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208 NORTH ST - BUILDING INSPECTION (3)
� � � ='� The Commonwealth of Massachusetts {'� , ;� 4 ( �f / .� I,�y � DepartmentofPublicSafety ��1 D �:+' �.�• t \1.�sti.�rhutic11sti1.�IrRuildingCuJc(:RIIC�IR) fT� Uuilding Permit Application for any Building other than a One-orl'wo-Family Dwelling ('1'his Sectiun Fnr O(fici,il Usc Onl��) Huildin�; Pennit Numbcr: ----- D.ilc Applicd: _ Building Offirinl: _ SEC`I'ION 1: LOCA"170N (19casc indicatc Block#and Lot A fur locatiuns fur which a shcet aJdmse is not availablc) � � �_�,�, S _� oi�� _ V'u. ,ind Strcet Cil}'/lb�an Zip CuJc Namc uf Buildinf;(if,q�plirablc) � � SI:CI70N 2: PIiOPOSF.D WORK [Jiliun ul�Ir1 SL�Ic Codr uscd if Ncw Cunstrucliun nc�ck hi�rc O ur chcck all th.V oppl�' in Ihc hru ro�vs Fcluw-� Eci.s�in�; Building❑ Repair❑ rUtcratiun ❑ AJJiliun❑ Ucnndiliun ❑ (Picasc fill uul and submit AppcnJis 1) Changc of Usc ❑ Changc uf Orrupancy ❑ Othcr ❑ Sperify:._ Are builJing plans and/ur amstrucliun d�k'uments 6eing supplied as part uf Ihis permit applic.tiun? Yes L9. Nu ❑ Is an Independent Slrurtural Engin�rring Pecr Revicw rcyuimd? �/ Ycs ❑ Nu [3 tiri�F escriptiun uf Pri�Fn�snl lV��rA:�QYti.p fi�p,� 2"°� F�1UO� ��� W//�Pw , ��cl�e,,.� � �R�'N. l�rb ��aJR + kr�.�-, � — SECTION 3:COMPLETE TtfIS SCCTION IF EXISTING BUILDINC UNDERGOING RENOVA'PION,ADDI'f10N,OR CHANGE IN USE OR OCCUPANCY Chcik hcrc if an Existing Building Investigation and Evaluation is rnduscd(Six 78U ChIR 3+) O Enisling Usc Group(s): Prupused Usc Graup(s): _ SECT[ON 4:BUILDINC HEIGHT AND AREA � Existing Prupuscd No.uf Fluors/Sturics(include 6ascment levcls)& Arca Per Fluur(sy.ft.) 'I�utal Arre (sy.N.),md Tutal Hcight(ft.) - SECTION 5:USE CROUP(Check ae a licable) A: Assembly A-1 ❑ A-3❑ Nightdub ❑ A-9 ❑ A-i ❑ A-5❑ B: Business ❑ i: Gducational ❑ F: Facto F-I ❑ P2❑ - H: Hi h Hazud H-1 ❑ H-2❑ H-t ❑ H-�❑ H-5❑ 1: Institutional 1-1 ❑ I-2❑ I-3 O I-1❑ M: Mercanfilc❑ R: Residential R-1❑ R-?❑ li-.1❑ R-1❑ S: Storage Sl ❑ S2❑ U: Utility❑ Special Use O and please describu belu���: tipccial Usc SECI'fON 6:CONSTRUC'I'ION IYPE(Check as a licable) � Ir\ ❑ IB ❑ IG� ❑ 1180 IIIA ❑ 111B ❑ IV O VA ❑ VU ❑ � � . S[CTION 7:SI7'E INPORMA'I'ION(refer to 7K0 CMIi 171A for details on each item) � � Water Supply: 19ood Zune Information: Sewage Disposal: '�rench Permit: �>ibris Remu��al: , A trcnih�ivill nut bc I.ircnseJ Di�potial Silc❑ I ublic❑ Chrrk i(oulsidr IluoJ 7_unc❑ InJir,ilc muniripal ❑ rryuired O ur trcnch ur sF+ci if�':.