11 SUNSET RD - BUILDING INSPECTION The Commonwealth of Massachuse RECEIVED
a Board of Building Regulations anwonNAL SERVICES FOR
f Massachusetts State Building Code,790 CMR,76 ediiti`Lonop . nn . MUNICIPALITY
SE
Building Permit Application To Construct,Repair, aAK 6NDt'atol�h`d 2; ..Revised January
One-or Two-Family Dwelling I, 2008
This Sc&ioa For Official Use Only
Building PermitNumber `` ` Date Applied/; li
Signature
''• a Building Commis sinner/InspectorofBuildngs ,y Date
s SECTIONY:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map&SArod almilers..,r,.''
,r �41
1.1 a Is this an accepted street?yes_ no Map Number ti t 1 N3^ un
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(ft).
1.5 Building Setbacks(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 Information: 1.8 Sewage Disposal System:
Public❑" 'Private❑ Zone: _ Outside Flood Zone? .Check if es❑ Municipal❑ On site disposal system ❑'
SECTION 2::PROPERTY OWNERSHIPr
1.1 O err f Reco
-�,�e....� snna
Name(Print) - II Address for Service:
C 11- L tc Mrvu Qt 7141'- (06 l5-'
Signature - - Telephone ° -
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check al►that apply)
New Construction❑. Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ''❑ Accessory Bldg.❑ Number of Units - Other Specify:
Brief Description o °posed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Oniy.
abor and Materials
I.Building $Z / I Building Permit Fee $ Indicate how fee is,detetmined:,
2.Electrical. .,, '❑Standard City/TownApplicati6nFee
$, 1 .
❑Total Project Costs(Item 6)x mulnplter X .
3.Plumbing $ 2. Other Fees: $ �`
4.Mechanical (HVAC) $ List:
5.Mechanical (Fine $
Suppression) Total All Fees:$
Check No. Check Amount Cash Amount:
6.Total Project Cost: $ '0 I (JU , � 0 Paid in Full ❑outstandng Balance Due
.t�SECTION 5: CONSTRUCTION SERVICES - - 1
1 _, l0N
5.1 Licensed Construcfib¢.$upervtsorb(GSL)' �af
License Number. Expiration Date
Name of CSL-Holder Y M✓ ''_ -
��3} 1)b�O�n♦$lfeet ��. List CSL Type(see below) u
Salem MA 01970 :.T ... . Description-
Address `
U Unrestricted u to 35,000 Cu.Ft
Signature
R Restricted l&2 Farm �Dwellin - -
M.. Masonry Only
RC Residential RoofingCoverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home provement Contractor(HIC)
rltidnhcIm Weatiterizatinn. T.TICy�
HIC Company Name Wff�I�YC11Ue Regis lion Number
• AV,,-9"
Expiration Date
Signature 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 oEtlie building permit.
Signed Affidavit Attached? Yes.......... No........
SECTION 7a:OWNER AUTHORIZATION TONE COMPLETED WHEN
OWNER'S AIGENT OR CONTRACTOR APPLIES FOR BUILDING:PERMIT
ai cr as Owner of the subject property hereby
authorize C�, C. Pa f-✓1 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
cc " SECTION 7b:OWNERr,OR'AUTHORIZED AGENT DECI;ARATION
I, C ter Z PCt 1l K 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.
EC< L
PrintNeke • 7, /l�
!l,�.�
Sign�dMO neror Autho—nzed Agent Date
(Signed under the pains and penalties of
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 I IO.R6 and I IO.R5,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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
MassaChusetts Home f>ffis rovemeiat Samnle Contrae�
This Iota smisga all basic requiremeom ofdhe states Homelvipmlxment ConuaaorLaw(MGL chapter 142A),but does voriaeludesmndmd
Imguoge to protemhomeowners.Seel-leguadviceirmcessary.Ana-Ir; planningho haplot=mtssboWdfimobminampyof-A
Maca2husetts Consumer Guide m HomebapsorxmeaC baforea_meemgto anvnmk un romresidence.You may obtain a five rgn•byfa fling the
06ce ofComtmerA6airs and Business Re tivn's Consmnlxinf'ormatim Hodineu617.973-S7S7 m1'-868�8337S or oo aw x6vm.
