8 SYLVAN ST - BUILDING INSPECTION .cam The Commonwealth of Massachusetts
Board of Building Regulations and Standards CI"rY OF
d Massachusetts State Building Code, 780 CNIR SALEM
\� Revised.Y[ur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Drvelling
This Section For Official Use Only
Building Permit Number. Dat Applied:
f�
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
LI Property A dress: L2 Assessors Map&Parcel Numbers
g S�y��v�g �t/ f�
I.la Is this an accepted street?yes1G no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
�equired Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION2: PROPERTYOWNERSHIP'-
2.l Owner o cord•
art 6�i4C 1J4,+Jo YS� CCagIL jC5 - 1A1tXow9s �l
t�ne(Print) City,State,ZIP
No.and Street T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itc n Estimated Costs: Official Use Only
Labor and Materials)
I. Building .S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S ��� y
4. ��Icchnnical (11VAC) S List: U
5. Mechanical (Fire S
Su ression) � Total:Vl Pees:S
Check No._Check rlmoont: Cash Amount:_
6. Total i'ruject Cost: S ( ❑ Paid in Full 0 Outstanding Balance One:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) v 1 r /
License Number Espir ion Da
Nmneof CSL IIder
6 nn_ ra, List CSL'rype(see below)
No. and Street �//(� Type; Description
�A__� (� (� a / '� U Unrestricted&(Buildings2 Fa u el ing cu. it.)
`"�/ J d ( R Restricted I&2 F:unil Dwelling
City!b n,State,ZIP M Nfasonry
RC pooling Covering
WS Window and Siding
SF Solid Fuel Doming Appliances
I Insulation
Telephone Email address D Demolition
5.2 1 egiste'e Home Ina rrovem n ontractor(HIC) l a
r I `- %•� HIC Regist�r xpir. ton Date
HI um :m mr r Regi an N.0 4
J )
No.m d trc ' r,�, d Email address
Cit /T wn, State,ZIP 0 Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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[simance of the building permit.
Signed Affidavit Attached? Yes ..........6--� No...........❑
SECTION,7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.,
OWNER'S AGENT Olt CONTRACTOR APPLIES FOR BUILDING PERMIT .
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION-
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
k iL C D
r�r i titthofized Agee (Electronic Signature) D• e
NOTES:
I. 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(1-11C) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.1i1ass.1koe,'oca Information on the Construction Supervisor License can be found at wtvw.mass. ovltl�s
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 Number of half/baths
Type of heating system Number of decks/porches
'I'ypeof cooling system Enclosed Open
3. "rotal Project Square Footage"may be substituted for"rota) Project Cost"
!° CITY OF S.U.E ,I, N'L�SSACHUSETTS
BUILDING DEPART%W—NT
} ire i20 WASHINGTON STREET, 3w FLOOR
� a Tex.. (978) 745-9595
F.Ax(978) 740-9846
KINfBERLEY DRISCOLL THowsST.PIERRE
MAYOR
DIRECTOR OF PL'9LIC PROPERTY/BUILDLNG CO\L\IISS[ONER
Workers' Coinpensation insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers
Applicant information Please Print Legibly
Address:
VBlnl (&lain¢�sv/Or/gjanizatioNlndividual):
1 / T }/y � �y
City/State/Zip: �/`� , '! Phone #:��a
Are you an employer"Check the appropriat b@ oxi Type of project(required):
I.❑ I am a employer with 4. am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ lama sole proprietor or partner-
listed on the attachedshect.i 7• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workeri comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I If] Plumbing repairs or additions
myself. [No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. LNro workers' 13.0 Other
comp.insurance required.]
•Any applicant that checks box AI most also fill out the section below showing their workers'compensation policy inlb,Mation.
'I f nneowmrts who submit this aHicinvit indicating they are doing oil work and then hire buaskic contractors mast submit anew alTdavit indicating such.
=Cumncturs that check this box most attached on additional ah.1 showing the noun olthe sub<ontr ctom and their workers'comp.policy information.
I am an employer that is providing w ers'compeasadoV insurance jar my employees. Below Is the policy and fob site
information.
I nsuranec Company Name:—
policy R or Self-ins. Lic. d: Expiration Date:
Job Site Address: City/State/Zip:
,knach 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 ivIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line
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
fit vest igut ions of the DIA for insurance coverage verification.
I du hereby certi ruder It i and penaltles of perjury that the information provided above istrue and correct.
tr ; jute: 11
Phone s. w2E Z d o
officiul use only. Do aro! a fn this area,to be completed by city ur towa official
City or Town:Issuing Authority(circle one):
1. Board of health 2.Building Department 3.C'ity(rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
L Contact Person: .,_...-_.... ..- ---.......---- Phone it:
,s• CITY OF S.-1.LE1,f, NEXSSACHUSETTS
* . 11l;=NG DEPARTMENT
120 W-ASHNGTOY STREET, 3° FLOOR
TEL (978) 745-9595
F.tie(978) 740.9846
Kt\tBERLEY DRISCOLL
M,iYOR TH01Lu ST.P1ERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COSL\nSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
s
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of tMGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name'ofhaul )
The debris will be disposed of in :
(name of facility)
(address of facility)
i
gn�ture of permit applicant —
)9 /c/
ate
�.nrn�:dtd.x �d t-�L' 17
6 - Y 1 - 7 � fu7�,
0 1 `r
QUALITY - EXPERIENCE
SERVICE " Insulations
-r Hallmark _ Roofing
11011E l.4/PROI'l_�t,len'r
LICEVCE= 101444 — H®111es L.L.C.'+ - Replacement
CO.VURGCrION SUPERh7.SOR Windows Specialist!
LICE'.1'CE 7 064008 P
L)XI, BL ILDERS I.ICEACE=470
479 BROADWAY, LYNN 01904
IM (781) 592-5900
CONRAD McKINNEY,President ` Established 1964
" 1%ww.halhnarkhomes•net 6_1 / A Sc 3,20C
Member Better Business Bureau 7
Serving Eastern \'I esSeChusetts MENI BER OFTHE UNN& PEABODY,a REA CHAMBER OF COMMERCE
t
Phoned
i
.lnh,rdclrcs r .Le( ll t� $late . Zll)0
Specifications
`-�5��
r - 11
Cash price i t goods and services:
Dolan navmenl or pavment at conlmencement: ...........................................................................................
. UC��.CiL : " v
PaementIchen �(Irf%Complete: ................................................................................................................. S.. .(.�:�%.J.:.....
Ralancc upon Completion. .................................................................................................. ................... 5..
CC
fst_ Start_--_-------------SUBJECT__SUBJECT TO MASSACHUSETTS SALES TAX
Croar irnnr mill do all n/'sni2l ur>rk' in a gaod rrurkrnardike mmwer The honer agrees In nN fi the cono-ncan'in uriling, signed hr tirr ou'nc of inn'dej-rt in
�r.i'm;m.hip r .....crt 11, 7"hr cane actorshull he liable onh'if o%oils to repay am specified dcfret, including defective repairs, within drir n'clans of re,e,eipf nj
m'no,. nth not orhi rn¢cc w,l in au rrrru shin/the enmracmr he liable heron/%file calif In it at labor and material rngrured for<vq,repair rvm-k.
7hc Irmo ,,/or,hull he Paid br the ou ner(.$). all I cosonahle costs. anornci;fees and e.lpen.ses in addition to fire amount dale and unpaid. that.5he'll he incarr cci
in c,I/mrine dte rtvvrn,had coudifinns of drip contract and/or am lien in connection arereu'ith.
F"I nan cancel this ogrrenn•nt brit has becu convionnrated hr a porq therein at a Place olher than at address of der seller which may he his nmin office ar
If anch it r rC br o+"nfen notice directell ro thu seller at iris main or blanch'/ icy hr nrdinnrp moil pa�tai hi re(egram Sent or hr de(irere nor later Brun
medrri:,tit Ill till,,'bird hu;inras don h�llnwing the signing of this agreenteol. -
Co . ,,k I"he,i„r:r oa this m ape,Il ether than specifies in this conn'ucI n alma additional Cho,i"'s.
(tin ono f v cin¢rim< r•irlrulr aereemrut"11/1 u., (:lrmpanr o ill lin'ni.vh:aarrunti adpeeted ui the type of irorl:done on ahore properm upon completion a('
tdi• runea:1
r hrn,r r,r -fhi nl Ci"In"I hi., tine fch if oovC xmtrnct before ti o,k is stnrtrd. Cnnlrucmr nmr demand nee nti�/iire(3 s%)Pu'cenf al file cnmracf price n.s is
�.qa iut,.zr dcnn,re.•;)gin'dry hrtnrh-
Cu.r"W""f Ls ir,bject m sn'oc,'. oreidenb'. nr who deloi:e hernnd our control.
