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11 PYBURN AVE - BUILDING INSPECTION (6) The Commonwealth of Massachusetts RECEIVE Board of Building Regulations and StandardSSPECTIONAI S RVK91 OF Massachusetts State Building Code, 780 CivIR SALEM Reyise��/ry 2011 Building Permit Application To Construct'Repair, Renovate tfPt;�li515ti 1 One-or Two-Farnil Divellin y s This Section ForOfficial UseOnly: 1 Building Permit Number. Date. -pp(ed-" -Building Official(Print Name). - Sig,tgturey r I SECTION is SITE'INFORNIATIONV.' 1.1 Property Ad s: 1.2 Assessors Map&Parcel Numbers /l I VburN I.to Is this nn accepted street?yes_ no 6►ap Number Parcel Number 1.3Zoninglnformation: 1.4 ProertYblmeiytlona'=a ° ei11) Zoning District Proposed Use Lot (sq R) Frontage(R) IS Building Setbacks(R)Front Yard : Side Yards - RearYard - Reyuin:d Provided -Required Provided I .Required Provided 1.61Yater Supply:(M.G.L c.40,§54) 1.7 Flood Zone informations 1.8 Sewage Disposal System: Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposrtsystear 0 .. Check if es0. . SECTION2. PROPERTYOWNVERSHIV 2.1 Owner'of Record: pp Lon c Pe�ruCr I & /es~i .Nome(Print) - � - - 'City;Store,Z1PNo.and Street / Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED?.VOR[C=(cbeek nU tba6 apply) New Constmction 0 Existing Building 0 Owner-Occupied 0 Repafrs(s) 0 Alteration(s) d Addition ❑ Demolition 0 Accessory Btdg.0 Number of Units_ Other 0 Specify: Brief Description of Proposed Work=: G t•r. a r C - SECTION 4:ESTIMATED CONSTRUCTION COSTS = . Itaut Estimated Costs: Official Use Only. Labor and Materials) 1. Building S _ 1. Building Permit Fee.$ Indicate how fee is determined: 2.Electrical S u Smndard Cityfrown Application Fee 0 Total Project Cost?(item 6)s multiplier x 3. Plumbing S P Qther Fees: S 4.Mcchanical (HVAC) S List. 5.Afeehanical (Fire Su ression) S Total All Fees:S 6. Total Project Cost: .S 1 Check No.�f ZQ�heck Amount Cash Amount: at y� ❑Paid in Full ❑Outstanding Balance Due: M�tL4[a:Ip I ko (l i r 3b1 y�, SECTION 5: CONSTRUCTION SERVICES 5.! CoItstiu'ction"SupcitiisorjLiceuse(CSL) �}—)G/"] - j L—icense umber Expiration Date NamedfCSL1HolU0 C— KAL 0. ) List CSL'rype(see below) LA, Eric W.Palm Type oeseripuan .. No.and Street J M"14 treet .. U Umesiricled Do it "to 35,000 cu. It. Salem m A 01970 R Restricted 1&2 Fumil Dtveilin City/rmM,State,ZIP M aso St RC Roolia Coverin %VS Window and Skim / SF Solid Fuel Burning Appliances 1 Insulation Tele hone Email address D Demolition 5,2 Registered Home Improvement Contractor(HIC) 11 o g q 3 i Z /&, HIC Registration Number Expirution Date HIC Company Nam IC egt N Email address No.and Street Ci /town State ZIP Tee hone SECTION 6;fVORKERst COM1iPENSATION INSURANCE AFFIDAVIT c:ISZ.