____.____ - Pri�',ilc❑ nr indcnli(}�Z�inc: nr un sitc s�'strm❑ � — --- prrtnit is rncluticd ❑ Itaitruad righl-nf-way: Ilazards to Air Nm�igation: �i � i i�.i„n� � ,,���un,,,..,�, �'.�.�..,� i'...,,.,-.; . Nut :\F+plic.iblr O Is StruRivc wilhin dirp��rt eppruach,vca? Is thcir rovirw rnmplclrJ' ��. or Cunsonl I�� Ruild rnrlascJ❑ lv5 O or \'o❑ � Svti❑ iVa ❑ � tiF'C'1lON N:CUNI'[NT OF CI[R7'IPICA'fG OF OCCUPANCY Gdillun ut luJo: l.'nr C:ruup(5): I�cpc ul Cunti�fuC�lun', ______ OCCu��ant I..naJ pof I'�uuC � __ ._ __ _ _--_ -_ _. . � Ihirs Ihr I�uildin�;i�ml.iin,in ti�,rin{.li�r S�'nt�m?�.____ �prrial titipulaliuns: � � � ��/'� � II �' , D �p�� . ��/ �/"K� � l.l �L "V' V � SGCIION 9: PKOI'IiR�1Y UWNlili AU�I'll(/1iIZA'IIUN �, , �_ , \�amc dml AJdre.ss u�'ru��arty Owncr I l,ra1� c+., c�_ � H �v►he 12c� �id�e�n._l/��---- ----- —�— �-- �---- -- Citq/Tuwn %ip N.imr(Prinl) Nu.,md Strn�t Prupert�'O�vnar Contacl Infonn.iliun:�_ ^�� --��,�./�i✓i � ��_�1. �_— -- ----- 1'itic -- Tcicphonc Ni�. (business) l'cicphonc No. (ccll) rmail aJdretis If apF�lii�iblr, �hv FttopvriP o�cncn c�reb��au hurizcs —n �� ` ^ v, I �� -����, �ad,P� ���Za 2� ��„ N.unc Strcct Address V�ity/T�� Slotc Zip i��act on thc �ro,crlV ���+'���•r's bchalL in all maltcrs rrlativc lo work nulhurizeJ bv this builJin �ennit o��licatiun. SECI'ION 10:CONSTItUCiION CONTIiOL(Pleue fill out Appendix 2) I(builJin�is Iess tl�.m 35.1riIl1 cu.ft of endnseJ c,ace xnd or not imder Constructinn Cnnhol lhen check herc O and ski�Sectiun 10.1 101 Re isfered Professional Res onsible far Conslrucfion Control - �, �-. �� G� �S�Y56� 6riu�L���,ps e��.� M �v6 v�r s , — Nnmc Registrant) clephunc Nu. e-mail address � , a�b�s�r.,m,�,N��»h��1 2� !Z. �� Y2�'�A P�c ��L ��t� titrect Address City/Tuw Stah Zip Discipline Er irat nn D:�te 10.2 General Contrattor � a oa �' ov� (:�ompuny Name (� , _ ySS�" I VI�3� lr�--' ��'l l eti.r� �� �y/� Name of Person Respunsible fur Construction � License No. end TyEx if Applicab;� �. 2.nZZA ��l ��- � Street Address City/To� n State Zip ��-�? `��6� - � Tcic�hune Nu. business Telc ihon� No. i�ll e-mail address SHCTIONIL•w�nf.iJ`;'� u�ur�S:�uc�vi�,�Ur..