INTERSECTION OF ESSEX AND WASHINGTON - BUILDING INSPECTION "t
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�, PLANS MUST BE FILED AND APPROVED BY THE
1NSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of BuildinQ .-1����5 PG�'`e., 0 r �SSPSI
Buiiding PermitApp��catioo For:
'(Cucle whichever applies) Roof, Reroof, Install Siding, Construct Deck, SheQ Pool ��� �Q��5�'°�
Additio� Alteration, Repair�P laa,Foundation Only, Wrecking ,
O�her. I e� ,ST�.�� �
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AV.Om DELAYS IN PROCESSING
To ihe Inspeaor of Bui�dings: � . ' .
The undersigned hereby applies tor a permit to build according to the following�cations: '
Ownerd Nawe: G tf`'/ e� Sl�te►srl Contnetor: �YSj•� S�-t=b/� ��'�/.�/� ��
s�� c�«� sv«� l�os' ,�'ilsT c�ri DrDt,��
State Phone ( ) State�� Phone(78t) 3Z9' 9 00 �
A+'chiact: City of Sakm LidL
Street Citp State Lic#��sa�N
State Phone ( ). Homeowoero E:empt Form�es no
Strueture: (please circle) Single Famil}•, Multi Family�1 O�her .S�qc,
—���
Ertimated Cost of joD S_ Z a� o o a
WiU buildiog rnofirm to law?.�.yesT_no .
A�bestoa?_�u_.00 •
Dacriptioa of work W be dooe:
Drawiugs Submitted•�� no Mail Permit to:g �5�� .�C� 1U`�
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�gnaturc of Applicalion,SI�NED UNDER THE PENALTY OR PB[d.dUR�i'
CONSTRUCTION TO B�COMPLETED W1THIN SIX{�MONT�S OF PERMIT ISSUED DATE
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Department use only: Pertn3�=N � , Zoning Map/L,oc
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Permit fee S
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From:Carol J.Costa At:Fitts Insurence Agency,Inc FazID:Fitls Inwrence Agen To:Renee Date:6!7/2005 02:53 PM Page�2 of 3
ACORD,� CERTIFICATE OF LIABILITY INSURANCE o6,o„Z 5
PRODUCER (508)620-6200 FAX (508)620-0227 THISCERTIFICATEISISSUEDASAMATTEROFINFORMATION
Fitts Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
40 Union Avenue ALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW.
P.O. Box 565
� Framingham, MA 01704-0565 INSURERSAFFORDING COVERAGE
msuaEo Mystic Scenic Studios, Inc. iNsuaean� Utica Mutual Insurance
1105 East Street iNsuaeae�. Graphic Arts Mutual Insurance
Dedham, MA 02026 iNsuaeec Hartford Insurance Group
INSURER D:
INSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO iHE INSURE�NAME�ABOVE FOR THE POLICY PERIOD INDICATED.NOiWITHSTANDING
ANY RE�UIREMEM,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMEM WITH RESPEC7 TO WHICH THIS CERTIFICATE MAV BE ISSUED OR
MAV PERTAIN,hIE INSURANCE AFPORDED BY iHE POLICIES�ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR rypE 0F INSURANCE POLICY NUMBER POLICY EFFECTrvE POLICV E%PIRATION LIMRS
LTR OATE MM100 DAIE MMNO
I ceNeauuaeam G3662508 Ol/Ol/2005 Oi/Ol/2006 encHoccueaeNce s 1 000 000
X wmmeaau eeNeara uaeiury Fiee owna�e�n�y o�a n�a� a 50,000
CLqIMS M4DE �OCCUR MED EXP(My one person� $ $ QQQ
q PeasowLL a nov w�uav a 1,000,000
� ceNean�nccaEcn� s 2,000,000
GEN'LAGGREGATELIMITAPPLIESPER'. PRODUCTS-COMP/OPAGG $ Z,OOO,OOO
X POLICV jEd LOC
auroroei�e�wsam AC2220442 O1/O1/2005 O1/O1/2006
COMBINEDSINGLELIMIT $
�Y�.o �Eaacci0enq 1 000 �0�
ALL OWNED AUTOS BODILY INJURV
X SCHEDULEDAUTOS (PerOeison) $ �
A X HIREDAUTOS
BODILY IN,AIRY $
X NONOWNEDAIII'OS �Pereccidenp
PROPFRTVDAM4GE �
IPeremaenp INCLUDED
GARAGELIABILIiV AUi00NLY-EAACCIDEM $
ANYAUiO OTHERT144N EAACC $
AUiOONLY'. q�G S
Excess�usam ULP2094581 O1/O1/2005 O1/O1/2006 Fa.cnoccueaeNce s 10,000,000
X OCCUR u CLNIMS MADE AGGREGAiE $ lO�OOO�OOO
B s
oenucne�e a
�tTENrioN a
WORKERSCOMPENSATIONAND BNBNJ6275 OL�ZS�ZOOS OL�ZS�ZOOB X TORYLIMITS FR
EMPLOYERS'LU1BILtiV ELEACHACQDEM $ SOO OOO
C EL.DISEASE-EAEMPLOYEE $ SOO�OOO
� E L DISEASE-POLICY IIMIT $ SOO OOO
OTMER
OESCRIPTON OF OPERATIONShOCATONSNEHILLES/E%CLUSIONS r1DDED BY ENOORSEMEM/SPECIFL PROVISIONS
roject: Salem Statue Event �
17 cancellations done in accordance with applicable state statutes.