§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 a building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION Toe OWNER AUTHO1tIZAT/ON"TO BE.COMPLETED"W HEN': OWNER'S AGENT OR CONTRAC[ORAPP[dEff FOR-BUILDING.PER&IIT' f,as Owner of the subject property,hereby authorize frr`C Pk lr,�r t9 act on my behalf,in all matters relative to work authorized by this building permit application. Date Print Owner's Name(Electronic Signature) SECTION 7b:OWNERu OR AUTHORIZED AGENT DECLARATION By entering my name below,/hereby attest under the pains and penalties of perjury that ail of the information curate to the best or my knowledge and understanding. contained in this application is rue and nc Print Oiv.rer's or Authanud Agent s Name( ectrome Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,of as owner who hires an unregistered contractor (_not reistered in the Home.improvement Contmctar(HIC)Program);will tot have access to the arbitration --- -- program or guaranty fund under 1,I•G.L.c. Id2A.Other Importani inform"u on on the at Aw gram can beto`un a tvww nras cov'oca information on the Construction Supervisor License can be found at www.mass^u�.41ns t 2. Wlren substantial work is planned,provide the informationn} belng gamge,finished basement/attics,decks or porch) 'rota(floor area(sq. ft.) - Habitable room count Gross living area(sq. ft.) Number of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches 'rype of heating sysicm Enclosed Open Type of cooling system j. 'Total Project Square Footage"may be substituted i'or"'road Project Cost" Avlamach sett Rome hm17ds loon topram.,bom oo oftbesare�xome7maravemrnrem IDIIl�g11�t�'�ffi �(� fC`®Hfl�$"act p C �lopffiTmmP.ptvGstl¢eFppppt912Ea0a onsC6 marA Rome o0°1s1>®0-gW A°Yoensoo pannm6g]y7�A73-8e7b8�7o r142A) bedvotm3ade adAusmc weagoLh 6sm�,d imayo[Vteadmm Ya aayaA 1-Itama&ee copYbY-✓O- the name 3757 oraaaar weloite �Wa@a¢tpr.IIrxfpP6tafi0s3 Lonpppprr e fru cc ; compaoY ama Stree;Addres( nr eaPoyt Otirecit ) '' Coaatpctur/SaA tlmlic W"herimL LLI,YN� lUli CityrTona 6p+J w°O� Stae:. jade.„ feelsssrt Avenue { _ - HtcmtaAddaass(o�aio2 Dapime Fhouee"'.. - -• 7C/ q Eiinog phene 3 /O `O City?rma State Mailing AdwiI(it di5vmtEmn abmx) J 9��- Ztp Code Hmia—Phme 7!"/)�,,t— !J p/y Fedsat HmPmYerID ar SS Nmabc RaKc r".earagt-,�m dodtefdll �'= '3 /�•/ (D (1 iv degil d`a Void, com°Ietad,Orb'Wor$for the}]oaanrynar sP`n•YioS therype.taaad,andtFad..r �t /-r Offieiak m7�bry)us-d,� C' e D// 14-1 oPitdwi�eseoio,dj he wntra gbui3dm9POrmits amregaimd� �C� (P3sr-OMW;oc ctarasthebomeounets PrOPassi Startan3 ComPtaliaa SaS¢CWS2 agent: beedh edote-lhefnl7 e£r-adezi� E'jeur ocrW Pe�;�a,;-IH he erect to wlea ei,-e�cesbe Q0. Bseherhdcm7l flWa*fit¢�zz?raWigr Ruad -Ymd