\�t:�l':V_iii��. �9_i_ M.G.L.c.152. 25C6 A Wurkers'Compensatiun InSunn�e Aff�davit f�om th�MA Depvtment of Ind�strial Acodents must�complrted and submin�d with this applicatiun. Failure to pruvidc this:ffidavit will result in the denial of the usuance of the builiiing permit. Is a si�ned Affidavit submitted with this:� lication? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PE2MIT FEE Estimated Costs:(Labor ��Q°� and Aiaterials) Tutal Construction Cust(from Rem 6)_� L Building � Build'uig Pcrmit F�ti�Total Constructiun Cust x_(Inscrl hure ''. El��trical S apprupriatc munieiv.I faetor)=S 1. Plumbing � Note A1inimum fee=$ (cunlacl municip�ilily) . -I. \-I�t'hnnic.d (HVAC) 5 . , , 1 3. \tcdi�iniral Othcr :S Endusc ch�rk pa}'ablc �o �(�� . n.Tot�d Cost 5 I (runtacl municip,�lil}')and w�ritc chcck numbrr herc---.--- � SGCT[ON 3:SIGNA'NRE OF t3UICDING PGRMIT APPLICANT N�'enlrring n»' nante brlin.', I hereby.�ltcst,uN�Jer Ihi�p.�ins and pvnaltics of perju�� tha�,ill uf Ihc infurtnntiun a�� I,�ined in lhi.s ,ippliialiun is true,�nd ,�eiuralc tu Ihe besl�d my knu��9cdge and undentanding. -�Y iG✓� ���P� _�_a'''�_1�C�LPS _ _ _6� ���1 -------- Plc,�sc prinl ,ind si},n namc ��Nr �I�r.. �I nn�N��. D,�Ic —�� _�'�--��'_�-�--------- �,,.��`� ----- -�� -- � — tilrcrl :\ddress Cih'I�fuwn� __ Stati� ..ip �funicipal inspector tu fill out this scctiun upon application approval: ----��J�� -- �,`�-'�-f N,,�»� � i����1 , . � � '`b CITY OF S.�L.E.`t, L�L�1SS.�CHL'SETTS ' BCII�L�1G DEP.�R'[�IErT ' 1?O W.�.iHLYGTON STREET,3iO FLOOR � t1�L (97� 7iS-959S F,�t(97� 7�9&16 K(��ERLEY DRLSCOLL 1�UYOR 'I�+oaus ST.P[exas DIRECTOt OF PI:HtlC PROPEA7Y/Hl'II.DLYG COSL�(ISSIONER Construction Debris Dis osal Affidavit P (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR section I I I.5 Debria, and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the dcbris resulting from this work shall bo disposcd of in a properly licensed waste disposa! faciliry ae defincd by MGL c l 11, S I SOA. The debcis will be transported by: rw �� l� � Sol� d w �S�-e (nyne oChauler) The debris will be disposed of in : � 1 (name of faciliry) \1 � C����� �� �o�l e� l�� . , (:1ddR75 Of�fJ�l�llY� signa�ure oCpermit applicant 8� � )l �:IfC -�.Anvd�bR . '. - ,--�'� CITY UF SALEM � � '" '� /' [�UBL[C 1'RUPRERTY � .-�� � DEPART1�IEN1' � �\u:. Mf 1 Y'�e1N��11 . . ' \�11�M I!:1VnHn.