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35 HAZEL ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF WBoard of Building Regulations and Standards SALEM Massachusetts State Building Code,�7p80PCN41RfE(�Cp�EpILED IC gevisedMar2011 Building Permit Application To Construct,Repair,lienovate i3r'Demo�I J. One-or Two-Family Dwelling This Section For Official Us y Building Permit Number: Date Applied: 1 Building Official(Print Name) - Signature Date SECTION 1:SITE INFORMATION �J) 1.1 PSoper Address: 1.2 Assessors Map&Parcel Numbers L la Is this an accepted street?yes „ no Map Number Parcel Number ,Y l 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Pnnt) City,State,ZIP 35- 1-14 ?, tri . � Jr 9)e AIC>6626 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repalrs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : % U L y J !� U r;l n ,n 42&rY! 9 7� ys ��6 ✓ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ K 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x mul ' erxx 3.Plumbing $ 2. Other Fees: $ �4�� "C_]ZI'T— <� 4.Mechanical (HVAC) $ List:. s✓ 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ` U t ❑Paid in Full ❑Outstanding Balance Due: YYlf�l t_.� � (Ze��YzTs SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �_�s �2�--L �/¢ '�}. ,7� s License Number Expirati on Date , Name of CSL Holder List CSL Type(see below) No.and Street Type I I Description. yip o 1�D2 U Unrestricted(Buildingsu to 35,000 cu.ft.) j ' R Restricted 1&2 FamilyDwelling CtTy/1'Swn,Stale'ZIP M I Masonry RC I Roofing Covering WS I Window and Siding /l SF Solid Fuel Bunting Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Utz z.1a r� -f , u >4- < /3Gis y7 9/12/ /6 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name _a a C e_o Yt S f No.and Street Email address C. /Town State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AMDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN - OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Thw-4,,4 f Pia-f P�,kns Zt,0, a ,4;90� Print Owner's or Authorized Agent's Name ectronic Signature) Date NOTES: „ 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at wvnv.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"- OTY OF SALEg MASSAQ3usms BIat.DINGDEPARTAeNT 120 WASHINGTON STREET,3ID FLOOR IkL(978)745-9595. FAX(978)740-9846 RIMBERLEYDRISGOLL MAYOR THCMAS ST PIFRRF DIRECTOR OF PURUCPROPERWAUII-DINGODM OSSIOMR Construction Debris Disposal Affidavit (required for all demolition and,renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, 5 54; Building Permit is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, 5150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of fa ility) ignature of applicant Date The Commonwealth of Massachusetts Department oflndustrialAccidemts 1 Congress Street, Suite 100 t� Boston,ALL 02114-2017 www.massgov/dia Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information - Please Print LePibly Name(Business/Organization/Individual):- 7L".,/d rye 1^, 4 N-S Address: Stl t7 tr atc v! 5 / City/State/Zip: Lt A 4. O 1 ClG2 Phone#: 1/— <S-7 - qee I Are you an employer?Check the apprepriate box: Type of project(required): I.�am a employer with 3 employees(full and/orpart-time).* 7. ❑New Construction 2.❑/am a,sole proprietor or partnership and have no employees working forme m g. ❑Remodeling any capacity.[No workers'comp.insurance required.] . 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]1 9. El Demolition 10❑Building addition. 4.