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44 STATION RD - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code,780 CMR,71h edition MUNICIPALITY > USE Building Permit Application To Construct,Repair,Renovate Or Demolish a , a Revised January One- or Two-Family Dwelling f.rpglt ,v 1,2008 This Section For Official Use Only q, y, Building Permit Number: Date Applied: Signature: Building Commissioner/Inspector ofBuildings Date SECTION 1: SITE INFORMATION 1.1 Property ert A/Addr I y 1.2Ar,s;Map&;_Par.;cdNumb¢xs I.la Is this an accepted street?yes no Map Number a Parcel Number 1.3 Zoning Information: 1.4 PropertyDimensio6s Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 BuildingSetbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone I nformation: 1.8 SeNage Disposal System: Zone: _ Outside Flood Zone? Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 OM1ofRecord (� p /�/arf 3 fRi✓ (f cf Jfnfii/t ✓ f r/1 Name(Print) Address for Service: /� �wfn� q7 9-62011 - 7?73 Signature Telephone SECTI ON 3: DESCRI PTI ON OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building O Owner-Occupied ❑ 1 Repairs(s) 0 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other pecify: Brief Description of Proposed Work': col SECTI ON 4: ESTI MATED CONSTRUCTI ON COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ _ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑ Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check NoQgn—Check Amount: Cash Amount: 6.Total Proj ect Cost: $ � , ❑ Paid in Full ❑ Outstanding Balance Due: 1 2-1 b mPvtuz;--b 1 (,3 5vvs,�, SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) ?-7 11-7 77 y/L3 //8- License Number Expiration Date Nameof CSL-tIdpr nc W. Palm List CSL Type(see below) Address on St Type Description Salem MA 01970 U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Signa e M Mason Only RC Residential Roofing Covering Telep WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) Atlantic Weathe178at1o9,L LC HI HIC Company Name or C n Registration Number �ft ee ame rsoh Aveaue 311z//g Addr s • alem,MA 01970 Expiration Date Sign Telephone SECTION& 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 OW NEyR'SAGENT OR CONTRACTOR APPLI ES FOR BUI LDI NG PERM IT I, // a 1��1 w �L( / ✓ as Owner of the subject property hereby authorize ,V a L W+ to act on my behalf,in all matters relative to work authorized by this building permit application. 11130 Signature of Owner Date QSECTI ON 7b: OWNER'OR AUTHORIZED AGENT DECLARATI ON •I, Cr C {t ti/V,-, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. r. G Print Na' • 06ft QM l� 13 � Signamr o kner or Authorized Agen Date (Signed under the pains and penalties of a du ) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors 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 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" Ihisfmm stGsBesall baste oftyespte'eHame7m7aoeommtCm¢ertorLaa•(Mfa7.eitapier la ' Immptagxmpratea0o Iegaladsimli 2A).hntd52P d M%nvrdtanttsCmrs®aCuidetoHame7mPmt2m®t°bef 'A¢YI>�o¢Plannulglt®eia>pr¢vzmenLsshould O$ce¢fCa¢s(maASznsaadHasmea ogt<tiingmmmywotL•anyomrtydd�Yo¢ We Noma �ODD'LCLOP�OY7DIif10t3 Campanyt gtrtt Addres(dowt meaPost p!8noR=dd(�) . L Cae¢-mmdSy e�� fCffCtSpfl/�v Ciryffo\� SWe A� ✓Ct l-Ci>7 �Cede 8azmesddd,.s(�t• � �tq� _ Deolmaphaa:. .;_- 'eveomgP)(wd 1970 7 fig t7 o Ciry/raua State zip Code 66 O Mai linS Addnss((t diffvem limn abmx) Bwh=phove Fdwi IeicIDorSS.Idm bz 3/�/' -rr=arata++ma�m U Tire Caa!racmr ogr+...S to do awl mxiagnrrkforffieAomonvasr. 