135 LAFAYETTE ST - BUILDING INSPECTION (2) ck -_7
ED
INSPECTIONAL SERVICES
SS
The Commonwealth of Massachusetts 0
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
BulldnngPermitNumber: Date Applied: Building Official:
SECTION LOCATION(Please i di ate Bloc .and Lot N for locat'ons for which a street address is not available)
No.and Street ity/Town Zip Code Name of Building(if applicable) -
>;SECTION 2:PROPOSED WORK - -
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
'Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Pee Reviewrequ' ed? Ye ❑ No
Brie Desc i 'on of Proposed Work:
P
SECTION 3:COMPLET THIS SECTION IF EXISTING UH.DING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA -
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable - - -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
E. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S; Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use: I I
_
SECTION 6:CONSTRUCTION TYPE(Check"applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) - -
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?,
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY ,,
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: A&
Does the building contahi an Sprinkler System?: Special Stipulations: / ,/
C,r Fo P--- p!u
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nazne�rtdJA�ddr s of Property Owner
ame(Print) No.and Street City/Town Zipe
P erty Owner C tact rformation:
itl T lcphone No.(business) Telephone No. (cell) e-mail address
If appli le, proper wner he y authorizes
ZZ61 �1�
Name Street Address Ci� take Zip
to act on the property owners behalf,in all matters relative to work authorized by this buildingermit a ]ication.
SECTION 10:CONSTRUCTION CONTROL,(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and Wp Section 10.1
10.1 Registered Professional Responsible for Construction Control - - - - --
Names gi ant hor Vo. e- ail achic Registration Numb
f'C �
reet Addr City/Town State --Zip Discipline Expiration ate
10.2 General Contractor
Coal p Nu e t
Name of Person Res vsible for Construction �. and Type if App icable
c
St 11 et/ dres,� y-Ci P n 4� �State Zip
ele>hone No. business Telephone No. cell f e-mail address
SECTION 11:WORKERS'COMPENSATION INSUILI.NCE AFFIDAVIT M.G.L,c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ �o
1.Building $ Building Permit Pee=Total Construction Cost x_(Insert here
2.Electrical $ t- appropriate municipal factor)=$
3.Plumbing $ 1
4.Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ -" Enclose check payable to
6.Total Cost $ ��� (contact municipals )and write check number here
SECTION 13:SIGNATURE OP BUILDING PERMIT APPLICANT -
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 m le a an erst ndsn .
Please r' t d si itn Telephone N Date
Sheet Address City/Town // State Zip
Municipal Inspector to fill out this section upon application approval: ' �
Name Date
CITY OF SM- ETM, TNLNSSACHUSETTS
BUILDING DEPAM,MNT
130 WASHINGTON STREET,3'o FLOOR
TEL. (978)745-9595
FAx(978) 740-9846
KIMfBERLEY DRISCOLL
MAYOR THomAs ST.PIERRH
DIRECTOR of Punic PROPERTY/BUILDING COMMSSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in : n/n
(name of facility)
(address of facility)
signature of p applicant
9--ate
date
Jebrisalfdx
CITY OF Sm Eim, IMASSACHLSETTS
' BUILDING DEPARTNIENT
3 ' p 120 WASHINGTON STREET,3w FLOOR
TEL.(978)745-9595
FAX(978) 740-9M
K. BERI.EY DRISCOU
.MAYOR THOb1As ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COWNUSSIONER
Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Naine(ausinessiprganizado vindividwl): j
Address; s / / 7 /J
City/State/Zip �/GL �I ` /� ,'j�6 49169
r c y an employer?Check e a prlate box: Type of project(required):
m a a employer with 4. 111 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet,1 7• ❑Remodeling
ship and hove no employees These sub-contractors have S, ❑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 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12oof repairs
insurance required.]t employees.[No workers' 11.Rther
comp,insurance required.]
•Any applicant(hut check,box el must also till out the section below showing their workers'compensation policy infomtntion.
'Ilntncowrsr,who submit this aPodavit indicating I*uro doing all work and then hire outride contractors must submit a new affidavit indicating such.
: namin.that check lhls box most mlachod an addniunal sheet showing lhannme*(the aub,nuactoro and their wotkari comp.policy fnfosswnon,
lain as employer that is providing workers'cotnpensatlon btsurance for my employees BelowlythepolleyonerjobsIty
Infurulnce C.
Insurmtce Company Name:
Policy H or Self-ins.Lic,M /0 Fxpiration Date: —
Job Site Address: /?� / yl� J pQ� City/State/Zip:
Attach a copy or the workers'coal ns on po cy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMOL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwwded to the Oftice of
Investigaliotts oldie DIA for insuranco coverugo verification.
adhere hereby ceNlfy rue er the al and penalties o perjury rhaf the bifurmurlou provided above Is true and correct,
'n I Ire, et 7"
a
Official use only. Do not write In flits area,tote completed by city or town of vial
City or Town: PermldLlccnse.t1_ _
Issuing Authority(circle one): - -
1.Board of Health 2,Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Cuntact Person: Phone d:
Q� 4 p ' 4 iF n •
L FA YETI Peq T STREE
l B ET
9 P a l II 0
e P
01' I
S o� 1 �ge�Aag r� O 0 I@
6 1 e In
A 1 P _
° 1i mrt h P • 0
N @• a
Y i A
n 11
—s u
s
i
SA I
STREET
Pa
rking plan 115 2—....
366 Lafayette Unit 81 1pfl1e3(umnarked)
129 Lafayette Unit-10 spaces(marked in red)
20 Harbor Unit-27 spaces(marked in green) f�"
yog
vii
yffi�R�� t l; �gill
�pq Sit 91 gi gal 1$ All I=$AF9`g 1 11 01 5gp 1111 .qQ a@IARI I �- i 3
bgg A
@�
��5g5g��i it
gA�A9 x xie A p q p` C 9 �' x 9 �B x x • x �R`diA F. %^'G Alyt��
B3 99 RRS • . z �F9
�. .. 5.�.. S. S a % � �A
v91!
P it B � a affi S F
x S A.R x v v v v' v q z
6g� gQ A:xv&q19. 5@ gg
a9gil A Ap 0 ffi@ d %E.A B@"••d a.'gggi %E"Rffi 'g�@:. '.q®� �fl�p�. gg�g�r; A
ail �S� @S` FX 1p9 ! [� 9 .F�S 6 dgg BgA 9g dyy p�'9$.ggggg Bgg gill
a paa AC
TA e.�x2 g R A p @ AAA %� A` a @1'p3' 9 a EA9 9 Sgy@g �x g% A&A :q"1 E A F A S q r y I gg% g�ftlA: S.fggg 6: g°�. R gg "AA' @ . ,>A "� I81 N gpillPl ��
A � A "kAl
tySsA �qa� �o $ .�'ffi"','eA' al A��•A SgS AN
jig 1 v ` 6@E�
11 INllll
g SALEM LAFAYEl7E CONDOMINIUM AS9 i RgeAp�i q@deAN ES tgAI 1 [
� 3F 129 203HARBORS REEfTTSREET
SALEM,MASSACHUSE R
RENTOFB-01 CHAWKINS
ACORO' DATE(MMIDDmvY)
CERTIFICATE OF LIABILITY INSURANCE 9/11/2014
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
NAME:
760 West Main to Agency,Inc. PHONE FqX
Suite
West Main Street ac Ne EA)'(800)323-0131 uc Re;(847)277-2600
Suite gto - E-MAIL
Barrington,IL 60010 ` ADDRESS,
INSURERS AFFORDING COVERAGE NAIL p
INSURER A:SPARTA Insurance Company 20613
INSURED
INSURER B
RenBoston Of Party
Rent,Inc. INSURER C
- Boston Party Rental
1161 Adams Street INSURER D:
Boston,MA 02114 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.
INSR INSOLTR TYPE OF INSURANCE IWO POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,00
CLAIMS-MADE FXIOCCUR 028CP01522 03131/2014 03/31/2015 PREMISES Ea occurrenceI $ 300,000
MED EXP(Anyone person) $
PERSONAL a ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
X POLICY O PRO- ❑
JECT LOC PRODUCTS-COMP/OPAGG $ 2.000,000
OTHER: $
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000
A X ANY AUTO 02BAU01412 0313112014 03/31/2015 BODILY INJURY Ea auWent (Per person) $
ALL OWNED X SCHEDULED
AUTOS AUTOS BODILY INJURY(Per acddent) S 1,000,000
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Peraccidme S
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS UAB CLAIMS-MADE 02BUM02432 03131/2014 03/31/2015 AGGREGATE $
OED I X I RETENTIONS 10,000 aggregate $ 1,000,000
WORKERS COMPENSATION PER OTH.
AND EMPLOYERS-UABIUTY YIN X I STATUTE 1 ER
A ANY PROPRIETORIPARTNEMEXECUTIVE 028WK01235 01101/2014 01/01/2015 E.L.EACH ACCIDENT $ 500,000
OFFICE"EMBER EXCLUDED? ❑ N/A
(Mandatory In NH)desorbe under s Ir , E.L.DISEASE-EA EMPLOYE $ 500,000
r
DE SRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S 500,00
A Business Auto 028AU01411 03/31/2014 03131/2015 11000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Romance Schedule.may be anached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Rent-All of Boston,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Boston Party Rental ACCORDANCE WITH THE POLICY PROVISIONS.
1161 Adams Street
Boston,MA 02114 AUTHORIZED REPRESENTATIVE
-4,vit-
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
R 8.0.2
THANK YOU FOR CHOOSING
BOSTON PARTY RENTAL
YOUR PARTY NEEDS HEADQUARTERS
TEL 617-690-2232
1161 ADAMS STREET
DORCHESTER MA 02124
NOTICE WE WILL CHARGE 50% OF THE RENTAL ON ORDERS CANCELLED
LESS THAN 2 WEEKS PRIOR TO THE EVENT NO EXCEPTIONS THANK YOU
! ! ! ! ! ! ! ! ! ! ! ! ! 24 HOUR EMERGENCY SERVICE 617-877-1162 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
---->> ALL DELIVERIES ARE TAIL GATE DELIVERIES ONLY <<-----
--» Check your delivery time DISPATCH 774-223-5330 <<---
0 CHILDRENS GAMES - BEAN BAG TOSS - SACK RACE - AND MORE ???
FOR COMPANY PARTIES WE HAVE TUG-A-WAR ROPES,MOONWALKS,
VOLLY-BALL SETS HORSE SHOES AND MUCH MORE
** B B Q GRILLS PROPANE OR CHARCOAL **
Customer ID____________-------------_____________________________Contract Number
617-350-8885 *** R E S E R V A T I O N *** 02-296023-05
09/18/14PLANNING OFFICE URBAN AFFAIRS--==
PLANNING OFFICE URBAN AFFAIRS >> ROSE HILL <<<
>> ROSE HILL <<< 84 STATE ST, SUITE 600
84 STATE ST, SUITE 600 BOSTON MA 02109
BOSTON MA 02109
617-350-8885
--------------------------------------------------------------------------------
DATE USING-09-27-14 TIME USING-11:AM Rsrvd• MON 09/15/14
CONTACT-SCOTT & PHONE-781-794-1000 Delivr: FRI 09/26/14
ORDERED BY-DANA & PHONE-617-350-8885 Out: FRI 09/26/14
DELIVERY ADDRESS-135 lafayette st / salem X113 Pickup: MON 09/29/14
Due: MON 09/29/14
ALL DELIVERIES ARE TAIL GATE DELIVERIES THERE ARE ADDITIONAL CHARGES FOR
BRINGING EQUIPMENT UP STAIRS OR LONG DISTANCES WITH IN A BUILDING
DAMAGE WAIVER WILL NOT COVER ANY MISSING ITEMS. ALL. BROKEN .ITEMS MUST
BE RETURNED TO BE COVERED UNDER DAMAGE WAIVER .
WE ASK YOU TO CALL IN ANY CHANGES AT LEAST 48 HOURS BEFORE YOU PICK-UP
SIGN HERE **
=Item No.====Qty=Description=====------=====Rate Info=====___=====Unit==Extended
160-0110 30 BROWN FOLDING CHAIRS CK 1.40 1.40 42.00
225-0430 1 TENT FRAME 20X 40 WHITE BE 750.00 750.00 750.00
119-3275 1 _top end male 201x101whit
119-3300 1 _top end female201x10 whi
119-3325 1 _top mid 201x10, white
119-0020 3 _top storage bag
119-0625 12 RATCHET 1" SMALL
119-0250 4 —corner fitting
119-0325 2 —crown 6-way
119-0375 6 —leg fitting 4-way
119-0475 42 _pins for frame L
119-0550 2 cable for20' frame tent
119-0525 10 —leg pads 18" tent yellow
119-0075 10 pipe 618" LEG BLACK
119-0125 11 pipe 9,4" WHITE
Pg Sales Agent: Date: Customer: Contract:
1 DONNA ROBERT 09/18 PLANNING OFFICE URBAN AFF 02-296023-05..*more*
R 8 .0.2
THANK YOU FOR CHOOSING
BOSTON PARTY RENTAL
YOUR PARTY NEEDS HEADQUARTERS
TEL 617-690-2232
1161 ADAMS STREET
DORCHESTER MA 02124
Customer ID______________________________________________________Contract Number
617-350-8885 *** R E S E R V A T I O N *** 02-296023-05
119-0150=======6 —Pipe 10.61, GREEN
11
119-3325 1 -topemid 201x10' white D
119-0020 1 top storage bag
_
119-0375 2 le fitting 4-way
119-0450 1 _ridge fitting 4-way RED
119-0625 3 RATCHET 1" SMALL
119-0550 11 �cableffor201frame tent
119-0525 2 _leg pads 18" tent yellow
119-0075 2 _pipe 618" LEG BLACK
119-0125 3 wipe 914" WHITE
119-0150 2 _pipe 10'6" GREEN
119-0025 2 tarp brown 201X 30'
119-0725 10 _water barrells f/tents CK 10.00 10.00 100. 00
900-0899 1 PERMITS CUSTOMER WILL GET
160-0080 2 TABLE Banquet 8' 301lx96" CK 11.00 11.00 22.00
105-0520 1 P A SYSTEM PORTABLE 2-PC. CK 95.50 95.50 95.50
105-0283 2 SPEARKER PA ANCHOR
_
565-0099 1 SPEAKER CABLE
565-0585 1 —cord charger cord f/ p.a
560-0030 1 —microphone for system
560-0033 1 MICROPHONE STAND /FLOOR CK 10.00 10.00 1000
105-0250 1 PODIUM GREY RUG floor mod1CK 50.50 50.50 50..50
-------------Receipts Summary------------- --------------Summary-------------
Office-A.V. 156.00
No payments have been made Party 64 .00
Tents 850.00
Pickup/delivery 5 > . : 140.00
Total 1210 .00
Deposit 150. 00
MON 09/29/14 16:51
Pg Sales Agent: Date: Customer: Contract:
2 DONNA ROBERT 09/18 PLANNING OFFICE URBAN AFF 02-296023-05
JOSEPH F, MOL,0Y
CONSTRUCTION SUPERVISOR
22 SPRING STREET
N. PEMBROKE, MA 02358
. i
I, Joseph F. Molloy, DULY LICENSED BY THE Commonwealth of
Massachusetts as a Condtruction Superviseor License#CS 058191 authorize
Elizabeth Driscoll from Rent-All of Boston ,Inc. dba Boston Party Rental to apply for
permits for the erection of tents and stages and I will personally supervise the erection of
said equipment. In addition,
I am insured as an additional insured by Rent all of Boston Inc. dba Boston Party Rental..
seph Molloy
.0aazszi;huseltts - Department of p
ibiz 3a'b_ty '
Board of Bu1lUing =eguiations en •3anda ru;
'6nNrul'il,.n :5;.n_rt ian;'
License: 6.056187
JOSEPH 6'MOLLOY
1O BOX 346 f ..
Nor&Pembroke MA o23so -
i-emmissiener ii127 ols
l
WA
utrttf mate of .11a me Aot'Ota are
REGISTERED i
9s APPLICATION fssuw BY pate treated or
CONCERN No. ANZ'TENT& CANVAS manufactured
375 MAPLE AVE. 04/22/05
�F R .pP° FA-415o1 TORRANCE, CA 90503
This is to certify that the materials described on the reverse side hereof have been flame-
retardant treated (or are inherently nonflammable).
FOR BOSTON PARTY RENTAL ADDRESS 367 NEPONSET AVENUE
CITY BOSTON , STATE MA, 02122
Cert)flcatlon is hereby made that, (Check "a" or "b")
(a) The articles described on the reverse side of this Certificate have been treated with a flame-retardant
chemical approved .and registered by the State Fire Marshal. and that the application of sold
chemical was done"In conformance with the laws of the State of California and the Rules and
Regulations of the State Fire Marshal.
Name of chemical used....................
..............._..........................
.Chem. Reg. No.,:................:.........
Methodof application..................................................................:.... ................................................
a (b) The articles described on the reverse side hereof are made from a flame-resistant fabric or material
registered and approved by the State Firs Marshal for such.use.
Trade name of flame.rssistant.fabric or material used................. ....Reg. No.FA-41501
The Flame Retardant Process Used - will_ toot n_......
Be Removed by Washing
.(will er wlll x
SANTOS C',UTIF.RRF.7. By RALP14 r MATrrTFL Pam¢
Name of Applicator or Production Superintendent Title
l
I '
fl
CONTROL NO.
CUSTOMER ORDER NO.
CUSTOMER INVOICE NO.
YARDS OR QUANTITY
COLOR
STYLE
DATE PROCESSED
THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING:
h
4- 20X20 (1PC) ULTRA WHITE 16OZ B/O VINYL
a' 4-20X30 (I PC) ULTRA WHITE 16OZ B/O VINYL
,z� 4-20X40 (1PC)ULTRA WHITE 16OZ B/O VINYL
2- 30X30 (1PC) ULTRA WHITE 16OZ B/O VINYL
1- 30X40 (1PC) ULTRA WHITE 16OZ B/O VINYL
2-20160( IPC)ULTRA. WHITE 160ZB/OVINYL