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� The Commonwealth of Massachusetts �'
� Department of Public Safety � 'J 7
y,. � Massachu.setls State Building Code(7S0 CMR) � �.
`�- Building Permit Application for any Building other than a One-or Two-Family Dwelling 7 9 7
(T'his Section For Official Use Only) S�
1 ✓�
'-` Building Permit Numbec Date AppGed: Building Official: �(�a
.� ' SECTION 1:LOCAITON(Please indicate Block#and Lot#for locations for which a street address is not available)
,
� i�v dlq7a
� i Town � Zi Code Name of Build'm if a licable
No.and Stxeet C / p g( pp ) .
9i �
SECTION 2 PROPOSED WORK
Edition of MA State Code used $77f If New Construction check here O or check all that apply in the rivo rows below
Existing Building lB� Repair Altera6ion Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Q�ange of Occupancy ❑ OFher ❑ Specify: �
. Are building plans and/or consiruction documents being supplied as part of this pemvt application? Yes No ❑
Is an Independent Structural Engineering P'�r Review required? Yes ❑ No Cd� .
BriefDescriptionofProposedWork: �!1"�'�'�L A��h /3.fTN20Ot� .QLr1vOd/fr7AKS
SECTION 3:COMPI.ETE TI-IIS SECTION IF EIQSTING BUII.DING UNDERGOING RENOVATION,ADD11'ION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and EvaluaHon is enclosed(See 7S0 CMIt 34) O
Existing Use Group(s): 1:-2 Proposed Use Group(s): f2-2
SECTION 4:BUII.DING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Zj 3
Total Area(sq.R.)and Total Height(ft) G �jOd ' ± 2�7� G�3d�S1� '~ 2�'j�
SECI'ION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: InsHtufional I-1❑ I-2❑ I-3❑ I 1❑ M: Mercantile❑ R Residential R-lO R-2 R-3❑ R-4❑
S: Storage Sl❑ S2❑ U: Utiliry❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION T'YPE(Check as applicable)
IA 0 IB O IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7: SI1'E INFORMAT'ION(refer to 780 CMR 111A for dMails on each item)
Water Supply: Flood Zone InformaHore Sewage Disposal: Trench PermiY. Debris Removal:
Public❑ Check if oulside Flood Zone❑ Indicate municipal❑ A trench will not be Licen.sed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required O or trench or specify:
permit is enclosed❑
� Railroad rigltbof-way: Hazards to Air NavigaHon: MA Hisroric Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Coivsent to Build enctosed❑ Yes 0 or No❑ Yes❑ No ❑
SECTION 8:CONTENI'OF CERTIFICATE OF OCCUPANCY
�Edition of Code:�'�!r Use Group(s): 'Z Type of Construcfion:� Occupant Load per Flooc ��
Does the building contain an Sprinkler System?: Special Sdpulations:
�_ .
�
,
.- `,
SECTION 9 PROPERTY OWNER AUTHORIZATION
� Name and Address of Properry Owner
� <.� ��
�� Name(Print) No.and Street City/Town Zip
Pro erty Owner Contact Information:
�f i�l�--- �-����
Tifle Telephone No.(business) Telephone No. (cell) e-mail address
If appficable, e properiy . ereby authorizes �
Name Street Address City/Town State Zip �
to act on the ro ownefs behalf,in all matters relative to work authorized b this buIldin ermit a lication.
SECI'ION lU CONSTRUCI'ION CONTROL(Please fill out Appendiac 2)
If buildin is less than 35,000 cu.k.of enclosed s ace and/or not under ConsWction Control then check hee�and ski Secdon 10.1
10.1 Re 'stered Pcofessional Res onsible fox Consdvction Conirol
�I�IE� <,G<-� �-����� Dkf.li�L�y,.tft765rGN_ 2l�38
NameLx egistrant) Tele ne No. e-mail addr Re ' ation Number
!Qo����s��u��� �.d'�t � D !r` �_ 8 �' //
Street Address s'� �3G City/Town State Zip Discipline ExpirationDate
10.2 General Contractor
�i[GUfF' �(i1ST��'(/`�[q �iflG
Compaqy Name
T�� J, d��Y�,cl Gs 7���
Name of Pers Responsible for Constructlon License No. and Type ff Applicable
a� �urff �'t' ��� Z M�'-v_�,eb � '� v2«s
Street Address City/Town � S� taM Zip
�- � 7v` — vc�v �g�lJ
Tele hone No. usiness Tele hone No. cell e-mail address
SECTION 11:WORKCE�225 COMPENSATtON INSURANCE AFFIDAVIT .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 pemut.