\�;lu.\jCICL•1' � $All•.N. M.1Ud�.111 41 nJ177,^, � ►�'urkcn' CumpenaaHon Insurunca lffidu�it: Bulldcn/Cunfr�ctur�/E��tric►ynyp►� \ � illc•rnt In urmulio mberf . � ' � � e ' h VJ�M �Uu.nk.ri7rp�num��rvinJn��luu1 : / / 1 ' � 1�1i • � � �P c aN � Ir�sr: 12Q72w Qp c��Y,s�:�<<.ir���rv-�1� /�1�q q� g SZ, yq 7 I'hunr it� I� .�ry�nu�n vuiployar?C�eaN th�:�pprnyrluq but: I,� 1:un a emplu�nr wi�b N 0. Q 1:un�y�ncnl cn�i�rx�o�pnd 1 �)M o1 pro�uef(ruqulrrd): �•OanipluyccM(lull�mYur putt•�ime).• huva hind thu.�uh•cumr�cwn �'� ❑New cu�tvtrueuun I,�m d yulu pmpricnr nr punnur• li�r�d un rh�.�n;,cheJ.�hcee : 7. �RemoJNin� .hip:�n,l h�vo no umpluycay Thear iuseontqetan haw , �.urkiny �iu inv in any c�p��iq. �vurken'eomP, �ny�nn. �' �molirion �Kn worken'cwnp. iuyur�na J. Q W�an o ce�pon�irni�nd i�s 9• ❑ OwWinr�dJi�iun nyuircdJ ��tttcen h�vo,;�,;r�i��y�nc�ir 10.0 Elecrtiea!repain ur addi�ions 7.O 1 ;int a humcown.r Join��II work riyh�uf u.�anp�ion pur AfCL I 1.0 PlumbinY rc�uin ur aJditinry my+wlf. ��'o ��arkan'cump• c. 131,��N)�anJ we hnva no in.rurJncn rcyuirad.J i :mpluyc�w.��o�rorltar�' I�.O Ruul'repuin rnmp, in..uhn�v nyuind.J I J.Q UU�a �4ip .�,�pLru�ihW aEeeYalu��I mwl alw illl uw�M w�Uw�Iwlur Jw�ru� i � I I.,Tw�rn�n wM��Jinul��i�aIAJ�N�inJk��ip iAuy.u�J�in YII.+urt aml i�wurYr�'�un�pmwllw 4,M�n.uw.ihN�M��t inn Ao�n�uu�a>�wl,u�Llu. � Mw A4a uw�iM euwms �i�r�nlwinwww► wiW..hwl Ju�in�IM na�M d�M iW�M Wn mwl.�hnY a nw NIIiYvJ inJt�win�rw�. � /'��u���•���p/ayri�hul lr prvv1Jlnx ivrrrA�rt'ru�nornendon In.rrninrr/'w iay�in �,M'��y��'� ���y n�� i���unnWGiia P�1�« Bdmv!i ihi p�qay un✓/ul.rih Innuranca Cump�ny.Vame: �. r=Vi s . ��, Pulicy 4�M SvlGina. LiC.M:�l�I� � � —. .._^__ I . `0� �VOr�. S . .. . E.ipiruhon Dab:_�_ Job Sii� �1dJ�cs.r: �� �ir�.h u cu Cl�y��lutei"Lip: Jv"1 � MY u��h� �rarkan'eumpunwtloa pullcy Juelrrallun puy�phowlnp rM polley numpur�nd eTplr�tlu�dup). P��Iwu w.ccuro cu�eruy�y rcquireJ unJcr Srciiun:!A ul'.�IGI a I J]c�u lead io rh�imp��ition oYe�iminal yenolriq of� r'�'���p rn S I 1u0.rM�nJ/ur�ue•ye�r unpri.r�m�ncnr, �� wcll.��ci.d�wnulUw in ihu lunn ul'o STfJp�YURK URDER �nd� Rnt a/up rn i?!q���Jay.i�uin�t ih� vfol.ua�. Ile adv�.ti�d rhw�cupy uf ihi��iuiemwu�muy bu turw�rJvJ iu ihe Ullira�Y Im..ny�m�m ullliu f)1,1 ;or�n.ur.in<.:r��cr�3u �ci ili��Uurt. /rlu h�•irAr t crl�%'Y�u�dei dq pninr�urd ��ni✓Iir�u � /p�r/xry ihr�di�iu unnrl/ow . - � l yrvriJe�uOu y it�rp�����,/�•orrvrt \Id�i I�y�—` Pf�, � . .i --L •. 