Homeowmer Information - Contractor information
�•' 1 Cenprs±lse
14ann /N iH _ .
strew Address(doammeaPess OrnceEac f Cesaer'S w��I>�ZC
11 SN 11 4= 61 R deffeftil Avenue
G Toon Sum Zrp Cnd a.�:nes Address(r.,iv d:
n,W d19"10 j 391WM 970
Da, n.Prmae &crag one Grrnown sm. 1 Zip Cede
\(aiGnE Addrass(11 different own abore) H'Imssphmre JFcdeMl1nupRyerW,,SS.\umbe
L-n rGa1 v5a glee `
Ltevrsa=a cr.'�
The Contnmoragreas to do the followingwork for the Homeowner.
tDen,nte in devil thewort to ampletei,specifiinetfiatip:,brand.aotlzzad--af msseilkIt,used, ad' F '
41s
Requited Permits-The following building permits amrequited Proposed StWead Completion Schedule-The follmrin_gsebedWe well
and hill be seemed by the mnvactarm thehomenutes agent i be adhered to unless cirtnmsaacs ir_)andlhemntmttotscontulatim
(Owners who secure their own permits mill be
excluded from the Guaranty Fund provisions of !, �Damnitmoontrncmrwill begin mntmetedwmk.
_iGL chapter 142.4.) �Z
/J owe aban rovgaatd no will be substantially mpmpletvd.
Total Contract Prim and Payment Schadule /ln'-
TheContdctoragre
In esperfotmdtework,fiwish%be material fi m tillVV
nd labor specified abmxfor the total su (_)
Pa)menrs uill be made according to uefollowingsebedWe
S_76L up
on sigoivg contact not to venal Ir ofine mud conaam ptice Qr the tmstofspecial oideritaos,whicher'erisgeeater)
S by ,_/A or upon completion of 1 j •J�1
by 1 arupoa eompledm of t 6
r
upon completionafdheemntrxct (layfotaids dmhmdmg fug pa'.Ment until contact is completed m bath parry's satisfaction)
The fWlawing IntUrid'equipmemen m bespsial s to paidfm i
mdaed befine3ec=u=ednodc berms iaard¢' /
eoav me waPledonsrhodWe(•') x aheIt
NOTES:(-) fin�taebazgs t'•)lawfequ"g¢that am depai:¢dawa•pa}meu rwo"ned ay thecantrzam b_¢e nmi cam ma,
notes d thegreueror(a)one-third ofthe to.]wmtxerpda v(b)fheonurl cast vizor spsiW egnipmwr meewom madeswiW
nbich austbespecvl amend iv emana roman maven:ryleuonsrhv'We' '
ErUenewarMM-lean ezneeee. n-Wong..mi til hr whimC ❑y t II
Submatmctors-Tnecontmeaw Wm to be solely responsible for completion ofine wwtk described regardless ofthe actions cfmy third
pzmiwbwlmmormlizdbvtbeconmctor. Tne mnaaaorfutiberagrea to besoWyresmasible farall pz)mencs ioatl subcontractors for
al_n tejalgond labo.under this mcallunt I
ConttamAcoepmuc¢-Upon signing,this doc meat becomes a binding contac:under law.Unless otherwise noted within this doeummt.the
contract shag not imply dui my lien orothersenuiry homertbasibem placedm theresidmce.Retiewtmfagowingemtionsandvotiees
carefully before signing this contract
e Dot be pressured into liming the contrzcC Teletime to reedand fullyundetstand it.Asktprestionsifsometbiagis endear.
{,la n,ra th mnvactor rasa vidH ma Loomanmt ono- orR 'radon.Tne7aytegmtamost bomeimpmyemeot mnvactors and
mbcontmcmrs to beregistad pith theDireaarafHome impmr>amt ContmcrmRepisQation You trey inqubezboattmvactm
re�nrztivn M•nri®g to Ne Direttc m Id Pad;Plea,Rvom 3I it,Bosroa,bU.03I16 or M•azlling dl;'IA73�87 or88S-3S3-37i7.
Dos thecvneattarhxra inslrmce?Asl-the Cmtrattot for hismsvmvce tampmy ivfolmmionsa tnatyau ten rnn5rm corvage,orz:;;In
s:e a topyoi x'proaf of ihuurance`docommr
?:nowyour dghu mdresponnbtides. Read the tmportm[Intolmatun ov tbe:erer�side ofdts tam zod ga acopy of the Consumer -
Guide to the Romelmormelrrent ContmdarLaw'.. �-.
You may ee¢cet Ibis aczanmt if it hxsbeen sired m a place olhmtban the mutmnots normal place of busmen;,pmrided you notifi•the
ant rorin writing azltivb"'reen o�morbreorfi oGm by otdinm)'tmd poned•bvtelegmm sat or by ddiyan•,nun lmutban midnivnt of the
Ihitd business dayfolloftvhglhesigoiae vftbis ayPeemeot. Sea the attacbd nadce ofemcellxdon iv not a¢esphate o"idsdght
M NOT SIGN THIS C?! CT IF THERE ARE AIRY 3L�NK SPACES:!!
(�^�Jl.T.na�po:i7ai�ef�ma�crh�:�I�rl�,:i ameel=ern:Tcci:.resr—Si'aN icz
t{amemsne.a Signature
Canlmttots Sigumura
� ��►� � IZsII�
Daze Date
Contractor Arbitration i
The Home Improvement ContractoIr Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if theylimm a dispute wvith a contractor. The same right is ryq_t automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both patties arose to the optional clause provided below. This'clai se ivould give the contractor the same right it,
arbitration as is afforded to the ho i emvnerby the Home lmprovement Contractor Lave.
