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60 LINDEN ST - BUILDING INSPECTION (2) g The Commonwealth of Massachusetts RED W Board of Building Regulations and Standards INS ECT16�ditFAivLSER ICES Massachusetts State Building Code,780 CMR Revised MarSER 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish One-or Two-Family Dwelling �01 MAY 2 b A 4 3 ' This Section For Official Use Only Building Permit Number: Date pplied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 40 L 1AdF� sr i zIs this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) 1 �n Front Yard Side Yards Rear Yard \k\�1 Required Pro Provided Required vided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private ElZone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: N e(Print) `� City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(sZq Alterations) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ I Number of Units Other ❑ Specify: Brief Description of Propose Work : /L /a9 C �lLn/✓3 J2 /t / ( � z SECTION 4.ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ S62p 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard Gty/T'own Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) � o8 2`^t q 3 _q LV —L� G 1A,11, d O yj( - License Number Expiration Date Name of CSL Holder / /y// List CSL Type(see below) lO 7 //V ��/� ` ' r T e Description No.and Street C 17 f ,,/ Unrestricted(Buildings u to 35,000 cu.ft. /t� /* Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding / //// n SF Solid Fuel Burning Appliances l/G/AW/9 (p4>(/ I6t' �}-Or I Insulation Telephone Email address n All,c D Demolition 5.2 Registered Home Improvement Contractor(HIC) J I/C i Y�✓n Cl O��NZ /HIC Regis r Expiration Date HIC Compan sine or,I-q�Re 'str t Name CD /Lf 0/ y t1 No.and Stre t Email address /h�� �� 7_�F�r/ �fr c6 od City/Town,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 7a: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:OWNERt 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 th' pplicatio7true an�to the best of my knowledge and understanding. Zz-i 5 Print Owner's or Authorized Agent's Name(Electronic 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 w%nv.mass.eov../oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" 109 Bainbridge St , Malden MA 02148 6177106906 Contract 05/07/2015 60 Linden st Salem Christian Della Piana Date Description Total Replace front porch railings and floor US$4,500.00 The Commonwealth of Massachusetts Department of IndustrialAceidents a I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): (1' 4f 1119 L/Alb-- Address: k e 13,,t/A/ 6N1W 6- a S J City/State/Zip:_,t,4-e a//= ✓ Phone M Z/ -/- Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with employees(full and/or part-time).- $ ❑New construction 2.Q 1 am a.sole proprietor or partnership and have no employees working for me in S, ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. 1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition. ensure that all contractors either have workers'compensation insurance or are sole I I.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROOF repairs These sub-contractors have employees and have workers'comp.insurance.= 6454 'Ve are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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 their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: pp Policy#or Self-ins.Lic.#: 0.( � S Expiration Date: 3— / 0— / 6 Job Site Address: 6/0 4 IIV CI q Al Tl' City/State/Zip: �h'6%,15 1144 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 under the sins and penalties ofperjury that the information provided above is true jan{d'correct. Sien iture: Date: ) 7 7 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 permitAicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitAicense 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 dog 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. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A� CERTIFICATE OF LIABILITY INSURANCE DA E(NmvD�mrl14 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 endorsemen s. PRODUCER CONTACT NAME: Hasbany Insurance Agency PHOWC_NE 978) 685-3188 FAXC.Na: (97e) 685-9460 236 Pleasant Street EWAIL Methuen, MA 01899 ADDRESS: eric@hasban .Com INSURE $ AFFORDING COVERAGE NAIC# INSURERA:NEEE - Northland insurance INSURED INSURERB:MA - W/C - Travelers GC Remodeling Services, INC INSURER C; C/O Gilson Cardoso INSURER D: 109 Bainbridge ST INSURER E: Malden, MA 02148 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.LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS-11POU CY NUMBER MIDOIY Mr1MD1YYYY LIMITS p GENERAL LIABILITY WS206759 3/18/14 3/18/15 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENE PAL LIAB ILITY OAMAGETO RENTED PREMISES Es oxnnence $ 1001 000 CL4IMS4ADE D OCCUR MED EXP(An,one Palm) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY .FERO- LOC $ AUTOMOBILE LMBIUTY- CO a Titlenl $ ANYAUTO BODILY INJURY(Per Person) $ ALLOWNED SCHEDULED BODILY INJURY(Per acddeM) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eraccident UMBRELLA LIAR E OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-AMIDE AGGREGATE $ DED RETENTION$ 1 $ B WORKERS COMPENSATION 7PJUB-5B87746-5-13 3/19/14 3/19/15 WCSTATU- oTH. AND EMPLOYERS'LIABILITY ' ANY PROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACO DENT $ 1,000,000 OFFICERMIEMBER EXCLUDED? YJ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000 000 Ifrs,desaibe under DE SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Atlech ACORD 101,Additional Rermrb Schedule,B more specs is requred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Emily Crossman © 1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: L r r ertn-u sszo-e� ��f Massachusetts -Department of'PubhcSafety ( Board of Builduig"Reg ulatiofis a&t Standards, Construction Supersisor r / License CS-082993 LUCIANO R DOVj�L n f 107BAINB It`S EcZO LL MALDEN MA 0f148 s Expiration ^ja _ 'Commissioner 02/0g/2016 c�a zszo yo y�zc-u �ezr,-tt '19 _ - 4y 6ZZ0-Ll ` ZZZO-ll Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m')of { ; enclosed space. Massachusetts -Department of Public Safetyy + - Board of Budding Regulations and Standards Construction Super%isor License'' CS-0829V � tic fiy 7) Failure to possess a current edition of the Massachusetts LUCL\NO R 1>9�VAL State Building Code is cause for revocation of this license. - 107 BAINBR16GI� For DPS licensing information visit: wvuw Mass.Gov/DPS . J.'�•'- tens.: , Expiration ;Comrtmissioner 02MW2014 y License or registration valid for individul use only Office of Consumer Atfairs&Busioess Regulation before the expiration date. If found return to OME IMPROVEMENT Office of Consumer Affairs and Business Regulation CONTRACTOR egistrabon 140144 Type: 10 Park Plaza-Suite 5170 r Bostorr`,MA 02116 - 3 Expiration 9/1,9/2015. Individual - LUCIANO R DOVAL I,UCiANO DOVAL 107 BAIN BRIDGE ST Not valid without signature - MALDEN, MA 02148 Undersecretary v CITY OF SALEM MASSAmUSEM Bu DING DEPARTMENT 120 WAsmNGTONSTREET,31DROOR TEL. (978)745-9595 KMERLEYDRISCOLL FAX(978)740-9846 MAYOR THomAs ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUIIDING ODAMSSIOMR 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, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: /�-IL 1�� ,�(name of of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant -2 J Date ' GI< Sa I ZS The Commonwealth of 1VIass����ED SERVICES Department of Public Salk W Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than Iff fr Teo-FAme 15AFlling O (This Section For Official Use Only) , rLLu/JJJ\ Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION 1 _ _115 Derby St Salem 01970 House of the Seven Gables �) No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2: PROPOSED WORK 1V I 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 ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Tent Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:—Install 40'x 60'tent from 5/29/15—5131/15 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING 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 applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ HS ❑ HA ❑ IIB ❑ ILIA ❑ HIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Private Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ ❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA 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: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: inn (—\I t—f--71D (v I I SECTION 9: PROPERTY OWNER AUTHORIZATION y Name and Address of Property Owner . Hmrsa of the Seven Gables 115 Derbv St Salem 01970 Name(Print) No.and Street City/Town Zip Property Owner Contact Information _GebCosta 978_-_144_-_Ori1 - - dcosta(r),7gable"M Special Events Director Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf;in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.fL of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/To" State Zip Discipline Expiration Date 10.2 General Contractor The Event Co Company Name _Taylor Hedges Name of Person Responsible for Construction License No. and Type if Applicable _PO Box 419 _Gloucester MA 01930 Street Address City/Town State Zip 978_-_283- 4884 617_-_967 -_5666 tavlor@rentent.