Loading...
26 READ ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts `• {`� Department of Public Safety 'f• •y \lassachuwtts State Building Code(780 CMR)Seventh Edition v n City of Salem Building Permit AEplication for any Building other than a I-or 2-Familyell' (This Section For Official Use Only) Building permit Number: Date Applied: f 0-0t-1 3 Building Inspector: SECTION 1: LOCATION (Please indicate Block 0 and Lot* for locations for which a street add ss ' no vailable) �6 gem A • S-�k fp-7 " 0/070 No.and Street City /Toavn Zip Code Name of Building(if applicable) SECTION 2: PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other pecify: Are building plans and/urconstruction documents being supplied as part of this.permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Pr osed Wo rk: d5 �ira,JN , c //mot oSC_ S SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): Y Existing Hazard Index 780 CMR 34: proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area (sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc Cl 'A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 Cl R-3❑ R-4 ❑ S: Storage S-1 ❑ S-2❑ I U: Utility❑ 1 Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IM0 11813 IIIA ❑ 11I80 IV VA ❑ VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)Debris Remov• ' Trench Permit: at: Wafer Supply: Flood Zone Information: Sewage Disposal: Licemrd Di.I�usal Site❑ Public ❑ Chuck it outada• Plood G A trench will not be mr❑ Indicate municipal ❑ roquirrd ❑or trench ur�paci ta': I'ricatr❑ or mdentilc Zunr: or un ate>a'aem ❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \1:\ I h>tori;t." unmi>.im Rv,u•+, I'rn',•..: .N\'t ,\pphiable❑ I.jtrmctwc+cith,n aupurt apprnach area.' I.their review completed.' ,a l',1n.cnt 40 IlLllld rnclo.e.{ ❑ Ye.❑ or No❑ Yea❑ Nn ❑ SECTION 8:CONTENT OF-CERTIFICATE OF OCCUPANCY - I L,e Groupie f(pe of Con-troo on: Occupant Load per How: I)nv.lha•bwldin ;auVam,m Sprinkler?c.tem.': Special Stipulations SECTION 9: PROPERTY OWNER AUTHORIZATION 'N� ,dr 'n+prrly rVutso0, & ^ � �/ /✓lam GC/70 :Nome(print) J No.and Street City/Town Lip Property Otaner Contact Information: Title - Telephone No. (business) Telephone No. (cell) e-mail addnvss I(,tpplicable. thepr!u,vrty t wrier hereby atuhuri es ��+ c Ya/m 3 /f ��T y Sf• �t�Glr� (f1 0/970 Name Street Address City/Town Stale Zip to act on the +ro pert% owner's behalf, in all matters relanie it)work authorized by this building permit application- SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) llt buildin+is less than 35,UIN)cu. tt.of enclosed s pace and/ur nut under Construction Contrul then check here D and skip Section 10.1) 10.1 Re istteered Professional Responsible for Construction Control Ila _211 - W113 TPc.I.nl O )eCcrnt�sl Name( gistrent) Tel= e-mail addre-, '�� Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor ( 9 Cum my Name: Name of Perso esponsible for Construction License No. and Type if Ap licable 3 f 1 I , 5 l Sr:-I , � o/? 7 a Street Address City/Town State Zip ) )8 -7 jY - $?/`/_3 �b _ 7u _ /03! -T17' C i (1,Cas22ri�it Tele hone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ AJ00 •W Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact muniypnht 5. Mechanical (Other) $ Endorse check payable to 6. Total Cost -- $ jQQQ .(fu (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this application istrue and accurate to the best of my knowledge and understanding. art � /Ce`�✓l ��,7 �!iL C i,� �f7� .