❑I am a homeowner and will be hiring contractors to condom all work on my property. I wr7] ensure that all contractors either have workers'compensation insurance or are sole 1 l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the atached sheet. - ❑ 13.p Roofrepairs These subcontractors have employees and have workers'comp.insurances 6.❑We are a corporation and its officers have exercised then right of exemption per MGL c. 14'LI`7tber lop r G�) ' 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing&a*workers'compensation polity mtomiation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rContracrms that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those®tities have employees. Ifthe sub-contractors have employees,they must provide then workers'.comp.policy number.,. . lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: $.f1��Y Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Jr N A Z, &1 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u der the pains and hies ofp Pry that the information provided above is true and correct. Signature: � -,�Z, `✓ Date: Of Z S1 fS Phone#: Official use only. Do not write in this area,to be completed by city or town official. 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#: Information and 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." An 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 permits 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ,! CITY OF SM.EM, AL sSACHUSETI S BUILDING DEP.kRT\tE`:T 3 4 1i�c a'f 120 WASHLNGTON STREET, 3'tt FLOOR TEL (978) 745-9595 FA.X(978) 740-9846 KIMBERLEY DRISCOLL THobtAs ST.P2FxJts 11YLAyOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\WISSION ER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumber5 Applicant Information /r� (Y� D Please Print Legibly VBmC(florines.aUrgvtiratiarolndividual): SEACOA.]1 TFNr Address: .5 CHA-DVWX AYE. Cily/State/Zip: �I$1WN-H nV,.4y; Phone 8:A09j• %2. _g600 Are ylu an employer!Check the appropriate box: 'type of project(required): 1. I am a employer with_-11D S. Q I am a general contractor and 1 6. New construction employees(full and/or part-time).- have hired the sub-eomractots 2. 1 am a sole proprietor or partner- listed on the attached sheet.t T ❑Remodeling ship and have no employees These sub-contractors have 3. ❑ Demolition working fix mein any capacity. workers'comp. insurance. 9. Building addition (No workers'comp. insurance S. ❑ We are a corporation mid its required.) officers have exercised their I0.❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself,[No workers'sump. C. 152,§1(4),and we have no 12.[ I;aof rLpairs insurance required) t employees.[No workers' I L. OtherT' sump.insurance mquircd.l •Any applicml rut check,box JI must also fill nw the section bolow showing their workeni compensatim policy inl'uroo.nun. ' lumcowtwvs whu:uhmil this aff-111ivil iodioling they my doing ell wore and the,him ounufe eontme ,m,ul submit a new afndovil indicaing such. $\nnrwtun thus chwk this box most atlachui an uddiiiueul nhcc,showing lbc nwoc of the subsntraeloo and their.moors'comp.policy inrormmion. I unr att eurplaper that is pruvidinK rvorkrrs'euwpensadua(n.mruace jot my emp(uyers. !fe/utv/s the galley and Jub rile injnnuurintt. /�r� , tnsumncc Company Name: V$ V-yp. (,/E Policy 4 or Self-its. Lice.M:,_VqC�D�S1 bzz(o Expiration Date: Jub Site Address: I I1J DFAIRV `ST cYrYx2F2Nd 'v a�T City/State/Zip: ,5�� Attach a copy of the workers'compensation policy declaratlen page(showing the pollcy number and expiration date). Failure to secure coverage as required under Section 25A of kIGL c. 152 can load to the imposition ofcriminal penalties of a line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the loom ufa STOP WORK ORDER and a fine ar Lill to 52i(i a day against the violator. pe advised that a copy of this ctalement may be forwarded to the Office of Invrsliguiions ofthc DIA for insurance coverage verificalion. I du hereby certify ur'Jyr r/ poi s yu peoul rs of perjury that the h+furruudou provided a/boovee;.v true and c'orrecL Phone:i 663.382-36M 7 --- OJJiciul use only. Do nor write to rhfv area,to be completed by city or taiva offir/a2 Ciryor'1'awm: _.,__ .