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(2nf�;•m(rttfe-ici=i crrvrenN .thaniTjtlred}n the nlmct party/subwntdcmr� �eSO�mm)"dYrasponab!c forwmele6on ofthexvdrdos(mbd�ti1•z=d bytyecaatdcmr Tocw¢tmttorfmtbc m@ma7e;+aftbeanioaa of ma edPJs-rd laborund thi ataeam °�'ffimx��Yaesponsfdefmall �� C¢atrect?cr_phrsw- - Paymmis to a➢subronSacton far Uooa siga!ng this dorsmmeat hsaaatgabiaaimg cmm¢nMmdm•larr Ttn7a�oWernisenotedwiW�thisdowmmS We ca¢trct Sbollnotimpiythat aa}•➢w araW¢semairy!men5tlrsbem nlaradan Wemsidmce Rcviemtfiefo➢owio ca¢' carePolly before signing this Imnhaci g tmosaadaotiam = Doalbaprppivgttiewnbact T+J- a ifde sum Wowntrsporb:s 1'Iv m r snmemd mmdfully tmdeam¢dii Astiq¢�fioasifsomethutg!s mmclear.h ----�---�— mtCnntra_ mar_��,.7•aemostbomc' "p rwtnm theDnegarof73ome anptmremmtconbactomand =cds¢atioa byxztingto IDeDir,2mrs l0 F�,;PI 704®mt ContrzetnrRam-ebaa You mayiaqucnabouiwno¢e[or° Das Ute contmetorhatn msmance7 aB,Raam S)7q Boston,t1dA 02716 er by wllmgG17A73-87B7 ar888283-3757.seep 2wofa'yroofafiosn w. Cmm �ia,-nisiv,,-mnowcampaay iofmmadoa so Watyon pa wn➢(m wvmae= Knar. nr doctmmmt gora5:q to 3 trtig(tisaadr�oamb➢ides.?Imd LheImpottaat 7nfotmsbaomthcratases!doofthisfomc andge2acopy ofthcConsomer Quide to aieHome7mpmve mConanc!or7atr. Yauma)�canwlffiisaa aeatifitbasbeca�gnd araptaceoWath2 Wecoab-mtot'saoaool Ibildb Lorin wriyfallo dhermain o8swn;brmmct olaca motorbbosinesgptavidd Wird 6asioess dyfo➢awing We si ofWis aat�dr�a��aop pcey�. telegr��atar deli Ym(notify��t� c±¢ae➢aHan fatm form m9lmmation afWisild, ! ®PRuT Mgzily Tlus CONT� s fiF n r�pr=arclGs..�.�>mh�IdBarauv m=� erP✓• dbaL-pt o amen re,ignmme , " fj 1 A 1 / cc Silprwm �Z Dm Contractor Arbkradon The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)ifthey have a dispute with a contractor. Ile same right is not automatically s@brdad to a contractor,however. The contractor would both parties agree to the optional clause provi vm to resolve any dispute be/she has with a homeowner in court unless ded below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. ' The contractor and the homeowner hereby mutually agree in advance mat in the event the contractor has a dispute concerning this contract,the co cto {{i� a dispute to a primate azbitration firs which.has been the Secretary of IEVP j,Ye;QEli � og approved by to submit[o such adlnttatio Afram and Business Regulation and the consumer shall be required trati t( aclusetts General Laws,chapter 142A. r AT {5jll e Homeowaees Signature Can c a s Inmattlre NOTICE:the signetnres of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately sigac�d by the parties. Homeowner's Rights A homeowners rights under the Home Improvement Contractor Law(MGL chapter 142A)and other conr protection laws(i.e.MGL cbapter93A)may not be waived in anyway, even by agreement However hsumomeoewners maybe excluded from certain rights if the contractor they choose is notpmperlyregistered as prescribed bylaw. 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 work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the connector guarantees or provides an express warranty for wodoneaship armaterials Provided by the contractor,all goads sold is Mass In addition to guarantees or warranties achusetts cant'an implied warranty ofmerchantylility and fitness for a particular purpose. An enumeration of othermatters on which the homeowner and contractor lawfially agree maybe added to the terms of the COmtact as long as they do not restrict a homeowner's basic consumer rights. Ifyou have questions about your consumer/homeownerrights,contact the Consumer Information Hotline(listed below). Ezecution of Contract The contract must be