CERTIFICATE HOLDER AOOrtIONAL INSUREO;INSURER LETfER: CANCELLATION
SHOULO ANY OF THE ABOVE DESCRIBEO POLICIES 8E GANCEL�E�BEFORE THE
E%PIRATION DATE THEREOF,THE ISSUING COMPqNY WILL ENDFAVOR TO MNL
MTV Network Special Events ��DAYSWRITfENNOTICETOTHECERTIFICATEHOLOERNAME�TOTNELEFT,
1515 Broadway Bl1TFAILURETOM0.1L5UCHNOTILESHALLIMPOSENOOBLIGATIONORLIABILRV
22nd Floor OFANYKINDIIPONTHECOMPANY,RSAGENr50RREPRESEHrATNES.
New York, NY 10036 a�oa�oaevaesetrtanvE /,,.,�
Geoffre Fitts/A75 '�"`��" Q` '�`�
ACORD25S(7l97) FAX: (212)258-7869 OACORDCORPORATION196
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electripfN h8ated 1'8di8nC�2neYgy sourGe pO61qOn8d to pravlde a'consdnt irrdaiallQm (QVEI
of 2.5 watt4lsquare � on tha speelmen surfaa. Measurements arp r�c,�rtletl througlt a
photnmeuic systam employing a vertical deam at Iipnt and a pnoto data4tp�poSlCloned ta
deteCC the attenuaUon of Ilght tratlsmltCdnce caused dy smoke eccumulatlon Wltitin tho
thdnlber. Th2 IiphC Cranslrlittancg rri@aSuf6R18t1Cs are Used t0 calcule� SpeC1f1C OqtIG'dl
qe�Sity, a qUd�kitiitlV9 Velue whfeh Cd11 b� fdC�OtCtl CO 69q�'idGR Ch6 5moke DOtettilel O4
� materials, 11ero buming condPtlons can be s(muiated bv st+e test apparatus. fie radiant
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combustlan in the presence aP suppoKing redt�don con9titutes the Wamtn9 MOGe.
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. 'r ::++^"':s��:"::?:.:: .•p_...,.,..... . . . ....._. ,.�..;.. ��::r� ase:_.:.K�rwl,r.
_._ ._�..��::"'����'.::;.t:nJ�,,.`..s,.'t, .
_.nd:� M• c—. oa•„r.
��� �'���;�����=��`"MMIn81aFHb8MCementaoartl �
'�;j;;:;,_.. DIY9Gt GIU!DOWII . .
, •,:,�Ti4�%��S SYbESt7000 .
� �r� `�s..;��;,�v�
;4`.�.I����kg,�:���;? meh te�esemp�e yyas conditkned a minlmum of 96 hours at
^r';;.- ,,. -.�.,y..,� 70 t 5° FonalD 596 h
� re�dve um�
d�v.
� T63T RESULT6
....,..� • �:-:..,�.... .. . .. __...�,;.;. W:�.:
� �: °��;:FAT�Z SA�fA�ARJ�i'r:i- _ '". �,.. -�.
_ C.�'..-_ '�;::���'
���'0.��P��:� S6 cm 54 minuoes � ,�1 watLslsq sm
.-;�'P�uA�O['�: se cm
5�minums ,E3 wat[s/sq em
.-:ry A�nEMi�"'i 52 em 51 minutas .35 waRt/sd em
,.,....: .............._... .
� ��....-... _ . _.__...,. ..::r•.�........-:�._::�::.