The contractor and the homeowner,herebp mutually agree in advance that in the event the contractor has a dispute
concerning this conuac[;the conttactormay submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration as j ro iaedYa Massachusetts General Laws,chapter 1 F2A.
C t 6L A nk - 4e IrA e
Homeownees Signature i ContracWsMM2fffftureF
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by thetuntractur. The homeoter may initiate alternative dispute resolution even where this
section is not separately signed by the patties.
Homeowner's Rights i -
A homeowner's rights under the Home Improvement Contractor Low(tv4GL chapter 142A)and other consumer
protection Imes(Le.MGL chapter 93A)may not be waived in any way,even 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'eccluded 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 contractor
guarantees or provides an express vynrramy for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied watram y of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terns of the contract as long as they do not restrict a homeowners basic consumer rights, if you have
questions about your consumer/homeowner rights,contact the Consumer information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached Parties are also advised not to sign the;document until all blank sections have been
filled in or marked as void,deleted or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other,kept be the contractor. Any modification to the original contract must be in vvritin�
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 Pavments
.4 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.'However,in instances where a contractor deems hintiberself
to be financially insecure,the contractor may require that the balance of fords not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. 1Vithdrawzl of funds from said account would require the
signatures of both parties.
Additional information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or if you wish to obtain a flee copy of"A Massachusetts Consumer Guide to Home Improvemem"' -
contact: -
Consumer Information Hotine
Office of Consumer Afiairs and Business Regulation
110 Park Plaza Room 5170,Boston NIA 02116
617-973-8787,888-283-3757 or visit the OCABR website at iita:+•:;: -..z
If you want to verily the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home hnprovemant Contractor Law,contact:
i,
Diiector of Home improvement Contractor Registration
Office of Consumer Affairs and Bus ness Regulation
l 10 Park Plaza_Room 5170,Boston,IafA 02116
617-973.8787,888-283-3757 or isit the WC wvebsite at:as;:r
1
Go online to view the status of a Home Improvement Contractors Registration:
- 3:,= a.us�hutn: ^=oy -�,i<ii• - 'Lis:. i .
For assistance with informal mediation of disputes or to register formal complaints am st a busimess,call:
i
Consumer Complaint Section T
' Office of the Anro oev General
617-737-8400 -
AND/OR
Better Business Bureau
:ng_a:•r_rann :nc_�::_�sas n�11 Z_9Z:6Z7 id
t
The Commonwealth of Massachusetts Prmt_ arpt
Department of Industrial Accidents
Office of Investigations
1 Congress Stree4 Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lessibly
Name (Business/Organization/Individual): Atlantic Weatfitrization,LLC
JellergOn Avenue
Address: Salem MA 01970
City/Stat 1p: Phone#: q7� 7 Y- kii-1
Are y an employer? Check the appropriate box:
1. I am a employer with Zb 4• ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have S. 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.❑ I am a homeowner doingall work officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
c. 152, 12•❑ Roo airs
insurance required.]t §1(4), and we have no
employees. [No workers' 13. ther Z7J,S wlu;�t�
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
[Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. "the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees;Below is the policy and job site
information.
Insurance Company Name:
Policy#or Selfins.Lic. #: Si3,77ppQ �� Expiration Date: p
Job Site Address: / Si-t City/State/Zip: SG/elyt 70
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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.
r do hereb certl u r t(ne a Ides a er ur that the in ormation provided above is true and correct.
ii afore: - Wt# _. ! Date. 6 Z�
'hone#: 7,V0- F/L/ '3 1
Official use only. Do not write in this area, to be completed,by city or town official
i
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other i
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE D3/10/201410/ 14
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(tes) 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 endorsemerd(s).
PRODUCER CUNT CT COnstruotion
NAME:
Eastern Insurance Group LLC PNONE - (508)651-7700 PAX
No:
233 West Central Street inADW
, C.
A INSURERS AFFORDING COVERAGE NAIC#
Natick MA 01760 INSURERArbella Protection Ins. Co. 1360
INSURED INSURER aArbella Indemni Ins Co. 0017
Atlantic JeffersWeatheron
Avenue
INSURERCNautilus Insurance Cc
61 Rear Jefferson AVenlle INSURER D:
' INSURER E:
Salem MA 01970. INSURERF:
COVERAGES CERTIFICATE NUMBERFtaster 2014 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.
