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208 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts l� v ,1 Department of Public Safety f. \hitis.rchusrtls Slate Building Cute(780 C%I R) I� Building Permit Application for any Building other than a One-or Two-Family i t ---_-- (PhisSalion Parr Official Use Only)Building Permit Number: Dale Applied: Building Official:' - — SECTION I: LOCA"IION(Please indicate Block tit and Lot N for locations for which a street address is not available) - No. and Street City/'town Zip Code Name of Building(it applicable) "--- SECTION 2:PROPOSED WORK lidition of MA Slate Cade used--_— If New Construction check here❑or check all that apply in the two rates below Fmsting Building§Q Repair❑ 1 Alteration ❑ Addition�- Ucnudilioil ❑ (Please fill 1) Changvof Cie ❑ 1 Change of Occupancy Cl Other ❑ Specify:--- Arc building plans and/or rnnstnhCIion LitKnnlC1nS being Supplied as part of[his permit application? Yes p No ❑ --- Is an Independent Structural Engineering Peer Review required? Yes ❑ No IT Brief Description of Proposed Work:._ do5FDOrtier�fj_ 6?e— <einer qccot-noyott m tPmn e lnc���—c�r��at� R4-Y�•_ -- 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 M) ❑ Existing Use Group(s): —_ Proposed Use Group(s): SECTION 4: BUILDING HEIGHT AND AREA Existing proposed No.of Flows/Stories(include basement levels)&Area Per Floor(sq. ft.) To[ai Area(sq. ft.),utd Total Height(ft.) . SECTION 5:USE GROUP(Check as applicable) A: Assembly.A-1 ❑ A-2 Cl Nightclub ❑ A-1 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Fade F-1 ❑ F2❑ H; High Huard H-1 ❑ H-2❑ 11-3 ❑ 1I-4❑ 11-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ �VI: Mercantile❑ R: Residential R-113 R-'_❑ R-3❑ R-4❑ S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: special Use SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ t LA ❑ IIB ❑ 1 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORNIA'LION(refer to 780 CINIR 111.0 for details on each item) Water Supply: Flood Zone information: Sewage Disposal: Trench Permit Debris Removal: Public❑ Cheek if outside hood Lane❑ Indieale municipal❑ A trench trill not be Licensed Uiaposal Site❑ rc,pined❑or trench or specify: _ Prirald❑ or indonlil} L,ntc: or on site system❑ _. permit is enclosed ❑ Railroad right-of-way: Ilaarrds to Air Navigation: N1 I-..i . Net:\pl+licable❑ Is Sim,turn trilhm ,iirport,ipproo,hares.+ Is their rey iew conhpleleLI or C o wol to Budd enclosed Cl 1 es❑ or No❑ Srs❑ No ❑ SECTION 8:CON I*FN'T OF CFRIUIC'AI'1;OF OCCUPANCY I.dilion of Code: _ ... L'se l:nmp(e): _ k pe of Coll'Irm lion: OIL ulmot I.oed per I loor Does l he building omtain,m Sprinkler Seslem' spec1,11 Slipulmions. SECI'1ON9: PROPf111YO) VNI;Il AU'T1N.11tIZATION \,uue and Address of lProvvrl. O%vncr Name(Print) No.and Street -- - -----City/Town Zip Property Owner Contact Information: Title I'ekephone No.(business) Telephone No. (cell) a-mdil address If applicable, the property owner hereby authorizes Name Street Address _--- City/f State Zip to art on the property owner's behalf, in all mottos relative to ding urmit a ,plicatloo. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,0W cu.ft.of enclosed s ace and or not wider Construction Control then check here O and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control - ef)g+m & 91 9, Z(fi 7 iU6v9s Name(Registrant) Telephone No. e-mail address Registndion Number _ 7/2 Z �Z Street Address City/Town State Zip Discipline Espi 'It on Dote 10.2 General Contractor &NIn go C& a 60.1wme (an S I Company Name 16, sk, ySS7 6 Name of Person Responsible for Construction License No. and Type if Applicable IR Re -21W &M44 ✓1144 a/S /S Street Address City/116wn ) State Zip �z y967 qk -9Z/- /��! �P>C r,)b(7C�,PJ fie' 44 Mg% fog r Tole,hone No. business Telephone No, cell a-mail addre35 SECTION 11:m IrKi,In t %1\11'1 1,sn nt?\ iN:•1j1\'.Vv.'I m I p.m] M.G.L.c.152.g 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most 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(tram Item 6) S_ I. Building S 10 , 000 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical S Q 0 p appropriate municipal factor)-5 t. Plumbing 5 J. Mechanical (HVAC) S Note: Minimum fee=$ (Contact nuurtC polity) '.. 