Company furnishes insurance coverage
:I die oslner(s)of the premises mentioned above,hereby contract with and authorize you as contractor. to furnish all necessary materials.
I Thor and IIorSmanship. to install. consuuci and place the improvements accort irl to the specifications,terms and conditions,on premises
chile do crihcd_ Irhich we warrant and represent that we have good local reeor the to as oxlIners our own naht
an dris dot /_ �
.f:n,�r. htcu:. rlr�- wrti-I boirh rrurru siymdtheir nnnri„s e ... .
J
...
(' \D�•D NIc, 'IN. E- /D \'T��11 Signed ..��1(�C.� / d er ... ..... .
OR Signed...... '
Representative Owner
✓/re �oomaiwnwea(!/i o�'✓Glaaoacbu�e!!a t
Office of Consumer Affairs&Business Regulation p
HOME IMPROVEMENT CONTRACTOR (9¢
Registration �,�t01444 TYPe
• Expiration i;f2612014 DBA
� j 1
HALLMARK HOMES -
Conrad McKinney
479 BROADWAY
I. LYNN,MA 01904 _ Undersecretary
u
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supmisor
License: CS-064068
CONRAD L MCI() IN `
16 CASTLE A 'S
: =
PEABODY MA 91960?
Expiration
Commissioner 01/21/2015
, 9 Y71 /oni9 Fc 'dfil AM PAGE 2/002 Fax Server
a13 WED .16:52 FAX 781 S98 6430 DAVID ZELLER INSURANCE
�.r ' �f - R001/001.
*'CERTIFICATE" CERTIFICATE OF LIA
BILITY INSURANCE iiisi2oi�'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: II the certlllcate homer is an ADDITIONAL INSURED,the 1: Ili(iea)must be endorsed. N SUBROGATION IS WANED, sulnfeot to
the terms and conditions of the policy,certain policies may re"Ire an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Use of Such endorsem a.
PRODUCeA -B ^.�MaryEllan Good Min
David n. Zeller Insurance Agency, Inc, PHONE (731)595-2071 FAX
370 Lyn ay •1YS1)exa-rasa
.ADDF .ma rye11en0davidsells-ill
Lynn MA 01901 INSUREIRI AFFORDING COVERAGE NAIC•
INSURED INSURER A:Nd4ti 146 Ins. Co.
James Rasmussen NSURER B:
INSURERS:
39 SouthStreet Ct
INsuaeao:Lynn 74A 01905 INSURER E:
COVERAGES allF: '
CERTIFICAT 1311601207 REVISION NUMBER:
ENUMBER:CL
THIS 16 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 13 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID SCRIBED
PoSR
L GB1EnA1 1ew,ry INSURANCE POI NUMBER �"El � up LIMITS
M Y
K OOAAFACIALGENERALLIABIUTY EACH OCCURRENCE—�$ 1,000,000
A CLANS-MADE ❑X OCCUR 301968 /10/2013 /10/2014 S 100,000
MED'AP( one pormn) S S,O00
PERSONAL A ADV INJURY S 1,000,000
GENEPAL AGGREGATE S 2,Q00,000 G EN1 AGGREGATEURST APPLIES PER:
8 POLICY FPb LCC Pfi000CTS-COMPAJF AGp : 2,000,000
AUTMIOBILE UAMUTY - $
COMBPoED SI LIMIT
ANY AUTO �i M)
ALL OWNED SCNEGULC-0 BODILY INJUPY(Per p¢,spn) S
lJROS A(1T05 8OUILY INJURY(i a:citlen) S
4:RED AUTOS '1ON-0WNED
AUTOS PROPERTY OANAGE S
Par C m
S
UMBRELLA LIAB OCCUR
EXCESS UAB CWMSNADE FACH OCCURRENCE S
AGGREGATE S
DSO Rc'TENi!ONS
T.'O ill COMPENSATION S
AND EdPLOYERS L4BIUTY YIN WC SiS O1H.
