11 PYBURN AVE - BUILDING INSPECTION i
The Commonwealth ofMassachusetts RECEIVED .
Board of Building Regulations and StandardjNSPEMONAL §P
Massachusetts State Building Code,780 CMR I7 Y
�n USE
Building Permit Application To Construct,Repair,Renovate(NISeHM41II eq:;efj(ar2011
One-ar!Wo Fan*&elling
This Section For Official U e Only
Building PeimitNumber Date Ap 'ed:
Budding Official(Paint Name) Sigoanne Date
SECTION 1:SITE INFORMATION
G1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_ I J i
( 1.14Is this ad accepted street?yes no Map Number Parcel Number
t 13 Zoning Information: 1.4 Property Dimensions
n Zoning District Proposed Use Lot Area(sq ft) Frontage(1t)
1.5 Building Setbacks(ft)
Front Yard Side Yards - 1• . . .. RearYa�d
i� � Provided Required Pmwded RaWfied Provided
1.6 Water Supply:(IvLO.L o.40,§54) 1,7 pApod Zone Information; 1,8 Sewage Disposal Systgm:
Public❑ Private❑- ° ,. Zones— - Outside Flood Zone?
_ .. Check if es❑ Municipal❑ Onsitedisposalsystem ❑
SECTION2: PROPERTY OWNERSHIP'
21 OwneitofReco
an
1 Co�'rurr
Name(Pnnt)J ( O City,State,ZIP
i ti k4rr.i
No.aadStree— 'Telephone EmaHAddress -
's..MON 3:DESCRIPTION OF PROPOSED WOW(check aft that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Rep�(s) ❑ teiatiom(s) ❑ Addition ❑
Demolition . ❑ AccessoryBidg,❑ Number of Units-- j Other Specify
BriefDescriptionofPro o7s�'��l Work?-
SECTION 4:ESTIMATED CONSTRUCTION COSTS T
Item Estimated Costs:
abor and Materials Official Use Only ,.
1.Building $.. 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard.CiVrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. OtherFees: $
4.Mechanical (HVAC). ,$ List
S.Mechanicat (Fire
Su cession $ Total All Fees:$
6.Total Project Cost '$ �(() rCheckNO' Check Amount: C�h Amount
' ❑Paid in Full . .; ❑Outstanding Balance Due:
T C� r12{l�l�t2 3I31IIS
SECTION Sc CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) k+ 7 q -7 aZ /
license Number Expiration Date
Name of CSL Bolder
IAA.CSL Type(seebelow)
n " .Eric W.Palm
No and Street Description .
3HiltonStreet Type Unrestricted two 3saoow.>G
Calera MA 01970 .. -R Restricted 1&2 Family Dwelling -
City/fown,State,ZIP i M Nksmay
RC Roadiagcoveling
WS Window and Siding
�� a SF _ SolidFuelBummgAppliances'
-I -
-( 71✓f/(/,/� a �� I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ( 20 3 I Z &
Atlantic Weatilenua(tvti, I,,.-
HICItegishation umber lbi foul
MCCompanyNameorM _ AVen, lde. - -
selem as♦ 01970 i
No.and Street Email address _
Cityfrown,State,ZIP Tel hone
SECTION 6:WORIMS'COMPENSATION INSURANCE AFFIDAVIT(NLG.L.C.152.§25C(6))
Workers Compensation hummace affidavit musdbe completed and submitted with this application. Failure to provide
this affidavit will result in the denial=oftheimmance pffie budding permit
SignedAffidavitAttached? Yes.....,..... l No..........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR AMme FOR/BUH DING PERNIIT
I,as Owner of the subject prapetty,hereby authorize (A f
to act on my behalf;in all matters'relative to work authorized by this building permit application.
314(1
Pant Owner's Name(Eleotromc Signature) j Date
SECTION 7b;OWNEle OR AUTHORIZED AGENT DECLARATION
f
By entering my name below,I hereby attest under the pains and penalties ofpmjwy that all ofthe information
contained in " applicatipn is try�n I the best of knowledge and understanding.
Pilot Owner's orAwhonzed Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hidher own work or an owner who hires an miregistared contractor
(not registered in the Home Improvement Contractor(111C)Program),will nor haw access to the arbitration
program or guaranty fiord under MG.I..c.142A.Other important information on the BIC Program can be found at
www.mass.eov/aca nformaton on the Construction Supervisor License can be found atwww.mpm.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.&) (including garage,finished basement/attics,decks or porch)
Gross living am(sq.1t.) Habitable room count
Number of fireplaces Number of bedrooms
-Number-of-bathrooms Number-ofhalf/baths
Type of healing system Number ofdeckd porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for`Total Project Cosf'
-Massachusetts Home lip roveffiemmt Sam
le Contract
"Home
lbasicrsoFmeztam's HomaLnP+ovemmt Canbadtorfav tiSecklegaladviaifnecessnry_q¢yp�p (MGL chapter ta;A).butdoes notindudestandard
merGuide to Home fmpmamenPhefareage A"ypa Pmkm•ghomeimpi%, IssboddgMg bmioacc%Wof-AdBmineSSRmolatimt's Cnnaniv7oFo,mapao Hmiaaatsm�Y�n�o6lain atrceeo{571erinformai '&7g7pr1-1188-337.gryTora oor. g_ :' ContracmrInformafion . . ,
cempanra�
Seen eddnss nanmaPau0 rely' C`1 . .
) Cmmectm/5nlerpmm�, , ..
Cinfrotm Sine zip _ 61'RTe# AVem _
r a daAdd�(aen neti )01970 De}nme Phone QI.7 7
E0 I - / mmS Steele CUT Sim Q V Zip Cede
.11ailingdd,bne diffie eclam obV4 + -
susiasephee Fedeml rmolamIDnrS.5Manbc ..
.. .- /an aCeWNa n°a0xe a.stcmcee�racxet �. . .
•� 1�a0�9 3117,
The Cpntmcmragree;m do Ma toliotsiogwork fortheHomeotm¢r.
rDascdhc in demo Ne,na4m ?
,{/Sfeomplped•sPesifii(n';ftt/p���-imo/^d.-dioudeof nma"vkm
'✓4✓v.-vy "�/�-C G11C- homed.mea nt h� 'Fm.,
Required P e9 permits Thefollmving bmldmgpermlts m¢rsgtdra{ Pro
and will beseaued 6ythe mapaaprasthehome"es Posed Shwand Completion Schedule-Iltefailoniue achedeleuiR(Owners whoseest eir own a aFmt 6eaditsedtounlessmmartstmcsbtytmdthe mdhxtorsoaoapl arise excluded from the Gaston a p rmits will be /,/
�IGLchapter]a2.Lj wdprovlstonsof —:LLY_Dateohen
aacmrooll begin caatrnmednnrl,
—_.L_LDme nitro Tom]Contract Priceaotl contracted Mt I'M besubsom iely,emphead.'
,Rm,th Seb edWe
The Canoaaoraaees m perfomt thenot"umisb 0Vetrcm1W 1d Iabur 'specified aboreforthe towstrmof.
Pa}/cents ni86e madearepn(ingto tha followingsebedulc.. r')
5• _apon slg*gmvaad(nut to
esceed lD eil e
by taml rmttractIm—m ar�the c�amO-
speual ordattans.
, vhicho%wjs8raaer)uPonmmpimionof
S-t=V-
by or upon completion of C(.'
S�+ -upon completion of the (Laivf¢rbids �y
The fovaoinqeh= full tmb7 mntmm ismmpl toboth parry'ssmsiku(n)
aduedbefpremtmmtbespnial s ro yE
ca°tmaed -)pnsmoche /
to men Ne ram➢ieioa seheduls(odk b - -
> hP-i
�GTfiS:('1 Weludin�dl fitmnreehatgs(••ly.¢v¢�¢iB�m,depmit a-domhpynaem rcgmredbrdrc retmamo:Leforenarkb
na esceed thegmreroF(a)on.^rhnd ofNetami cntmaa ..
nmeh mm�bespeeia}mdemd inad�-.nre tomee the aanmlei�sehWWearoml can oFmrrapeeml egoiPmmr¢emamaoadetmoNa -
¢ ed
•~ neeantrn��o_vided lrcN ❑\ ❑ terms rh
/ L amesm besolel}resp ambl formmpieb a FNe dl dbyN conaaaor. ]iteamnactor 'orl.darnhbreeardles ofthe acnons aF
room r i fmmeragrees to 6esoldpre�tonnbie forall my Nhd
ContracrAcce Lance- Pa}'meouto a8 svbmntractors iar
contratt shall opt' i.�Pon 9gn1°g'mis dnauoembemmesabm
�P} et'I lim orommsewdty(ntereahasbem wopem uaderlew. Ualess olhenvis¢voted uithia this docmnenr,Na
emefe1}beFo1., 13,this cnmracL Placedwthet®dmta Revien•Na Follonin- gcautions aodnodea
° Dao't be Pressured into sigmogthemnbaeGTatetimetoreadaod fWl)unders
Make^mthero trzctorhas validH mndil Ask uestio¢s iFspm - .
submnuacmrs m bermst ontrn P eVmB is imdea.