the=tmctl s etI arise;cep=,e':ag�£zr39�.tj Ar'wa�Pi:iWWs©f �Ihte w7ten oontmcim-wgt bcgia Omaa�ed wad: ni.c ,ne ar g—=-d c'oYmanFSolaedalc Dare when mnaaated aydr an716es:ebyynnOapYaompleted, the Coniraatorngt�mPeform thcwadc,fmvjsb dre am Payments vti C°�a0diahorspxiiied above _ bemedee0cordipgtobaeolfovdn fnrWetoml S gschedde: — f YsdL•_-upon sirdng coatia,q(aat m el=d 113 aft]r or etpWeoatrzctpaw ar tnemsttir, alorda- °non completion r�s adriebe eris i 2 eoan of &aas) / or upon camnired !m o- noon ledm nfdre entract (t.awforbids rvc mllcrdvgmaadaVegaiPan demanding fM md_-m vefinema evrrmotbesymfm s ©tmtr7 coatiay,isramolemdto borbparty'ss°' m me_thc "ahieei rat begins in o.-de, mhe !w tisf5ction) m'apl ooschedeln(++°) lrnav^-tl¢.B5('°)Eimicif r-a Um rv;e:c�Wepms,o-of C�ba Noi Lie a�'d pim yr t rdtirn mvs:hetiy my no:dmta adv+r:mtomearm o @)Ne-ayyy emtm trYlhemvtmttorbefam ea -htpns mOrO°ordaasafiedule °f�YSPe<'ial c9uipmmt cremaom made n,mmy Pa-h Ysuba � coiein rtnv[v 1.�rr vmvedvd tnm^mv e_ Pa;}/sWemtr+ IhgIQ Ot°ra.�msto be selydyr t..�"" Q'.atorutiliazd hythe can xp0o_nbteFar °QYcr rJt erirn[ermavneaa niarerials old labor render it isa a On 1b000a�tort ent OR ofthewor% mint he meberro the Cm:raet Acce-+ mdtc-agrr�mbesolel °�O�O�vtSardi�s ofrbe+ mvaanl a.mn2-Unan si }'SeSpansfWeforal! .nLoes afrmy WI wnrct shall notim l,. gumgddsdocnineo, PaYmrata to nH;ttbmmanGom far czmfvpY bafora si Mgdms�bm°arob5ersequityta[ereyibnbano x�d���laty. Unlesa Othenviszn°ted withhin gninihis ,yq- rsidonce.Revieasthefol}mttian thisdocon.the o Don't hegriinrediatosi g®tionsandnadcet ° iVzce sure the c°abar"lein 8 lid 1q. et-Fa[.�timeto reed _ subcomantors to been 'g ,lid bnanr:3n�tCont zctao Yu°desgOd it Asl: �gp roe' tation to �taitb ds tradon. 7-aalaw 4' oasiFsumedtmgismr3ear. bytNdagio WeDiectorm l0�pintipl Ho meIntere yea[ConL�ator ra4oiresmostbemcitnotoyament wntraK ° n^-acopy of, -W, `i05m"°C0°Asl tbeC 'x0Dm 3I70,S3ostoq tylA 02I1R � Youmayia to°tor otsnnd P oaFaF- Ontmpori hisim-nr- Ysaltiog6t7A73 70�SEE-n ° -Kaorvycuri amand, msarana^d°gmaeat mwr0mpanyinfmmaSoo°n Wat 253-3757. Crnidetotheill e' �ponsfndlden Readthebnvmtmat 'Y°°Om Opn�cOvarage,ornssto tmp:avemeniCmaactoriar. 7irfaanrioa m tbereversn9de ofthis fmm and You my caaoet dais, got a copy o mer ftbcConsa abir hnsiaae>td-mrc otij dcc-51 e°rbaacerte�([„OmtxWs the ccaaegotsa°�nl pltxof "-D Rrt�^ g6JpgOft�-`a�aemmat Sec t6omen��oas"ed.bJ'tete�am svtor 6��•Providndyo°aatitydte ran re=d_amuoarU��'IST mmctaednodreafa�-au"Ri>,t'an fmm�rzp vmlaterthnn vddnigbtofdae _ -r'FSAI{ng• Thmalim o£9hisriem. inn b_ F N-y 1'2t ' �-;psmpy-+-a.+!dSv ca r]a --rv�ZcurJd 4Pha` .