3 l � i ��//l��iu/ini an/y, /)o��nl,.�.;,,r„u,r��.�•�. r��.��,,,,,i�•�.d e � y.uy�.�o�.�„i���;�t � t�irr,,. l'���rn: , � I��vinq .\uihnrii ��--- N�'r�nif/I.Ih•ntaY r (circla�iucl: . � I. IL�,�rd �dllr.illll !. Ihuldw� Ucp.irtmwil L Cii�.'I'oon CIcrM J. j 4 Iliher L•'Iccf�i�•.il hup�•crur i. Phnnbin� In�yccror � l'����I.�el P�rwn: - .. -__ I'Aane f i [ nt'ormation and Instructions , �I.ui.�chuseusU.nar�IL�•vi.hayarli2reywrr�.+lleveplay°ionin �he�sa�'u�ut �^wherCumlern�ry ���nct fhre.,. . I'ur,u.uti� w uur.uw�a. .+n rmyluyn is J�tineJ as". e �Y iri :.prcas or ��npliuJ, or�l or wnuan..• urauon or uthar Imgal cnnry.ar�ay two ot m�rt urtnsnhip..ltY0C1�11JY.�ory �r or iha �n .�npfu�•a�������n"� �"�O �nJrviJurl. p �� �� ,,n� lo�eeti Howaver�ht ,�� ihu I.RGtjJ�n� Cf1�J�C�I m +1um�enierpr�s�, ind iiuluJin�{�ha ley,al repceyen�a�ivm ot i dece�scJ emp�Y ' � �ece�ver ur uusia�ul'.u� iudiv�dwl, piumeroh�y�+i+a�auun ur oiher le��l¢naty�omp Y � ' P �wner ut a Jwellin�{hawit Iwvin�nM i.ore ons to�o ni nienun r,unhvucdon ur rop�v wurk oo�w:��atllin�huua ,���.Iliny huus����+�o�het Whu employ (+� .�r ,����hs gruunda or builJin�{ +ppurten+nt J+ercto shrl!iw�beea�w of wch amploymcnt ba daame�w b��n r�nployer.' �SC 6 �Ito stateti i�w�"�vrry��v��or los�l Ile�nslor+R�sey �hsU wi�qhold th�Isauosa or �ti,l �h�p�er I S2. d- ( ) ulred.' r�nswrl uf r Ile�o� ur prrmit�n uy�ra���bu�ln�a ot te ca�uYpe,wi��'thw n�urane�ov�ot��Qqor a� , :�yplleun! »I�a has not p��duerd•+rc+p rob���vld�aa uf eumy of iu pali�ie+l tubJivi�iaoi+hsll WJillonully, �IUL clwp�sr l 31. �?SC111 .�+�as"Nai�her ihe commonwe�l nor on wmr�e� ta ih�Parfumwnc� ul'public wurY un�il ucepr.�ble evidenc�utcumpli+nce wi�h the insutanca ,near ina �ny ' �evan�eJ w the conuutin4 autAori�y." r.yuinm.n��uC�hir.lwpar how heen p' • .�yyUcanu checkin{ih�6oacs�hat uDP�Y��Yuw�iwa�ion an4 if Qui;►tion atllJavit eatl;P���°�y�M nwnb�d4�IO^�wi�b the'u uAiAcutel�)uf PI�:�++ lill.wt ihe workart' comp r��� � p P��r��p�ILLP)with na amploy�'�r u�har�han�h� necu�y:uy.tupply subaontr�ctor(f)n:une(�)� ' have imw•�nc�. LimuaJ Liabiliry Cmnpani��(LLCI or Limited Liabiliry memb�n or p+�+n• �r�no�requirad tu carrp woriean' eomp��tion imurona. Itao LLC or LLP J�+ en,ployaa�.u poliey is raquirod. 