3. Mechanical Other 5 Fndose dimk payable to --- h. rolal Cost S /6 10 d fj (Contact numicipahty)and %%rile check number SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Itv suturing m}' name below, I herhbv attest under the pains and penalties of perjury that all of the information cont,iined in this appl ition is tru and aCCur dC to the hest of nrp kno//%Lled�g'ej�%d understanding,. 8r)q r)h _bckeS --- ,alJO ' 6>�rS - --9 S? W) /Z/6/ij Noose print and sign name title I,Ic phone No. I{ate �t«ct . ddress City/f n%n Rate Zip Municipal Inspector to fill out this section upon application approval: -_--.__ .--- Nome Itdte crry OF SmEmI lL1SS.ICHLSETTS ` BUILDING DEPAIMLEINT 120 \' ASHINGTON STREET, 1u`FLOOR TFL. (978) 745-9595 FAx(978) 7404846 KnmERL.EY DRISCOLL ,(LAYOR THObtAS ST.P1FJtR8 DIRECTOR OF PUBLIC PR0PERTY/8UMDING CONDIISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorn/Electricians/Plumhers A t tllcant Information / Please Print Le ihl M1111C lBusin ..oOr�aniratiun Indivi1lgal): Address:- Iq ge-?Zw 0 II City/State/Zip: 6 Phone k: Q_ 17fJQ MZ G(/947 Are you an employer?Check the appropriate box; Type of project(required): IA I am a employer with__,� 4. ❑ I am a general contractor and I b. ❑New construction employees(full and/or part-time).' , have hired the subcontractors rtrtec�i 2.❑ lain a sole proprietor or partner- listed on the attached sheet.: 7• M Remodeling ,hip and have no employees These subcontractors have V. C] 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,E] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.INo workers'Gump. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers' I3 []Other camp, insurance required.] -Any applicant aW cheeks but rl moot also fill ma the victim below showing choir worken'compeaudun pulley inromution. 'I beneuwners wins whmit this sflidavit indicating they am doing all work and then him outside commcto,most ,hmit a now amdavit indirming ruck " :(\nnmaon Thal chmk this box must auxhW an addoiurui sheet shuwing the none of the subOagomtom and their workers,camp,poiicy infermatian. /am an employer that pruvidlnx Ivorkers'cumpeusmlon insurance jot my extpiuyers. Below/s flit policy and job site injurarution. ,{ Insurance Company Naine: I G kA Z, L �,.1._._ Policy Our Sclf-ins. Lic.4: Will JfYaa IV)� Expiration Date: Job Site Address:_X20 R A)lA 5'� City/State/Zip: eZd 0/ /q 7 Q Attach a copy of the worken'compensation pulley declaration page(showing the policy number and expiration date). Failuru-to secure coverage as required under Section 25A ot'AIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/ur one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to 5250.00 J day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of hrvest igaa ions of the MA Tor insurance coverage verification. rlo hereby l/certify raider the pinny Cold p u�ltlr�s ojperjury that the injurmaNmt provided uve '.v true Cord correct J'Jp'Lt)m (�l�J/p�.rQ�M & "��'7VLJ 1)atJ: -1-1 1 t I'httne.i I / 0 OSzy -I / �II F"e o,rly. Do not rvrite in ibis urea,to he completedby city or townojjiciab n: P('rmlt/l.lcenve AtIt,. o leircle one):Ileai(h ?. Building Ucpartumnt ).Ci(yirown Clerk 4. ElectricalInspector i. PhinnhingInspector nuO° Phone th. ------- .. _ . . ------ 1 Information and Instructions, Mmsachusetts 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 ajoint 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." ,viGL chapter 152, §25C(6)also states that"every stale 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-contractors)nume(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 t the city or town that the application for the permit or license is being requested, not the Department of be returned o ry pp p q 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. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Official 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 rill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permitilicense 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"ail 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ofilce of Investigations 600 Washington Street Boston, MA 021 It Tel. 9 617-727-4900 ext 406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 5-26-t15 www.mass.gov/dia CITY OF S,V-&`i, .ti us,kCHUSETi'S BLtIDLNG OEP.1RT�jLN-r 120 W.kjmLVGTON STtEBT, ya FZOOt M (978) 745-9595 KIMBER' EY DAMOLL FAX(978) 740-9s" ,1(AYOR NOMAS ST.PMj" DIAELTOt OP PLSUC P ROPE tTY/at:MDLNG CO\L\ttsszo.