�- 1'Ira e j. nt annd agn name Title A Telephone No. Date Atrcel Address CityiTot%n State Zip .Municipal Inspector to fill out this section upon application approval: .Norse D.ue J Massaefibsetts Rome improvement Sample Contract if nis farm s21155s all bxsicmquitiMCI is ofihe as Home Imo nvemantCan!raetorlaw --� ilanguxgc to protect homeowners' Seciclegat advice ifneressa (l+dGL-haplcr 142A),but dos aotineloda stundard Ih'fESCarhasetlr tonsltmot'GS[ide ttjl�omepmprovement"before ry �YDeaonpl®nog homeieano no to should Am obtain ac p residence; Your _ e andof a Gino ofConrsmerAEairs andBaiiness Regnla., Cansna¢lmarmg33oaHonm m day C, 6179 you may obbba on:...y-bir_:'ailing the Homeotvner Informahon Contractor Information T:me 1. .a:rtdc—(- :o ao[me¢= Of'ncb$or d O-C xiny7fim[o eµSG�/•/'I e �/J �{ •S_s te �:r- �Z,a Cc dv p 3`Caasniitrn tex sa[s p.vrl lSdarelesss2(.-m,zu[rlAPL61 ac e,46no-:eJ-tRc-ieTv t rf- - y^,. v.3 3L�b ?bonn inctudeK,ceYMM 01970 Pcag?hone - Ci[Y/forn Sure Z p Cad: ----- t`.... MCI (et divoctfray chore) - 3sineu Pha:e FrdaalcaployerIDvrSS.Nuaher 21 l-:�-.�im:L-avathma •�-L•�Cc:.T�:aCh'+av The Comnotorae=reay io do the following •-w r moots / �„�:3 /`i I/` (➢cscdbs is deeil We µw0 coat e" worlt for the Homeol"er. PI: Tl+eehying the type,broad,e=tl grda of mabirals to to osey . ILL V/ _ -: VZIvy S t _doer Requued permits-Tne f2lowm�dSufldiag or.�i(s e_.e Proposed Short and Completion Schedule-Tnef �? cd coil to rmrad by the co- re3ulad p ollmvmg schedule will -aL-aC.oi os Ihuhomeawnets 63enC be ndhe,ed to unless cucumstancs b^ d the Cmd z b,,, cosad (Grvners)r'ha secure their own permits Fvill be _Yon . arise � excluded 11•nm the Guaranty Ftmd provisions of /U Dole when, 1'1GL chapter 1?2A) n canhador wit begin con'aged wore o / Dc*cwhm contracted µorkwill bembSmmiallycomplel-a. I ' Tonal CtrecteiP'cand Pa)'m 't. hedulc T.:c Contmctorxgres to lb,, to[k wv*!yin±nth the material hod!abermeeiiied above for the mt.l;[nn of: 3611 ?zymems will beside eccordogtb�efonowing schedule: - M . i+pans!_vnng cdn:ec±jnotm exceza7:3'of dfazd1::fcbetlnc[pnce_r me cos o:sxnz orde:3@ ins,-ivTidoeye; t':cic)-..- - ... S by 1/_c:upon Completion - SaUQ, by&L/IUI_a or upon wmuleemt of _ T-z� IJ. M„ n�o� S 3�Q• loon wmplctioe of the contract (Lawfatid;demand'ag ivl payntxnt tots Canuma is noted e• to both non ssads3rdon y ) 'rue folldwdn,DooeiaVcga. c;l out he s_—w _ S ard,nd t�o:e U.roabeaed va<;be ho se osid fur :a.:_toecmal.C1ansc'•C1I,: ) in c;=c S ' hole paidi !NOTES:(>)acicd'eb all cecu e;(`>)�w•reecirestitar de - a°::x.—dttie"ce"_:ofi• Y fasit ordcna-p.+men[re5uhxd Ey ecaetactorbefeteuvec s• (_)ace-thm ofie toll courentpdce o:(b)Ge eu+.�clrort¢i aaY ePcLI ui ouch mart aespsial-747ed is ae"Im to Co.the=PL-dan rhedaL. ei pv:ater eutom male rre:_J. . Sm: Naranr.-u ar.cn wA"'.nt beta.oro.idad Svfherant-aced ONo❑ _-bCaaa"Ct,, 1- YC,(nll tC'TS of[heTT p•muSt h!2tfncia to lil¢mn^ye[1 tn_ro Abyth ag`r_sm xsz-iy[sans,bL=fs Campl:tiaa oftenµodc descried mgar�lss ofthe actions of.=yt •d _�/mSxaC-ems:eS! d'ep�e2 b-Cm.-. T w.Laear,, ere hobo sale)end is-ad labor - se t ve gees Yrespaudin farallnayonueloal!mbcoecr_ctoefor ContractAccephonce-IIoon sigoiho this docnmehtbecamsebinding contract[mdwim,.unless oho _matracish3l notimnty rhxt L"Y Lea Ur other Seeati 1 Cavimmotadwithmdusdorament,;- tzrefillYheforesigniag this wnlgcll tY 9i^mstius bins paced on the residcoce.lieviaw the fallowing cautious and notices Jaa4 bep:ssvzd into signing the co,.h¢ct Ta4x®in to read eed 5dlyundestmd it .ik oustions if something is nucleon. Metz sbz tie ca�ttacm-h =.•J'dF C be R h 1LronteCDS to o_re^ts�.1.,n'mt_ . The law reauirs most home iprovenum-Conners end regs i. t1'eDu==.n:of Eooe Improvement Coate ctor soution. Yen me inquire about comm seedonb sµitin o=.D_ : 3' 9Vor Y gt �e-w._.IUPml;plaz Rvom5170,Boston,bLi02116mb?calliag617-973-8787or888-253-3757. Jaes_caDdracmr have has dee? ;.s!;the Cpnhaetpr inr his t,seme,Dom, peso.infonection so toes ypn can cor_ia cove:�ge,a:as:to sx x cony of e'bmof of�r:acea'docmnent ?:now;:osrght;end responsfpiliEs. ReadL^e Loa',zn±iro^a_5c**.an tee worse ode infests fnc and getzopy o_`;ac Gde to the Home h=n.•ui-�.ct Cantu�o:Lsµ. Cava: jyou may canted t^is a_z-een•_;±_i[cs be_sped e1 a n!zccn¢ceto.'s ne:zal aline ofoasiness,provided}pnnetify @e ronCZCeri•;a-itngta±tih c mz&�;25tc or circa e_co by o-ds_yaza posted,by tdeEem Satorhy delivery,no:tote that[midoi^a af�e i tai�ils;:us LYfn_otisn3the sigir?g of lsay; e_t Sea�:zr,__d noSN ofc=cl!-cn na=ldaaadon oft:^.isriga: DO NOT SIGN THISCONM-iCTIFTHERE PM-42\ 'BLS\7�SPACL+SII!.. _ _ . --_��t✓/Y� / - '_.__ mow_ --5 "- P i p- Jzte - �ate Contractor-Arbitration -The Home improvement Contractor Law provides homeowners with the right to initiate aniarbitmtion action(as a. alternative to court action)if they have a dispute with a contractor. The same rights no automatically afforded to a contractor,however. The contractor would have to resolve any dispute ha/she has with a homeowner in court utl]es5 both parties as ee to the Opfloagl clause provided below. This clause would Elva the Pont'actor the same right to azhrtrahou 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 conimotor has a ' wneeraing ths.conimet,.the-contrtctor maysubmit the du dispute to W aispsae -Se of tlieEiebirtive piece of Consumer AE' P private arbitration fi-xat'hick has been epnrpved by to sub ad[to such aYliittatiori"as provided In Massachusetts General Business the er shall be required ` I47�A i _omeowner's Si a -� NOTICE:The signatures Cc, actor's The Signapme� gnatures of the parties above apply oniv to the agreement othee parties to it' dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resglittion even where this is not separately signed by tb=parties Homeowner's.Rights - A homeowners rights under the Home improvement Contractor Law(II GL chapter 142A)`and other consumer Protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreemenf.�However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeotwets who secure their own building permits are automatically excluded from all Gtiazanty Fiord previsions of the Home Improvement Contractor Law. The contractor s responsible for completing ti,e�.;fork as descrbed,a a timely and workmanlike manner. HumeOINOM may be entitled to other soecific legal tights if the contractor guarantees or provides an express werrany for workmanship or mzL^rials, in addition to gtiarame c nt actoaz,ties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fimess for a Particular purpose. An enumeration of other matters on which the homeowner and contractor]atviuliy 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(homeotvnar rights,contact the Consumer Information Hotline(listed below). Execution of Contract -The contract must be executed in dunlicate 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 other kept by the contractor. Any modification to the original contract m_us3-bt iatvritin. and agreed to by bothpartiea-.-Conttdetedtvd3'Sn�y notegtn'duiil'boTa,paitie5'havz receyded e fiiLy'e%ecuted cony o` the contact,and the three day rescission period has expired. , Accelerated Payments - A contractor maynot demand payments in advance of the dates specified on the payment schedule in Pass where the homeowner deer soh.�/herelf to be iinaaPizlly iasecure. However,in instances where a contractor deems him/herself to be fieartc.el!y msectre,'the contractor may require that the balance of funds not yet duej qe placed in a joint escrow account as a prerequsYe to continuing the contracted work F11ithdrawal 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 ifyou wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"contact Consumer Information Hotline Office of Constmer Affairs and Business Regulation i 10 Park Plaza,Room 5170,Boston,MS 02116 j 617-973-8787,888-283-3757 or visit the OCABRwebsite at htto://vnvw.aass.Eov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically abort the contractor registration component of the Home Improvement Contractor Law,cAptact: Director of Home Improvement Contractor Registration Office of Consumer.4uai s and Business Regulation - 10 Park Plaza,Room 5170,Boston,M4 02116 617-973-8787,888-283-3757 or vs it the MC website at hum://vnvvLmass�v/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: h://db state ma.us4iomeimRmvement/l'cemeelist aso//db state maus(:nomeimorovement/1'cemeelist aso For assistance with informal mediation of disputes or to register formal complaints againit a business,call: Consumer Complaint Section ,1 is -. `Off ce of the Anomey General 617-727-8400 AI�D!OR - Better Business Bureau 508-652-4800,508-75i 2548 or413-734-3114 V.za.2.1-1 UMP010 mass Save PARTICIPATING PERMIT AUTHORIZATION FORM 1, Louisa S Kling owner of the property located at: (Owner's Name,printed) 26 Read St Salem (Property Street Address) (City) hereby authorize the Mass Save Horne Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature .� U .Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date fo,Cffi:e Use Only Rev. 12132011 +T 1 The Commonwealth of Massaeh usetts Department of Industrial Accidents Office of Investigations ^ J 600 Washington Street v Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Fame (Business/Organization/Individual): AflMtiC N'JeatbeTlzahOn,LLC _ 6112 Jeffclson Avenue Address: Salem NM 01970 City/S e/Zip: Phone #: Are y u an employer? Check�propriate box: Type of project(required): I. I am a employer with 4.,❑ I am a general contractor and [ employees(full and/or part-time).* ` have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y� 9. ❑ Building addition [No workers' comp. insurance comp. insurance.' required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12 ❑ Ro repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.216ther comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z Lt ri C,� _ Policy#or Self ins. Lic. 9: O 1rz I Expiration Date: �O � Job Site Address: aG R2u,r� ��• City/State/Zip: SIC i 0/9 70 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalttes of perjury that the information provided abo a is true and correct. Sienature - , Date: Z7 /) 3 Phone 4: Official use only. Do not write in this area,to be completed by city or town official City or Town:- Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: - Phone#: I CITY Off' S,6UZNi, A-usiwi-iUsETTS BULLOLYG DEP.IM NT 110 WASHNGTON STREET, 3w FLOOR TFL. (978) 745-9595 KIMBERE Y DRISCOLL FA-' (978) 7•t0-9345 'NrLwoa T�iosci3 S .PtERRs DIXECTOR OF PUBLIC PROPERTY/EJULLOLNG CONLMISSIONER Construction Debris Disposal AftIdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 ChiR section 111.5 Debris, and the provisions of tN(GL e 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be-disposed of in a properly licensed waste disposal 111, S 150A. facility as defined by t'YfGL c The debris will be transported by: &—av-4 l d e Ca 7,-wt (nine urliauter) The debris will be disposed of in : (name u�t�'t,*,cii ity) � - -- 0/&-/0, (]JJIY5.5 of fJdilll�) signanua ufpermit ap�plic�an�t� 1 Z7 �13 J.uc Right£ax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/,002 Fax Server CERTIFICATE OF LIABILITY INSURANCE I DATEIMM/DD/YYYY) T TIFICATE 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 WAIVED,subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL ST (A/C.No,EX1): (A/C,No): E-MAIL NATICK,MA 01760 ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC a INSURED INSURERA: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER On 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: IS IS TO CIERIIFY THATLISTED 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. LIMITSSHOWNPMY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMTOD\YYYY) (MM\DMYYYY) LIMITS GENERAL LIABILITY =ACH OCCURRENCE $ CMAGE TO RENTED OMMERCIAL GENERAL LIABILITY CLAIMS MADE �OCCUR. R'REVISES(Ea occurrence) $ MED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY F-1 PROJECT ID LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE - AGGREGATE $ DEDUCTIBLE IS RETENTION $ - S A WORKER'S COMPENSATION AND X we siATuroRv Or HER EMPLOYER'S LIABILITY Y/N UB.5B270121-13 0320/2013 03/202014 LIMITS ANY PROPERPOR/PARTNEWEXECUTNE a WA E.L.EACH ACCIDENT $ 500,000 D OFFICER/MEMBER EXCLUDE (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 1 yes,describe under EL.DISEASE-POLICY LIMIT $ 500.000 OESCRIPTiON OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAOE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 93 WASHINTON ST IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR 7 TAPVE SALEM,MA 01970 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. AC40ROCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/13 Y) 3/11/2013 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 tS WAIVED, 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 endorsement(s). PRODUCER _ COME CT Construction Eastern Insurance Group LLC PHONE - (SOB)651-7700 FAX 233 West Central Street E- IL INSUREADDRESS- RS AFFORDING COVERAGE NAIC N Natick MA 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURER 6 Arbella Indemnit Ins Co.' 10017 Atlantic Weatherization INSURER C Nautilus Insurance Co 61 Rear Jefferson Avenue INSURER D: NSURER E Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBERd4AS.TER 2013 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. INTR UUR TYPE OF INSURANCE POLICY NUMBERPMUDpY EFF POLICY EXP LIMITS GENERAL C EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL UABILIry 1 E Es coca e e E 50,000 A CLAIMS-MADE F OCCUR 500042816 /20/2013 /20/2014 MED EXP An one Person) $ 5,000 PERSONAL S ADV INJURY S 1,01000600 000 GENERAL AGGREGATE E 2, 000GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,0000 POLICY X PRO- LOC E AUTOMOBILE LWBIUtt COMB EDSINGLELIMIT Ea accident 1 000 000 B ANY AUTO BODILY INJURY(Per person) S AL OWNED$ X SCHEDAUTOS LED 020015871 /20/2013 /20/2014 ( )AUTOS AUTOS BODILY INJURY Peraccbent 8 X HIRED AUTOS X NON-OWNED AUTOS PPR PEcclCY AMAGE E an X UMBRELLA UAe PIP-Basic S OCCUR EACH OCCURRENCE $ 1,000,000 X A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED ETENTION 600047820 J/20/2D13 /20/2014E WORKERS COMPENSATION TATU- OTH- AND EMPLOYERS'UABILITYANY.PROPRIETOR/PARTNERIEXECUTNE YIN FP (Mandator,In H)EXCLUOE0NIA E.L.EACH ACCIDENT S (Mandatory in NH)I/ SO PTIONunder E.L DISEASE-EA EMPLOYE DESCRIPTION OF OPERATIONS GelowE.L DISEASE-POLICY LIMIT S C POLLUTION-LIABILITY - PL2003786001 1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 11H,Additional Remarks Schedule,if more space Is redulned) CERTIFICATE HOLDER CANCELLATION tAAUTHORIZ:EDREPRESENT:AT1VE HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF RAT,EM CCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET SALEM, MA 01970 —waFulhamMA �w.e.-.a.�JH! ACORD 25(2010l05) ©7988-2010 ACORD CORPORATION. q11 rights reserved.IN5025 nmmarm Tho ar.npn n>,rao>nA Inn..>w ron:>br>d m>e4a of ACr-IRrI �1=ss2 h s-Dep3rtrne z of -- tssard oi Builama R R i3 t, ns nd Si ndar1s LOR rurTion.%iponistw ` K� Unrestricted-Buildings of any use group which License:CS-087977 contain less than 35,000 cubic feet(991 rW)of �11A Ienclosed space. ERIC W PAIM 4 3 HILTON S'E g-y`, ,_•• . SALEM MA--`01970 ,� y b4 _ Failure to possess a current edition of the Massachusetts Lo;n:rsssic;ie: 04/23/2094 State Building Code is cause for revocation of this license. _. For DPS Licensing information visit. w .Mass.Gov/DPS Office o nsome�. airs `mess egu ahof n --- - -- ----•-_—----_e.—�_._—. f lyHOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only - li y.r Registration 142089 Type: before the expiration date. If found return to: k. , 317 212 01 4 Ltd LiabOity Coryor Expiration. i Office of Consumer Affairs and Business Regulation M !TMWs -IC WEA7HE 10 Park Plaza-Suite 5170 ATNTlZ2AT10N:LL:C. - - I Boston,ALA 02116 ERIC PALM 6tR JEFFERSON AVE SALEEM,MA 01970 Undersecretary Not valid without signa re {