Is a si ed AKidavit submitbed with Htis a lication? Yes� No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Esfimated Costs:(Labor
and MateriaLs) ToYal Construction Cost(from Item 6)_$
1.Building $ � i�a� � Building Permit Fee=Total Construclion Cost x_(Insert here
2 Electrical $ (D� a�° appropriate municipal factor)_$
3.Ptumbing $ ( a� e�o
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municiPal�tY)
, 5.Meclianical Other $ Enclose check payable to
6.Total Cost $ .� (p7i��� `� (confact municipality)and write check number here
SEC1'ION 13:SIGNATURE OF BUII.DING PERMIT APPLICANT
By entering my name below,I her y attest under the pauvs and penalties of perjury that all of the information c ' ed in this �
application is true and accurate t the best of my knowledge and understanding.
�
Please print and sign nam fle Teleph ne No. Dale
Street Address Ciry/Town State 'p
Municipal InspeMor to fill out this section upon applicarion approval: K/ � .
Name Dare
. � `�
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections aze properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building pernut
application. T'he building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block# and Lot# for locations for which a street address is not
available)
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes � No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
� 1
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mazk"x"wh�e a licable
Na Item SubmiNed Incom lete Not R uired
1 Architectural
2 Foundation
3 Structural
4 Fire Su ression
5 Fire Alarm ma r uire re eaters
6 HVAC
7 Electrical
S Plumbin includelocalconnections
9 Gas Natural,Pro ane,Medical or other
10 Surve ed Sibe Plan tilities,Wetland,etc. �
11 S ecifications
12 Structural Peer Review �
13 Structvral Tests&Ins tions Pro am
14 F've Protection Narrative Re ort
15 Existin Buildin Surve /Investl ation �
]6 Ener Conservation Re ort �.
17 Architeclural Access Review 521 CMIt
18 Workers Com ensation Insurance �
19 Ha�ardous Material Miti ation Documentation
20 Other S ec'
21 Other S ec'
22 Other S
*Areas of Desig�or Construcflon for wfiich plans are not complete at the time of application subauttal must be identified herein.Work
so identified must not be commenced unffi H�is application has been amended and the proposed construction document amendment
kias been approved by the authority luving jurisdiction.Work started prior to approval may be subjected tn Mpk the original yermit
�.
Registered Professional Contact Information
�Nl�� �—rKoc.s fG� q1�Z°-�-�1�__ 2PiD 38
Name egistrant) Telephone No. e-mail address Registration Numbe
0o a 1� � !� � � S � !l
Street Address �(�jj� City/Town State Zip Discipline ExpirationDate
Name(Registrant) Telephone No. e-mail address Registration Number �
Street Address Ci /Town State Zi Discipline Expiration Date
, Name(Registxant) Telephone No. e-mafl address Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
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' Remove wmdow and
�^ ' Room to be fuly repamted . ' Remove/replace cabmets
' New vanit /sink/faucet mfill openmg. Wall ' Remove/re lace sink and faucet ' Remove wmdow and
Y cavit to be insulated. p infJl opening. Wall
' New floor Fmis�ies to match ' Remove/replace floor with sheet mnyl camty to be msulated. pi .
' New todet existmg. ' Room to be fully repamted fimsnes to match
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Scale: 3/I 6"= I'-0" �S'� ' LEGEND: p
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&� �tv,� � � � _ _ � WALLS AND ITEMS TO BE REMOVED '�L ' ,�s� >.
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�SG. t�' i f�r P.a � A .