� �I6RAGF6RPp. ..FI:LHFz';�.¢• �3S W8LtU9QWf9 Cm
t'EFII ��A6YGf��lf= •:�:"�:~:r;°G:; .02 Wdl�slSQWf@ Gil
•��'^�j^_�], ♦N..rN�rSl��.s.�L4 � �(
4lIOYL��YI[TlA1l,�.. �:J�i� 87y
CF�MIM�ry M{l.�V.Q'
ApPRDVeb gY;
�'��
tw neuq.a.+anoa�ed q ax wmuw N�amn ud•wery.�eaaoue neryn ra u9 W�e+aq�d reaeaea+�ntla l!CaM froi97� 7�4 �p /,���
re.eaMnmt�eamnumxn�ane�nqn�kMaearwrwY6rNaTnvq.f,.��lavurna��u.te•rrn�nen�NrdrmAm�nre. M�y/aUV�
rta n�n N ry�rMra re�a�admb.r.n nr nm r.�k.a ro.nom x u eu�..w. �*.r pn r.a h iu nw�nr«�a owdue�s<mwe w. u y u
..sw.w wnrw�w �N.r�yp�wF�^d+Y•n.M weMM 4p1Y w u nr�+�Ym�r M q�.wMy uwM�d r w�v e�Ana tl�iu
M�,o.Me�rJ Me�qYdW*ry�hn IMv�bx dr.nml wthe uw waY.�.ryAn+nqwh yMrnm�qe.a..�,,,�p�y.
�,a aienwaoa Piece oaim�,pa smat �a�ue•szea F�x:709-z2e�6Te9
f
MRR-��-2003 ��11 FFtOM:STRGERIGHT 9B93B63506 T0:17818�14092 P.6�'2�099
`�j���SqS U.S. Testing Cempany 1nc.
5555 Tela�raph Road REPOR7 NUMB�R; 124�35
Las Angelaa, CA �0040 DATE; 5113/99
Tel: 323 S$8-16�0 PAG�: 1 OF 4
Fa�c' 323 722••8251
CLlENr; BTAGERIpNT CORP.
495 Holley DrivelP.0.8ox 208
Clare, MI 48617
SUBd�CT: FLAME SPR�,Ap CUISSIFICATION AND SMOKE DENSITY
� p�VELOP�D
w� REFERENCES; 1. Qur conArmation to the Client dated M�y 11, 19g9.
2. Test sample received on April 29, 199�.
�.w� 9. Testing Condu�{ed on May 11; 1999.
�. Testing authorized by Snaron Schuldt.
� S. ClienCs Purcha5e Order No. 25259.
n SAMPLE ID: The Gli�nt submitted and idanGfiad the sample materiai as:
`��
TechStage Deck Pnnals
�
� T�ST
QPROC�OURE: Perform stand�rd fiame Spread and smake dansRy develaraad cfassification
-
FROM :USR HoSton FRX N0. :1781H214092 Jun. 09 2005 09:06RM P2
. ; MGR-2r�-�Q3 09e�1 FROM:6TR�RICaHT 9��3BE3500 T�.17B1Be14092 P,0��009
��r���SQS U.3. Teatiny Comperry Inc_
5555 Telegraph Road R�pORT NIJMBER; 12q335
loa Angeles, CA 9qp4p DA7E; 5N 3/99
Tei: 323 638-7800
Feuc 3Z3 722-8231 PAGE: 1 QF 4
CLIENT; $TAGERIOHT CORP.
495 Iiolley Drivg/P.O.Box 208
Clare, MI 48617
SUBJECT: FLAME SPREqD CLAgSIFICATION AND SMOKE DENSITY
�„ C1�VELOPEO
wREFERENGE5; 1. Our confirmation to the Client dated May 11, 1999.
2. Test sample recelved on April 29. 1898,
t"""' 3. Teeting conducted on May 11, 1999.
a. Tasting authorized by 8naron Schuldt.
� 5. ClienYs Purchese Ordar NO. 25259.
�"'ti SAMPLE 1D: The Client submitted and idendfled the sample materlal as:
V
Tech-StaBe Dock Panels
�
� TEST
� PROC�pURE: PeAprm standerd flame epread and smake dansity developed tlassiflcaSion
� tests on the 9ampie 9upplied hy the Cilant in accordance with ASTM
Dasig�atinn E84-97a, "Standard Method of Teat for Surface Buming
W CharacterisdCS of Bulldinp Materials". 7he faregoing te9t procedure is
� comparabla to UL 723,ANSUNFPa No. 255, and U8C No. 8-1.
P PARED 9Y:
� / SIGNED FOR C M�ANY�Y:
.
j ��.,��.�,' `�, /�;c���1,��- .4��`l<<�
nan Ort� /� ` �Mfchael � lOtt
Test Technicianlqb ManagedFir Tech. Oepf.
Mamoa ol qfa sGs G'ou
ApALMONekNY1C(8 �P6AFOIIWNCETE51�N0•SGMCNppiN4WAilON•
ooD u�R Ti51m0 COMW7IY INC,RB�OIIY01 M�E Wfl TMC iNLL19K ll![OR 7NE OI.RNT M NMOY M Y ��GTIGN
aT�uGNAarT�6�6G0.lKTHF6W110i1AFntp�PRe�RP.Cr ! w+EM�Op666l0.4NvouePReV6M��C��TlM SOULelo�OEw
m7N6MMMP.PlF316D.RCTNEaR�OWYMaTNiunro�mTOPi�rwi�OfdvOFnlEl1�MMNOdOnA�ocFOWlBmFNlme0ivT11E16sIP uG�eo�+oMau,.roo
��'WIOVCTCo�Xvpyy��CpiiiM11R7pGX�Y �Ep�McIT'MOM'MiaO�f�vN�rllW�GTM6NWSU87Gl71W6��ry0�WWNCf
M�MOp1lhpMpnOwMO9tlA1NwfM0iw*MEwoonMFR}Vx.wpPwL� 1!lIINOC�MMr�uDlMel1lPWYrWM�,���wOMAY�G110iDINM�YIOMIF
Oui'M1@ v�EN��flMBBIGN0�1wE 808 VA.fESnMI CGFWMVMC�f+MR[!M�TMYTRO'�EDIN T691NtlME pyOBEDOF11i1Ex f0 WYS
u�owaao rocoa�r�rw.w�ru-
�
FR�M :USR Boston FRX N0. : 17818214092 Jun. 09 2005 09:06AM P3
. h�1R-�FJ-2903 09:11 FROM:STRf�RIGH7 989�63589 T0:17B10214092 P.903%009
� a
� SQ$U.S�71�tlng Com{fenY!na
R�PQR7 NUMB�R; 124336
DATE: 5113/99
PAGE' 2 Q�4
CLIENT: 3TAG�RIGHT COFlP.
����a�rio� a�Q
CONDITIONING: The semple materiel was submitted In three pieces, 24"wide by 96"
lang, conformin0 tn tast chamber dimensions.
� p�bf�o �esEmg, �he specimen was placed in the conditioning roam
� (maintalned at 73.4 t 5°F and a relative humld�y of 50 t S°�) and
allowed to reach moisture equilibrlum.
W 3UMMARY dF
� A5TM E84 RESUIts; �ecsuse o�tne possibie vanations in reproduclbility, tne reau�ts are
adjusted to ihe nearost figure diuiaible by 5.
� SdMPLE FLAM� SMCK�
a IQENT�FIC T�N SPREAQ AENSIIY
Tech•Stage 65 475
� qeek Panels
I /�� In order to obtain the Flame Spread Class�cation, the above resutts
�wJ should b9 Compared to the fqllowing table:
� Q..
W 5S U.BG, GLASS FLAM�SPREA➢
� A I 0 through 25
I 8 II 26 thrnugh 75
C I II 78 thraugh 20q
BIIILpIMG CQpEB CITED; 1. National Fire Protection Association, ANSVNFPA No.
101, "L'rfe Safety Code", 1894 Edition
9 I Inifnrm Cnilriinn f`rnrin 100A G�lifinn ('hanfer Q In4crinr
FROM :USR Boston FRX N0. :17818214092 Jun. 09 2005 09:10RM P2
� MAR-2e�-2Q03 69:11 F'kOh1:5TRGERTGHT 9893863500 T0:17a1621Ae92 P.0��e0S
�ir����&Q$ IJ.B. Testiny Company Inc_
5555 Telagraph Rpad REPORT NUMBER: 124335
los Angeles, CA g00qp DA7E; 5/13/gg
Tel: 323 838-1600 PAGE: 1 OF 4
Fax: 323 722-8231
CLIENT; STAGERIONT CORP.
485 Holley Drlve/P,O.BOx 208
Clare, MI486t7
SUBJEC7; FLAME SPR�AD CLASSIFICATION AND SMOKE DENSITY
�.. p�VELOPEp
WREFERENGES: 1 Our conBrmation to the Client dated May 1�, 1999.
