10 WHITE ST - BUILDING INSPECTION (20) fL7M1MT*EfRfi9 M APPROVED BY TW
\ J &MMIB PWR TO A PERMIT BBWG GRANTED
CITY OF SALEM
No. Da. -30� o�
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Instal
Siding, Construct Deck, Shed ool,
RepaidReplace.�l�'�-�ll7oo2a�r �
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSBIG
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accon:6-V.to the folbwNig
spedficaftm:Owners Name fy##xkc e0k^e. lya<llm-
A reat3 & shone -9 87o
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
Whet is mw wPoa a mrmr,sa
mom an haw qlI// oQ 611ga n a dwaanp,for how mriy won?
WE ka ft oontonn to low? AN>1Not? ---
ENbrNd wd oaa aW Liodn e 1 stab WOOD•CS 060 a/9
arme Lie. �so+rnt � z ��
Souture of Applicant
STOW UNDER THE PENALTY'
DESCRIPTION OF WORK TO BE DONE of PEwuRIr
Z7 6;;�EeC>— 3[7rX(,O' - - 20 1 3610
MAIL PERMIT
l/l//v/c�%es�ec M4
No. —&4,/!l'
APPLICATION FOR
PERMW TO
LOCATION
PERMIT GRANTED
APPROVFD
INSPECTOR OF BUILDINGS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
- Boston, MA 02111
www.massgov/dia _
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElePle se Pri t Le bl
Applicant Information
Name (Business/Organization/Individual): -
Address: S' �.a
Phone #: ��'� � Z
City/State/Zip:
Type of project (required):
FF11
mployer'. Check the appropriate box: 6. ❑ New construction
]o er with �O"� 4. I am ageneral contractor and I
mp Y have hired the sub-contractors Remodeling
es (full and/orpart-time). fisted on the attached sheet.
ole proprietor or partner- 8. ❑ Demolition
to tees These sub-contractors have have no emp Y workers' comp. insurance. 9. Building addition
wog for Me in any capacity.
[No workers' comp. insurance 5 ❑'we are a corporation and its 10.❑ Electrical repairs_or additions
officers have exercised their
required.] right of exemption per MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work 4 and we have no 12.❑ Roof repairs _
C. 152, §1(4),
myself [No workers' comp. employees. [No workers' 13.�C ,Other ?'�A �T�
insurance required.] t comp. insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'Wo penaetion policy information:
tic information.
t Homeowners who submit this affidavit indicating they are doing sll work and then hire outside contractors must sulmdt a new affidavit indicating such.
tCmu,actors that check this box must attached so additional sheet showing the name of the subcontractors and their workers'comp.policy
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
D
062 7— Expiration Date: 140 9'
Policy#or Self-Ms.Lic. #: � '
Job Site Address:
jp l /l �/ ST 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 cop civily
of this stapenalties tement may be the form Of aforwarded to the O STOP WORK ffic of d a fine
of up to $250.00 a day against the violator. Be advised that a copy
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains penalties of perjury that the information provided a14 usove e and correctinss
Date- 7
c onature O
Phone L.
official use only..Do not write in this area,to be completed by city or town official
Permit/License#
City or Town:
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. other
Phone#•
Contact Person:
�J
intorrnation anti instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
Am employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who.employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required.to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,.an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
Policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in
(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future perints or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
P
OR
... '(i llmnmwir� o/✓l�/O40/6C/eu4P.�d
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Board of Building Regulations and Standards
Construction Supervisor License
License: CS 60219
BirtOfdate: 412 711 9 5 4
Expiration. 4/270009 Tr# 11766
Res -c om 00
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02190 Commissioner
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5 Certificate of Flange Resistance REGISTRATION ISSUED BY, V�l�na Date of ShipmentAPPLICATION o snzizoosNUMBER G I�NlmslRIE iNc.
5 • �i EVANSVILLE, INDIANA 47725 Tent Identification
5
rlao.l � ° MANUFACTURERS OF THE FINISHED oaoossr
5 5 TENT PRODUCTS DESCRIBED HEREIN 5
This 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 rj
5 111 SWANTON ST 5
5 WINCHESTER MA1890 5
. 5 5
5 5
5 5
5 5
5
5 Certification is hereby made that: 5
r5� 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 # 8109101 (1) 5
Description of item certified: CCS�
5 CENTURY MATE 30WX60 SNYDER r5�
WHITE VINYL 16oz
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric S
5
5 5 SNYDERMFGNEWPHILADELPHIAOH Signed:
SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5
O rJ�rJ�cPrlcPcPrPrJ�rPrJcJcPrJ�cPrJ�rJ��PcPrJ�cP�PcPrJ�rPr1rJrJ��rJ�cPcPrJ�rJ�rJ�rPr�rJ�rJ�rJ�cPc PcPrJ�rJ�rJ�rJ�rJ�r1rJcPrJ�rJ��PcPrJ�rJr�cPrJ�r1rJ@J�C3QrL3rr3Q PL rr3m mJro I7r3 r,3 iO
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IMPORTANT D O C U M E NT'rP'��������� PLfL 5
5 Certificate of flan k vesistapee 5
5 REGISTRATION ISSUED BY 5
Date of Manufacture
5 APPLICATION v �` i F! 9Re 05/24IO2 5
5 NUMBER NDUSTRIE INC 5
5 5
5 r EVANSVILLE, INDIANA 47725 Order Number 5
5 F121.4 �y � MANUFACTURERS OFTHE FINISHED 354594 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5
5 (or are inherently noninflammable) and were supplied to:657150
5
5 PETERSON PARTY CENTER INC 5
139 SWANSON ST 55
WINCHESTER MA01890Mi
5
5 5
5 5
5 Certification is hereby made that: 5
SThe 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, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FIR chemical application is: S
5 Serial # 8001800(2) 5
55 I5
5 Description of item cer9i`gq.20W x 30 VL W W 5
5 5
5Flame Retardant Process Used Will Not Be Removed By 5
5S Washing And Is Effective For The Life Of The Fabric 5
5 JOHNBOYLE STATESVILLENC SI ned: � 5
5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5
O r�rJ�J�rJ�rJflTrl�cPJ�cPrJ�cPJ�cPrJ�cPcPJ�J�rJ�rJ�rJ�rJ�r�PJ��P�PcPcPrJ�cPcPcPrJ�J�rJ�rJ�lrJ�J�rJ� �J�7PclIEli P :1 ii1.�rJ��P�PEl1-1 PUPLIULPEPr ULPE EprrJUIP[illPU EPUPL O
r This acrtihcale is cceculed by Liberty MuWBl lnsurnnce Group Is h"
g_e is affoMed by thos<comryanms.
Crtlftcete of[nsurance i0fM8
Thiscenihcme is;11..listed l<r of infonnalion only and confers no dgh6 upon you the certif ate bolder. This eenifcate is not an insumnee policy and does not amrnd,extend,or ah::r the coverers;:
nffordetl b the oalides listed below.
This is to ceraify that(1111e and address of Insured)
P
C oil'
Party Ocntcr In:: --'
Swantonit ��'Iy�pA.01890-1918 Li Wlirty
e issue dale nfWrs ten'1 n%insured by the Company under the pohcy(ies)Iiaod.brjow. Theinsumnecaft'ordal thelisted li
is not ellerrd by anY uirement,ICliil or conditiono .. comract or olhel document Mlh r_ act to which this certificate ma be issued.ry(ms)is subjeq to all Weir semis,ezdusions and wnditieus ai
rxp-�
rtion Type ER✓Ex Date s Polic,h umber s ntinuous" 10/09/2007/10/09/2008 WC2- Limits oI LiabililIl1-259617-027 Coverage affordeU tinder WClew of Employers Liability
:x[ended the following states: _icy Terrn Bodily injury By Acciden I
--- MA $500,000 Each Accident
- Bodily Injury By Disease
Workers C'Ompensation $500,000 Policy Limit
Bodily Injury By Disease
$500,000 Each Pelrsou
10/03/2007/10/03/2008 TB7-I L1-2 51 617-03 7 General Aggregate-Other than Prod/Completed Operations
General Liability -
$2,000,000
Claims .vlade Products/Completed Operations Aggregate
X Occurrence ] $2 000 000
Bodily Injury and Property Damage Liability per
Re[ro:Date $1 000 000 Occurrence _
=� Personal and Advertising Injury$1000000 OPer Person
r ersoina__
Other Liability Other Liability S-
10/03/2007/10/03/2008 AS2-111-259t 17-017 Each Accident-Single Limit-B.I.and P.D.Combined
Automobile.Liability -
$I,000,000
d �� Each Person
Ti Non-Ovrrled
X Hired Each Accident or Occurrence
Each Accident or Occurrence "-
10/032007/10/03/2008 TH2fi11-251TF 7-0b7 $5,000,000 Produots/Completed --
UMRRF.LLA ISXCFSS $5,000,000 BI&PD
Description of __- $5 000 000 'Aggregate
Operations:Re:Inslucd's operations renting equipment for besimss&social functions,including erecting trnts. --- -
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Office: WESTON,MA-SOUTH Phone: 781-891-8900
Certificate Holder: r- rd11+
Peteruon Party Center ICATHERINE MACDONALD
139 Sla.anton Street Authorized Re resentadvc
Winchester, MA 01890 --"
Date Issued 10/17/2007 Prepared By: KS