ANY PROPRIETOR ARTN=R/ .SCUT!YE
OFFICEINENBER ECLUDEDI ❑M NH) N/A E.L EACH ACCiD'eNr S
(Mand.by
tl 1"Qawoe yMer - E.L.INSEASE-EA EAPtAY >;
OSCAIPTION OF OP310.TX3Y5%low
El.OISEABE PO!ICY UhST 8
OESCRIPMU OF OPERATIONS!LOCATIONS 1 YEWCLES(AWq,ACORO eDl,MlmulM I10mYrtA SehetlWe,p mom apAee is npi,e�Evidence of General Liability, coverage is subject to policy terms, conditions and exclusions.
CERTIFICATE HOLDER CANCELLATION
(978)531-0212 -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED DI
Hallmark Home LLC ACCORDANCE WITH THE POLICY PROVISIONS,
Attn: Conrad
16 Castle Circle AUIHORI REPRESENTATIVE
Peabody, f% 01960
David Zeller/NARYEL
ACORD 2S(2010/06) ®1988-2D70 ACORD CORPORATION. All rights reserved.
INS02S Miooei The ACORD name and logo are registered marks of ACORD
1L1�11 L16A 11,/--i 1L/ [.1/ LV1L J SUJV !Ll'1 YI'1V 1.. L/ VVL l GA V1:1 Veil
CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY)
• FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RICH 15 UPON THE CERTIFICATE5
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED -
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to
he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
he certificate holder in lieu of such endorsements .
PRODUCER CONTACT
NAME:
DAV?D E LLLER INS AC-CS' PHONE FAX
370 LYNNIM'AY IAA,No,E)M; WC,No):
EIAAIL
L OWN,MA 01901 ADDRESS:
`SDbn INSURER(S)AFFORDING COVERAGE NAICN
INSURED INSURER A: TRAVELERS INDE✓NIT Y CO.
RAShf'JSSE\EXTERIORS INC - INSURER B:
INSURER C:
INSURER D:
39 SOUTH STREET
INSURER E:
LYNN,t1A 019,04 INSURER F:.
COVERAGES CERTIFICATE NUMBER: - - REVISIONNUMBER;
STO T RCM5 1 BELOW 8 TO THENSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDINDANYREOUNOAET/T,TERAIORCONOIMNOFANYCONTRl1CTOROT ROOCUMENTH9TNRESPECTTOWNCHIMCERTFICATEENYSEI55UEDORMAY
PERTNN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREN 15 SUBJECT TO ALL ME TERMS,E LUSNNIS AND CONDITIONS OF SUCH POLN:FS. ILBrSSHOWNNAY
HAYS BEEN REDUCED BY PAW CLAIMS '.
MSR AM SUB P IGY FFFOATF POLICY EXP DATE
LTA TYPEOFINSRNANCE L R POLICY NUMBER (mwIokYYYY) IMMD0IYYYY) LINES
GENERAL LIABILITY - ACH OCCURRENCE g
COMMERCIAL GENERAL LIABILITY
CLAIMS MACE OCCUR. DAMAGE TO RENTED s
❑ EMISESfEa Occurrence)
ED EXP LAM one person) Is
RSONAL S ADV INIIURY Is
GEJL AGGREGATE LWIT Al VUES PER;
POLICY ❑PROJECT QLOG GENERAL AGGREGATE is
PRODUCTS-COMPlOP AGO S
AUTOMOBILE LIABIU TY COMBINED SINGLE $
NJY AUTO LIMIT(Fa accidert)
ALL OYdIEL`AUTOS BODILY INJURY Is
SCHEDULE AUTOS (Perperson) I
HIRED AUTOS BODILYINJURY is
NON-OWNED AUTOS (Per accident
PROPERTY DAMAGE S
(Per accidenl)
UMBRELLA LIAR 'OCCUR EACHOCCU2RENCE Is
EXCESSLIAB F—ICLAIMS-MADE AGGREGATE IS
CECUC T[FILE $
RETENTION S S
A WORKERS COMPENSATION AND X WC STATUTORY OTHERI
EMPLOYERS LIABILITY YIN UB-49B7POe2-12 12H0!_NJ12 12/1012013 rIN�IT.