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y� CO CARBON MONOXIDE DEfECTOR, 11ARD WIRED A �
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' New tub and shower controls ' New tub and shower controls
' Room to be full re ainted � Remove window and p ' Remove wmdow and ' Room to be fully repamted
, Y P infill o enm Wall ' Remove/re lace cabmets ' New vamt /smk/faucet
' New vamty/smk/faucet camty Co be msulated. ' Remove/replace sink and faucet infJl opemng. Wall Y
' New floor FimsFes to match ' Remove/replace floor with sheet vinyl cavity to be msulated. ' New floor
. ' New todet ex�sting. ' Room to be fully repamted FimsFes to match ' New toilet �
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, ``b ��:;, C = - J WALLS AND ITEMS TO BE REMOVED � s. ' a °
No.2 .,a3 �'.�, . O p � £ �
g�,� , . �� ....0 NEW WALLS � : �
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�.� �w� � EXISTING WALLS TO REMAIN � �" " � '
��;�;;_�-���°,.;� OS P SMOKE DETECTOR, h1ARD WIRED, PI10TOELECTRIC TYPE
r,kz;,;�,:,.�.�.��`�
�` ''��'';l�l'�{ CO CARBON MONOXIDE DETECTOR, f1ARD WIRED A3
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•" �� /' ['UBLIC PRUPRERT'Y
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° DEPARTNIENT
.��ub Mf I Y:iNIN��I I
\�\1�M
I!:\VAMIIAGIU.\!18[l•T �$dll•.N. M.1U.1�.111 q�1 n�177,".
1'ci. n}�iSvi�i3 � f�x ��7M.J�C•��.rM
��'urkcry' Cumpen�atlon (nsuruncr �f(idn�it: liulldcryCuntnctur�/ElectrklrnyPlumben
� � ilfcant In unn•r110
p��L1� ���q� P� ' � rinf le 'hl
` �l;iiii�Uluu�w.ii)ram���iinrvind���duu11: T 13��,� .
���dr�s�: �1 G��U11,V J1� 5�11' �
City,.Sr:ire,ir��__ u- ��.R��11� I �}! Phunr i��
�n�ou�n.mployar?Check ih�:�pprnyrlm�Dos:
I I,� 1 ;un a empluyar wiih 4, ��YM��/pr��joet(rcyulrrJ):
❑ I;un�guncral cuuuuto��nd 1
�mpluy.u�(iull�n�Yut p�rt•�ime).• huv� hired ihu auh•cuntracwrt (�. ���w�unxtructiun
-'•�� •mi�tula pmpncux or p;uincr- li�red on rht art�chcd shaeR � �•
.rliip;�n,l luv¢no mnployc�y Thea�eubcon�rscron hav� ❑ Remalelin�
��orkin� �iu m�in�ny cap�ci�y. wurken'eomp. �nawonee. d' ❑ �moliriun
�n�woHt�b'cump, iuyur�nc� S. Q W�an n c�ipontien;uiJ iq 9• ❑ OulWin��dJitiun .
l.OroyuircJ.) o�Tlccn havo ex�ni+uJ ihcir 10.0 Electrieal tepain ur additions
1 ,�m u homcu�vner Juin��II work riyhr uf�x.mptinn pr hlQt, I LQ Plumbin�rc�uiry ur aJ�li�inn�
mysclf.�Ko �verM�n'cump. c. 157,§�(�)�anJ wr hirvu no
in.vurancu rcyuired.l � .mpluy.rs. (No worked I=•O RWI�ft•(lylq
com(r. o�surrn�w nyuinvl.J I).�Uthar
•q�y.���pLcaY ihW rlxcY�lw��I muN alw�ill uw tla�aa�wo 41uw�lwrm i
' I�um.n�rrrn..Iw��Jinu�ihi�eRlJ�rh inJlu�in�ihy Y Mw wwtui evn�yn�uuluw ryli�y infi�iwwiun .
�C��m�r.wWn ihM�M�ct i�i�Em1�n�W ana�Mi,�n ulJil7urW�MM duwi��iM n M o/fN Ia�.�NMf,�1ChM aMI AfN rwlt+nwr�111J�ri�inJluYin��N�.
/nin un eu�ployrr ihu�l�prvviJlnX iv�rAira'ru�nprnmdon b�.mrnnrs�'w iMy emp/upra.r. Br/ary la rA�1 y ui����i
iulunnurGin,
Imur�ncu Cump�ny Vamer�_— . . .
Pulicy 4 ur SvlGinr. LiC.d: — " ----
� �� e '` ' . E�pirulwn D,ite:
IJI7 �1W ��tl/IIl'S!1: I �1 I' p:�J�/M1�.�7� O` 11p
��t�cA u cuyy uf�li� �rorka►i'cumpcm�tlun pollcy Juelur�llun puy�phowl NI rA�,pollty numbur�nd expl►�rlun Aute).
I�,�luru w,u.uro cu�eruyt as raquircd un�kr Scctiun:JA�I'�IGI a 131 eau lead io rh�impa�ition of'uiminal penalria o/a
tina ��p n�SL1a0.r��nJ/uruue•ye�r i�npriv�m�nenr, �� ����II,,.�ci.�l�wnulouw in ihu �urm ofo 5Tt)p WURK URDER �nd,t fin�
otup ro i�SQ.rM U�IJY d�Jlll)1 1�1f v6�lamr. Ik advi.tid rhur u cupy uf ihi�..iu�emmu may bc Iurw�NvJ iu iha Ulli.a�j
LIP�\II�JIIn14 JI ;II1; UI�� ;q�i�i.i�r.��.�.��.��.���� ���ilic�Luh.
/du hprrAr�rrli��iui,/.r d�r p��in��ind �im�/�i�•r u/yrr/nry ihui ihi in unn�l/ow
. l prvriJeJubur�ii rrai on�/�•orretC
;,., � ,,, . _ . Db�►F� sh,�a�l ,�1�bh��, pur ��ai�v,ti�r �r
���,, : . , A�I�r �l' PM►�I� �66�,h
i �)%/Jciul n��o�i/y. /)�,�nl�rrii�iw dil�ureu. iu A�ru��ry/eaJ Ay a•irr ur ione,i��lrruL �
I i
I (7fYu� 1'q�rn;
I — Penninl.kcmr Y
I��uinq .\u�hi�ri�y (circla nnc�:
iI. II��.�rJ ��!Ilrahh !. Iluddui� Ucp.�rtmcnl I. (:il�.'fu��a C'Icrk J. Llccfrir�il lu�pcclur 9. PhnnOiny h�.yector �' .
I 4. Ihher
j l'�,n�.�ci P�nun: �_ i
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i
[nformation and Instructions
„ raon m ihe s¢rvice uf�nu�her un,lcr.�ny��n�n�t of hirc,
�I.��;.�chu:etu licnar�I Law�:h�pat 1 i2 r.ywrex�II uuplu�ars�o prov�da wurken coinpen+�U��n fof ihc�r cmp oycet.
I`unu,uu w iins ,utu�a. an r�pfu�'r� i+Jctincd,u"._e ery f10
:apreea-or �mplieJ. or�l nr �vnuen..•
�n.�npluyai i�dc�in¢d as"an �nJrviduai, Purtnenhip.,�ssoeiruuo.�oryurouun ur u�her Icgal cnnry.or�ny two ot m�re
►u in �m loyee�. Howuver�he
,�i ihc 1.�(Cy'JUi�Cf1y'�►�, �A j JJlfll CI71�fpf110. JIII�IIkILL�IIO�IIIQ I��'iI fCPftiilllJUvH JI],lCCJSt{I CI11pIU1 JI�M e
,ecewer ur uuaiea ul'.u� indiv�Ju�l. Pr�menh�p.:.sweuuua or o�her le��l�ndiy.�mD Y � ' P
• non�ta�lo main�enuncs.�un+auciion or repu'a wuck on wch Jweliin�{huuu
�wnet uf a Jwellin�{hou�t I+avin�not more �han ihrea�p��enu�nJ who residef�hetem.ur�h�acu
.la.11�ny huusa ,�f uno�har who employ (+� ,
,,r,�i� �he araun�ls<�r builJin�+ppurten:uu iherc�o shaU uo�becausa of sucA amployment be JaemeJ w ba�n r�nployer.,•
�luL ch�p�er 132. �=SC(6) also staeey�hu�"�v�ry�lal�ar loeal Ik�n�la��+k�sty ihaU wildhold Ih�Is�uaecr or