�V4F H r' w e �f{i/.pJ�, S gpote h oc D / �A CQnaaC[aYs Sipiabvz Dm Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor-however. The contractor would have to resolve any dispute he/she has with as homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor.may,.sub_rrWhe dispute toa private arbitration firm which has been approved by the Secretary of the Executive OEfice Of Co uu��rr��!!er Affairs and Business Regulation and the consumer shall be required to submit to such arbitmtipu,ast.fto'Uiia'@ n id5sachusetts General Laws,chaiiLer 142A. 0 Homeowner's Signatufu •„'C�o Contractor's Sismature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties_ Homeowner's Rights A homeowner's rights under the Home lmprovement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Pond provisions of the Home improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose_ An enumeration of other matters on which the homeowner and contractor lawhilly agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Lxecutiou of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the otherkept by the contractor_ Any modification to the original contract must be in writing and agreed to by both parties-Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself m be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work 'Withdrawal of funds from said account would require the signatures of both parties. Additional Information - If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a Lze copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affair.and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at htmJhxgiiv"mass.gov/ocabr/ if you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at fitinahvanvmass aov/ocabr/ Go online to view the status of a Home Improvement Cormactoes Registration httv-//db state ma.us/homeimorovement/licenseelistasn For assistance with informal mediation of disputes or to register fommi complaints against a business,call: �-Consumer C plaint Section ' omey General -'"• 3tw 617-727-8400 AND/OR Better Business Bureau 309-652-4800.508-755-2548 or 413-734-31 l4 version zr-I rnit_oto N The Conzinoizwealtlz ofKassaclzztsetts Depart of__"dalstrialAccidents I Congress street,sirite 100 Boston, MA 02114-2017 www.ntass gov/dfa Workers'Compensation Insurance davit:Builders/Contractors/Electricians/Plumbers. Applicant Information TO BE FILED WITH THE PERttiIITTING AUTHORITY. Please Prtnt heatbJv Name (Busmess/Orgamzahon/Indtvtdual): A (antic Address: "I P. 7e9�Clr[3e City/State/Zip: Phone M Cj 7g - 7419 _ 8 [9 ?S [6. re you a employer?Check the appropriate box: 1am a era to er with _ Type of project(required)- P Y .5 employees(full and/orpatt-time).❑I am a sole proprietor or Partnership and have no employees working forme in �' 0 New aonStiUCtion am•capacity.