ILX NSR !WE SUBS
TYPEOFINSURANCE POLICY EFF PMIDD EXP LIMITSGENERAL LIABILITY POLICY NUMBER
EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LABILITY PR I ES NT Onm S 50,000
A CLAIMS-MADE OOCCUR 500042816 /20/2014 /20/2015 NED EXP(A one person) S 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPIOP AGO S 2,000,000
POLICY X PRP LOC 5
gF0AuTN0,D
MOBILE LIABILITY CEOMBIINED SIN LIMIT a awdentl S 11000,000
8BODILY INJURY(Perperson) S
asSCHEDULED 020025871 /20/2014 /20/2015 ( )OSAUTOSBODILY INJURY Pereaitlen! S
IRED AUTOS X NONOVINED PROPER DAMAGE
AUTOS (Per a 'tl nl S
PIP-Basic S 8 000
X EXCESS LAB X OCCUR EACH OCCURRENCE S 1,000,000
A EXCESS LIA CLAIMS-MADE
AGGREGATE S 1,000,000
OED I I RETENTIONS 4600058654 /20/2014 /20/2015 1 S
WORKERS COMPENSATION WC STATLL OTH-
ANDEMPLOYERS'LIABWTY
ANY PROPRIEiORIPARTNER/E)cEWTIVE YIN EA-EACH ACCIDENT S
OFFICER/MMOEXCLUOEDT NIA
(Mandatary in NH) E.L DISEASE-EA EMPLOYEE S
u yyea.despiba under -
DESCRason OF OPERATIONS below EL DISEASE-POLICY LIMIT S
C POLLUTION LIABILITY I PL200378602 0/1/2013 0/1/2014 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD tet,AddHiMal Remarks Schedule,Irnmm apace H requlredl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
{ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORED REPRESENTATIVE
Ronald Cleaves/SMEG—�—�"—
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. Ail rights reserved.
INS025rmtrmAiM The Ar:nOn nemo enH loon are ro iahamd mar"of Ar.nRn
u181161G.A 1TJ-1 0/ 14/ LV1Y / L r [U( ML9 r'HV1:. UJ/ VUV l bA 001 Y01
4
A �® CER°TIFICA°TE OF LIABILITY INSURANCE 03Tt2-2D14
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 poficyCies)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 endorsemerd(s). -
PRODUCER ' CONTACT
NN:
EASTERN INS GROUP LLC i PHONE Fax
233 WEST CENTRAL ST j WC No Eu: No:
NATICK,MA 01760 E-Mat
- i INSURERIS)AFFOROPIG COVERAGE NAIL%
INSURER A:AMERICAN ZURICH INSURANCE COMPANY
INSURED INSURERS:
ATLANTIC WEATHERIZATION LLC 1 INSURER C:
61 REAR JEFFERSON AVE r
SALEM.MA 01970 INSURER D:
P ;I INSURERE:
INSURER F:
rOVrRAr.Fq CERTIFICATE NUMBER, ON
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 TYPE OF ADD SUB POLICY NUMBER POLICY EFF POLICY EX? LIMTrS
LTR I SR M d M"UYYYY) MM!D IYYYY
DENERAL LL401UTY EACH OCCURRENCE $
COMMERCIALGENERALUABILITY OAAIAGE TD RENTED S
CLAIMS-MADE❑ OCCUR R AI
I MEO EXP(Ae,onepermn)
I PERSONAL&AOVIWURY S
GENERM.AGGREGATE S
G NL AGGREGATE LIMIT APPUES PER: ! PRODUCTS AGO S
POUCY JEC /AC I S
A OMOBILE LIABILITY i !, McINE051.VGLE UAIIT S
a aeodent
ANY AUTO 7 ALL O'NNED SCHEDULED BODILY IWURY(Pei parson) S
AUTOS AUTOS ( BODILY INJURY(Per a¢Een1) S
HIRED AUTOS A TOSWNEO ( OP AMAGE
ii S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS UA9 CLAIMS-MADE I I AGGREGATE S
JUED1 IRETEWION$ S
WORKERS COMPENSATION `� WC STATU- OTH-
AND EMPLOYERS'LUMSUI Y X TORYLWITB ER
ANY PROPMETOR1PARTNEIVEXECUTIN , E.L.EACH ACCIDENT $500,000
OFFICERIMEMBER EXCLUDED? N 6ZZUB 03.20-2014 03-20-2015
(AleMem,hiNH) i 58270121 E.L.DISEASE-EA EMPLOYEE $500.000
c It Yes,deateondei
DESCRIPTION FOP RATIONS tielmv £t.DISEASE-POLICY LIMN $500,000
II
iI
DESCRIPnON OF OPERA'nONSILOCATIONSI VEHICLES(Attach ACORD 101,Addabnal Remarks Schedule,it mom&paw is requlmd)
t
i
i �
CERTIFICATE HD O
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
93 WASHINGTON ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
SALEM,MA 01970 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
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AUTHORIZED REPRESENTATIVE ® - -
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