Ilrae�wl�h �he`Inauronu cov�roQ�req
ulrad:'
renewal uf r IleeaH ur permll lu uy�ran�bu+in�sf or te eomlruet bufldin�{�la �of iu vo i c. SYbyv ai�s+hall I
:�y pllcunt nbo has not produ�+d�S C 7 1 aw eiriNeuher he onunonwcrl�h nut my
�JJi�i�wlly. �IGL cl�up�ar l S_. i- ( i
anmr inro iny�untr�al'J°fet haw been p e+entedbo ihe contc cI�i a�1whore�yviJence ul'cump l i u�ce with the insuranco
r.quirom.niyul�h�t � i
.ayyUcanu p 1 to uur tiwa�ioa an0.it I
niauon atYtdavit eompletelY�M numbed�)v�II wi�'h hair�anillcute(4��
Pl�:�+a lill.wt ihe worlcen' cumpe wi�h no employ��ey uther�h�n�ht
neccsyucy.supply vubeonerrcior{s)n;unaf�).rdJrtsqn�l'+nd P
worksn'eompenw��o���y°�°Of' �f�°LLC or LLP�havo
inyurunoe. Limital Liability Companiu�(LLC)or Limitad Liabiliq PaN�enhip�(�� )
manban or p�an.°t� u red B��lvix������Jn�vit m�y b�iubmitmd to th� Departrnant af Industrial
.mployaa�.u poliey i� req � a�tmcnt o[
lieation for th�pannit or licen�iy b�:ina requasted.noE tha lhp
\cciJann for contlm+a�iun uf in�uraneo covuro�{a �I/0 p�fYf�(0 fI�M YOI)VYI��b1 Y�`o obmin a'workcn•ou
hu �.�„�me�io�hs city or iown thut�he�DD �aciooi rcQnrdiny��luw ur if yuu ure re4
InJuxtriul Accidenu. Should y�u huve mY 4
���n��atiun policy. ple�c�l the Depucm�ent yt du nwnbar Iliad b�low. Self-in�uced compauie��hould eatar ihev
.alt•inauronn tieans� numb°�un ih�n ro riute lino.
Clry o�'foM�O(fklali
�Ica+e hc.ura th+e�hQ ��1�uvit is comple�a :�nJ printed 1��{�bly. Ths Depacement hw pruvided u�p�u:d•rt�ho bo�u�m
��t�he�IPJuvit fur yuu w lill out in �he¢vent�ha OlZlca uf(nvesti�{atians hrs to cuntact yuu re�{ordin�the applicanc
ivea eu.nead only sub�mt uns adidovit indicwin`c`neUt
I'I:u�� ba surc�o till in iha pu�++iuticenye nwnM:r which will ba uscd;��+referencc numbar. fn rJJici�a,an�pphcant
ihai muat submit multipla pennio'lica�ma aPPlications in any� Y yi; roviJcJ tu�ha
���licy iuf'ormrd"'�he uFA�uvryhu ha� bsen ofAe ully aumcp�J ur morrkedlbyi I�uai�y or�owe i�y�iunp in (' Y
tuwnl,,'�\copY
upplicant a�ptoof�hat a vuliJ�IRJuvit is an fil� for N+tun pe�mite ur licensa�. A new a�TiJnvit mu��Ee �llled out aoc
�i°�,�,i ���R�enyn� permi w bam laave���)`�P���u�VOT'reyuired coJ ampletc �h�e�ffldavit ���ereial venmrt
I ha �)111��UI IIIYtVfIl�'J11U11Y 1WYIII IIAO W U1811It )'UU 111 71IV:IOCC IUf YJUf.00pero�i�m and+huuW yuu h��u.�ny 4ue�uons.
plc�+e Ju nw hasi�aro ro yivc m u c�ll.
