 1170
/rep
Iprrty Chv ivr Cunta,I Inft'nnal it'll: '
I itic telephone No, (business) relcphone No. (cell)
Ipl lied+le, lhv ro erh' ,Iwo • tare v aulhuriics n /1 Q
2 Q(x.L ±-- -� l Abe/ (X - C� l�
Name
Stwel Addre li CIt}'/Town State Lip
It' it t on the poll erly own er'+bvh df, ill all matters rclativc to work authorized br this building permit a ,+licatian.
SECTION 10:CONSTRUCTION CONTROL(I'lease fill out Appendix 2)
If building is less than 45,m00 Cu.ft.al enduse,l S ACe end or nut under Construction COLorol then check here O and ski+Bretton lO.l
LO.I Ile+istered Professional Res onsible for Construction Control
Nance(Registrant) -.Telephone No. a-mail address Regislnrtion Number —
tiurct Address City/Town State Zip Discipline Expiration Date
General Contractor
rM C t
opal Vanes
__---
Nance I erson Rvsponsible for Construction // License No. and Type if A plicable
33 ajP,6# — _
St'•ct r\ddress City/Town State Zip
V, , yo v-o — — _ - --- --
Iclr,hone No. business Tcie,hone No. cell c-mail address
SECT ::rlcnItIN".ult+\_ 1 M.G.L.c. 152 25C6
A Workers'Connpensatiun Insurance Affidavit from the JIA Department of Industrial Accidents must be anupletud,and
submitted with this application. Foilure to pruviale this affidavit will result in the denial of theyrsuance of the building permit.
Is,%ei+ned Affidavit submitted with this a lication) Yes�l No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
E.slimated Casts: (Labor
Item and Materials) fatal Construction Cost(from Item h) 'S__--
I. Building S Building Permit Fee.Total Construction Cast It_(Insert here
'. EIcetrical S appropriate nmmicipai factor) S
1. 1'lunnbing 5 -
i \Ivchanical (Inv:\C)
5 ,Vole: \lininnun fee- S_—__(Conlait numieipalily)
1 i. Nlvr hanical Other) 5 L'ncl�se ihcik l+evablu to —
n. focal Cost ih)and write Chvik number here
SECTION 13:SIGNAIURE OF BUILDING PERMIT Al'1'LIG\Nr
I1v rntrrinl; nay name below, I hereby aticst un,lcr the pains and l'• aIlic.of perjure' that of of the till o matwil aall.uncd in this
"I'I'lic.Itiun is Irue and aerur.me In the last of nil kilo„led gv am understanding.
I'Ird;r print aml .Ilm nanny _. Illle I rlrphono \u. P.nc
I
CIty, town �ta4• /Ip
Nlunicipal In.pcdur to fill out thii section upon application,approval: .
..\'.mar I+IIr
- rJ@&Prr-Pr- PLPrJ'2Mcj-L Li-Lr -rJ�rJ�cf S ® R T/� ®®C T?��P�P�n�n�PLr�P�P�n�n�P�PLr��PrP o
5 Certificate of Flamm lResistapee 5
t7 REGISTRATION ISSUED BY Date of Shipment 5
5 APPLICATION o- ���� 07/16/04 5
S INDUSTRIE ING® 5
NUM
BER
ER >NU
5 yT Tent Identification 5
5 r EVANSVILLE, INDIANA 47725 5
F121.4 �M cN'P°r MANUFACTURERS OF THE FINISHED �'89790; 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
SThis is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
657150
5 PETERSON PARTY CENTER INC 5
5 139 SWANSON ST 5
5 WINCHESTER MA01890 5
5 5
5 5
5 5
5
5 5
5 Certification is hereby made that: S
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 was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial # 8023300(t)
121 Description of item certified: 5
5 FIESTA EXPANDABLE MIDDLE 5
20WX10 WHITE VINYL
55 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
CC JOHN BOYLE STATESVILLE NC i
Signed:
5 "SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5
rJ�r�rJ�rJ�cPrJ�rJ�rlrlrJ�rJ�rJ�LPLPLQcPrJL3PL J�cP�PcPrlrJ�rJ��PrJ��PrJ@P�r11 i I !PLjL rlrJrPrJ�rJ�r�rPr��P�P�PcPrJ�rJ�rP�PrJ�r�rJ��PrPrJ�rJ�rJ@PrJ�rJ�r�rJ�rJ�rJ�cPrJ��PrJ�rJ� O
El LnCnC�LI7E_rLonLr--pr- PCPLLpr--L-rLL r I M P T T p _ �. C�.'C1nErErErC.nLI-ErL(7ErLnLl-C.r�LrCnL� o
5s Certify of :la We 'Resistayee 5
r7 REGISTRATION ISSUED BY Date of Shipment 5
APPLICATION v " snzrzoos 5
5 INDUSTg1E INC.® 5
5 NUMBER 5
PC57 r� uP vP EVANSVILLE, INDIANA 47725 Tent Identification
04048575
MANUFACTURERS OF THE
::]
5 IT;
c ENT PRODUCTS DESCRIBED HIEREIN f
5
5 This is to certify that the materials described have been flame-retardant treated 5 5(or are inherently noninflammable) and were supplied to: tI
S
S 657150
PETERSON PARTY CENTER INC 5
5 139 SWANTON ST 5J
5 WINCHESTER MA 1890
5 5
5 0
5 5
55 Certification is hereby made that: 5
The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the applicatior2 of said chemical was done in conformance with California 5
I Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109.
5
5 Serial # 90243300(0) 5
5 Description of item certified: L5
5 FIESTA EXPANDABLE MIDDLE
20WX10 SNYDER WI II'IT VINYL Cl!
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 5 SNYDERMPCNEWPHILADELPHIA0H Signed:
U SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. rj
O LPCPGICPCPCPCPCI�C.PCPCPLI�LPCPLI�LI�CPCPCPCPCPCPCPCPCPCPCPEPCPfJ@PCPCPIJ�CPCPCPCPEPCPLPCPLPLI�CPCPCPCPEPCPCJ�CPCPCPCPCPLPCPCPCPCPLI@PCPCPCPCPE.I�C�CPGPCP Q
o rrsE n�nEn����E f�E-Pdn�E rs�lEr�tEn��r�u�u I M P O R T A N T D O C U M E N T !n�n�n�E rs� n�r�n������s��rs��r��nE�� o
5 C,
5 %Ctrttfifote of ifta r Rr5f9taurr 3L
5 REGISTERED ISSUED BY
APPLICATION IESIR®
Q. uliF p yam� Date of Manufacture C
5 s c 5
NUMBER T
s N�USRIES INC. 09/29/00
5 rq�i EVANSVILLE, INDIANA 47711 Order Number
5 F121.4 f M�Ppr 312748 5
5 E MANUFACTURERS OF THE FINISHED 5 M TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
55 (or are inherently noninflammable) and were supplied to: e5
657150
5 PETERSON PARTY CENTER INC
5 139 SWANSON ST 1�
5 WINCHESTER MA 01890 51
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 was done in conformance with California Fire 5
5 Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
rr5 The method of the FR chemical application is: r5
5 Serial #: 5
1 8023300(4)
5 Description of item certified: 5
FIEXPMID20WXIOVLWW
5 5 _ Flame Retardant Process Used Will Not Be Removed By. 5
Washing And Is Effective For The Life Of The Fabric 5
JOHN BOYLE STATESVILLE NC Signed: _'� �,,_,.,,.-e—Q 5
Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. CL'J
81�s�n�n�n�r�n�rPssE r�nEr�nE rEnEr�E ICE r�n�nEr�������n��s�s��s��r��EnErsEnE r�ErsE rE r�n��n��n�n�r�s�r���Mp���n�n��n�n�s�r�E n�nE nEr��n o
o F3 s�rn���l��, rr��,�,�rnJ IMPORTANT DOCUMENT�,��r��,�I��r�r,����,
5 Gert�aficate. of Plate Resis"ce 5
5 REGISTRATION ISSUED BY 5
5 APPLICATION Q ?/�y(yy�'+ /� Date of Shipment 5
5 NUMBER 1911�� WDQu'sE3r�� sizaizoos 5
5 ,�OyCL7a�a ' EVANSVILLE, INDIANA 47725 Tent Identification 5
r5j dO I MANUFACTURERS OF THE FINISHED 0433769E 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated
(or are inherently noninflammable) and were supplied to:657150 5
5 5 PETERSON PARTY CENTER INC 5
139 SWANTON ST 5
5 � 5
5 WINCHESTER MA 1890 5
5 S
5 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 T
5
5
5
chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109.