__ PcrmitflAcense# Issuing Authority(circle one): 1. Board of Ileulth 2.6uildlm;Department .1.City(fnwn Clerk 4. F'Icetrical Inspects r 5. Plumbing luspeetur 6.Other Contact Person: I ma y„ CITY OF SiUE1,[) L%L-kSSACHUSETTS 3LtLDL\G DEPAR-MENT 130 WASHLYGTON STREET, 3' FtOOR TaL (973) 745-9595 F 45 ICI\BERLcY D2ISCOLL .Aa(973) 7-i0-93 NULY01 T2-10bLAS ST.PI88Aa DmECTOR OF PUSUC PROPERTY/aR mmr,CONwISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) (n accordance with the sixth edition ofthe State Building Code, 730 C(44R section l l 1.5 Debris, mid the provisions of NfGL c 40,S 54; Building Permit # is issued with the condition that the debris resulting rrom this work shall be disposed of in a properly licensed waste disposal facility as defined by(NIGL c l 11, S 150A. The debris will be transported by: y i &=ASt T \tF Panm c (nantc of hauler) The (Icbris will be disposed of in (name of f'�elity) 03 S 65- (address or riicilitY) i rure -p,, m a leant etc SEACO-1 OP ID: LW AfORO' CERTIFICATE OF LIABILITY INSURANCE DATE 14 0812a12 Yol5 6/2s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Joe Potthast NAME: Foundation Insurance Group Inc PHONE .703-5278780 FAX No:T03-5328300 PO Box 6326 ac o Falls Church,VA 22040 EMAIL Joe Potthast "DRESS: INSURERS AFFORDING COVERAGE NAN:M INSURERA:Axis Insurance Company 37273 INSURED Seacoast Tent Rentals,Inc. INSURER 8:AmTrust North America Attn:Jim Whitney INSURERC: 5 Chadwick Avenue Plaistow, NH 03865 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS" TYPEOFINSURANCE ADOL UBR POLICY NUMBER MM/LDI pY EFF MMNU/YFY�IYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 '.. DAMAGE TO RENTED CLAIMS-MADE OCCUR X 1SENH001-00815A1 05/o1/2o15 owili/2016 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,00 X POLICY JPERC LOG PRODUCTS-COMP/OP AGG S 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Es accident) ANY AUTO BODILY INJURY(Pet pmson) $ Ij ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ H TOSAlIf05 NON-OWNED PROPERTY DAMAGE $ Pm accident UMBRELLA LIM OCCUR EACH OCCURRENCE S EXCESS LAB CLAIMSMADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION X S7AME EH AND EMPLOYERS'LIABILITY R B ANY PROPRIETORIPARTNERIEXECUTIVE YIN C0826226 05/01/2016 05/01/2016 E.L.EACH ACCIDENT $ 1,000,00 OFPICERIMEMBER EXCLUDED9 ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,ODO,OO N yes desaibeunder 1,000,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S A Equipment Floater ISENHODI-00815.01 05/01/2015 06/01/2016 Blkt Egmt Blanke DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD i1n,Addillonal Bananas Schedule,may be attached If more apace Is required) Equipment Rental City of Salem Inspectional Services are listed as Additional Insured in regards to General Liability per written contract. CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salem Inspectional Services 120 Washington St, 3rd Floor AUTHORIZED,, ,REPRESENTATNE Salem, MA 01970 liJl7NAn— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 29(2014/01) The ACORD name and logo are registered marks of ACORD IMPORTANT DOCUMENT Certificate of Flame Rpistance ISSUED BY Date Shipment 05/21/1/13 