%Et 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 I 1 I.1 Debris, and the provisions of MOL a 40, S 54; Building Permit p is issued with the condition that the debris resulting from ( work shall be disposed of in erly licensed I I I I. S I30A. s prop waste disposal facility as defined by MOL c The debris will be transported by: �� �h l � 5,0 name of hauler) The debris will be disposed of in : -AW � ) A161 10 —4me of fudiiy) -Gd_ 4� (iddrv„ or ri.+1+1y) + ynamre ofpermrt rpplic�nr — ' 12/6/2011 11:24 AM FROM: Fax Gerald T. McCarthy Insurance Agency Inc. TO: 1-978-740-9846 PAGE: 001 OF 002 FAX FROM: Gerald T. McCarthy Insurance Agency, Inc. PO Box 839 - 92 North St., Salem, MA 01970 Office: 978-744-6433 — Fax: 978-744-3575 Recipient Name: CITY OF SALEM - BUILDING Fax #: 1-978-740-9846 From: Deborah Tournas Date/Time: 12/6/2011 11:24:48 AM Pages: 2 Subject: BRIAN BOCHES Note: 12/6/2011 11:24 AM FROM: Fax Gerald T. McCarthy Insurance Agency Inc. TO: 1-978-740-9846 PAGE: 002 OF 002 Gerald T. McCarthy Insurance Agency, Inc, P.O.Box 839--92 North Street,Salem,MA 01970 978-744.6433-.Fax 978-744-3575 December 6,2011 City of Salem City Hall Salem, MA 01970 Re'. Brian Bochesd/b/a Coastline Construction-Travelers Pol#6KUB0246N82509 Dear Sir: By law, certificates for workers' compensation insurance must be issued by the assigned insurance carrier;therefore, we have faxed a request to the above mentioned company to issue a worker's compensation certificate of insurance which they will mail directly to you. In the meantime, please be advised by us that this coverage is, in fact, presently active for the period of 3/1 411 1-1 2. 1 hope you will find everything in order;and if you have any questions, please feel free to call. Sincerely, �G��/O7�h CrCy//'•�'✓ Deborah Tournas DT 1 v^ u nm ao CITY OF SALEM, MASSACHUSETTS oM BOARD OF APPEAL 4 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 j TELEPHONE: 978-745-9595 'VINE a'� FAX: 978-740-9846 KIMBERLEY DRISCOLL MAYOR November 30, 2011 Decision City of Salem Zoning Board of Appeals Petition of WLODEK MATCZAK requesting a Valiance from number of stories, and a Special Permit to extend a nonconforming structure, to construct a shed dormer on the three-family home at 208 NORTH ST (R2 Zoning District). A public hearing on the above Petition was opened on November 16, 2011, pursuant to Mass General Law Ch. 40A, § 11. The hearing was closed on November It, 2011 with the following Zoning Board of Appeals members present: Rebecca Curran, Richard Dionne, Annie Harris,famie Metsch, and JimmyTsitsinos (alternate). Petitioner seeks a Special Permit pursuant to Section 3.3.4 and a Variance pursuant to Section 4.0 of the City of Salem Zoning Ordinances. Statements of fact: L Wlodek Matczak presented his petition at the hearing. 2. Ina petition date-stamped October 27, 2011, petitioner requested a Special Permit to extend a nonconforming three-family home and a Variance from number of stories, in order to construct a third-floor shed dormer addition. 3. At the hearing, no member of the public spoke in support of or in opposition to the petition. The Board of Appeal, after careful consideration of the evidence presented at the public hearing, and after thorough review of the plans and petition submitted, snakes the following findings: I. The proposed modification mill not be substantially more detrimental than the existing nonconforming structure to the neighborhood. 2. Owing to conditions affecting the building, literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise, to the :appellant, since the configuration of the roofline does not allow for usable livin; space in this portion of the house. 3. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the zoning ordinance. 