executed in duo6cate 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 ormwked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the otherkept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract and the three day rescission period has expired; Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/hetself 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 funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Utithdrawat offords from said account would require the sigtatures ofboth parties. Additional Information Ifyou have general questions orneed additional information about the Home Improvement Contractor Law or other contact: ghts,or ifyou wish tooblain a free copy of " contact: A Massachusetts Consumer Guide to Rome ImprovemenP' Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,Sill 283 3757 or visit the OCABR website at ht o:/Awnv nas o If you want to verify the registration of a contractor or if youhave questions or need additional information specifically about the contractorregistration component of the Home Improvement Contractor Law,contact - Director of Home improvement ContractorRegistratlon Office of Consumer Affairs and Business Regulation 10 Park Plam Room 5170,Boston. 617-973-8787,83�83-3757 or visit the HIC website at hroO/J nv v.mass ao/ocabr/ Go online to view the status of a Home Improvement Contmetor's Registration: httr'//db.state.maustho eimpmement/l' seelistaso For assistance with informal mediation ofdisputes orto register formal complains against a business,call: x Complaint Section �^ ?? O> be' Attorney General 617 727.9400 AND/OR Better Business Bureau 508.652-4800,508-755-2548 or 413-734-31 I4 Vasion 2.7-I lr'.N_010 The Commonwealth ofMassaclausetts (Department of Industr ial Accidents Office of Investigations rq � 600 Washington[Street Boston,M4 02111 wwminass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrPanization/Individual): Aaazna ?lcS«suii, LLI, ij9 to.4'2?"l�f:i<1F .ae:viluC Address: srrien \n n tti o?F City/state/Zip: Phone#: 7�' 7//W- Are yo�employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): [2� .©`I am a employer with ❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 3. ❑ Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp. insurance.- 9. ❑ Building addition required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doingall work officers have exercised their 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]T c. 152, §1(4),and we have no 12.0 Roof r pairs employees. [No workers' 13. ther 'l1ySti/G X comp. insurance required.] "Any applicant that checks box—'] 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 shorting the name of the sub-contractors and state whetter or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. rain an employer that isproviding workers'compensation insurance for ttty employees. Below is the policy andjob site information. Insurance Company Name: O U f"r G H Policy 'M or Self-ins.Lie.#: j&�I 70 J Z / Expiration Date: lob Site Address:_ y TTA,+i o Yy �Zd ' City/State/Zip: SG I ehi s'h4 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties ofperjury that the htfortuatiot:provided above is true and correct. Signature: 1 Date /Z/ Phone#: Ojfcial use only. DO'lot write in this area,to be completed by city or town offrcial City or Town: Permit/License# issuing Authority(circle one): I. Board of 3iealth 2.Building;Department 3. Cityfrown Clerk 4.Electrical In 5.Plumbing Inspector 6. Other Contact Person: Phone# Massachusetts Department of Public Safety t P Construction Supervisor . 047 Board of Building Regulations and Standards Restricted to. License: CS-087977 Unrestricted-Buildings of any use group which contain Construction Supervisor less than 35,000 cubicfeet(991 cubic meters)of . enclosed space. ERIC W PALM zi ` 3 HILTON ST SALEM MA 01970 , �r�"/�^^�� CA— Expiration: Failure to possess a eummt edition ofthe MasmchusMts Commissioner State Building Code is cause for revocation oflhis license. 0 412 312 018 OPS Licensing Information visit W W W-MASS.GOV/DPS � r license or ttgistration valid for individoi use only Office of Consamer Afairs&Business Repie600 - - _ before the expiration date. If found tffiutn fo:, �I ME IMPROVEMENT CONTRACTOR O$ice of Consumer AT£airs and Busmen Regulation V - ,istrabon: 142069 Type: -10 Park Pizza-Suite 5170 - . 7ration: W12P2018: Ltd LiabMV Corpor Boston,MA 02116 ATLANTIC WEATHERIZATION•,LtC. ERIC PALM j/� 61RJEFFERSONAVE (/- '+ SALEM,MA 01970 Not valid without signature Undersecretary i i rSIX server r CEf+� F1 ATr ®F LIA IL&�'�Y INSURMICE DJYvvY) - 9'-CERTIFICATE DO E tS OT AFFI AS p Mg7TER OF iNFORBBAYdON ONLY p1V®CONFERS NO RO S UPON TyE CERflFlCpTE y06D✓s yt6 CERTIFICATE DOES NOT INSURANCE OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. j opgmlo THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSURER(O AFFORDED BY 4ZED REPRESENTATIVE 1 OR PRODUC 10 TyE CER71 TE OLDER. IPA terms TO If the idol certificate t holder is an Lain POONAL INSURED,the po0cy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and eontlitiQns of the policy,certain Policies may requhe and endorsement A statement on this certificateSUBROGATION does not currier rights to the Certificate holder In lieu Of such endorsements. PRODUCER CONTACT EASTERN NS GROUP I.LC NAME; 1 233 tV CENTRAL STREET PHONE �(,VC,No,E:t): FAX NATYCf(,MA 01760 (AT,Rol. 22MLW E�AAIL ADDRESS: INSURED INSURER(S)AFFORDING COVERAGE ATL.AN7TCAT-ATHE INSURER A: AAtERICANZURICH OrS1JRAIVCL COMPANY NAIC# j R[ZA'ITON LLC :' 1 'INSURER S: 1 INSURER C:61 REAR JEFFERSON AVE :INSURER D: S.ALE4i,LIA 01970 INSURER E: COVERAGES CERTIFICATE NUMBER; INSURER F: T T S ORBIENYTHAT THE POLICIES OF 1ISUfl4N1 DST1 l� ANYREQUIReCiENT,TERPB OR CO.WmON OF 4NY Cp' ELOWH4YE BEEN REVISION NUMBER: AFFORDED BY THEPOLICIESDESCRIaED HEflEd1g5U CTOR OS}i GSt1E0 OTRE wSURED NAN1Ep ABOVE FOfl7HE POLICY PALL CLAW& HE TISH M1'.EEXCLU vj I REBPECT IU MUCH THIS C PEB(OR MAY ATEp. N JECr TO ALLTHE TERNS,E:.CLUSDUO IONS AND CONDRIO,VS OF$pSGipOLky M1SAYBE Ia SHO UWAYPFAT4DL THE INSURANCEURANCE LYSR E5.4^lR6 BROWN NIAY HAYE&EEN REDUCED BY LTR. TYPE OF INSURANCE ADD UB L IA POLICYNUImER POLICYEFFDATE POLICYEXPDATE GENERAL LIABILITY �--� 0'-�iDDivvvv) tm6wDlwwl I COMMERCIAL GENERAL LIABILITY LMITS If , - � CLAIMS S1ApE ED OCCUR CH OCCURRENCE $ DAMAGETORENTE0 S PREMISES(Ea 0MUDence) GENL AGGREGATE LIMIT APPLIES PER SLED EXP(Aryonepwson) s SSgg7i POLICY OPROJECT®LOC PERSONAL&ADVINJURY S AUTOMOBILE LIABILITY GENERAL AGGREGATE S PRODUCTS-COMP/OP AGG S j��—f PAN Al1TU j (C—d ALL OWNED AUTOS COMBINED SINGLE IS L--a SCHEDULE AUTOS LIMIT(Ea acddeNj 10 HIRED AUTOS BODILYWJURV S (Pw person) . NON-OWNEDAUTOS BODILY INJURY 1Per acciUentj S � a PROPERTY DAMAGE S UIL4817ELLA LNIB OCCUR 1 (Peraccidani) C EXCESS L TAB I( DEDUCTIBLE CLAIMS-MADE EACH OCCURRENCE __jI I RSTENTION S AGGREGATE S A 1'"ORKER'SCOILIpEN BATTON qNp I S EIYIPLOYEq'S LIABILITY g YINANY PROPERITORIPARTN D � IVE US-5827U121-t6 03/2Uf2pt6 WCATRYOFFICERIIABSBER EXCLWED7io 2017 11 S � 1 OTHER (ldandmmyinNN) 1m,� LUITS U yes,desaibs Yndx i E.L EACH ACCIDENT OES—NNITON OF OPERATIONS EJwi EJ.DLSEgSE- S S00I ESCRIPTIONOFOPERA'IONSILOCAT(ONSNEHICLES)RE 1 PLOYEE S 5(10,000 BTRICIONS/SP E.L.E.L DISEASE-POLICY LIMIT S 500.000 HIS REPLACES ANYPRR)R CERt1RCATE LSSUW TO ECIAL ITEMS THE CERTIFICATE HOLDER AFFECTUJG WORKERS COMPCOVERAGB. SRTiF[CATE HOLDER CITY OF SALEM CANCELLATION 93tVASHih`GTONST SHOULDpNYOFTHEA80VEDESCR78EppOLiCIEB6ECANCEUEO ACCORDANCE V�jpIORN.IE POLICY PROVISION CE NALL BE DELNERED S•u-Eb7.MA 01970 9AUTHORIZED REPR1" ORD 2s(201Di05) The ACORD name and logo am r rstered marks of ACORD .. 