fhe U:panmeni'+ a��iror�� c�lcphune anJ f,u numMr:
The CommeaWeolth of MauacAusetu
, , . • pepazaaent o[[ndutitrial Accidents
Otfle�ot[svaUqadan�
600 W�Bt� Street
Boaton, MA 021 I 1
'fel. p 61'1-121-4900 eat�06 oc 1-871-MASSAFE
Fax M 617-727•7749
, .. ,..� <.�n us www.miv.aovldi�
�� OP ID: RP
'���R�� CERTIFICATE OF LIABILITY INSURANCE �oei o�,��
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�3�, AUTHORIZED
REPRESENTATNE OR PRO�UCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the eeRifieate holder is an ADDITIONAL INSURED, Ne policy�ies) must be endorsed. If SUBROGATION IS WAIVED, subJect to
i the terma anA condifions of the poliey,eertain policles may requlre an endorsement A sfatement on Mls certlficate dces not eonfer dghis W the
eertHicate holdar In Ileu M such endorsemen s. �
PROWCER 781-914-1000 T T
Thomas Gregory Assxiates Ina vHoxe F�
607 Edgewater Drrve 5235 787-246-2601 ac No:
Wakefreld,MA 07860 E o��
VincentJSutera PR°°ucoe .pAGLI-1
INSURERS AFFORDINGCOVERNGE NAICO
MSUREU pagliaPlastering�I11C. INSURERA:CI�IZQfI3I113U�8fiC@COIfIF10O]/
� Independentlnsulation,lne. �xsuaeae:HanoverinsurenceCom an
Attn.Donald Paglia lNSURERL:
60 Concord Street,Suite 3 �
North Reading,MA 07864 ir+sursen o:
INSURER E:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERI00
INDICATED. NO7VJITHSTANDING ANY RE�UIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICAiE MAV BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CWMS.
INSR rypE OF INSURANCE p�3UB POLICY EFF POLICV E%P UM�
GENERILLW181L1TY EACHOCCURRENCE E �.00O�OO
A X CAMMERCIALGENERALLIABILITY LHN853820904 �y���0 �y���� PREMISESEaoccuirence E 'IOO�OO
CLAIMS-MADE �OCCUR MEDEXP(Myonapenon) $ Sr�
PERSONALBApVINJURV S ����•�
GENERALACaCREGATE 5 Z��Or�
GEN'LAGGREGATELIMITAPPLIESPER: PROOUCTS-COMP/OPAGG $ Z�OOO�OO
POLICY PR0. X LOC E
� AUtOMOBILELUIBILITY COMBMEOSINGLELIMR E � QD�QQ
(Ea a¢itlanq
B ANVAUTO BOOILVINJURV(Perpereon) b
ALLOWNEDAUTOS BWILYINJURV(PerecciUent) $
X SCHEDULEDAUTOS MN8555720-04 �TJiS��O 12115H1 pROPERTYDAMAGE
X HIREDAUTOS CV COMP$500 DED (Peraccieenp $
X NON�OWNEOAUTOS ACV COLL$500 DED W/W S
5
UMBREWILIAB X OCCUR EACHOCCURRENCE E 6�000�0
EXCESSWIB CL41MS-MA�E AGGREGAIE 5 6�000�00
B UHN853620704 72175N0 72115111
oeoucne�e 5
X a r+nori NIL s
WORKERSCOMPENSA710N X WCSTAN- OTH-
ANOEMPLOVERS'LIABILITY ',L'�'O ,�y��,�' S00,00
A OFFlCE�RIMEMBEREX^CLUDED? CUTIVE Y� N�p WBN 4618742-02 E.LEACHACCIDENT S
(MaiMatorylnNN� ELOISEASE-EAEMPLOYE S SOO�OO i
tt yos,eeacnba untler
OE RIP N F PERAII NSEelmv E.L.DISEASE-POLICVLIMR E SOO�
10 Days Notice of CANCEIlLAT10N
II policies for NON-PAY OF PREMIUM
DESCRIPTON OF4v ERAl10N /LOCATIONS I VEXICLES(Almeh ACORD 101,Atltlitlaul Ramarlu ScMdule,ilmore space Is repulmtl)
Plastering or Stueeo Vl�ork u
16 Pralt Street LLC
CE TIFICATE HOLDER CANCELLATION
HOLL002
SHOULD ANY OF 7HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
7HE E7�IRA710N DATE THEREOF, N0710E WILL BE DEWERED IN
Hollo2n Real Estate VenWres, ACCORDANCE WITH THE POIICY PROVISIONS.
Ine.
18X: 878-744�OSGB AUTHORIgDREPRESENTATNE
47 FairmountStreet .0,�
Salem,MA 07970 'd��
� OO 1968-2009 ACORD CORPORATION. Afl rigMs reserved.
ACORD 25(2009109) The ACORD reme antl togo are registered marks of ACORD