8�aJvlxeJ�hat�i�Atw E�+�u�,t ol�r rsJ Juu s�yl'11J��611eT�u'Ill�cot ofw e cov.ra�{w uasaJ, nM�h� LkP \cciJanu tor eontlrma�iue uf inauran� lie�on for�h�panni�ot licana is bcin4 req �to obmin u workcrs' h� ��i�imaJ iu th�eity or town�Rut th��DD ��tiaor rcQardiny��u luw ut il'yuu ac�roy 1e��h�11 enlu�heir ln.lu�viul Acui�enu. ShaulJ ynu hrv�unY 4 ��inpanaatiun poliey. V1C0�eall�h� Depuctmdnt y<<�nwnbar liyud balow. Sslf-inyuteJ compan .alf•inxuranc�lieann� numb�r un th�a ro na lint. ��Iry or'Cow�OMchU w ruviJed u spuca rt�h�bu�tum rintcd la�ibly. The De ranent hw p the applieant Plca..c hc wra thnt the aftlduvit i�cumple�� ;�n1 p I�eont ��i d�e�IfiJuvi� tur yuu tu lill out in �ha avenl th+Oltlet oP lnvvs��nuy`u i eed only tub n t ona�11dov��it indicatin�curtent Pl:us� ba sura �o tlll in iha p����licen���W��IQ��in any � used;'•1 `J"C A u I J'write'ulltlucu�unr ln n rPv (�ity or ip:u maa�s��bmit multipl� �xnni�'IN J`L71°Jer P'lab 5itt AJJteai'tha�pp '. y� �o�iJcJ w iha pulicy i�d'ormueion 1 if necassary) ' �J ur muk�d by �h�ei�y o�town may P wwnl.�•,\copY��t�ha utlldrvi��h+t ha b��n offloial�y xump' �pplic+nt:u p�f'that a vuliJ�IltJuvil ii un fil� f'or fLtun pe�mit�ur licenye�. A n�w�I11Juvit mui�b� Illled�ut toc y e;u. ��'he�+hum�uwn��ur ci�izcn ia ubminin{a lian�ur pannll nol ralatcJ to�ny buyinesf ur eummereinl vantur� �i �. ,i .lu�{lican.w or permit �u bum laova c�eJ�aiJ pe��on i� VOT required ro camplaw �hi�ulflda u�h J`� �y 4uQ,I�ons, 1 Ix �)�li:e ul Invawiy;:+tiuni �wulJ lu�w Uwnk you in �Jvance fur yout:oupua�iun �nJ+huulJ y ple�+e Ju nu� I�esiiats to y�vc u�o c�ll. . fhc U:�:If110Ctl1�� .11J�IliY{. ccicphune:+nJ f;u numb+r The CommceWealtA of Ms+sa��ux� pepactrnent of InSustrial Aacidenu Ol1fe� of IsvaUQadans 600 Wuhin4ton Street 8o�ton, MA 021 I 1 'fel. N 617•721F 9�6l1 702�7�49"•�SSAFE ���.uS www.matt.�Ovldi� t: ,...1 . - e/3/2011 9:07 AM FAOM: Fax Gerald T. McCavthy Insucance Agency Inc. TO: 1-9�8-790-9846 PAGE: 002 OF 002 ACORD CERTIFICATE OF LIABILITY INSURANCE DATO8/03/�201n1� . � PRODUCER Pnone� �sie)�aa-sa33 Fm: (9ie�]aa35�5 THIS CERTIFICATE IS ISSUED AS A frU1TTER OF INFORMATION - GERALD T MCCARTMY INSURANCE AGENCY,INC ONLY AND CONFERS NO RICHTS UPON 7XE CERTIPICATE 92 NORTH ST HOLOER. TXIS CERTIFICATE DOES NOT AMEND, EXTEN� OR P O BOX 8]9 SALEM MA 01970 INSURERS AFFORDING COVERAGE NAIC# WSURED INSURERA: TfaV81ef51nde1fl01fyCompany BRIAN 80CHE5 INSUREft B� DBA COASTLINE CONSTRUCTION INSURER C: 79 REZZA RD BEVERLY RNA 01915 INSURERD: INSURER E: COVERAGES THE POUCIES OF MSURPNCE LISTED BELOw HAVE BEEN ISSUED TO THE MSURED N4MED ABOVE FOR THE POLICv PERIOD INDICATED, NOTNIRISTANDING PNY REOUIREMENT, TERM OR CONDITION OF PNV COMRACT OR OTHER DOCUMENT WITri RESPECT TO WHICH iH15 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, hiE WSURANCE AFFORDED BV THE POLICIES DESGRIBEL� HEREIN IS SUBJEQ TO ALLTHE TERMS. EXCLUSIONS AN� WNDRIONS OF SUCH POLICIES. AGGREGATELIMITS SHOWN M4Y H4VE BEEN REDUCED BY PAID CLAIMS. INSR A00'l TypE OP IN9UR/INCE POLICY NUMBER POLICY EFFECTVE PO4CY EMPIIVATION LIMRS LiR INSRp OATE MMND/YY OATE MMNp/YY ' GENERAL LIABILIN E4CHOCCURRENCE $ COMMERCIALGENERPLLIP8ILITY DNAnGETORENiE� $ PREMISES Eaa[[URn[¢ �� CLAIMS MME O OCCUR MED.EXP(My one person) $ � PERSOWLLBPDVINJURY $ - i 6ENERALA6GREGATE $ ' GENLAG6REGAIELIMITPPPLIESPER: PRO�UCT&COMP/OPAGG. $ POLICV PE� LOC AUTOM081LE LIA81LIlY � COMBMED SINGLE LIMIT PNYAUTO (Eeacbdenp $ ALL ONMEO AUTOS BODILY INJURY SCHEDULEDAlfr05 (Perperson) $ HIRED AUTOS BODILY INJURY � NON-OWNEDAUTOS (Peraccl0an[� � PROPERTV DAMHGE g (Peraooidenq GNRAGE LIABILT' . . AUTOONLY-EAACGDEM $ �Y�T� OiHERTH4N EAACC $ � AUr00NLY'. qG6 $ E%CESSIUM6RELLALWBILrtV FACHOCCURRENCE '� OGWR �CLAIMSMADE AGGREGAiE q $ �EDUCTIBLE $ REiEMION $ $ WORKERSCOMPENSATIONAND 6KU80246N82509 O31'IA/'H OJNANI i�ORvumis OinER EMPLOVERS'LIABILITY ELEACHACCIDENT $ A ANTPROP0.IETOWPAFINER/E%ELUTIVE �OO�OOO OFFlLENMEMBE0.EYCWOEOt EL.OISEASE-EAEMP�OYEE $ 'IOO�OOO nves,aeze.ie.��a.. 500�000 6PECIALP0.0VISIOH6Gelow EIDISEASE-POLICYLIMIT $ OTHER: D SCRIPTION OF OPERATIONS/LOCA IONSNEXICLES/EXCL SIONS ADDED BY NDORSEMENT/SPECIAL PROVISIONS JOB: 208 NORTM STREET SALEM,MA 07970 � CERTIFICATE HOLDER CANCELLATION � CITY OF SALEM ' SHOULD PNV OF THE ABOVE DESCRIBED POLIdES BE CANCELLED BEFORETHE qTY HALL EXPIRATION DATE THEREOF, hiE ISSUING INSURER WILL ENDEAVOR TO MAIL ID DAYS WRITiEN NOTICE TO iHE CERTIFlCAiE HOLDER NPMED TO THE LEFT BUTPAIWRETO SALEM,MA 07970 DO50 SHHLL IMPOSE NO OBLIGATION OR LIABILITV OF ANY KIND UPON iHE INSURER,IPS AGEMS OR REPRESEMATWES. 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