2. Tes�sample received on April 28, 1 A99.
� 9. Testing conducted on May 11; 1999.
4. Tasting authorized by Sharon Schuldt.
� 5. ClienPs Pu�ahese Order No. 25259.
, � SAMPLE ID; The Client Suhmitted and identl�ed the aample materlal ae:
TechStage Oeck Panels
�M
�'�" TEST
QPROC6DURE: Perform standard flame spread and smoke densRy developed p�8C6iflcaNpn
� tasla on the �ampie supplied by fhe Ciient in aetordance with ASTM
Deglgnation E&4-97a, "Standard Method of Teat for Surface 6uming
W CharBcteristics of Buitding Materials". 7he foregoing tR�t procedure is
� comperAble to UL 723, ANSI/NFAA No. 255, and UBC No, g-1.
P
PARED.9�Y; SfGNED FOR C PANY �Y:
, •
,...
� . . . " %%`� � L"
� ����`-� �- �- t `���1,�� -�: 1�'1���"
rian Ort�� /� � Michael � lott
Test Technician/gk� ManagedFir 7ech. Dept.
Mem40�01 Ua SGS
. AMnW�M7N6Elrv¢ea�Mp�`ONMIINCt1F8YM0. eT4maIlp�Cr�uNT10N�f.�N'/IPN.A710M9EqVIC1g
76B u.s.765nNn co1mMM�xc.RFp(IaTs aHe I011 hlfi f#kuBUF.V9E aP 1MK CLCNT 10 wMm
SrIwCN.LnF7N2C6TM�PIFT1[Rh4Wk7mILM�VpnTERiAELrPol1UlT8W.Y0FTHPDTANO�A MroClD�ARBIOEN7wYD*OR�I[6c18�M 9paItOW��g14
ro»u�r.etee�o.rear�uuswn1nrwiwcw+rvemn.�w.urimxrw�or.aw�wrn�a�nea�,vi,cHaar�a ��xoMpuwroo
��oW��Mwe7uonvrewvJTrmnma.qlocnw1/ipP11�CUYNruEmmRpTMp�.ButAMMk6x011N8laanOrsGaul�E9TNC 9CO�M1UWrmpMAYOYU�GCGq1N1YAp�
EM�c6��N6�����F90lu9iEB11NOCGw�wrqplMORfPONrauItNCTOEFFPpaq,pOppG7RP1HALwT�1.
+�NN mG.4Wryee NGTCEYf�p'lDR1 T6011nGN4 O�B�DpEDaFM�Y�n 70 WYS
-
FROM :USR Boston FRX N0. :17618214092 Jun. 09 2005 09:10RM P3
, MRR-28-2003 99:1i FR[n1:STFIG�RTGHT 9893�3500 TO:STB18214092 P.003•999 !
��p SGS U.S.Tnting Company Ina
REPOR7 NUMBER: 124335 i
DATE_ 5f13/99 !
PAGE: 2 pF 4
CLI�NT: STAQERIGHT CCRP. �'I
PREPARATION ANO �I
CONDITIONING: The sample materiel wea aubmitted ln three pioCes, 24"wide by 9B"
lanp, confonning to tast chamber dimensiqna,
1___ Prior to teating, the specimen was pl8ced in tne aqnditioning room ,
�"� (maintAined at 73.a t 5°F qnd a ra�eUve Humidity ot 50 t S°h) and
� allowed!o reach moisture equliibrlum. ,i
� SUMMARY OP '
�^ ASTM E84 RESULTS: Beceuae of the possible vanations �n reproducibility, the roaulta are
adjusted to ihe neerest figure divinible by 5.
� 9AMPLE FI.AM6 SMOK2
� IpENTIFLCATION SPREAD p,�J�
Tech-Stage 65 475
� Deck Panels
�
^ In ord8r to obtain the Flame 5pread Giassfication,thc abave I'96ufte
\.J ahould be compared to the foflowing table;
C�..
LLJ NFPA CLASS UBG CLASS F�SPREA�
� A I Q through 25
B II 28 through 75
C ��I 78 through 200
BUILOING CODES C176Cf: 1. National Fire Protection Associatlon, ANSI/NFPA No.
101, "l.rfe 5afety Code", 19@4 Edition
2. Uniform Building Code, 1994 Edfion, Chapter 8, Interior
Finishee, Seetions 90�-807.
FROM :USR Boston FRX N0. :17818214092 Jun. 09 2005 09:10RM PS
MRR-c^8-�63 09:11 FROM-STqGE12IGHT 9893863500 70:1781�1H692 p,005�g09
�•
SQ8 U.&,T�otl�ro Campeny Mo. �
R�PCIRT NUMBER; 124336
DATE: 5113/gg
PAGe:a o�a
CLIENT: S7AG�RIGHT CORP,
FLAM� SPR�AD AREA
7ECH-STAG�OECK PANEI,S
zo —- — - •�----
� 15 ..
I . �IA W �� /� /
a
W 5 ,
�'". o _-- -- - --��--
o + t s < s e - � e e �.�o-
� � . TIIA�(MINWTES)
� �—�— SAMPLE �- - REOOAK • . . . . . fSAflgq
��y�+
I.i..
Q SMOKE pENSITY
d,
W TECNSIAGEDECKPaaEL6
,Ap �-�-- _ _.
� Ap . _
y
� 80 -
.
a"
$ 44 -
�
` 20 �/�`'. '� �" -.. �'�...
D •�' .. _...___.__ � `` —•• �
0 7 1 3 4 5 6 7 q g �p
TIME(�11NUTES)
-- SAMPLE -- — RED OAI(
�11tRRR��
End Of Report
r
FROM :USR Hoston FRX N0. :17818214092 Sun. 09 2005 09:10RM P4
, MAR-28-2�3 09:11 FROM�STpGERIGHT 9993B6�F1Q TO:i'781�19F7� P.004�009
I � •
� 8Qs u.e.Ts�qna Comprin�Uro.
REPORT NUMBER; 12q83g
DAl'E: 5/13199
I PAGE; 3 OF 4
GLIENT: STAGERIC�HT CORP,
E 84 TEST DA7A SfiEET: CLIENT: �AT�:��
SAMPLE: TechSta �
�"� THICKNESS:.�Qminal
N J .,.,�,��.
w FLAME SPREAd: IRNITION:
� FLAME Rf�ONT:
LL„ TIME TO MqXIMU1N SPREAD: 5
� TEST DURATION: 10 miny��
L �ALCUI.ATION: 0! _ •�
1—
� SUMMARY; FLAME SPREAO: 65
O9MdKE �QNSITY:475
w
� QB3�F�yqTION$; S�mple 9u�Faoe Ignition oeeurred at 1 minute, 14 Seconds. A
maxlmum flame frant
advance of 19.5 feet was oDserved at 7
minutes.
FROM :USR Boston FRX N0. :17818214092 Jun. 09 2005 09:11RM P6
MRR-28-2003 09:11 FROPI:STRGERIGHT 9893863566 Tp:17918214092 P.B06��9
iieoelvede a/ �/B9 8:46: .r 87AOGRYOHT� paqa 9
OB/Od/99 'ZHt) 08:46 FAE S9AN YNROILIdTION CEW'ipt
�00�/005
ProfeasfOnal TEST REPORT "��!..."..,."' Q050965
Testing '" � � �
;w_:� �.��'.,.�.,.�
La6o�atory :`� , ::� l „ 1?l23/97
Ino. =�?:�W,=.�� .W:'
1 aP 2
' "-:��x•.rqtt.:•
. ;�I�IV�T�s'':<:������:;�:::'�r:�:? vHiu�o��vwiacARVEr�oiv�sHnw
������"i� _-�;?y AS�M E6a8�94a C7i4wl Radiant Ftux aP Flocr COv9Nr1p
,;�:...,:...;,:�:�.��;.;;�...,w.:, sY9tems usin
- s?����j�,:s��-. .•y.:.-.;;:,::. g A Radtant HaaC Energy SOurC�, atso
�"�.•�iZ":=.`:'."�a,_;= refer�encea.es NFPA Z53 and FTM St�ntlarq 372
�:.-_�� • :,;�� ;�u:a �•, -- -- �� _ • '
,,�':�"�:...a„� — ��•,;,y-->_ .:.,�::Ta; �: �. .
—;.:.,,•�ti.-::;:., _ .:� .�.�t:c4fwr<_z'?ii'r-'` : "���i�ck:
. sos75 Neyland 20 �
y�,' n" ...._
".6�ea'�'e ci,Ft�� 22428 .
:=R�I���'.: - - Z52582-0 . '
�?• �CP�f1,1,�.„. loop PilO '
. �'� _^ii�,.�i�i..