Registration Number `nNICHOR9 USTRIES INC. Sales Order# FA444.02 15153763 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: SEACOAST TENT RENTAL 5 CHADWICK AVE PLAISTOW, NH 03865 G�STER z 99�Ff� MP OQ' Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial# 8048381C (2) Description of item certified: NAVITRAC MID 50WX10#702 FERRARI WHITE VINYL#1030510A Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric / FERRARI LA TOUR-DU-PON-FRANCE Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC ../IMPORTANT DOCUMENT ` Certificate-Cate of l'!�(I�me " Sistance Date of Shipment ISSUED BY 05/21/13 VIRLISTRIES CHORRegistration Number INC. Sales Order# FA444.02 15153763 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: SEACOAST TENT RENTAL 5 CHADWICK AVE PLAISTOW, NH 03865 G�5TR CAC/,c0� o t 4 RErQ' Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial# 8048380C(2) Description of item certified: NAVITRAC HIP END 50WX25#702 FERRARI WHITE VINYL#1030510A Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric FERRARI LA TOUR-DU-PON-FRANCE Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC 19 `PI'`f'`P`P`1'`1'`P`P`I'`I'`P`P`P`r'`I'r11 M P O RTA NT D O C U M E N T212001 MI11ME o 5 Certificate of Ilan-e Resistance 5 5 REGISTRATION ISSUED CM VR Date of Shipment 5 0 70/3/2008 5 NUMBER INDUSTRIES INC.® 5 Tent Identification S EVAACTUR R IN F THE WISH 5 F-tzt to MANUFACTURERS OF THE FINISHED oanuas 5 5 TENT PRODUCTS DESCRIBED HEREIN 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: 5 5 5 716965 5 SEACOAST TENT RENTAL 5 5 5 CHADWICK AVE 5 Ili 5 PLAISTOW NH 3865 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 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 — SSerial# < 5 8021000(l) 5 5 Description of Item certified: 5 C 5 5 FIESTA EXPANDABLE TOP 16WX16 5 WHITE VINYL 5 Flame Retardant Process Used Will Not Be Removed By 5 Washing And Is Effective For The Life Of The Fab,/rric/p��//n/� /�// 5 JOHN BOYLE STATESVILLE NC Signed: � ( J'1'6/Y� l SL( '6 5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 ���CONO/T City of Salem, Massachusetts R Fire Department 9gGa'F'. 48 Lafayette Street David'W. Cody Salim,'Tlassa,::usetts 01 9 7 0-3 63 're Prevertlar. Chief 7cl 978-744-1235 . Bureau 975-744-6990 'fax 975-745-4646 378-745-77 77 dcody&aL m.com . fr};kk*IFiF*'kx:Ft*n*i},Fi!}Ft.�f�:i['IF*�k]F'X]F1::F*]ifli:i('titkzlF J23(�:'h]t�tt*]Ft{JF'Xk�<*%nz1(}**]Yx*z k:YXt Ti(:f if.S iC]i tic*xilX i! APPLICATION/PERMIT TO ERECT TENTAGE OVER 120 SQUARE FEET IN THE. CITY OF SALEM ACCORDING TO THE MASSACHUSETTS FIRE PREVENTION REGULATION 527-CMR 19.00, AND THE SALEM FIRE CODE, ART. # 20 FEE $30.00 CHECK r APPLICANT:: MDASI ADDRESS: S C( .�/v1G1G �1Vfi CITY: STATE: q5f H ZIP: n') 4�„ PRONE: LOCATION OF TENTAGE:11S D�I{��y,�;J���.r� _ -�`�/�-(���- D OW;v EF. OF PROPERTY 1 IV1/1SF �F il�y�N Cg ft C ADDRESS: IL5I�n� �Sf C -�-a�! to CITY: 1.D�71.6 .,Stlt STATE: M/i ZIP: -10 PHONE:91a•l 1�(•Qqq INSTALLER/RENTAL CO. OF TENTAGE: f ftET eM &((ft PHONE:Off; 3823 b6D ADDRESS:5_CMAD I�i(At ft CITY: 91,Aji1w . STATE: NL44 _-..ZIP: XI) INDICATE WITH REFERENCE TO PROPERTY LINES AND OTHER BUILDINGS THE LOCATION OF THE TENTAGE ON THE BACK OF THIS FORM: MATERIAL USED: _WTI1C VINIL _ MANUFACTURER: FEYL�,,IkN Rn(F - JJ SIZE OF TENTAGE: OX6 f NAME OF TESTING AGENCY: 1/+1U�L 04-71114g F- 1 AGENCY H.PPR^u i�AL NUb[B ER:fA4110CEP,TI FICATE OF FLAME RESIST_ANCE: J CONDITIONS OF APPROVAL OTHER THAN AS PER FIRE PREVENTION REGULATION: ! i SALEM BUILDING DEPARTMENT PERMIT NUMBER: !! i DATE OF ISSUE: SITE INSPECTION DATE:_ EXPIRATION DATE: !I APPROVED BR: TITLE: ! FORM BQB (Rev. 8/99) .SOB