Bred Lodi dre DttectorofHome ttnpmtgmmt CovlmctprLnc,qm0n homeimpmvmamtmmtzctarsaod 'registration br tvtiting to Ute Duectorm le Pate Re_vistrMML Yau marfnquire abourmnlmgor
° Dpes the conpadorhaveioswa¢ce7 Ask m¢C¢¢py Sliq Hpstoq,yA a?i ib or byeallin 617-9T•3737 or888-38,;37Si.seeacopr ofa`prpofofinsutmre"domm t uM tnsman¢esompanY ioformadavmthaz}rou wo too, coceracc,orBsSto° Guidetothe Home Read the Imponxntlnfmmmion no lhemersaside of fmm and
Guidemthe Home/mprosemenl Covtrac[arLan•. gas copy oFthe Cottsvmer
You ma}•rnveel this aereemmt ifithas been aimed m aplaceathermm 0emnaacmr'saormal laxofhnsin
contractorin nritingal hisRter main aScemhrmcho�cebvmdhmrvma7 s[ P e$.l> idedynn ndtifvthe ...
third business day follmlingtLesimmg afthis Pp ed.bytdegtatn seat orbydsgnu}•,vm lsmrthan midnight nfthe
agRemall See 0eanached aadceoftaacelhatian from form esPlaoatim ofthisdgbl
—np D®KNOT SIGN THIS CONTR4CT IF THERE AI2E p,�y$��SPACES!:! '
°aPaanaesaG-raotbaRppsdegy'yv�,pzmT_ShtnS°6tL'-y_^A�mS 7y-teE2[mrL'v"36C1sPrhrllCc°u-jp; .
Homeounerssrgomme -'�-------.
3I�� GnpaCms - -
Dme
Gate
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action vas 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 comractorwould have to resolve any dispute he/she has with a homeowner in court notes
both patties agme to the optional clause provided below. This clause would give the coniraetorthe same rigbt to
arbitration as is afforded to the homeownerby the Home improvement Contractor Lmv.
The contractor and the homeownerhereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the coan actprpray submit ihe dispute to aprivate arbitration firm which has been approved by
the Secretary of the Executive Qffiae of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration as provided]&Massachusetts General Laws ch ter 142A.
=
Horrieownees Signature Contractoes Signabue
NOTICE:The signatures of the parties above apply only to 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 Improvement Contractor Law MGL chapter 142A)and other consumer
protection laws(Le-MGL chapter 93A)may not be waived in anyway,even by agreement However.homeowner
may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by law.
Homeovnes who secure their own building permits are aummaticaOy excluded from all Guaranty Fund provisions of
the Home lmorovement Contractor Laws. The contractor is responsible for completing the work as described.in a
timely and worlam like manner Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for worknianship or materials. in addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an impliedwariaimy of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms ofthe contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consmnedhomeownerrights:contact the Consumer Information Hotine(listed below).
Execution of Contract
The contract must be executed in duoficate and should not he signed until a copy of all exhibits and referenced
documents have been attached. Parties am also advised not to sign the document until all blank sections have been
Had in ormarked as void.deleted.or not applicable. One oriOnal signed copy of the contractw•ith attachments is to
be given to the owmerarid 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 cf
the contract.and the three day rescission period has expired _
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems himlherself to be financially insecure. Howeve,in instances where a contractor deem him/herself
to be financially insecure.the contractormay,require that the balance of funds notyet due be placed in a joint escrow
account as a prerequisite to continuing the contracted wo& tithdramal of funds from said accouatwould require the
signatures of both patties. -
Additional information
Ifyuu have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or ifyou wish to obtain a fiec copy of"A Massachusetts Consumer Guide to Rome Improvement"
contact
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 ParkPLva,Room 3170,Boston,MA 02116