Serial #
5 5
5 8024000(I) 5
5 5 Description of item certified:
5 FIESTA EXPANADABI_E TOP 20WX20 5
55 SNYDER WHITE VINYL 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 Signed: ZZ : ' l IG 5.. ?H�NF6 NCW I'111LhBELI't lhh,6N1 � 5
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC.
1®f Massachusetts Depa^men! 0; Public Safety
Board of Building Regulations and Standards
- Cnn-truiti. n Sul m"'r .
License' CS-060219
_ r"1
MARKTRAIAA
33 NA-,FORD RDA `: '. ' a
Stoneham NIA (7s140
C ommis s:one,.. 04/27/2015
�xa t,rmoneG?uuKr�u�,�✓�� eav/:r.:er7^,
office of Consumer Atf3ir5.4 Busmees RC nlutioa -
ROMEIMPROVEMENTCONTRACTOR
�gRngistrtuon i1Fi9022 Type:
( + Explmsion 91`98J2015 Individual
MARK R TTRIAN IA
MARK 1RAINA
33 HANFORD RD
STONEHAM,MA 02120 Uu4cr5ecret.,
License or registration valid for hulMdul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
I I)Park Plaza-Suite5170
Boston,NIA 02116
`o[�'nlid without signaw rc
- -- — — -- GITY OF SAL EM-
- P L ELIG PRO PRERTY
DEPARTMENT
KimtILRt.EY DRISCOLL
MAYOR 120 WASHiNGTONS'I REEr ♦ SALEM,MASSACHCSEI-FS01970
TEL:978-745-9595 ♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 0 n Please Print Le ibl
Name(Business/Organ zat on 1 dividual): PC 0s 1 r Q54,/ l en rt
- - _ -Rd —
—
Address:
City/State/Zip :(.t 0 J ZVl J. 1 r V, 01901 Phone #: 791( 7d9- Vo o-_0
Are you an employer? Check the appropriate box: Type of project(required):
- 1. L®,-hama-em to er-with_ _ 4. ❑ I am contractor and I
P y C =- m a general -----6.❑-New-construction --
-- - -• - have hired the sub-contractors
employees(full—and/or - - --- ----- - -- -
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their l0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof r�irs
insurance required.] t employees. [No workers' 13.2 Other ^
comp. insurance required.)
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I urn an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information. /�
Insurance Company Name: `lo /
Policy#or Self-ins. Lic.#: 6 io Expiration Date: Q g �Y
Job Site Address: k t Sf 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 of MGL 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 S250.00 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.
I do hereby certify under
the pains and penalties ofperjury that the information provided abov is true and correct.
Signatturue///./.fir-d�. '.Z "Date' 7�0�9�`�
—Phone'# ^7' 1 -7�j—yU y b rx 1 _ _iI
Official use only. Do not write in this area, to be completed by c 1y or town o e1aL i i s
City or Town: Permit/License#
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#:
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