7 ROOSEVELT RD - BUILDING INSPECTION a o(,' �
y5� The Commonwealth of Massachusetts
f �°h}y Board of Building Regulations and Standards CITY OF
47t Massachusetts State Building Code;780 CMR SALEM
IW(� Revised kfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
Ibis Section For Official Use Only
t1ding
*(Print
Date p 'ed:
Dte`
SECTION 1:SITE INFO ATION
1.1 PropertyAddress: 1.2 Assessors Map& Parcel Numbers
QD05_eYPtT de'i`m
1.1 a Is this an accepted street?yes—Lz no_ Map Number Parcel Number
1.3 Zoning Information: { ""r- 1.4 Property Dimensions:
r..
Zoning District. Proposed Use Lot Area(sq It) - Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard
vided Required ' Provided Required Provided
Required Tw
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 8'� Private❑ Zone: _ Outside Flood Zone?
Check ifyesC9� Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
rLi&de.J jjetcN°J 7 tocseyeL: /�Flx�l srf2ptir In� CIl r7b
Name(Print) �nJ City,State,ZIP
N nd Stree q19-7Yr(_0� r0 'Ll<Pdn'6:��J Corn CLiSiltp�
Telephone Email Address
TION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteralion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
B_riefDescriptionofProposedWork': er ,4,� iT,c.ht,t/ y p2f+.r„w y-d e-r-4A5 Rc'�CACL1
[}.Q[r CA?i/n:f'3' r'e -[ter st,Cc��nNT'Ce-S P�.] �'iX1'u2e.5
{ � x1�W 2['cPSSrp�
d. 2, 71eV G�/NDELJJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated-Costs-
SEC
Labor and Materials Official Use Only
1.Building $ ` 7 DY3 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ y' ❑Standard Cuyi town.Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ % 3 f D 2. Other Fees: $
4.Mechanical (HVAC) $ Ana List:
5.Mechanical. (Fire
-Suppression) $ Total All Fees:$
y Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ Sp 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Cl6GG3 S 7 I zoiz
License Number Expi ion Date
Name of CSL Holder
�r List CSL Type(see below) u
Nono
.'and Sveet Type Description
to?5 zF/eLO./IQ/f 0e U Umesvicte I(Buildings u 10 35,000 cu.ft.)
city/Town.Staler ZIP R Restricted I&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
CgrYCOoPen1,11c9zvN. ce., SF Solid Fuel Burning Appliances
1 Insulation -
Tele-hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t7F'e'.✓MC' UP-f �'oNasa� /G3D36' a yy,�
eJa�rrJ /tfi nl� HIC Registration Number Expir ton Date
IiIC tom,patty N or HIC Registrant Name
/S rvtyYh�v�lo `J
No.and Street. Cary
2xPs rr ie� )yl q 61 S6 3 �76 3iy<s"ad Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 f the building permit.
Signed Affidavit Attached? Yes ...:...... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize �Pf'ti2 mf f& n% rYrM,a3
to act on my behalf,in all matters
relative to work authorized by this building permit application.
J-Ercee^1"O Iecef--4 -2AY,6 ,w 1 Z--3-2a)z
Print Owner sName(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
24 ) L
Print Owners or Authorized Agent's Na a ctronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nor have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
inn .mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dam
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces - Number of bedrooms
Number of bathrooms Number of halfibaths
Type of heating system Number of decks)porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1
CITY OF SM.F.M, INWSACHUSETTS
BuILDIAIG DEPIR'I1IEDiT
` 120 WASHINGTON STREET,r FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
iQ*,tBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONL%ISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.5
Debris, and the provisions of MGL c 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 facility as defined by MGL c
I11, S 150A.
The debris will be transported by:
AA L�
n(naame of hauler)
The debrrii�s—will be disposed of in :
(name of facility)
(address of facilit )
signature of emit applicant
date
debrisdrdoc
CITY OF S.UXA1, NWSACHusETI'S
BL'l3DDJG DFPART%sENT
• 130 W ILMINGTON STREET,30 FLOOR
TEL (978)745-9595
FAX(978)740-98"
KINIBERLEY DRISCOLL
MAYOR TH0biAs ST.PtERRz
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMMIONER
Workers' Compensation Insurance Affidavit: Builders!Contmctors/Electr[cians/Plumben
Applicant Information / Please Print Levillially
Name lBusinemOraani:alionAndividuall:.
Address:
City/State/Zip: .- o es4er c. WIA a ii r9B3 Phone#: 178
Are Y19dan employer?Check the appropriate box: Type of project(required):
L I am a employer with al _ 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or pan-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partn r- listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contmetots have S. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,¢I(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.) 13.0 Other
;Any applicant des checks btxt al meat slap rip ow The section below showing their workew'�mutim policy informadoa -
t I lnmeownes who subma this afpdsvh indicting they me doing all work and thm hire amide eamm era m r,aabmit a new allidovil iodieming seek.
:Co matora that chock this box mum shocked an addidural then showing an nmm of an n and their martens,comp.policy inronrmdoa.
I am an employer that ir providing workers'compensation lnsumme jar my employees, Below Is the polity and fob slh
infornmtion. 1A/�
Insurance Company Name: Ll oeg" l"I l t rL
Policy#ur Self-ins:Lie.#:- Wei-.3/S- Expiration Date: Z'`/ 7 �/3
Job Site Address: Je✓2e y� o
City/StateRip:
Attach a copy of the workers'compensatloa policy declaratba p118e(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 6. 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 Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
!do hereby certl under the Ins and peualNes ojperfary that the information provided above is axe and correct.
Sieoalure• a, Dr 2-3- J/Z
P_honee g2j1 3 6rG
Offreiad use only. Do not write In this area,to be completed by city or town of/lciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of ttealeh L Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person• Phone#•
VDN Liberty
IssuB4G OFFICE 181 jV1Att1dL Workers Compensation and
INFORMATION PAGE Employers Liability Policy
FACCOUNTNO. SUB ACCT N0. Liberty 111utusl Instum ce Group/Boston
943 OOp0 LIBERTY\RITUAL INSURANCE CO Is=
NO. TD/CD SALES OFFICE CODEHASMESIGNED
CODE N!R 1ST
0943-01] XX X 7VFSTON 102 TIVE 3000 1 YEAR
2D71
Item 1.Name.of OPEN MEADOW HOME LLC
Insured FEIN 20.1108512
Address 75 RIVER RD
TOPSFEELD,MA 01993 RISK ID BOS096
Status 46.LIMITED LABILITY CO
Other workplaces not shown above: SEE ITEM 4
o,Day Year a.DayYear
Item 2.Policy Period:From 02.04.261, to 02-04-2012
12:01 AM standard time at the address of the insured as noted herein.
Item 3:Coverage
A. Workers Compensation Insurance: Pan One of the policy applies 10 the Workers Compensation
here: Law of the states listed
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each stale listed in item 3A.The limits of our
liability under Part Two are:
Bodily Injury by Accident 100,000 each accident
Bodily Injury by Disease 300,000 policy limit
Bodily Injury by Disease 100,000 each employee
C. Other States Insurance:Pan Three of the policy applies to the stares,If any,listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4.Premium-The premium for this polity will be determined by otu Manuals of Rules Classifirntions Rates and Rating Plans.
All information required below is subject to verification and chain e b audit.
Prtteiam Bari. Rue. LINE110
1er5r0a Eatimued
Classification Cade Estimated or RE- - Aaaaar
SEE EXTENSION OF INFORMATION PAGE No. TOM Aaaual Prtnaiuw aeuaem io. Premium.
-Mi2-imu�7emium $ 500 (141A ) Total Estimated Annual Premium $ 504
Interimadjustmeni0[premiumshallbemade: ANNUAL
This policy,including till endorsements issued therewith,is hereby countersigned by
a a nlme Data m- a- 3
Lac Cade Term. ow, Audit Bair Nriodic Pa.mem Retiay Dui, Pol.H.O. Rome stme Dhideod
03-16-17 1 1 NR I I MA NEW
OP0 4030 Rl Copyright 38137 National Council an Comperaation Insurance WC 0000 al A
I
None Copy
OPEN MEADOW HOMES LLC
HOME IMPROVEMENT CONTRACT
Homeowner Information Contractor Information
Name Company Name
Eileen Bellew Open Meadow Homes LLC
Address Contractor/Owner Name
7 Roosevelt Road Cary Johnson
City/Town State "Lip Code Business Street Address
Salem MA 01970 16 Market Street
Daytime Phone Evening Phone City/Town State Zip Code
508-527-2443 978-744-5950 Ipswich MA 01938
Mailing Address(If Different From Above) Business Phone Federal Employer ID
SAME 978-356-5454 201108512
Home Improvement Contractor Registration# 163038 Exp.Date: 05/04/2013
Construction Supervisors License# 96663 Exp.Date: 5/21/2012
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Homeowner:
PLEASE REFER TO OPEN MEADOW ESTIMATE#6273A dated 1/30/2012
Materials Expected To Be Used:
PLEASE REFER TO OPEN MEADOW ESTIMATE#6273A dated 1/30/2012
The following schedule will be adhered to unless circumstances beyond Open Meadow Homes LLC control arise:
Completion time is expected to take 45 days after work begins. Work will start after receipt of a building permit from
the City of Salem subject to weather conditions.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the material and labor specified above for the SUM of: $55,788.04.
Payments will be made according to the following SCHEDULE:
$ 11,157.00 upon signing contract;
$ additional disbursements shall be made based upon the % completed of the items per the Estimate;
$ 2,789.00 final payment upon final inspection.
In order to meet the completion schedule,the following material/equipment must be special ordered once the Contract is
executed and down payment received: Anderson Windows and kitchen cabinets.
---------------------------------------------------------------------------------------------------------------------------------------------------------
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Identical copies of the contract shopld go to the lIumeowner and the tractor.
Contracto S gnature Homeowne 's ignature Homeowner's Signature
,`6 S 26/w l-C --) t-�
Date Date Date
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,
which may be his main office or branch thereof,provided you notify the seller in writing at his main office or branch by
ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the
signing of the agreement.
See attached notice of cancellation for an explanation of this right.
Page I of 3 Open Meadow[Ionics LLC 2/3/2012
REQUIRED PERMITS
The following building permits are required: Building_plumbine and electrical permit It is the obligation of the contractor to
secure such permits as the homeowners' agent:
NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty
Fund provisions of MGL c. 142A.
Is an EXPRESS WARRANTY being provided by the contractor? NO X YES
"All terms of the warranty must be attached to the contract**
NOTE: All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place,Room 1301
Boston,MA 02108
617-727-8598
Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has
been placed on the residence.
ARBITRATION
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 submit such dispute to a private arbitration service which has been
approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer
shall be required to submit to such arbitration as provided i M.G.L7142A.
Contractor's Vignature o eown 's Signature Homeowner's Signature
Date Date Date
L
CE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO
RNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE
RNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE
IES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity -A 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.
Contractor's Financial Insecurity- In instances where a contractor deems him/herself to 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 from said account would require the signatures of both parties.
CHANGE ORDERS,ALLOWANCE ITEMS AND ITEM PRICE CHANGES
*Change Orders are determined by adding the price+Construction Management Fee and to be paid upon receipt of change
order invoice.
*Any unused amount of an ALLOWANCE item will be credited back.
*Should an item increase by 10% from the Estimate cost of the same item, then Open Meadow Homes LLC may pass along that
increased item cost onto the Homeowners.
*All materials and services are supplied through Open Meadow Homes LLC with the exceptions of those listed on the attached
Estimate as PROVIDED BY OWNER.
Page 2 of 3 Open Meadow Homes LLC 213/2012
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN THREE
BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED
WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND
ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN
SUBTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS
CONTRACT OR SALE;OR YOU MAY, IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER
REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM
UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE OF THE
GOODS WITHOUT ANY FURTHER OBLIGATION.
IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE
GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL
OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION
NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM TO OPEN MEADOW HOMES LLC,AT 16
MARKET STREET,IPSWICH,MA 01938 NOT LATER THAN MIDNIGHT OF October 5, 2010.
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
Page 3 of 3 Open Meadow Homes LLC 2/3/2012
2/22/2012 6:00:13 AM PST (GMT-8) FROM: insurancevisions.com-TO: 19787409846 Page: 2 of 2
A�"® . • CERTIFICATE OF LIABILITY INSURANCE onrE1MM/2nig
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 endorsements .
PRODUCER DOOLEY INSURANCE AGENCY INC CONTACT NAME'
IPSW ICH, MA 01938 Central Street PHONE 9 $)356-0581 EAK AC No: $ 51
E-MAIL ADDRESS:
INSURERS AFFORDING COVERAGE NAIL 9
NSURERA:
INSURED
OPEN MEADOW HOME LLC INSURERS:
15 RIVER RD NSURERC:
TOPSFIELD MA 01983 INSURER D:
DISURERE:
INSURER I .
COVERAGES CERTIFICATE NUMBER: 12445739 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 I
TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICYEXP
LTR POLICY NUMBER fiMMLpDIYYYYI I tMMODIYYYYILIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY OHMAGE TO RENTED
PREMISES a marldaca $
CIAINIS-MADE OCCUR MEDEXP(AnyoneiNamm) $
PERSONAL a ADV INJURY $
GENERALAGGREGATE $
GEN'LAGGREGATE LIMITAPPLIES PER: PRODUCTS COMP/OPAGG $
Pei--ICY PRO LOC $
AUTOMOBILE LIABILITY O GE LIMIT(Ee eaitlenn $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BOODILY INJURY(Per accidenQ $
HIRED AUTOS NON-0WNED AUTOS PPe�eiaCervitt AMAGE $
$
UMBRELLA UAB OCCUR
EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE
AGGREGATE g
DED RETENTION$ $
({ WORKERS COMPENSATION WC1-31S-380943-012 2/4/2012 2/4/2D13 WC STATU� OIN
AND EMPLOYERS'LIABILITY YIN TORY LIMBS ER
ANY PROPRIETORIPARTNER ECUTNE
OFFICER)MEMBER EXCLUDED? F NIA EL.EACH ACCIDENT $ 100000
(Mandatory in NH) E.L.DISEASE EA EMPLOYEE $
If yes,dascrAe under 100000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (AftacNACORD 101,Additional Remarks Schedule,If nmre space is required)
Wor L§come afion ins ce cov a I' only to works ensatio awS of the t to MA.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
93 WASHINGTON ST ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM MA 01970
AUTHORIZED REPRESENTATIVE
Jeff Eldrid e
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
CERT NO.: 12445739 CLIENT CODE: 1528232 Deb Oerochemont 2/22/2012 5:56:30 AM Page 1 of I
1h19 CPYtl£iCatP CaaCe1S and Sal. edPS ALL Pievi0u9Ly !SSaed C,tjfiCIte S.
A� CERTIFICATE OF LIABILITY INSURANCE D121/ IDD/Y2
2/21/2012
THIS CERTIFICATE IS ISSUEO 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 certlficato holder Is an ADDITIONAL INSURED,the POIILy(ies)must be endorsed. IF SUBROGATION 19 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 andorsement(s).
PRODUCER NAME CT Jay Dooley
Dooley Insurance Agency, Inc. PHONE (978)356-0581 FA% (9'r6)356-P60o
2 Central Street e�nnlL ,lay@dool6+yxna.cvm
PO Box 264
INSURE S AFFORDING COVE NAIC II
Ipswich MA 01938 INSURER A:Endurande American
INsuaeo INSURERa;LIBERTV MUTUAL
Open Meadow Homo LLC INSURER L:
16 MARKET ST INsuRBRD:
INSURER E
IPSWICH MA 01938 a ERP;
COVERAGES CERTIFICATE NUMBER:CL122 21337 7 9 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.
IN6R AUUL SUNKPOLICY BFF POLICY LIMITS
LTR TYPE OF INSURANCE POLICY NUMBS
OENEML LIABILITY
EACH OCCURRENCE $ 1000000
COMMERCIAL GFNERAL LIABILITY PMAUh rVRE _ $ 100000
A CLAIMS-MADE ❑OCCUR BC10000841000 /3/2012 /3/2013 _RREMIMED EXP Anyone arson s 5000
PERSONALBAOVINJURY $ 1000000
GENERAL AGOAEOATE 9 2000000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP AGG $ 2000000
71 JECI POLICY PRO• LOC
$
AUTOMOBILE LIABILITY UVMtlINEU SINGLE UNITI
E xaOelH
ANY AUTO BODILY IMURY(Pm pernw) 5
ALL OMtlED SCHF13U4FD
AUTOS AUTOS BODILY INJURY(Per a Wdent) S
HIRED AUTO 6 AUTOSEO PerNelCYntUAMAOE $
P
UMBRELLA
LIAB OCCUR EACH OCCURRENCE 4
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DEB ETENTIONS S
H WORKERS COMPENSATION 2319380943-12 /4/12 /14/13 4VC STATV• 0TI4
AND EMPLOYERS'LIABILITY
ANY PROPRIFTORIPARTNER/EXECUTIVE YIN $ 100000
OFFICER/MEMBER EXCLUDED? N/A EL EACH ACCIDENT
(Mandatory In NHI
bri sunder E.L,DISEASE.EA EMPLOYE $ 100000
ANIPTION OF OPERATIONS OWI F.L.DISEASE-POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ABaCN ACORD ae1,Addftlanal Ramnrhs Saheaulo,If mere space Ia mqulmd)
JOB: EILEEN BELLEW 7 ROOSEVELT RD $At= MA.
WOMMRS COMB 13 AN ILLUSTRATION OP OPEN MEADOWS CURRENT COVERAGES OPFICZAL CERTIFICATE WILL FOLLOW
DIRECTLY FROM LIBERTY MUTUAL
CERTIFICATE HOLDER CANCELLATION
(97 B) 740-984 6 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
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