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13 ROSLYN ST - BUILDING INSPECTION (2) cr- 3Sa� The Commonwealth of Massachusetts �a Department of Public Safety r Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ap (This Section For Official Use Only) 1� Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ( nmo QQ No.and Street City/Town Zip Code Name of Building(if applicable) iSECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below �-! Existing Building❑ Repair❑ Alteration Addition❑ Demolition ❑ Please fill out and submit Appendix 1 �' ( PP ) F Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M/ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ml__� Brief Description of Proposed Work: 'Tnl-SFaII iltA1J <. aln/1 nln Jrtlyfwnu q"J, nIIVSP /.11nr -,Q(7�1'Si o n IitnucP t= SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): 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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H5 ❑ I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 9L R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ FIB ❑ IIIA ❑ IIIB ❑ IV O VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazazds to Air Navigation: NIA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: i SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Atlkc fir; fl V Lmy Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �/ 'f IUt t kt _ 2a-r - - Title Telephone No. (bass) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Dv pr—17 21 IlS Alor_ILt S 9, YOA- Oig70 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building pernut application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) Of building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control C,Ori r oez2N1- I a gist ant) T h ne No. e-mail add ss Registration Numb r r Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor ul 4 Q F2t1�CeS Company Name Name of of PersonXesponsible for Const4uction License No. and Type if Applicable � is' l�Chun S' �S�f841P-, _7b Street Address City/Town State Zip Telephone 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 is ,nce of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicati i true a d a urate to the best of my knowledge and understanding.. Please print od sign ame CV1 VI- POP✓ 7o4 Title Telephone No. Date Street Address A r� //_ Ui City/Town �Statel,�- ^ Zip O I a D Municipal Inspector to fill out this section upon application approval: "' 7 , ✓ /[��/ //� Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building PP a Permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot # for locations for which a street address is not available) �l No. and Stree City /Town Zip Name of Building (if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No V Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No V Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No V Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No O� Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) � / Yes ❑ No 15- Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) 30 w �+�p�/�/1r,1�+ At A SERVICES, INC. A&A SER 1ICE 115 NORTH STREET, SALEM, MA 01970 • Telephone: p (978) 741-0424 Fax: (978) 741-2012 Contractor Registration No. 101609 Federal EIN: 04-3090162 Construction Supervisor No.CS057733 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Bu er S Name / Date of Contract / Bu e s Street Atldress, Ci Staled/d Zip Code 3 Daytime Telephone Numb Eye. T I In Me Number Mobile T h Number � E-Mail Address The Buyerjs)listed above hereby jointly and severally agree to Purchase the goods and/or services listed on me accompanying specification sheets,in accordance with me prices and terms described on the front and the reverse of this agreement and any specification sheets(cols•Agreement"),and Buyers)have cord ance that such goods or services be installed or provided at at Buyer's address listed above.A8A Services,Inc. tiContractor"),hereby agrees to install orcausetobe installed me Products or services listed in Nis Agreement at the euyer(s)address written above.This Agreement represents a cash sale of goods and services.The Buyers) agree to pay in cash the Cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase. Purchase Prim tr,✓7 y/,�� Est.Starting Date' Down Payro l .,Sic..� Est.Completion Date: Amount Due on Stan of Job:`': 925V_ UI Cash P,Check Amount Due on_of Completion: q1 Credit Card No, Amount Due on of Completion: O 1 / ` Expiration Date: Balance Due on Upon Co mpletio / 6 CVC Code: It is agreed and understood by and between me parties that this Agreement, front and back and any addendum, constitute the entire understanding between the parties, and there are no verbal understandings or modifying any of me terms of This Agreement Buyers) . hereby acknowledge That Buyer(s)has read the hoot and the reverse of this agreement and has received a completed,signed and dated copy of mix Agreement,including the two attached Notice of Cancellation forms,on the date first written above.Buyer(s)also(i)acknowledge that they were orally informed of their right to cancel this transaction;an (11)request that they be contacted via their telephone numbers or email,as listed above,in the event Contractor believes Buyers)would be Interested in any addidonal quality products or services of Contractor.DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. A&A e7v'cesI[nc. Bay ev: �U f Sign atur e / _ ' ' .— !. { 7c z Slg�Aa�tu - Print Name / //hI� "" -- ` Print Namn -_... - Signature Print Name You,the Buyer(s), may Cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the following Notice of Cancellation form for an explanation of this right, ARBITRATION:The ran recluread the hom¢mmer hereby mutually agree in aavanee that the edam ttiNerpany has a dispute wnceming this mnvacr,ellM1erpaMthey auernt such di privaa lm immn 5ernce forioo has been appovee by me Secretarypr Ne Exemava Ofice of Consumer Affairs antl Business q sW b b a r0aation as proved In M o L c.14PA. egulamse antl the Omer pam shall be requiretl to subnul to suU pad, "6`7✓�i NOTICE O� F CANCEILLATION NOTICE OF CANCEILLATICIN pate r -Oneunn Y^LT�a-/,lvou may cancel this xaneemibn,remora any Penally or pate or tomeamm� phlgavon,.min three business days from me above date.If you canrst may cancel Nis you comen,„;mom any penalty m any Prriants mile by You under me contract or Sale,and an any protcM traded in. omigaeon,HNin three business eeya homm¢abbve date.nrou ranwl,any pmp¢rry lradea in, by you will derelumed within 10 do'Morning Y11-1 Of bin,conumem¢uaktl any payrrenta made by You under the Contract or sale,and any negotiatleinsWment ee¢cmetl and grewlpl it Me Boller of Wuou canceu yoentice, py you doll be rebmm Cher 10 da tollowi Make yadait theS1edsingour of me andson Mllbecrk in as It onn¢L you rmsl 5's rgre¢enso bel or Snaredr of yifyouour ust notiw, mike available to IM1e Seller at Your residenre,one suhsbntial and any Shelia interest S ller at out or the tansand bs be canceled 11 you nncel,You trust vee.any 5oons eef Me Sto on in as acre is math as when hake available b the Seller at toot redden¢and subsGntlaYy in as gbo]mnditino as when wu unaerws enno-aer pr$ab;pyau mad,nrm,dean,emmlr ivee,nnr doom adNeree 1p cap me Ind nor is of me iker regarding the return shipment of me gelds at es seller's MN me instructions bl IM1e Selle�uegaNing under 'N contract by a going ship e;t you tray,if you vthe,SAM,s expense and ask.If you the rryke me Your No re of Co a me Seller one m Boller epos not pick soluble and ask.If groan!of the goods at the seller s memupµRhin any 20 tletterata Of tbetlateotybur Notice of Canoegood yourreheinmoreiilevse if you them up You do nuke the your our Notice eaof Ca the Beller and the seller ocesnotpick goals e.,a anY goods 0 Inc Son.apu hit0 drake thegeWsoneiladebme Selletwn pwn 20 days ofrablmiifo"far!t Cance-9re,yqurmdelri the Sispoxm Agree helnegmes to Inc Saba parse fered this tloso,then You Me acres You agree 0 usto anyNMero the saferend fail betake0e You remain liaeb0serionsaril yy remain liable Mpedomunceof ofalloigaterWmtbe the Cods les,Tocrandlt ilbtloso,N¢n You remain liablesfmpeawmanw all otlof igaepns under me Contract To ren¢N lM1is