617-9Z'r-8787,888-283-3757or visit the OCABRvtebsiteati_M .nr.rta_sn_:i:catsr
If you want to verify the registration of a contractor or ifyou have questions or need additional information specifically
about the contractor registration component of the Home ImprovementConttactorLawv contact
Director of Home lmprovamant Contrac tor Rendstradon
Office of Consumer Affairs and Business Regulation
10 ParkPlaza.Room3-170.Boston.MA 02116
617-973.8787.888-283 3757 or visit the HIC vvebsite at attp:ie+ :vv.mass uwot bur
Go online to view the status of a Home Improvement Contractor's.Reastration:
:1,'dbsrate.mare%nomcimprov�n.••tt,'q...i-•,1:_.:�-r
Forassistance with informal mediation of disputes or to register formal complaints against a business,call:
Conm_mner Complaint Section
Office pfthe Attorney General
- 617-727-8400
AM10/OR
Better Business Bureau
508.6524800.509-755-2548 or 413-734-3114
t'azioe2l-tIPJ]dnp
The Comntonweidth oftMassachuseits
Department of IndttstriaiAccidents
OrIce ofdnvesugations
I Congress Street, Suite 100
Boston,MA 02114--2017
MWIV..nzassgot/dia
Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information
Please LnLnit Le blv
Name(Business/Organization/Individuai): Atlantic Wcatltc[ImuutL i.,i
Address: 61 R Jefferson Avenue
1020
City/State/ •p: Phone.#: ]�
Are you employer?Check the ro Hate box;PP p
1. am a employer with 4. Q I am a general contractor and i Type of project(required):
employees(full and/or part-time).z have hired the sub contractors 6• New construction
2.❑ !am a sale proprietor or partner- listed on the attached sheet. 7. El ship and have no employees These sub-contractors have Remodeling
working for me in any capacity. employees and have workers' 8, ❑Demolition
[No workers' comp,insurance comp.insurances 9. Building addition
3.[] required.] 5. [� We are a corporation and its 10.0 Electrical repairs or additions
1 am a homeowner doing all work officers have exercised their
mysetE i l.[�Phmmbin pairs or additions
[No workers comp, right of exemption per MGL
I
required,]t c, I52,$1(4),and we have no 12'Q"pairs 1
employees• [No workers' 13. ether Z��t i ltA�llL
comp, insurance required.]
"Any applicant that checks box,#I must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this must attached
indicating they am doing ad work and then hue outside contractors must submit a new affidavit indicating such.
employes. that checkthisboxmustattached an additional sheet showing the
name of the subeontmetms end state whethaor not those entities Iwo
employees. Ifthesub-contractors have employees,they mustpmvide their workers•comp.policy numbs.
I inn an employer t/rqt isproviding workers'compensation insurancefor my employees Below is tbepalicy andjob site
fnformatfoa.
Insurance Company Name: ZzUv l /_
Policy#or Self-ins. Lic,#: -70/a j✓✓t
A Expiration Date;
Job Site Address: _l-//�Grw Jf G[ ��
Attach a copy of the workers'cb City/State/Zip: = l e-011
mpeusation policy declaration
er and expiration date).
Failure to secure coverage as required under Section 25A of MGL C. 152page(can lead t showing hthe�uaposidonlicy bofcr criminal penalties of
fine up to St,500.0o and/or one-year imprisonment, as well as civil penalties in the form of a STOP aVORK ORDER and a fine
OF up to s250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office DE a
Investigations of the DIA for insurance coverage verification
s errs u er Me po s utt t res atper�ury that the urforn:gtron providrd above is true and correct Si alum
Date: Z
Phone#: 7�y gl
Ofjlcial use only. Do not write in this area,to be completed by city or town oriclal.
City or Town:
Issuing Permit/License#
e Authority(circle one):
I. Board of Health 2.Building Department 3.City/•rown Clerk 4•Electrical]Inspector 5.Plumbing Inspector
6.Other
Contact Person
Phone#
Page 3 of 4
CERTIFICATE OF LIABILITY INSURANCE 31°"'Elu�=,wr"y'5
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 WANED,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 endomement(s).
PRODUCER C NTACT Construction
AME:
Eastern Insurance Group LLC PHONE (800)333-7234 FAX
E-MAI
233 West Central St L NO
INSU S AFFORDING NAIC 4 COVERAGE
Natick MA 01760 INSURED INSURER AArbella Protection Ina. Co. 1360
INSURER a NaUtilUS Insurance Cc '
Atlantic Weatherization INSURER C: -
61 Rear Jefferson Avenue INSURERD:
INSURER E:
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBER34ABTER 2015 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE MIR POLICY NUMBER MPr°s UDA'EEFF N YYYLIDY EXP LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
PREMISES Ea $ 50,000
A CLAIMS-MADE ®OCCUR 8500042816 /20/2015 /20/2016 MED EXP(Any One parson) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
G POLICY FX]E RgIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000,000
POLICY X PRO- LOC If
AUTOMOBILE LIABILITY COMB 0 SIN LE LIMIT
Eaamtlmn 11000,000
A ANY AUTO BODILY INJURY(Par person) $
AUTOSALL OWNED AUTOS AUTOSU�D 020015871 /20/2015 /210/2016 BODILY INJURY(Per accident) $
X HIRED AUTOS X NON-OWNED
AUTOS P OPERTY DAMAGE $
EXCESS
L
PP-Basic $
X UMBRELLA DAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS U1B CLAIMS-MADE
DED RETENTION$ 600058654 /20/2015 /20/2016 AGGREGATE $ 1,000,000$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY WC STATIY OTH-
ANY PROPEM PJPARTNEPJFXECUTIVE YIN
OFFICER/MEMBER EXCLUDEW ❑ NIA EA-EACH ACCIDENT $
(Mandatory in NH) -
DES6descnEeurlder E.L.DISEASE-EA EMPLOYE $
DESCRIPTION OF OPERATIONS below El-DISEASE-POLICY LIMIT $
H POLLUTION LIABILITY PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000.,000
EA POLLUTION CONDITION $1,000�,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANach ACORD 101,Additional Remarks Schedule.Um m apace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE -
John Roegel/PMA
ACORD 26(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INR025 r�ntnn5t M Thn aCnizn name and Innn am wnlefnrod madras nF aCnRn
`$ CERTIFICATE OF LIABILITY INSURANCE DATE(MWDO/YYYY)
"T1141124.0171FICATE 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 BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
QRPRODUCER.AND TH"-ERTIFICOIE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require and endorsement A statement on this ceri icate does not confer rights to the
Certificate holder In lieu of such endorseme s.
PRODUCER CONTACT -
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 W CENTRAL STREET (A/C,No,Ext): (A/C,No):,
NATICK,MA 01760 _ E-MAIL
ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE NAIC4
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:INSURER E:
SALEM.MA 01970
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THE'6 TO CERTIFY T A HE POLICIES OF IINSURANCE LISTED ELOW HAVE BEEN ISSUED TO THE DSURED NAMED ABOVE FOR THE POLICY PERIOD N VXST DICATFD.NOTTHANDNG
ANY REQUIREMENT,TERM OR CONOITION OF ANYCONTRACr OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MY BE ISSUED OR MAY PERTAIN.THE INSURANCE
AFFORDED BYTHE POLICIES DESCRIBED HEREIN 6 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAD CLAIMS
NSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MM,ODIVVYY) LIMITS
GENERAL LIABIUTY [AICH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE OCCUR. MAGE TO RENTED $
EMISES(Ea Occurrence)
B RSONAL A ADV INJURY $
D EXP(Anyone person) $
GENT.AGGREGATE LIM APPLIES PER: � NERALAGGREGATE $
POLICY PROJECT❑LOC RODUCTS-COMP/OPAGG $
AUTOMOBILE LIABILITY
OMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Par person)
HIRED AUTOS 30DILY INJURY $
NON-OWNED AUTOS Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DEDUCTIBLE
$
RETENTION $ $
A WORKERS COMPENSATION AND WC STATUTORY OTHER
EMPLOYER'S LIABILITY Y/N UB-5B270121-15 03/2WO15 0312W2016 X LIMITS
ANY PROPERITORIPARTNER/EXECUTIVE $ SOO,000
OFFICERIMEMBER EXCLUDED? M N/A E.L.EACH ACCIDENT
(Mantlelsabe In ) E.L.DISEASE-EA EMPLOYEE $ 500,000
it yes,tlesalbe urMer
DESCRIPTION OF OPERATDNSbeIM E.L.DISEASE-POLICY LIMB $ 50Q000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESiRESTRignONS/SPECIAL ITEMS
7TIIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERIMCATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINGTON ST BEFORETHE EXPIRA71ON DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM,MA 01970
AUTHORIZED REPR .A VE
ACORD 25(2010/05) The ACORD name and loco are registered saris of ACORD 19as-201 0 ACORD CONIOIMTION. Al l rigMa reserved.
TM Massachusetts-Departmentof Public Safety
Board of Building Regulations and Standards
Construction Supenisor r I1
License: CS-OM77
ERIC W PAI M
3 HILTON ST '
Salem MA 01970�
Expiration
Commissioner 0412302016
i
V/LC�O>)f//f(✓N[OCY/h�.0//C�/��LIiJ?C�![i�lrl .
Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
j istration: 142089 Type: -
1vp
iration: sXI2/20W Ltd Liability Coryo
o
ATLANTIC WEATHER¢ATION L L.G:�
y ERIC PALM
s
61R JEFFERSON AVE
i SALEM,MA 01970. Undersecretary t
t
3