:d�l�di��:='�4'�� accion eac
?��;±��; Test No: 921697fi .
3:6i:r "4�-�::`'•� ����il�m�
:i^"`.� ��iqlCS Tei�'i u`�o(�"�{B dil'i(1i�
..�, ,::.�.•;_,::. e QIOQAdA9
t�sr� • • m�wodyoamMeiaw�oi,•
�����" ` � �--__.__��.„M�.,�":' ,33wattslsquarecm
�:...:-
OENp L
This procAdure is tles(gned to measure t�e crlprdi radiant flux at flama out, oF
harizontalty mourrted flaor eoverin9 �yst�ms txposed � a tiaming Ignitlan In a teaC
chamher whlrh provld�a graded radlant heat anergy�mt(ronm¢nC, The Imposetl radlant
tluxstmWates�he thermal radiatlon levels Bkelv to►mpinge on the Aonrs of a puildtnq wnpse
upper eurfaces are heated hy }lames of compartment. The te�t resWt l�an average Cr�'dCal
radlanC flux rovatGSlsauare cm1 which Indiates khe�eve�of raaiant heat energv requlred to
sus�in flame propaGat�on in tne floaring sVscam, riteoreticalN, ft a ro�m fire doe� na�
Impose a r�dlant flux that ea�eetls qt�s crlUal levsl on a co�Tidor floor �o��ing system,
'• ffame spread will not occur.
Tb 411bry N�lmwliwl u�me tuied NqnW�IYMAM Y�nJuYvr Inow b qw�pa�Ae�^F d am!lm�m w!w U►G4�Wl4/. � a�a��
rv�Aeummn�...w.Wua�n tiu.v.nmbmuAemen,aype.�u�.etfa.+n�n+�d W uAM AxM Cw�..�wro fw dr w���..os
�lu.�.n b pro-qlA M uN aw�ir.e�e or lM Gle��m w{�oli U is JM11.n..1 0�IV M�1e4�n In pmt(ry ro 9H P�n�1wn hm�EN/
f�NMwl uA9Wn. ih��rpvR yq�r."^,'IPlMp Wnpk.ynN MI h nM�Ih hekYM�(,�WwuA.VNt�a IMMIM p W�[� IAM
W�N.M�M�AIR�O��N�askN h�ld�WMI1�1Af 1�Er1N�401MI YNII MXfp�1 1�[iTMR hl�IMp�I 1�M'AMI�I�Y�t.
714 Glenwoad Plaoe p01m�qq�0721 706-�6�3283 Fsx:908�976�97
� The Commonwealth ofMassachusetts
Departmext of Industrial Accidents
O�ce of Investigations '
� 600 Wushington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance ARdavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le�iblv
Name �sns;ness�o��n;�auonanai�a,�t�: /IYtf/� f�l�•��- $-Sr.�i6s /�G.
Address: �I � f .�f S; Si � 17�/`!An �"'
City/State/Zip: D�Dll�+ 19A ouu Phone#: 7e/- 3L9 - 9no�o
Are you an employer? Check the appropriate boa: • Type of project(required):
1„�I am a lo er with S � 4. ❑ I am a general contractor and I
emp y 6. ❑New construction
' employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or parmer-
listed on the attached sheet � �• ❑ 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 cotporation arid its • 10.� Electrical repaus or addirions
r���� officers have exercised their
3.� I am a homeowner doing all work right of exemprion per MGL I 1.� Plumbing repairs or additions
myself. (No worke�s' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance requued.] t employees. [No workeTs' 13.❑ Other�N� Sl���?
comp. inswance requued.]
"P.ny epplicant that checks box#1 must also 611 out the section below showing the'v workers'compensatlon policy informetiov:
t Homeowners who submit this atFdavit mdicating they ere doing ell wmk and thrn lilre outside contraMors mus[subfmt e new�davit indicating such
� =Contractms tfiet check this box mus[ettached an edditionel sheet showing the name of the subcantmctors and their workers'comp.policy infonr�etion.
I am an employer that is providing workers'compensation insurance jor my employeex Below is the policy and job site
information. lJ
Insurance Company Name: //AJtfX�J� �.r�s��*+��r-r' ���+'
Policy#or Self-ins.Lic.#: OS��l3iV�I CiL7� Expiralion Date: � zs o F
Job Site Address: l�1YS!/ t- .t ls.r'� CiTy/Ssa�eJzip: ��1'�Br �A a�9 r O
Attach a copy of the workers' compensation policy dedaration page(s6owing the policy number and eapiration date).
Faihue 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 on�yeaz imprisonment, as well as civil penalties in fl�e 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 forwazded to the Office of
Investigations of the DIA for insurance coverage veri5calion.
I do hereby cenify under t6e pai and ies of perjury that the information provided above is due and conect
Si ature: �" ��M 1�'I Date: G 7 eS
Phone#• �017— 7/ g — ?G• 9 G .
O�cia/use only. Do not write in this area,to be completed by city or town ojj"�cial.
Cky or Town: PermiULicense#
Issufng Authority(circle one):
1.Board of Health 2.Buildiug Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Persou: P6one#:
Information and tnstructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' couq�ensation 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 unplied,oral or written."
An employer is defined as"an individual,pazmeiship, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a jomt eaterprise,and inctuding the legal representatives of a deceased e�loyer,or the
receiver or trustee of an individual,parmerslup, association or other legal entity,employmg employees. However the
owner of a dwelling house having not more than three aparnnenis and who resides therein, or the occupant of the '`
dwelling house of a"hbther wbo�o.y.s;p,e�sons to do,maiAtenance, conshy�rion�or repa'v work on such dwelling house
or on the�ounds or building appwtenant flieieto shall not because of sucL 'employment be deemed to be an employer."
� '„4 •.1 •...a,4, -. f�i ....., . -. .
.. ,� . . r... . . .� ._ f .., �� ,., .
MGL chapter 152, §25C(6)also states that"every state'or local licensing agency shall w�'tLbo(d t6e issuauce or
renewal of a license o1'permit�to opera;e'a 6asi�ess�or to conscruct b�ii_d�ngs��n,.�he commonwealth for�any
applicant w6o Las not produced acceptable evideoce of compliance with Y6e insurance co��i age iequi'red."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
' enter into any contract for tLe performance of public work unril acceptable evidence of co�liance_with the insurance
requuements of this chapter have been presented to the contracting authority." .
Applicants
Please fill out the workers' compensarion affidavit completely,by checking the boxes tt�at apply to your situation and,if
necessary,supply sub-contractor(s)nazne(s),address(es)and phone number(s)along with their certiScate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Parmerships(LLP)with no employees other than the
members or parmers, are not required to cazry workeis' compensation insurance. If an LLC or LLP does have
�,�pYe4si.a,p�olicy is r,equired. Be advised that this affidavit may be submitted to the Deparlment of Induslrial
Aecidenis for confiid�tton of insurance coverage. Also be sure to sign aod date the affidavit. T6e affidavit should
be retumed to ihe city or town that the applicarion for the permit or license is being requested,not the Department of
Industriai Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensaUon policy,please call the Deparhnent at the number listed below. Self-insured companies should enter their
self-insurance license number on ffie appropriate line.
City or Town Officials
Please be sure that the affidaviti§'�o�'plete and priet�d te'��rly=3'6apepartrnen3•liBs%�ib'w3ed a�space at the bottom
of the af3'idavit:fqr you,ta fi11 out in the event the Office of Invesrigations has to,coptact you regardimg the applicant
Please be sure fo fill'in the Permit/license number which will be used as a ieference nu�ntie't.^�Iih�d3irion, an applicant
t.' �that cmist s�bmit multi$1��g�iflicense applications in any given year;need only submit one affidavit mdicating current
ti
polioy infoimauon(if necessa�y)•and under"Job Site Address'the applicant Sh`ould�vnte"a'll locahons��'- � (city or
town)."A copy of the afi'idavit tLat 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 fudue permits or licenses. A new affidavit must be filled out each
yeaz.Where a home owner or ciUzen is obtaining a license or pennit not reiated to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete ihis affidavit
The Office of Investigations would U7ce to thank you in advance for your cooperarion and should you have any questions,
please do not hesitate to give us a call.
The DeparnnenYs address, lephone and fax number: .,� r • �,,' � .
` 1 i.i„� q.
�t.`'.
• The Commonwealth of Massachusetts '
Department of Indusirial Accidents .�R'� ���: - �; �.'. ^ ' �..
Oft'ice of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
' Revised 5-26-OS �,H,,mass.gov/dia
� From:Carol J.Cosfa At:Fitts Inwrance Agency,Ina FaxID�.Fitts Insurance Agen To:Renee Date:6l72005 02'S3 PM Page:3 of 3
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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 endorsement(s). .
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract behveen
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, eatend or alter the coverage afforded by the policies listed thereon.
ACORD 25-5(7197)
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