4. In permitting such change, the Board of Appeals requires certain appropriate conditions and safeguards as noted below. On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to, the Plans, Documents and testimony, rile Zoning Board of Appeals concludes: 1. A Special Permit tinder Sec. 3.3.4 of the Salem Zoning Ordinance to expand a nonconforming three-family house is granted in order to construct the proposed shed dormer. 2. A Variance from number of stories is granted in order to construct the proposed shed dormer. In consideration of the above, the Salem Board of Appeals voted, five (5) in favor(Curran, Harris, Dionne, Tsitsinos and Metsch) and none (0) opposed, to grant petitioner's request for a Special Permit and Variance subject to the following terms, conditions, and safeguards: 1. Petitioner shall comply with all city and state statutes, ordinances,codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finishes of the new construction shall be in harmony with the existing structure. 6. A Certificate of Inspection is to be obtained. 7. Petitioner is to obtain approval from any City Board or Comrnission having jurisdiction including, but not limited to, the Planning Board. S. Unless this Decision expressly provides otherwise, ,cry-zoning relief granted does not empower or authorize the Petitioner to demolish or reconstruct the structure(s) located on the subject property to an extent of more than fifty percent (50%) of its floor area or more than fifty percent (500) of its replacement cost at the time of destruction. If the structure is demolished by any means to an extent of more than fifty percent (50°G)) of its replacement cost or more than fifty percent (50%) of its floor area at the rime of 3 destruction, it shall not be reconstructed except in conformity with the provisions of the Ordinance. Rebecca Curran, Chair Salem Board of Appeals ACOPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A,and shall be filed within 20 days of filing of this decision in the office of the City Clerk Pursuant to the Massachusetts General Laws Chapter 40A, Section 11, the Variance or Special Pemut granted herein shall not take effect until a copy of the decision bearing the certificate of the City Clerk has been filed with the Essex South Registry of Deeds. 4 114a od r.. w4,_,' T`? ,.• 1F'+4`7- r` V a s r 'i t7 o f L�31 h o rxz - 5-3I X Fo ell iL y r 1 Q)IV a - k 3 ' S J _ do f Lul Leff W-A . gPoe' y s Rem f % o•c l(p oG xJtoMg0C It CA alit 11 7it CX145r- � 4 To RightFax N2-2 12/7/2011 7 : 16: 37 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 12/07/2011 ,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:U the certificate holds,ism ADDITIONAL INSURED,the policy(iesl must be endorsed. B SUBROGATION IS WAIVED,subject to the tamarind conditions of the policy,certein policies may require erd endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsement(s). PRODUCER CONTACT NAME: PHONE FAX GERALD T MCCARTHY INS. (A/C,No,Ed): FAX (A/C,No): P.O.BOX 839 E-MAIL ADDRESS: 92 NORTH STREET PRODUCER SALEM,MA 01970-0839 CUSTOMER ID C. 28WXD INSURERS)AFFORDING COVERAGE NAICB INSURED INSURER A: TRAVELERS INDENINIfY COMPANY NSURER B: BOCHES BRIAN DBA COASTLINE CONSTRUCTION INSURER C: NSURER D: 19 REZZA ROAD INSURER E: BEVERLY,MA 01915 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 PO UCIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POUCYEFFDATE POUCYEXPDATE LTR TYPEOFINSURANCE POLICY NUMBER (M%DDIYYYY) (MATDD\yYYy) UNITS INSR WVO GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED IS CLAIMS MADE OCCUR. PREMISES(Ed occurrence) MED EXP(Any one person) $ PERSONAL&&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILYINJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE IS DEDUCTIBLE S RETENTION S $ WORKER'S COMPENSATION AND WCSTAMORYLIMITS OTHER EMPLOYER'S LIABILITY YIN US 0246N925-11 03/1 IU2011 03/142012 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITORIPARTNERIEXECUTIVE Y E.L.DISEASE-EA EMPLOYEE $ 100,000 OFFICERIMEMBER EXCWDFD] (Mandatory in NH) E.L.DISEASE-POLICY LIMIT $ 500,000 II yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTffLCA7E ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SOCHI BRIAN. { CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 93 WASHINGTON ST ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE SALEM,MA 01970 Charles J Clark ACORD 25(2009/09) 1988-2009 ACORD CORPORATION. All rights reserved.