19808- 10 ACORD CORPORA710N. All rights eeserved. [HIS CER'iTE DOE IS ISSUED AS A IVlA77ER OF INFORIV1A710N ONLY AND CONFERB NO RIGHTS UPON THE CERTIFICATE HOLDERn THIS CERTIFICATE DOES NOT AFFI 3/9/2016 BELOW. THIS CERTIFICATE OF�INSURANCEARDOESANOT CONSTITUTE A COTIVELY AMEND, CA I ONTRACT BET OR ALTER WEEN THE COVERAGE G INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder isfan ADDITIONAL INSURED,the policy(ies)must be endorsed If SUBROGA710N IS WAIVED,subject to the terms and conditions of fha POlicy,certain policies may require an endorsement A statement on this certificate does not confer rights to the cer ificate holderin lieu ofsuch endorsemerd(s). PRODUCER Zasterrl Insurance Group j,yCi CAN-CT Coustrla°t1°IL 233 Tr7est Central St PNeNE - (800)333-7234 FAX E-IMIL AIC No)- ADORESS: INSSUREDURED IN C M& 017,60 INSURE S AFFORDING COVERAGE INSURERA-Arbel la HallAtlantic Weatheri.zation Protection Ins_ Co. 41360 WSURER B.WaUtiluS Insurance Co 61 Rear Jefferson Avenue IINSURERC: INSURER D- Salem NA 01970 INSURER E: COVERAGES CER-nIFICATF:1,11 INSURER F; THIS IS TO CERTIFY THAT THE POLICIES U1 INSURANCES S7 I? gBELOW HAVE BEEN ISSUED 70 THE INSURER NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NMAY BESTAMDING ANY REQUIRFMEN7, TERM OR CONOfIION OF ANY CONTRACT OR OTHER D NAMED ABOVE HOR THErSP CT TO ICY P THIS CERTIFICATE AND OI ISSUED OR MAY PERTAIN, WHI EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INSR I Wal OFINSURANCE D S e GENERAL OABILRY POLICY NUMBER IMMIDO M PDUCYEFF PDUCY EXp M/O UMITS COMMERCIA!GENERAL LIABIIIiY EACH OCCURRENCE A CLUMS-MADE a DEG G 5 11000,000 .r' OCCUR 50004281 PREMISES ENiED 7C CONTRACTUAL r-raa 6 /20/2016 /20/2D17 S 50,000 11+I17 MEMO EXP(Any Pne Person) S 5,000 +'�' Cc0001 10/Ol E-ORM GEN'L AGGREGATE LIMIT APPLIES PER PERSONAL INJURY S 1,000,000 POLICY PRO' GENERAL AGGREGATE S 2,000,000 :A LOC PRODUCTS- AUTOM081LELWeiUTY CONPLOP AGG S 2,000,000 ANY AUTO S COMBINED SINGLE UMM AUTOS A OAWEp n SCHEDULED call S 1 000 000 020015871 BODILY INJURY(Perparson) S HIRED AUTOS Ti NON-S /20/2016 BODILY INNRY AUTO /20/2017 (Peraccpani) S Y UPAB P aenD��BE REL A LIAS X OCCUR o- t S A EXCESS UAB PIP-Basic S CLAIMS-MADE EACH OCCURRENCE S 11000,000 IEO RETENDONS 10.00 600058654 AGGREGATE WORKERS YERW LIABILITY A ILIT /20/2016 /20/2017 S 11000,000 AND EMPLOYERS'LIABILITY AI:T PROPRIETORIPARrf�R/E)� Y/N WC STATU- OTH- 5 ((,II I DCERGItEMBER EC,CLUOEO? C��❑ NfA I 1PYa;9escrytipeunEer DcSCRIPnON OF OP^ EL EACH ACCIDENT S cRAnONS below EL DISEASE EAS 73 POLLIITI023 EMPLO 707,AOGIOb200378619 EL DISEASE_POLICY LIMIT s 0/1/2015 0/1/2016 EA POLLUTION CONDITIONDESCRIPTION OF OpERA710N5VEHICLES � $1,000,000 /LOCATIONS/ GENERALAGGREGATE $1,000,000 (i cIIACORD onaL RemaH¢SCAepPle,ifrnem space (s fequirM) CERTIFICATE HOLDER CANCELLATION SHOED ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL LED BEFORE CITY OF SAT.F.M THE EXPIRATION DATE THEIR SCRIBED NOTICE WILL BE DEL)VEI IN 93 �_SEIbiGTON STREET ACCORDANCE WITH THE POLICY PROIRSIONS. S-a=,ELvi, Mi? 01970 _ AUTHORIZED REPRESENTATIVE 'ORD25(2040/05) John Tc°egel/SB7G :025mm�n5,m 101988-2010 ACORD CORPORA I '�-ae:pr.(�Rn nemu�nri 1„nn -� RATI01 All rights "^L=A•�a n.�.l,�nF>srnRn ffi reserved.