10 WHITE ST - BUILDING INSPECTION (13) 5 REGISTRATION ISSUED BY Q
Date of Shipment 5 APPLICATION v = C�QR. 5/12/2005 C
5 NUMBER z Nousraie3�wC
5 � i EVANSVILLE, INDIANA 47725 Tent Identification 5
5 P140.1 °r MANUFACTURERS OF THE FINISHED 0404857' C TENT PRODUCTS DESCRIBED HEREIN CO
This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5�I657150
PETERSON PARTY CENTER INC S
5 139 SWANTON ST 5
SWINCHESTER MA1890 S
5 5
T 5
5 50
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 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
Serial # 8020500C(2) 5
SDescription of item certified: 5
FIESTA TOP 20m,X30 WHITE SNY VL 5
5 Flame Retardant Process Used Will Not Be Removed By 5
(5+ Washing And Is Effective For The Life Of The Fabric 5
s . SNYDER MFG NEW PHILADELPHL40H Signed: (n
75 U "'SPECIAL EVENTS DIVISION•ANCHOR INCUSTRIES INC. 5
O rlcPtPcPrJ�cPr1'cP�1'cPt.Pr�rJ�cPcfrJ�cPrJ�cfrJ@PcP�Pr.PcPrJ�tPtPCPtPrJ�cPrJ�CPtPrJcPcP�PcPtPtPcPrJ�rJ�tPtPrJ�rJ�tPcJ�rlotPrJ�cPrJ�rJ�r�rJ�CPrlCPcPcPrJ�r1CPrncPcPcPrJ� O
u � I
ISSUED BY Date of Shipment rn 5 REGISTRATION � 5
5 APPLICATION TT��1�`��R 06/08/04 5
5 NUMBER r NousrR�E iN�
EVANSVILLE, INDIANA 47725 Tent Identification 5
M ° MANUFACTURERS OF THE FINISHED 03850284 5
55 F140.1 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
S (or are inherently noninflammable) and were supplied to:67150
5
5 PETERSON PARTY CENTER INC 5
139 SWANSON ST 5
5 WINCHESTER MA01890 5
5 5
5 5
5 5 Certification is hereby made that: 5
The articles described on this Certificate have been treated with a flame-retardant approved 5
Schemical 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, CPA[ 84, ULC 109. 5
Serial # 8109101 (1)
5 Description of item certified: 5
CENTURY MATE 30WX60 SNYDER 5
5 WHITE VINYL 16oz 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 � S
5 SNYDER MFG NEW PHILADELPIIIA,OH Signed:
rj `-SPECIAL EVENTS DIVISION•ANCHOR INDUSTRIES INC. 5
O rJ�cPJ�c fc PrJ�rPrJ�rJ�rJ�r�r�tPr�c l�rJ�cPrJ�rJ�r�rJ�r�rJ��P�P�PrJ�rJ�cPcPcPrJ�r PrPrPJ@PJ��Prl�J�cPJ��PcPcPrJ�PrJ�cPrJ�rPrJ�lrJ�rJ��PrJ�cP�PJ�rPrJ�cPr�rPPcPcPcPrJ�J� 10
1
MThe Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
600 Washington Street
Boston, MA 02111
wwmitiass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Dame (Business/Organiz tiorJlndivid!�I): P S
Address:
City/State/Zip: /!?cues Phone #:
Are you an employer? Check the appropriate box: Type of project(required)-
1. I am a employer with l�—U 4. ❑ I am a general contractor and I
6_ ❑New construction
employees (full and/or part-time)' have hired the sub-contractors -
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity_ employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp. insurance
required.] 5. ❑ We are a corporation and its 10_❑Electrical repairs or additions
officers have exercised their I L Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑ g Pa
myself. [No workers'comp. right of exemption per MGL 121]Roof repairs
insurance required.]t c. 152,§1(4),and we have no �—
employees- [No workers'
comp.insurance required.]
'Any applicant that cliechs box#I must also fill oar the section below showing their worlcai compensation policy information_
t Homeowners who submit this affidavit indicating they are doing all wodt and then hire outside contractors must submit a new affidavit indicatingsuch.
'Contractors that check this box most attached an additional sheet showing the name of the and state whethcr or nor those entities have
employees. If the sub-contactors have anployees.they must provide(heir workers'comp_policy number.
I am an employer that is providing work--ers'tompensation insurance for my employees Below is thepolicy and jab site
information.
Insurance Company Name
Policy#or Self-ins.Lic_M e 9/0 a(p Expiration Date:�U— 7 rO7
C
Job Site Address: j /. / //1 CitylState/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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Inyestipatlons of the DIA for insurance coverage verification.
I do hereby certify under the pains and alties ofperjury that tie information provided above s Ime and correct —
r
Date: ?
Si!�muur e
Phone �:
(�,jr.iai use<. .j. Lo t..t, i nr r. . be e-.r;+t,
Cily or"fotvn: Permit/License $
— 1
Issuing :Authority (circle one):
I. Iloard of Health 2. Building Department 3.City/Ton"n Clerk 4 h;leetrieal luspeclor S. 1'lunthini,hisil"lor �f
b. Other �!
Contact Person: PhoneS__ ��
10ie:i/2006 15: 39 7813584022 PETERSON -ACCOUNTING PAGE 02
hIghtfax 10/3/7006 3 : 26 PM PAGE 2/003 Fax Sorvor
Cliemft:40743 PETERPARI
ACORD- CERTIFICATE OF LIABILITY INSURANCE M8310s°f"
rRwua_R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
U SI In R.Services of MA,Inc, ONLY AND CONFER8 NO RIGHTS UPON THE CERTIFICATE
12 Gill Street Suite 5500 HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
ALTER THE COVERAGE AFFORDEDDYTHE PCLIGESSELOW.
PO Box 4043
Woburn,MA 01988-4043 INSURERS AFFORDING COVERAGE NAICa
INRUREO NRIRERAI St PAul Fire and Marine lnsurenco C 247(F7
Peteraon Party Center,Inc. INBIRERe. North River Insurance Co. 99999
139 9,vanton Street INs,lsnc Commerce&Industry Inaularlce Compan 19410
Winchester,MA 0 1 8 90-1 91 8 FINERO
WSUREa7.
COVERAGES
THE PD 10rS OF NM W CE I.ISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATE.n.NOTWIWSTANONO
MIY REQUIREMENT,TEMA OR CONDITION OF ANY CONTRACTOR OTIER DOCUMEAIT WITH RIEWF,CT TO WHICH`D"S CFRTIFIC Tw MAY BE 1S9UED OR
MAY PERTAIN,Ttle INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI.TiE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POIJOES AL --OATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
LTR _ TYRO WIN MPANM RmICRN11riEw MO UNPIN
A aENERALUAMLrn CK00217138 10103106 10f03mT A000000
X lN]Mr.¢RT:W.LT'inL LiP81LITY BS0000
U...NNJE OL'CIIR IlED EYP M one omnn 55 060
PHCeONnLAAVVINJU" $1000000
@NERAL AG,¢ELATE $2000900
OEN1 nOGr1Ea11E LIMB AT'19.IE^•PEA: PTi000C19-CAIdWOP AGG e2000000
FOLK PRO'
rcT LOC
A AVTWGBs UABAITY MA00200291 10103108 101ON07
MoaewD RwmeuArT 71,DOQ000
b1V CllTO '
a.L OANEO AIITOR e(xBLY IN.LIRY
X A .DJLEO AU105 Pi^n�PRq 5
X HIIYn Nnc�, BODILY W.URY
X NO+.wNEn nlnTas P'+P'""`7 B
PHePIRNrr onMAc� _
pR AweeN)
GVNCeuMLITY Aurooml.y_ PCFmBn S
ANY NOO OMEaI EAACC S
AUTOONLY: A00 1
8 ExcEaauxmaELU L"'uTY SS30892346 10103106 1010-V07 E OCaRREN( 15,000.000
X arxalR �nAMa MAOC AnnsaATE $5000000
S
MDUCTME S
X REr"1104 $10 000 s
C NORNrnscompmmnoNm9 BINDERWC91W289 10189108 - 10169f07 X `"cBT^TL` 11
ENVLOYF,RR•LIMWW E.L.EAOtALx]OEM TS6600D
ANY PR WRIFTLPRARTI50.rcREWYT
LFFlOERMEN.BER E%QIIOEPT - EJ..pBFABE-EI1 FJdPL -. 1500000
Ir r �ris MrNxi fiL.pSEM1SE-POUOYLmrr S900000
OTHER
[N:tY]IPTCW OP OI'ERATIPIYILIXJ1Tg181VENICI,CCIQa.ViYONB AOOEO eY E110d1a:NeNT19+EOAL PPOIIBlp16
RE: In Rured'9 OperA6Ons renting equipment for husiness 8 social functions{-including
erecting tents.
CERTIFICATE HOLDER CANCELLATION
BNouLa nrrroFTlrenBNwE nEAaaeEa IMLPLTFb Bc CANOELLFb BEFORE THE E%PBUTKKi
WLTETNEREDi'.Tlle CteUINBIN811R9ipLLENOEAWRro NAIL JJI_ egTS FWI'RN
Nmx:C TOIHr O[RNFlUTE NOLAGINAN[D TO TNC LEFT,euT FAILURE i000 ad VMALL '
- WORE NO OILNNLTION O1 UARLnYQANY XINR WCH Vt INSURPR,ITS AMNT M
RLPR£BENTATrS.
ALIMCRIZ&'.P t.c6NTAiTrE
AC0RD2S(x OIt0B)1 oft 4S1394941M138493 AGDCD 0 ACORD CORPORATION 1988
✓ice �����« � o�,z
Board of Building Regulations and Standards
Construction Supervisor License
License: CS
60219
i Birthdate: 4/27/1954
Expiration: 4/27/2009 Tr# 11766
Restriction: 00
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
_ Commissioner
/// J V O
Fj -�0"- L�
p\�J��
PUBLICLROPETYDEPTMENT
KMMF.RLEY DRI5COLL
MAYOR 120 WASHwamN S rRE r SALFK MAsSAcxt;st1-IS 01970
TE :97&7i5-9S9S*FAx:97&7ie-9&16
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: W he- 6ovP �in�8uilding:
Property Address.
Cam✓ /7 Lo ,�
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.4 Owner of La
Name: cvP
Address:
Telephone: 97 f,— 7 YU - 9FQo
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
Brief Description of Proposed Work:
- - -
------ Mail Permit t0: , KS a� <� a / 9 c�a 7 S� me 61610 ----
What is the current use of the Building?
Material of Building? if dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ^
Mechanic's Name r2s Ci r�
Address and Phone 9/ SLc 10'1.
Construction Supervisors L�iiceensse__#,,�r 19 U(e°a"L9 HIC Registration#
Estimated Cost of Project i'�= Permit Fee Calculation
Permit Fee$se�!' 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
ttttoo build to the above stated
specifications. Signed under penalty of perjury
Date
of � -
N
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9
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