transaction, Iwdeliv¢ia signetl and Baled of all MIiga4ons under the Contrail.To cancel this bansagion,mail ordelivera9gnetl and dated cent lub correlation notice 9r any omen vsllten noise,m send a hlyyam,b ASq jerAce copy of the csncelladon ribose or any other carmen noure,or send a tel¢gr b ABA arenas 115 No h5treeC Salem M4019]O,NOi LgTEq THAN MIDNIGHT OF — 7-//, ryS NwN Sheet,Salem MA""it NOT LATER THAN MIDNIGHT OFjit 27-14 s col �.. I HEREBY CANCEL THIS TgANSgLTNIN rioter ' THEREBY CANCEL THIS TRANSACTION Consurrc Signature Date'. Consumers Signature pale: 91 we ,, /� i cam+ A & A SERVICES, INC. A&A SERL/ICES 115 NORTH STREET,SALEM,MA 01970 Telephone: (978)741-0424 Fax: (978)741-2012 ` Contractor Registration No. 101609 Federal EIN:04-3090162 Construction Supervisor No.CS057733 VINYL SIDING SPECIFICATION SHEET Buyer(s)Name - Date of Contract Buyer(s)Street Address,City,State and dZip /Code Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address &7—gor_2�9G The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification Sheet is a part. VINYL SIDING r ❑ Remove and di pose of existingsiding. Note:�' --[Lt"J/L� a:; 11 O art, s \❑ Remove and dispose of old wooden gutters. N ./ `�P Remove and dispose of aluminum gutters. on rAdvrp S,•Oc, 9 Install new.032 gauge aluminum seamless gutters and down spouts as follows: Open Gutter ❑The Gutter Shutter Color:I: AA:--e- Cover body of home with 3/8 inch thick Dow High Performance Insulating Board. Cover all trim with aluminum coil stock including the following: Color: Vtrim deluxe window trim upper porch trimoards door trim ❑ Otheroards N111 rake boards Install Soffit Panels: Stylel a f Color: Install vinyl siding to body of he as follows: Manufacturer:C, SryleZh`1 Color: r- S (, ❑ Replace existing wooden attic louver Vents with vinyl veOF nts. ❑ Cover porch ceilings with CertainTeed beaded porch panels. ❑ Remove and re-instail existing shutters. \❑ Install# pair of Girardin new vinyl shutters. Corner Post style: Z% '/ Color: Clean debris from grounds on a daily basis;clean grounds thoroughly at completion. Included in this proposal are the following items: ",Gt Building and Electrical Permits "Q Basic Electrical work including removal and remounting of fixtures electric service,and wires. \ vQ Basic siding accessories including light,outlet,spigot blocks,dryer vents,and exhaust vents. SPECIAL INSTRUCTIONS: L Rc / J 3 S. .B �J L` c?, ze A &A Services, Inc. provides a five-year labor warranty on vinyl siding installation to Include any re-installation of any vinyl siding, gutters, and aluminum coverage work due to any faulty workmanship. This warranty does not cover any Acts of God Including ice dams,lightning strikes,falling trees,damage from vandalism,or improper use. N Is agreed and understood by and between the parties that this Specification Shee%along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,consatums the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This contract may not be changed or its terms modified or varied in any way unless such changes are In writing and signed by both the Buyers)and the Contractor. Bureads)hereby acknowledge that Buyers) has read this Specification Sheet, Contractor Initials: '} p C. Z. Date: Buyer's Initials �„id Date: CITY OF S<UEN11 ANSSACHUSETTS Bl UMDIG DEPART\ENT N 120 WASHINGTON STREET, 3-FLOOR eel TEL (978) 745-9595 KI,,\BER1EY DRISCOLL RkX(978) 7.10-9W NfAYOR THOMAS ST.PW.ILU DIRECTOR OF PCBLIC PROPERTY/BCA.DLNG CO.XLXRSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le fbl Name (Business:Organizatiorvindividual):_ ] Jam-{ ` /—F � E S Address: I� � M O'2.i—) & G � / City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): LEI EI I am a employer with 4. ❑ i am a general contractor and i employees(full and/or part-time).* have hired the sub-contractors 6. Q New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity, workers'comp.insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'comp. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] employees. [No workers' comp. insurance required.] 13.❑ Other hAny applicant that checks box 91 must also till out the sectim below showing their worker'compensation policy information.Hum<uwnere who submit this afdavis indicating They are doing all work and then hire outside contractor:must submit a new affidavit indicating such. :Cuntmenors than cheek this box must attached an addiniorwl sheet showing aw name of the sub.co ant tots and their workers'comp,policy information. I am an employer that rs providing workers'co informamprnsatlon htsurance for my employees. Below Is the polity and job site tian. —}— fn,urance Company Name:_ l ' I] ]°✓4 U el•eel Policy 4 or Self-ins. Lic.q: �( .7 I t icy ----t-�- ' k d Expiration Date:_ Job Sire Address: Ciry/State/Zip: S�]� M A q'7 0 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 S250.00 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 unde I r the/pains and penalties of perjury that the information provided above is tr a and correct 'i gnat rre• � �-'✓ ��' 9v �6 ' Date: U Phon S: - Ofcral use miry. Do not write in this area,to be completed by city or town ojjlciat City or Town: PermidUcense 9 Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Ferron: Phone th ° CITY OF &U1.NI1 -L-�SSACHUSETTS ' BUILDING DEPARTMENT 130 WASHINGTON STREET, 3iO FLOOR TF-L. (978) 745-9595 FA.0(978) 740-9846 KINiBERLEY DRISCOLL MAYOR T Hoatns ST.PMRRs DIRECTOR OF PUBLIC PROPERTY/BCILDNG co%MSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State BuildingCode 780 C)VLR section t 1 I.5 Debris, and the provisions of MGL c 40 P 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 t 11, S 150A. The debriswill "bee transported by: - rl�V�iP�� (name of h er) The debris will be disposed of in 0 6 (name of facility) � ci�Ut(� (address of faeilit ) SA hem V� q 01910 signature of permit applicant l0 16 ate dcbrisatT.duc Massachusetts - Department of Public Safety Board of Building Regulations and Standards A&A SERVICES, INC Christopher Zorzy 115 North Street License: CS-057733 cif Salem, MA 01970 cHRlsToeHER�OR 115[NORTH ST � �� L,; P Salem MA 019707- M'Al ii 2W-06l11 c-� f Expiration - _ Office of Cmwumer Affairs&ISusiness Regulation Commissmner 05/2 612 01 7 7fi=(A HOME IMPROVEMENT CONTRACTOR Registration 101609 Type' Expiration. 6/26/2018 Private Corporation A:== A&A SERVICES, INCi Christopher Zorzy - 115 North Street - ---- Salem,MA 01970 Undersecretary ACC)R p® CERTIFICATE OF LIABILITY INSURANCE °"�'MM9/°51216 •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 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 CONTACT The John M.Sullivan Insurance Agen PHONE 781-449-9330 FAX P.O.Box 920047 aoC,No.F sullivan.insadvQver¢on.net aw Arc No: 781-440,3511 Needham,MA 02492 INSURERS)AFFORDING COVERAGE NAIC If INSURERA:The Travelers Indemnity Co 11347 INSURED INSURERB: A&A Services, Inc INSURER C: 115 North Street INSURERD: Salem, MA 01970 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 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 JIM L SUER LTR TYPEOFINSURANCE MORPOLICY NUMBER MMADD EFP MMIO YEXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY D GE TO D PREMISES Ea owurrenoe $ CLAIMS-MADE D OCCUR MED EXP Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY- PRO- LOC $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Par Person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per acddenn) $ HIRED AUTOS NON-OWNEDPROPERTY DAMAGE $ AUTOS Pet arrident UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR Ll CLAIMS-MADE AGGREGATE $ LIED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'UABIUTY ANY PROPRIETORPARTNERIEXECUTIVE YIN 9/13/2016 9/13/2077 A OFFOERIMEMBEREXCLUDED? NIA 6KUB-0243M81-5-16 E.L EACH ACCIDENT $ 500000 (Mandatory In NH)If yes,desrnbe under E.L.DISEASE-EA EMPLOYE $ 00000DESCRIPTION OF OPERATIONBbelaw EL.DISEASE-POLICY LIMIT $ 90n non DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N mare space is required) CERTIFICATE HOLDER CANCELLATION City Of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Washington Street#4 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRES E ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD