32 SCHOOL ST - BUILDING INSPECTION 10 23%
The Commonwealth of Massachusetts'
Board of Building Regulations and Standards JJECEJqEV R
�( Massachusetts State Building Code,780 CIv�rmpECT ION AL S tU USE
Building Permit Application To Construct,Repair,Renovate Or Demoli RS4,%ar2011
One-or Two-Family Dwelling o •r
j This Section For Official Use'Only<d,
Building Permit Number: I Date Applied:
Building Official(flint Name) - Signature - Date
SECTION 1:SITE INFORMATION
PM d ess 1.1 P 6 I S J 1.2 Assessors Map&Parcel Numbers
Lin Is this an accepted streep yes_ no Map Number Parcel Number
13 Zonin Information: '"
g 1.4 Property Dhnetisioiis:
,drtst}s �t G=- flat, ` [,�
Zoning District Proposed Use Lo[Ar (gg;ft)� F r*c ;tii. Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Regdued Provided Required Provided
1.6 Water Supply:(M G L c.4Q§54) 1,7 Flood Zone Inforpurtiou; 1,8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?ifyes❑ Municipal❑ On site disposal system ❑
Checic
SECTION 2: PRO PERTYOWNERSHH1
2.1 O err of Record: _
�wl N V e l a rc1 �c' I-Cyn
Name 3t) �GytdO' S� City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-0ccupied ❑ Repairs(s) ❑ 1 A ions) ❑ Addition ❑
Demolition - ❑ Accessory Bldg.❑ - Number of Units- Other pecify: -
BriefDescriptionofProposed Work2- ,-j ^*;, , >•
/11
SECTION 4:ES TED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ � , ijp 1, Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire '
Su ression) $ Total All Fees:$
Check No. Check Amotmt Cash Amount
6.Total Project Cost: $ a t ( ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor(}License(CSL) G -� �3 ��
to 1 �'�'l Y/i _ /
t ' License Number Expiration Date
NameofCSLHolder
G Eric W.Palm List.CSLType(see below) (/ _
aaig,u:ken glmd
No.and Street _ - "'''a t'+.�,a� Type Description
-1 Salem MA 01970 U Unrestricted(Buildings to 35,000 ca.R
R Restricted 1&2 FamilyDwelling
City/rown,State,ZIP M Masonry
RC Roofing Covering
WS 'Window and Siding
Q7 7 v1 U b� 3 SF Solid Fuel Burning Appliances
/�" 3 I huuladon
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Al ZO Rcf Z
HIC Company Name or HIC CrILd110fl, LLL(; HIC Registration Number Expiration Date
No.and Sheet 1 R kffirft Amue — Email address
Salem MA 01970
Cityfrown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I..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 ofthe lssuance a building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUUI/LDING PERMTT
I,as Owner of the subject property,hereby authorize L y) G I W[t ✓i
to act on my behalf,in 111 matters relative to work authorized by this building permit application.
Print Owner's Vame(Electronic Sigaature) _ _ Date
SECTION 7W OWNE10 OR AUTHORIZED AGENT DECLARATION
By entering-my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain this apon d aceumte to the best of my knowledge and understanding.
•t i ,Jr
Print Owner's or Authorized Agent's Name(Electronic 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 not 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
www.mass.goy/oca Information on the Construefon Supervisor License can be found atM .mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number-of-bathrooms Numberof-half/baths
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,
�assaclausetts l�oasie 1'oe
rovemoat Saar le Contract
nris farm sabsBa aii 6asc o' �
language to Pro fe9 °gp°°rs°Idre smte's Hor¢e Ln
i�lasszcitncetts Conmwerm�ers Seelr 1egW adviceifaeeessipl�em Cwvaporlasy(MG(•I oplew Id?A)•butdoes not include sbatlard
OtliceofCo Cndde to Home Onpms,wmPbe(orc yPerson PhmainghMe impml mmu should first obtainaroPY o0 o
nsumvASairsapd Business Rcp,dadoriz C1,numraa nom,ativo Hedinom6 larecdence You mayobminafre<ropybytaldpg the
h10me0R'➢er[➢fOfm8t10➢ I 'Bo8]ar 1-686-283 3]S�oran aurav<psla
None ContraetorInformatio➢
Corauzap Name
Same Address delm..
( Office Boxaddren) Cmtusetadsel s vN
Sa'O 7, 61RJe ,
Cinifmm J ' I I Avenue
t� p Code 'LL � Busmen dddnse(mmtinel
5°a4r9ftf 'pL70
Eainv Phone
Q_11 in9 Z
C°dekeilnAd N diffeem fmm,
xhoee) �
Bustmespheve
� Pederzl�Pto?erID arSS.Number
?s.mamr,mrono—r °�r4,nme�ej=--ore.�s� �' •t
TheCantmtaora c�-s`r ! 7j &
rDeseribe ind sreesm da the fa0orrirtgspHc(ordreHotuemvner. i
coil the wart to eompltted,spetifiing OenPe.bona ad gredeof/�✓ � auredabmheused.Psezdd"' ., ry f
te
Requited PermitsI Or ye,
e' f NSL(/,tA -
The(ollosviog buildingPemdtsmerequveit Proposed Smmwd Cos edonSrhedWe-
wdwnerslyhos e, t-heir oraz lhehommuner's ae®t) PI(Owners fromth➢retbeirow➢permits willbe headhvedmwieascimmnua°cesbey eContrearresng schactmisedule ll
occluded from theG➢araoh'Fund ,, �,� �0°dd1CC0°Irrusorsronwtarise
�YGLchapter742A.) pr➢visio➢sof I .5/ )l.
`� Dineuirmconttactarssiilbeginrontrdmad,,Cd,
Date warm caoaacted smrk III be substantiaity completed,
Total Contra"Price and Poynter Schedule
The Conoaaoragreas an perform themvrk,famish the mmerim 1dlabor eci( �1 �r��sp ed aboae£vibe mini sum of: �� .Payments will bemadeamotding to lhetolloxing 0(m schedule
S upon si_tming ronwct(cot to ecceed ID afihe[oW convect price or thecastof ec
S by//_oryPan completion or j _.� ordviteun,uhicheaais ercater)
S J/
by or uponcompledon of +17n
S/_a upon mmpledon of We rontmct
(Line fprhids demon -gfullpavm twill cooaav is row I Thefollvwi.'eme"ivpequipvtcntmwbespatiy S ' P ed[o both Parry's Sxtl,factian)
orderM hefinetaeconuatted work beginseanjv to Paidfr
U meetthemmvleaorsdedul.e.,
5 be Pm m
NOTES:(•)1nc1uding Wl tinm¢chaiges(")IamregWres iha min tlepost°:tlown-payment rcmdred by the earmamar hefa2 war¢h-:
notchatu thegrertmofendiathirtl ofthemml conoem Pdeeor(blthevrmW
nhiehmw 6especml ardemd in adtaaremmee:lhee curt ofan}• -ins vrzy
omvlefion sehedWe +Pe°al equipment arcmyom mzdematenW
Er tins rt'am. n-_[saner resss nrrnam '
SUbmatramors- 1° fO° Ne I:!;.M r? ❑N.�Yes vilt
Thecwlmmar aynees to be saldyresponmble for tmmplttiw of We work orrhe warranty mum he r ch I.the mnrrvrr
paw/submnrracmr uu7iaed by die conuactoc niemnuan°rf°ihei d�t�dr
'^area Is nb ru �yetees to 6e solely 4ardlen ofdre a<dons at any
[tiid- e y responsible fvall paymerm call
ContmctAccepmoce-Upwsgning,this d0awnmt becom arbmneractors for
conaam shag not imPh'that wv lien or other semuitybrouest has been glcomamdvlmv. al mhernise oared within thisdocumentthe
earaFWly before swing this mmm, i Pacedondrereslen .Revins thefollowing mudons and notices
^ Don't be pressured into spring the rotmaci isle dine to read and full veil
Makeswetheronaam rhaz id Y erstand it. Ash questions ifsomeWin suhcoatragors to be racist tovemmt oaea' eaismd . The lmv Sis wWear.
eyed with the DiraaorMHnntefmpneiemeol ComtacwR �t mosthama impmsxment mntrsnorand
agispatiw bywridngmihe Dire Moral 10PmkPlaza,Raom Sh70,Haan bi402 tbs➢auOR You maYin
Doesthemnbaclorluvem + 9traeabommnttact7
sumnto Askthe Cmt2norforhis-I °'' Ilb or by calling 617-973.878i or S88-?g;_�7i7.
see a copy 01-inoofofinsmance'datrunent mmuance rompans'rntomrauw so ibatyou rao con o I:nou}nvriehrand ftticcov".;or asL to
Guide m the Home hoppmVement Contract"LanMPonmt Infor i ation w die MI
ofthis farm and get a copy of 16e Consumer
roulm mncell usaoreemmtifitbu been signedp i
contranor in writing at hisPov main °ta Place the Can uaetorsaormai plain"£basin lhirdbusiamdayfdlosinethesi_®in ce or branch office by ordinmylmail posted,by tehemere seat 0 )usili�Pmaidedyounmifi•the
g ofdrisamaament_ See the atmrhed notice ufceocellad®fow fvao ary,not laterthm midnight of the
DO NOT SIGN THIS CpNTRACT I 'THERE RE ANY BLANK SPACES!� eht
Twv iderdyeop mofa<mao^�eon be arep!tmai siv�.Cd.Oo-miYsinvB soothe Eoxm vc—..hecUcmP.'s'rrv!dh4Prh.V:am+r:ar.
W n �
Hommuav's Sign
Cupaamgr
Contractor Arbitration
The Home Improvement ContractorLawpromrides homeowners with the right to initiate an arbitration action 1 as an
Alternative to court action)ifthey have a dispute xvith a contractor. The saine right is not automatically afforded m a
contractor,however. The contractor would have to resolve any dispute helshe has with a homeowner in court unless
both parties Wee to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Co'bactor Law.
The contractor and the homemvnerhereby mutually agree in advance that in the event the contractor has a dispute
concernine this contract the contractor prey submitrhe dispute to a private arbitration from which has been approved by
the Secretary of the Iixecutwe OHce of C onsumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitra" eras pcb4idedlu Massachusetts General Lays e cer 142A.
Homeowner's Signature Cokactor's Signalize
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The bomeowner may initiate altern five 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(i.e.MGL chapter 93A)may not be waived in any way,ei,en by agreement. However.homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the wort:as described:in a
timely and worlmranlilm manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for worlonanship or materials. In addition to guarantees or mtrmoties
provided by the contractor,all goods sold in Massachusetts cony an impliedwarmnry of merchantability and fitness for
a particular purpose. An enumeration of other matters on%vhich the horn eownerand contractor lawfully Agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner right%contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in du licate and should not be sighed until a copy of all exhibits and referenced
documents have been attached Parties are also advised notto sign the document until all blank sections have been
filled in ormarked 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 mast be in writing
and agreed to by both parties.Contracted work may not begin until bothipardes have received a fully executed copy of
the contract:and the three day rescission period has expired.
Accelerated Pavments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems hinitherself to be financially insecure. However.in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of Curds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work t�thdrawal of funds from said account n Duld require the
signatures of both parties. i
Additional information I
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 Consumer Affiirs and Business Revelation
10 Park Plus,Room 5170.Boston MA 02116
617-973-8782 888-283-3737 or visit the OCABR website at
If you want to verify the registration of a contractor or ify!ou have questions or need additional information specifically
about the contractorregistration component of the Home Improvement ContractorLaw,contact
Director of Home Improvement Contri ctor-Registtation
Office of Consumer Affairs and Bus-mess Regulation
10 Park Plug Room'5170.Boston.MA 02116
617-973.8797.888-283 37i 7 or Ndsit the HIC webs ite at tun::•.11 rut' _ot"ocabrr
Go online to view the status of a Home Improvement Contractor's Reeisnation:
---:i';d'rstate.ma.rr-:Lumtirmnnemem�iir.a���li,r.asp
For assistance with informal mediation of disputes or to register formal complaints against a business.call:
CfismehCe omlrntsection
Oobf oay
General
617-727.8400
ANVOR
Better Business Bureau
508-652.4800,508-753-2548 or 413-734-3114
l'mivr.31-I VJ2ata
The Commonwealth of massachuseus Peinf Form _
DeParftwnt oflndustrial Accidents
Office oflnvestigadons
I Congress Stree4 Suite 100
Boston,MA 02114-2017
wwx:massgov/din
Workers' Compensation Insurance Affidavit. Bu lders/Contractors/Electricians/Plummets
ARACaIDt Infolralatioln
Please Prsut p egilily
Name(Business(Organization4ndividual): Atlantic Weatherizatiun,LLC
Address: 61'R k:fTerst)n Avenue
City/State/Zip: Phone#: 97,f' 71W-(- 8/y 3
Agee,yo employer?Check the appropriate box:
1.i 1 t am a employer with�_ 4. (] I am a general7workers'
nd I Type of protect(required):
employees(fall and/orpart_time).a have hired thetors §• ❑New construction
2.❑ I am a sole proprietor or partner- listed on the a . 7. Remodeling
ship and have no employees These sub-con
working for me in any capacity. employees andrs' 8. Demolition
[No workers' comp,insurance comp, insuranc . 9. ❑Building addition
�Iwied•] 5. 0
We are a corporation and its 10.[]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their
myself.[No workers'co right of ex I I.❑Plumbing repairs or additions
comp. gh 4),and per 12.[]Roof repairs
insurance required.)t c. 152, §I(4),and we have no
employees.(No workers' 13.I yOther Z/✓Sa/u f ortil
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'co
t Homeowners who submit this affidavit indicating they are doing all work and then him outside mpensation policy information
eConhactors that chuck this box must emplo ees,they m additional sheet showing the contractors must submit a new affidavit indicting such.
employees- If the subcontracrors havea emplo name of the subcontractors and slate whether or not those entities have
yeeust provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance f
informationor my employees Below is the policy and job site insurance Company Name: t t r-i C A
Policy#or Self-ins.Lic.#: j 0 a 7 O 1 /
�^ p L Expiration Date:.
c
Job Site Address: J o�
_ � C/lt{,(11 City/State/Zip: X� fi�vt
Attach a copy of the workers'compensation policy declaration page(showing tine policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of cl penalties of a �,
fine up to$1,500.00 and/or one-year imprisonment,as well as ci riminavil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Pdo hereb cent! der the ' s a allies o e:rLu2 that the in ormallon provided above is tru and correct:
Si afire:
Date .- Z
Phone#
Official use only. Do not write in this area,to be completed by city or town q fficial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cltyfr'own Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person:
Phone#:
' -•• ++va vGd
A
g � Ia?�I�p",�! ( � s p
+ HOi THIS CERTJFICATE IS ISSUED A9 q h A ~pp gg �p (�
LDER• 4 �l�JuCt7�1� oa7E I
kFFO THI9 CERTIFlCATE D T'TER OF INFORN1ATtON r 0 72 207n RDED BY THE POLICIES OE8 MOT AFFIRMATIVELY OR •ONLY AND CONFERS -
I THE i99UING INSURER S BELO.l. THIS CERT1pryCAI OF dEGATiVELY An1END NO RIGHTS UPON
),AUTNORI_ED REPREgENfA71VE OR P SURANC@ DOES NOT E�END THE CERTIFICATE I
Ih PORTAMT- if-he NO at'ER THE COVERAGE
sub ceriiBcate RODUCER,ANDTHECERTIFlCA CGn?RA�8ET4V
lecito the iG holder is En ADDIYIONAL iNSLIRE TE HOLDER. EEN;
I notcolderr'D msandcondi3'onsatihe D,the
htstothecart- zholderinpowy,�'inP°rcres1ev oticy(zs)itwsibzeido;sed• IFSUBRO
PRDa c� endorsemard(s)•quire an Ors
Eli A statemEnt on th this�N i9WAIIIED,
EAS ERN INS GROUP LLC °rhficaiz dazs I
233`+TEST C- ccrrAa 1
� ORAL Si r'"''•- I
NATICK•MA 07780 FHG�=
tAti� 'nt• IFA:(
- I
Ci$!'-ey MSUA'AIS7AfTC'9D@ie CCyEgA
M$I:aE$A:attERlCA;t2uiRCli � I
ATLANTIC Wv�T(iERtZATiON LLC Rtsu• EAHYrcD I
fi7 REAR J?= =RSON AVE LtiuREa E: I 1
I SP.LEf.;idA 07E70. - t
IIVSUR_--A C_ I
MS`J.icR G: I I
f
COVERAC- rtsua -: i I
Milli P: I
THUS IS TO C=P11•-l' Fl Te -'H R_
A_Ot.- FOR THE POL CT �=PaIGt=S OP hNSUR REVISIO
CCN'iRACT OR PEP-IOD INDICAr- A+JCE USi-ED S-�t Oyl, HAVE^YSURANCE AFOTHER DOCUMENT WI _G- N'OTt"d'TJ;-01-N X E SEEN ISSUED p-
BE )
Ot-DiT10 c ORQEp 7'}1 RESPECT TO WI'OCH Tr1IS ANY REOUTAEMENT. TERM OR CO INSURED NAMED I J N,.OF SUCH P SY�' POLICIES DESCRIBE O CSLJE J CATE_F.MY BE ISSUED 6 NDITION r
Man OLICIES-Likil SHOWN MAY _D HEREIN IS SUEJe_ t , R N,AY? OF A\Y i
L"I TYPE DD $Ue HAVE 9E BEEN SY PAID CL4tMS- E TERM$ EXCLU ONIS� THE
AND
OEN L IM$iIAANCE IAOD qq
7 UAaR711 tH$ SWDI FOUCYNHMER FOILI
x
�`<E;c1ALe>,ELuuurY rzrriDarvYni raroa�P I
I� Cu,Ry^ DE UtN7$
I I it EaCHG'CURR_-NG=
I"'7 I •tADE7oas�ED s
i I 0-47,AGGa � trDE%F rA,;t Xse a
, S
EGAi EIIliR APiU- I -EA_MHty N IS
DDD��� AWAY
i ��O;;jjOi LLAB JEn,' �c I eE;+EAq_a0¢aECAr- �5 I
I�^NYAL'iD 1 XFAfN7U.':S_CDLL^.AFAGC- S
tiros-a OUL-0 I Is
Aros I I uBWsLugE UUr, I
t--lHr'°wUrLS' I AUMSY,ro + I I E>,^DILY I$
i F 1 M�ORY[tiDe¢an
EiIZ: ) I$
�IURIaAe'-LA UA$I I O I I �q LLY m.10aY(-�,e Ij IS 1
I I D<D I
A.TeMIOtis I I II EACH Occuana Y[OR;ERS CO:LFEN$AifON ACGREEAl S
Aao a lip
i CO'YEBSLIAEIUrY I -"�-�.
so?
Vrr Bt I Is
i
I (t �z cf•c: cYCyD 5�tt:a� i I
1L"1 a?-r,mstr un%er 6tZU3 j
a32i0727 �'20-207SI0&20207a E'"'"G'acpD3t;
i I a�'00.000 I
( �l Df$E/y5E_EA=wLol$500,ODD
or
6eSCRi �I `-L 06FASE- ,Ip,UU1r Ia00,000
� �IONoFaRAnDNsnacanoxs;YDHI�w$acnscoRDT>n,aa� I
Ina1 A°DXu1e$WnuLa,Omnteiml4teaDGa,,q I
I I
CERTIFICATEOLDER I
Ci7YQFSALEM 'SHOU ANY .................................
.
MZHINGTON ST
S.ALEM,1t1ADt970 �CANGE�L GP THE ABOVE DeSCRIssD FOLiCIEs SE.
(tOTICE> L BEFORE THE EXPIRATION i
iP011CYP DELIVERED (pi DATE THEREOF'
ROViSIONs. ACCORDANCE V�tTH Tye,
REFF3EA7Ai1VE
fir` XY h
i
T hE ACpRD R Q 19M2010 ACD I
alas and IDgo m "gi ELL naHrs of D CORPO
ACORD RAiTON All rightsreserVEd.
Ni ceR;tFrcnTE Is rssu®ERTWF#Cfilrc
cERa�icATE Does Nor �a LIABIL — a� �
BELOIR? T703 CERTTFICA AFFlR � OF INFORIDATION OAIIy ��CE
I REPRESENTArIVEORARODUCERpS��_�OnD, D CONFERS THE GERTI
INjPORTANT RANCE DO M?FND on AL NO RIGHTS UPON 3/20/
rt the cerdficate THE CERTIFICATE THe COVERAG FICATE HO 20I4
the terms and conditions opeholder is an ADD HOER. A CONT'RgCT B I LDgR, i H1S
cert acate Poricy,c �OHAL lNSUPE1EEti THE ISSUING ��Y THE POLICIES
FROOUCEB holder in lieu atsuch entlo ertain D, the Poltcy(ies (S). AU I
3 rsemem(sj olicies may re9uire an endo )mum be endorsed, rf SUB �HORIZEp
asie_�n rsement'A�mantonthisce�ROGAT10Ni39yA 0,sUh'a
233 �Mest Cut,,, Group LLC CO..c ficate does notSubject to
Street Coro; on COn�rri to the
EaHONE
NaRED oo ILA ' t5D8)651_7700
INSURED i� � I Fq„
0176D!
a Z.ietio r7eatiLerizatc_.on - 1HsuRERA� INBURERI �FOROIHGOGVERAGE
6 az .t t_ ella P
e_.erson o ne wsuRERa a��a Taotection Ins. Co. I NA IC*
Salem wsuraalCNatt• • demtti Ins Co, 1360
alas Insurance Co 0017
COVERAGES � 01970 . INsuRERe:
THIS IS To CER OJBURER a: I
INDICATED. ND TI�THAT .CFj�o�'ATENUMBER3sasc� 201I su F-
CERI 1MBE IS THE POLICIES -
USIO TE Mqy EE IS DING ANY REOUIR EM CE LIST-cD 8
E%CLUSIOills ,yS SUED OR '
Ggy AND CEEN
ONO CS
OF SUCy p0 THLUNr S 3H0 N TNDMON E AFFORD 0 ANY ISSUED OR ptNSU SI BOV OMBER:
OFwBU I yVAI MAY HAVE B BY THE POLICIES DESCRIg DOCUMENT yy FOR THE_POLICY
LERa1UA88nY BEEN THE EDH RESPECT PERIOD
COL{t� POu Initd88a I CEO 8Y PAID CLAIMS EREiN i5 FOR
TOO ALL
I GBy O Y u 10 WHICH THIS
IUA31Lr- n ( THE TERMS.cxAJ as L} of
.1a OCCUR Utdt>S
I S00042816 xCH OCCURRENT
/20l2024 a O S �,000,000
ACC REGATE Lu.11rAPPIJ6 PaR- NEpExP(Anyone-- 8p1000
PaucY - (� Is
AU1pN0a1LELUJA I ILOC PErIsoN;,La Is
51000
$ ANYA LItY - GENaRALAGGR8GA7E IS 1,000,000
uro
Is
��A7� SCHEQUL�� I PRODUC7q,.COLtP10P 11C'G I S 2,0 00r 000
;I HIREDMOS $ A yEp- 02 0 02 3 8 73. IE�at1-wnINtE UL S 00,000
z WfaRc _ � �/20/2019 J /20/20� aomylNJURYIPer S 1 000 000
'LLA LWB - SODILYINJUP.y PsSen) S
L �'C'�S UAB '� OCCUR PR /Parac� S
( ) eraCQ DALU,Ge S
IO 7 IR CW qq
V10Rt¢(��GPEAI ,Ous �R°asle I
wy E4tPCOyapa. 7ION LOOOSSES, , I EACH OCCURBEN 1 S ; 8.o0D
IO' C ,cj 3'1ri ..am� YtN "�1z012oi4 �ilz0/zo15 AGATE s ' r o00.00D(unnealo c ,000,000
L C>se{,1e HrAI
�CRH,nON Ord-OP_-.�,T10NS pw�,r I I; +lLSTAIl. O_Y.IS
-ICi• -.ZaBIZ;fig I
-LacCHACCID=-yr I_ s
+.200378602 L L OL915_ '^SUPLOYyeI S
IRtPTioDpDF �.0/1/201a IENERAL
OPERATIQ+ISI D/3/2014 =OLICY UTAIT S
LOCATIO$rVByuCLES IAtk bACORD101.AQtlINo11&Ra a � ❑m ? GENERAL
CONOmON 411.000,000
°�57'aoatsregnlrla} S1,000,000
tFf_C�in 1;:: HOipeR
CAIlicEl1AI of,
C13 S;) SHOULDANY DpI
_g;�..
Sl=xTG�?'0N S • THE E:P1RAi10N�A80VEDESCRISEDPOUCIES
? a 07970 EEJ. ACCOF,DANCFYVIi {AE AiR THEREOF, NO10E �CANCD DB POLICY PROV151oNs. WALL SE EFORE
AU S EWERED IN
- DalTp��°ENtA71Vfi
36(2070/OS)
i:nnnm Roaaid Cleaves/sam,
T++e ar•.t7Rn mnw �I.uan ire r°''-'c�mrt 1988. 10ACOROGvr OQRADO . Al9 pzfo
ts reserved.
9�]t Massachusetts -Department�Qf Public Safety
�f Board of Building Regulations and Standards
Construction Supen-iarr
License: CS-087W7
ERIC W PALM
3 H ILTON ST '
Salem MA 01970=
IV
W Expiration
Commissioner 0412312016
�e�oriuir�urrunll��-V�lairrc�u;e(h `
_Office of Consumer Affairs&Business Regulation
_= MEIMPROVEMENTCONTRACTOR
istration. 142089 Type: -
piration: 311212016 Ltd Liability Corpo:1
R
ATLANTIC WEATHERIZATION G.L.C. -
ERIC PALM
61RJEFFERSONAVE
SALEM,MA 01970. _Undemetretary