AW PRr>"FRITORRART?lER!FxFCVrNE NIA E.L.EACH ACCIDENT Is 100,000
DF I:P=I7cM5Hi EXCLUDKDI
RAaemo.y m HHI EL DISEASE-EA EMPLOYEE S 100,030
W'5 i.IrILP,
DESCRIPTION OF OPb:AT O'S xlaa E.L.DISEASE-POLICY Llwr 5 500.000
DESCRIPTION OF OPERATIONSLOCATIONSNE9CLESM-STFJCTIONSISPF:UAL ITEMS
TH:S iEP..ACES ANY PR:OR CE3T(r is AT3 ISSUED TO THE CERTIFICATE HOLDER AEFECTNO WORKERS C.'OMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED I
Ai.LVf.�RF:I;OV1E LLC 1
ATTN. CO\RAD
BEFORE THE EXPIRATION DATE THEREOF,NO TICE WILL BE DELIVERED €€
- IN ACCORDANCE WITH THE POLICY PROVISIONS.
16 CASTLE Ci:�CLL' AUTHORIZED REPRESENT - !!
?a.=30D•i,�L4 01960 (.,.�•i„ K.
ACORD 1 ) TheACOkD name and logo are registered marks of AC 5 R 1 0 ACO D CORPORATION. I rights reserved.
06-06-2013 09148AM FROM-CLE►ENT AROER INS. AGENCY 976-922-9276 T-727 P.001/001 F-926
A-CDM. CERTIFICATE OF LIABILITY INSURANCE 61220
PRODUCER THIS CERTIFICATE L4 ISSUED A$ A NATTER OF INFORMATION
(978) 922-4600 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ARCHER INSURANCE - HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CAHOT ST - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC S
ursUp�D W ADTHUTILUS INSURANCE CO
Hallmazk HOmas LLC INSURER&
16 Cas Cle Cir INSURERC - -
R D.
p MA 01960- w RERE.
CG
T POLI CIES SOF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWTTHSTANDBHI ANY
REOUIREMEM,TERM OR CONOMON 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.
A000.EGaTE UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID MAN&
uL�a TYPSOFIN9URANCE POLICY NUMBER DATE NIODTYYI DATE DUYY" uImas ,
A GermAAL UAn+UTY L877a556S Ofi/07/2013 06/07/201C sACH s 300,005 1
F=�M
GENERAi UABY,RY ISES mY°ia�9 i 50,000
/ / / / MEDEXP aw waW) S 5,000 °
CLAWSUOE nX OCCUR -
PERSONAL L ADV INJURY i 300,000
NBRALA EOATF L 600;000
LIMpIIT APPLIESPER DUCTS-DOMPIOP AGO S 300,000
JECf LOC
i AUTOuO91LE L1ABAJT' / / / / CCMRINED SINGLE LIMIT S
(£P bmlawTD
ANY AUTO
ALL OPINED AUTOS / / / I BODLYWIURY - S
(Pa pd Pn)
SCHEIXAEO AUT0.4
HAM AUTOS / / / / BODILY INJURY i
NON-C"20 AUTOS (Pg$� )
PROPERTY DAMAGE S
(PN 9COCNT)
GARAGE LIABUJTY AUTO ONLY-EA ACCIDENT =
ANY AUTO oTHERTHAN EA ACC i
R
AUTO ONLY. AGG =
ELOESMMBRELLALIABILITY / / / / EACH CCURREN i
OCCUR r-lCLAIMS MADE AGGREGATE i
DEDUCTIB'.E
RETENTION i
r10RXFRs wM►FNSATXJN ANTI / / / / To rTA� °ER
exw.oYER.v LNimun
ANY PROPRIETOWPART-EPAXEC'.I'NE EL EACH ACCa]EHT i
WYICERAAEMSER EXCLUDED? / / / / EL uIaEABE-EA eMn. vEE=
i YPF..—,AP-,m EL DUIEAS6-POLICY LSacf S
SPECIAL PROVAhD"dU+
OTHER
CESGWPnCN OF OPERATIONS'LGCAnO'LSNEWpF51F7fCLUSIONS ADDED OY ENDORBBIEITI5PBUAL PRDAS`GNS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ASOVC DESCRIBED POUCLES BE CANCELLED BEFORE The
EXPIATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTTCL TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
CITY OF LYHIS FAILURE TO DO 50 SHAM IIBNIsw NO OBLIGATION OR LUDPITY oa ANY HIND UPON THE
CITY HALL SQ. INSURER.ITS AGENTSO 'REPRE5ENTATVES.
AUTHORIZED REP f.
LYL@) MA -
ACORD 25(2001108) ®ACORD CORPORATION 1B
14 CR7A nH,m ni POW I