[No workers'comp.insurance required.) - s- Q Remodeling® am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition ❑I am a homeowner and wsll be hiring conactors to conduct all work on my property10 ©Bwilding addition ensure that all contractors either have workers compensation insurance or are soleproprietors with no employees. I I-M Electrical repairs or additions 1 am a general contractor and 1 have hired the sub-contmctors listed on the4nached sheet12.❑Plumbing repairs Or additions These sub-contractors have employees and have workers'camp.insutanc73.❑ROO-repairs we are a corporation and its officers have exercised their right of exemption per MGL a 14- Otherfj'V� •-rtb.tt 1 151_,x 1(4),and we have no employees.[No workers:comp.insurance required) Any applicant that checks box�I must alsoflll out the section below showing theirworkers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors MUSE submit a new affidavit indicating such. -Contactors that check this box must attached an additional sheet shovine 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 ant an entploper that is providing workers'cozapensation insa, ileefor;nJ1 etnplopees. Below is the police card job site i,rforntation. 1 Insurance Company Name:_ (iv^j r {n Policy r or Self-ins.Lic.ff:_ /J L/ I Expiration Date:��' Job Site Address: . << PNburty d City/State/Zip: le(r.-t Attach a copy.of the workers'c mpensatiOn 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office Of Investigations of the DIA for insurance coverage verification. P do kerebp cerfifjr under the pains a id penalties o.�pe,�7Fsry titer the information provided above is true and correct fr Signature: Date Phone,.. 7YQ:nd L/ F[. trot write in this area,to be ceittpleted by city or town official Permit/License mrcle one):Building Department 3.City(I'own Clerk 4. Electrical Inspector 5.Plumbing lospectorPhone#• ' C..ri:c'f=-.�•-• -r 8-'-� l�s�Ll:D OtrU i �f:' -^a II"1'i;%S:If,'.1cOGES iVO=:iF[i�@t.� Rr!�>�cl?BF ,rgCr Cai,lMl"UJ/DP/Y%VY) a is%�3•Pft<Q1fL?rialP COAL �lt7inn;i: I MI ELIELY OR REC 1iIVEL'r ctAcAl R Ai iJG+RC�!i?S LiPMI I, F! -n^x vli Pt=QDLCc? n 1Ce D0�81UT C011!g - t D;E).'TE!UD OR AL-E13.-'13F Q tr Q a'�HOLDEP. ?fife `� - „VD�:dECERi!FIC:t7t';1ULD' ' -U?E ACOf?r> :;C?3 !rsEfli%icet55(s'IQi\GIRidSUPERS5D 6."h�EPOLiC! 1 f h1T: e ce_'iiicate hold=r is an ( ):t� lrtTR?zmJ EPRESEf iFJ??!VE.11=rms and condirions ofi - '�Oi 0P AL e ISURE• -ificate holder f - h-Ro!icy,ca,-2iD PD!fcies e, v-e -_O'`he po!iey(i�)pus.hs end - �' n heu p _ �a _ _ d_ - rsuchendoseaantfsL 9�r,-a:,d endo,>-ererrL ;d.; !r S138RQGa!ION IS IIJ!-t7VE.Q,subJec;io i"he I n=ODUC'cR ZatarlEli an}his CEYiRCciG d0as 00i ea77i?-riylrS io the i E.If - !CCPJ7�CT 23= tv CEI\I_r:L' 5:R-EF %9A 01760 G iii 2 RDD>a>_'SSe INSURED, y �;� In!sURER(4)AFFpROIIDG CO? e CYEtr - +ERAG_ rt- -FGI$y?,aTOA! 11IiJSUREp,A;Ab,F�Z11.gNZDRICR - ,y WAtoom I IidSURc'R 4: IhSURgrPCECpdfPr -_���:'='-_t i a! 11 SUPER Il f S�-EAd.eai 01970 - UINI_URER D. { ! : ! i CDVEP,AGeo (1PoSURER ilfta`iS qTC CEn-,=Y r.�R`.-nE Pat CER7FfCa7Ei�Uirr6ER: :! Nt'i.iE?UIRE,',iEi:z',En ICES aFLYSURAN.C=US=7•, ! A.=FORa 21'<,;E POLSCi OaECalarJ, OP yuy �ELpt TAl Pdi}CCi;1i:SE. EREII o'C.SU..Z..J.E Ct-i i0pR�07. ELc:TiS7--1RaPECi OR BEPO:fRCcY+ !OaVa NUMBER. TOSl,11CR7H1E C'3rC-;CkiEG^Y3E 65UE7i OR,JCii P b:,3yP� --, LLiF!E�FFiig,�,CLUa^!ON3 Lnp C0MOT(a::S aFOLSCI-ic. LpT_pNOFJtJ E�+a�U(;��o L:G TYf•E CP EiaURAkCE' �"'Dr'�'•t/Bj-� _ _ POLICYh.0 P -''--r OaT_ ` I GENcRA!L IA4SUT/ ( L • ' nE� j OUCY o aL:CY a,P I COr.;h;EF.CiAL GSVERA r I r f fF.v'.1aa1YYYY) i l_/A37r 1iY LMI i CLAIpiSPRfiDE 1- -ACH OCCURR.-!CE!( Ij CCCUR. ,5 3 'DAN/AGETo REv7ED IS t Gtn!'-„ e i �`.''REi!f1SE5(c ocwr2nce) 1 _ GGREGAle Ui4fPAPPLIES PER. _ ! !�I ex pyyanz o=rs-j 5 _4h_a FOL(CY PROJECTi ;LOC f ( - 'PERSO\AL AHD'/!,,L1URY j, Is IryLLkgl! ' ! 4GEPIEAAL AGGREGAie e i It y AMYA[TO r ' IPRODUCTS-C r�f / _ Q)AP/OPAGG e Imo! Al L OINP!cD AUT05 j ' I I- 1 i�' SCr.'-^J c - - f ! ' iCp;U41n1EO SRdGLE i UI-2 A t 5 U.OS i, i hur' - -O AUTOS ! r +EODILY IIt•IURY Oc�.n •L^! lE7 ALr05 i-(P aPetsonj 1 I�� I -',4pDILY!iVJURY f` I f I i S t(pa ecc 1 U:i3RE r .r ,: I !PROPER iY D,vbiAC-E S •1f c 1-'+_I"5 L r OCCUR -- (Pa ecedf,) � AL'n ,�CCsivUip_ !OEOUCflBCE EAC..v I ? CCCUR.RERrCE i EN5TIOA .A i 1'rOR,:EP.'a 1 x s cof;iFEftsI An!e win!Ov uA�' ; Iu / Is 3!Y FRpPeR170.?•?An,T7ER2ctCUT!Yc :'iN U4:o_ _ ( fS I j==n'CE':•2n'c:.13eR EaC^_UOEO? +U I?7-i` 0=-02015 " iB It f G-:!andacary i�i-0Rr _-; fVk I ! j 0J22+<"076 -__ ,4C STAVO.iY a OTY,ER' iics.de-�=e ur,Te: i I F.L EACH ACCIDEnli' __D_eCP.14T(C.+O-oPEa.?IONGcc ' : { E.L DIS + f 500,000 a iSCR/nT10fU OF paERATi06'3+ �` - E-tSE-EA EivPlol^ I iSR3dACE3 ApnvPR10E',� LOCAT(C1En+EHIC -�" -I LERES'!'FIC E! IS Dome -POLIYEss7TO'.Ca7t4ISPECIALi C00000 ' OLD�1 AF-C-TG s/OR�Ce_P-•S CO.yP COVZAGE. 1 i 'FiF!C%t, =t 17QI Ocf3. _ i i.AIiGELLa=IN -- 1 ^!'IOULD f\ILY Op'-TjyC AEOV C EPpRETI'!E E',(FIRA±+Of� EDE GRISFD PCLJC,ES 6E CAiJCELLcC-r.F11 a• 9 ? Iid:i,CCORDAi JOE,i9,Tr!%Hga`EI-EREOF,Npi7Cr'r?I!LBE Dc'LlNSnED -OR2ED puCYPRpmslp:as. L PDa-ld 10., -r31_2,-_v_. - 0 CORPOPAI 101C 5i1_Ic$£:;2HL:V2e- ou L tlQ U 1�11 Il-" �Il�i�l�'�4 �!` 'v'� DATE(MfiJBDPNM THIS CEP,TJFlCATF IS ISSUED kS A Il7A 1 i ER Op CUFORftiIFlTfON CEF.T1,=!GATE DOES N07 AFFIP,Mk7fVELY OP, NEGAiP a 3�3�20_5 ONL. AND CONFERS NO R(GHT5 L)PON THE C£RTIFJCATE'JOLDER. THIS SELONI. TFliS CEP,7!F1G?-E':'Op !NSUR;'eN /EL- A1c END, E,.TEDSD OR ALTER THE COVERAGE AFFORDED D1° -S if pOL'ICIES ^CPRESEp!TATIV`:OR PP.GDUCE?,AND TH Cz ODES iVOT CON...T!'i i)1� A CONFR.ACT SET U!rEE(V THE .SSU1N- c nl,--GC,cR.IAC;.r;HOLDER, " C INSURER(„), r,,sr:OP,!rEn Intl?OP,TANT: if the celuFcaLe;Holder is aD iaDD)T10NAL 11715UEDz' Cer Cefns end c0rp lieu O of such endon,certain Pol!ciEs nay;zaolre an elldorsenenr. A staYenenz On this ceii,tcate lees not eon`e;rig;I�4o E;Js nz ODI!cy{ies) must be endorsed. I:aUBROGRT!ON 1S WAIVED,Subject to ceriFicafe holder in Ilea D,"sac>5 enda se nEnt(s). pRODUC'EP L''ES'i.e=� ou yC CON TACT SL-2s CEi C- NAME COi S4'-Ltef.+_OP_ 233 -+jest C'=<i,_ 7 PHONE 3 —a_ Se arc.Np E-i- tsDQJ 33-723A FAX chiA1L LAIC.NAI' dDOP.ESj- iIsu..CI; V,'-A INSURERIS)AFFORDING COVFP,AGE cnsuRsc �'+76U IHSURERA jzl_g ,�_OE�C'i.%OT S- CO• 7 r�-_C i:iE2 INSURERH7H22_ l - _3OO E2=_22 T-i0i• LLTS -a 5'c•—T'�•2CB CO I 0= pea U2=_g250� ?v`nge INSURER C: INSURER D- I SO V ER Oq 9iO t(\jUReRe- i:Q{)[I-.A[r_'EvC IMSURER F: I `.ER-11FiCe7F 11uM3E2?1 sue? zoi5 _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS INDICATED. NOT,.7THST.ANDINC-aN`f REQUIRErviERA REVISIONZEiiN6ER' TED BELOITI HAVE BEEN! ISSUED TO THE INSURED(AfI I ABOVE FOR THE POL1Cy PERIOD CERTIFICATE MAY BE (SSUEJJ OR WAY PERTAIN >-Rb7 OR CONDITION OF ANY CONTRACT OR OTHE? 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Y VI {B:xntlatcne in NH) `r +':IAI I -p li DES v-C IA.ncle: CRiPn EL EACH ACCIDENT I O;d GF GPc-i,gT(DNS 6=1c. r 1 1 I E-L DISEASE-FA nfiPLOYE�3 i "o �u_yOav _,_s3_TI`r=F I G I rT 2003 � f EL DISEASE-POLICY UrJI? j 7e6_3 f^0/2f201a ry0/I/2035 GE.tERALAGGREGATE J f S'_,GOD.DDD:RIFnoNOFOPERanexsr/.ccanoe!snrH¢LE3 IEaPaIiuTlofecouomoN sS(Aran AGCRD 9pi,AdtlLaml Penn. ,000,000� :ts Sepetlule,6norA sparnii rxquiretl) liJ'i_DL''s: CANCEL.''eAMKQN SHOULD AN;'OF THE ABOVE DESCRII , O_T OF s,=1_ THE r-�,'PIRATION DATE i1-JER'eOF, POLICIES BE CANCELLED BE-FORE 93 Ti)�S _Wjc! ( 5 _ ACCORDANCE IiJITH THE PO NOTICE IMLL ^05 DELRIERED 7P3 LIC:'PROVJSJOAIS. Sc_T.riT:iv1, iv;; �j i 97O , AUTdOR2tn REPRESENTAnve 1 25 ``- 3 1 MsssacRuseYs l-.Cepa:?T9n.'Ci'UJ!!csa?e:y Board of 3u iding Ragulattons and Standa<-as Cont.-ctinn 5unez i5ar ` _!ccnse: CS-067977 ERIC W PALM - ~ 313ILTOIV ST Salem MA 01970= f/J Commissioner 0412312016 J1e Vic.;rrucxrrrrfH of ff - / �— _ _ Office of lf ConsnmerAairs&Business Regal 400'cff.- License or registration valid W for individnl use only _ ME IMPROVEMENT CONTRACTOR before the expiration data. If found return to: g!stration: 142089 Type: Office of Consumer Affairs and Business Regulation Watt= 3/12/2016 Ltd Liability Colpo- 10 Park Ptaza-Suite 517 ATLANTIC WFJITHERIZATION LLC. Boston,MA 02I16 0 ERIC PALM 61R JEFFERSON AVE SALEM,MA 01970 q r� Undersecretary NO,valid With0[signature