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS' COMPENSATION INSURANCE 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 pf[¢e building permit Is a signed Affidavit submitted with thisapplication? Yes W No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor . and Materials) Total Construction Cost(from Item 6)_$ 1.Building $1320 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $1320 (contact municipality)and write check number here SECTION 13:SIGNATURE OF 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 th best of my knowledge and un Brstanding. Daniel Weinrebe 978 -771 - 9561 Please print and sign a Title Telephone No. Date _15 Whittier St Beverly _MA _01915 _dweinrebe@gmail.com Street Address City/fown State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date Certificate of Flame Resistance REGISTERED ISSUED BY Date of Manutachus FABRIC JOHNSON OUTDOORS INC. NUMBER BINGHAMTON,NEW YORK 13902 May 2005 F-140.01 MauAnehrom dMo F^,°ey Tem Pmduds DemiDedllamm This is to certify that the products herein have been manufactured flan material inhemmly flame natandard as here after specified by the material supplier. NAME: CITY: c.rdtmuan b hereby made dwe The adi d e de=bed an Me mttllrate have been manufactured weh an approved same retardant deduce!m mmph=e with California Slate Fire Marshal Cade,NFPh701',Undmwftm Laoaffiary of Canada,and have been te9ed in aomrdaxe whh me Federal Test Method Spedscalbre and meet or eared the Military Flanre Spedficafas d MIL-C430063. Type,seer and reighl of matenal 14 ar Write BWOW Desomtion of Rem testes Genesis 40 a 20 mid Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing,Inc. t4wmamowdFlmiw gewrdaa vmltanWen 7eNrturNiTMENT.JOHN^ANo as Certificate of Flame Resistance REGISTERED ISSUED BY FABRIC JOHNSON OUTDOORS INC. NUMBER BINGHAMTON,NEW YORK 13902 May 2006 F-140.01 MemdactummmNed Her Ten!Pra0utL9 Narein This is to cerldy OW the products herein have been mamAactuied frefn material Inheren0y flame retardant as here after specflted by the material supplier NAME: CITY: Certification is hereby made tied: The ad'xb desaaee an thb oeRdiWle have been mawladiped with an epprared flame retarded d erm,21 M mr4lorrce with California State Fire Mesta!Code,NFPA.791-,UMemaers Laboratory of Canada.and have been tested in ecmdarde wdh ere Federal Teel Melhod spedfimations and r eat o exceed the bhTftery Flans Spedflca0 rs of MIL-C-430033. Type.caw and waigst of maw" teat: Vdryt:WHDEBIOCKOUT Desdfnlion d dean certlfe3 GENESIS 4OK402 pig sectional Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing,Inc. MaloRumver of Flwre Rdadwd VhM t>enhwb TEI(f DEpIrR1YENr,JORN30NW RS gage Sob Y ' The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Viv orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricions/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. l Applicant Information Please Print Legibly Name (Business/Organization/lndividml):DTH Inc/The Event Co Address:PO Box 419 City/State/Zip:Gloucester, MA 01930 Phone#:9782834884 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 20 employees(full and/or part-time).' 7. []New construction 2.M I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• ❑Remodeling 3.M I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I LM Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.[]1 am a general contractor and I have hired the subcontractors listed on the se attached sheet 13.0ROOf repairs The sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised[heir right of exemption per MGL c. 14.❑� Other Tent 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *An applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Travelers Policy#or Self-ins.Lic.#:XEUB2186T50515 Expiration Date:01/12/2016 Job Site Address: 115 Derby St City/State/Zip:Salem, MA 01970 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 under the pains and penalties of perjury that the information provided above is true and correct. Sfimature: Date: Phone#:9782834884 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#: