17 TRADERS WAY - BUILDING INSPECTION (2) .. y The Commonwealth of Massachusetts
I
rl� I j Department of Public Safely
('.t..✓ \Li,.aahu.a•us jlalr BuJ.bng Code(.80 C.\fIi)Serrnlh Edttwn �
City of Salem
' I BuildingPermit Application for an Buildin other than a I-or 2-Famil Dw I
1 rhs<ection For Official U,e Only)
Ifudding Permit Number Date Applied: Budding In,pector
SECTION 1: LOCATION (Please indicate Black s and Lot s for locations for which a street address is not available)
LID,/ n t A nI9�70 l- tne oG j
No. and street C 11v /Tuavn Zip Code Name of Bud ing of.tppbcahle)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
----- -Ear..ting-Budding; - ----Repair- -Altrraliun-O AJdHia+n{3 -Urmolitiun-O-(-P-Incise-hll-out-aaa#+ubmit-AppraJix�
Change of Use ❑ Change of Occupancy O Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nolk
Nan Independent Structural Engineering Peer Review required? . /Yes ❑ No)
Brief Description of Proposed Work: IZ.e P(AaE ?P DM A/8/'/C -L/'S7�'�� /I SiM/�Ar EPOM
�lclnl tFlYl-MJL)Z-.� M-1942
G�t=•� Wit1-f�LL�1nI P'1 p�wi L'>Jz.4-r-1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR.34: Proposed Hawed Index 780 CMR 34:
=(include
ECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
rNo. ent levels)&Area Per Floor(sq. ft.)ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A•2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: HI Hazard H-1 ❑ - H•2❑ H-3 ❑ H-4 O H-5❑
is Inatftutional I.1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R_: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage SI ❑ S2 ❑ U: Utility❑ Special Use❑and please describe below:
a Special Use:
SECTION b:CONSTRUCTION TYPE(Check as applicable)
IA O I8' ❑ IIA ❑ 118 ❑ IIIA ❑ (fig ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION Irrfer to 7W CMR 111.0 far details on each item)
Wager Supply: I Flood Zone Information: Sewage Disposal:
french Permit: ' Debris It<moval:-
Pubbc❑ ChccA it rnd>iJe Ili�..l Zunv❑ Inabrete mumclpal❑ �\ bench wdl caul hr Lin•n,ed Ul.p,."il tine❑
n•quircJ (:]or trench a .pcalc.
I'ricatc❑ „r odcniih Zone:_ ur,m.or,c,trm ❑ permit 1,enclu.r.l ❑ _
I
I ftailroaJ right-of-way: Hazards to Air.Navigation: ......... --
'\rl \g•gdi..d•w❑ L•Vwlw c„Ilhln.urpurl.ipg•iu.iiharra' Lthcu lva lc,a onnplclr.l' i
. , 1'..n.cnl u. l4ol.l o,,0,."'f 0 � _ Nv.❑ --r.\n❑ lc.❑ ❑
SECTION 8:CON TENT OF CERTIFICA rE OF OCCUPANCY
.figs n .d l •,Io ._� L-o lirupi.i ___ f,po•.I l . n.trw hnn ___ laciuf`.utl l.. d.l pen llu, l ._. __._ ..__.
I F•,�ibo Dnl l.hna uvaLim in�prm1,for M.it-rn ?prci.il�upu h lnm
SECTION 9: PROPERTY OWNER AUTHORIZATION
V,nna• i iJ .\ddrvs. 1 I'n l• •rtr O)r nrrpp ..� ,,j� i— � -_--
/e'Al.fy 017'4 JG�NI�INTo /� P
Name(1'rint) No..utd?I n•et litse Lnvn / r .
I I'rnLc rtr(Aa nrr(-,,coact Inlormallonr C/O QbLJ LOIN Q�t�!J✓ 6/Y F0 2, •1 T-7G-1
( 000
fella relephone No.Ibumnasa) irlephone.Vo. (cell) r-rn.nl .idJrc�. j
II ap�•J ic.d+lr, Ihr pre• rlc oc.ner hereb\'.tulhontes
J�ionn�es � now Z6 Z,N�IN 1 S1J, IFRo57or•I e4 A _ozr3,r-
Vamr Strad Address Ci1v1 Town ?tale /IV
Io act on the •m •vrt% .n.ner , behalf, m ell matters relauce to work .iuthnrieed by this budabn • •rrmil a + •hcahon.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
111 building is los(Fun li,UlU cu tt.of enclo,vd s acc and/or not under C.mntructwn C•n+tmI then check here D and •kt•S•ali.m Ill d
10.1 Rr istered Professional Responsible for Construction Control
Na I,s - rep one No. e-maned-ress Regi,traition Number
Street Address City/Town State Lip Discipline Es�uatmn Data
10.2 General Contractor
,e.....1.4110 Do 1 B
Comfit Name:
1�o MAS L'qf-✓LE2 � S 1Dy368
Name of Prrwm Res)xmsiblr for C nstructiun 6� I License No. and Type i(Applicable,Z
2 S LM/66 Lf I or)
Street Address City/Town Slate Zip
�GZ .t�o� -7a/?S 316 /oao%rowZn�� — �o ia/ : Co.�
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'CONIPENSATION 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 issuance of the building permit.
Is a si ned Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE '
Item Estimated Costs:(LaF( a
and Materials) struction Cost(from Item 6)_$ /�31 C60
I. Building $ J/3, 6 OQmit Fee Total Construction Cost x$ _(Insert here
2. Electrical ppropriate municipal factor)_$
3. Plumbing $ � /' q
d. Mechanical (HVAQ S inimum fee=$ �,ZG R (contact municipality)
S. Mechanical (Other) $ payable to
6. Total Gist - S // 3, 6�boP•y
i alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Rv entering my name below,I herebv alles1 under the puns and penalties of perjury that all of the information o'ntamrd in thus
apj.+li<ahon is Inir.md accur�to l brsI of m%' knnsvledgeand understanding.
� —_ — _�
�omo Gil/J� Qa7 ;_J i�/,odor 6I S�Zs-7o3 4 /
llltz. pruu Hal •i);n Hama• role 1 e
l �• ! / p � fete •hin
26 C/n/6e L.N D,J• OJ �A D2/•� c'_
- fat . Gp J
II Municipal Inspector to till out this section upon application approval: _ r t2tl/
11.i:r
1
CITY OF S.U.&M, NL-kSS.kCHUSETTS
BULDNG DEPARTMENT
' 120 WASHLYGTON STAEfir,3w FLOOR
TEL (978) 745-9595
FAX(978) 740.9$"
KIStBERLEY DRISCOU.
MAYOR Tltows ST.PtERtts
DIRECTOR OF PCBLIC PROPERTY/BCILDLYG CO\OIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit Al 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:
�Np,plR�� .R/yDdsi21 �S
(name of hauler)
,The debris will/be disposed of in
�/1/00� 1�A578 08'7D�
(name of facility)
(address of facility)
—
signature of permit applicant
date
I.hna.If.6wK
CITY OF S,U_E.N1, ,NWSACHLSETTS
Bti ILD LNG DEP iRTMEINT
• 120 WASHINGTON STREET, 3.FLOOR
TEL_ (978) 745-9595
F.ax(9 7 8) 740.98.16
KIMBERi EY DRISCOLL THOhwST.PlFAm
MAYO& D iRECiOR OF PL 13LIC PROPERTY/at:BD ING CO\C�IISSION ER
Workers' Compensation insurance AMdavit: Builders/Contractors/Electricians/Plumbers
p y ?'cant InGtrmation Please Print Legibly
Name L l0usi'wsyOrgani:al*u JJiatvinJiviJual): /t`''II
Address: w?61 nl Like,ke, '3
City/State/Zip: RDS ,0eq MA 02139 Phone #: 5— 6 1 s���
Are you an employer?Check the appropriate box: 'rype of project(required):
1.0 1 am a cmploycr with 4, 1 am a general contractor and 1 6. ❑New construction
ent Io ees(full and/or art-time).• have hired the sub-contractors
p y p 7. ❑Remodeling
2. 1 ship
a sole proprietor o partner-
listed on the attached sheet.f
,hip and have no employees These subcontractors have g. ❑ Demolition
working for me in any capacity worers ,
k 'comp. insurance. g. � Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
right of exemption r MGL I 1.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work b P �
myself. [No workers'comp. c. 152, §1(4),and we have no 12. 00f repairs
t employees. [No workers'
insurance reyuired.j comp. insurance required.] 13.❑ ?her
•Any applicam neu dtucks box el most 21W fill uut the'calm below showing their workui compensation Policy mho motion.
t Ihvnuuwrsns who submit this affidavit indicating they am doing all work and then him outside contractors must submit a new a?:davit indicating such
=Cunoegaom that check this box molt anaehed an additional shot showing the nurse of the sub-eontndora and'heir worten'comp.policy infomution.
l um an employer that is providing workers'compensaton insurance for my employees. Below/s die policy and job site
information.
/EGJ' IfdlURO(✓Cg j�G _
Insurance Company Name; !V rod
Policy 4 or Self-its. Lic.0: O if 4 2-9 6 P 3 72 10 Expiration Date: it /,4 Ij /� /t
Jub Site Address: d iry4f. Dm PA2,� �� Zooms MPY City/State/Zip: �is�� r r✓� t/177n
,tttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tint up to S1,500.00 and/or one-year imprisonment,as well as civil Penalties in the form of a STOP WORK ORDER and aline
of up to S2SO.no a Jay against the violator. Ile advised that a copy of this statement may be fumardcd to the Office of
Investiguliurs ol'thc DIA for insurance coverage verification.
l da ihereb cnrh,`j''�1 uder the wins/uJ�,N' Menu/�/��lies of perjury roar eke information provided above is r ue and c•orrece
�t HUM IVl 'Gi0 �/!1 i /1 vLT� Dat : /1. �
Pho c 4 .I-7 5-6 S-)i Q� —
Official use only. Do not write in this area,to be completed by city at town off vial
City nr Town: ___ . .--
Issuing Aulhority(circle one):
1. Board of Health 2.Building Department 3.Cily/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other ---_-...- -
Contacll'erson: _ _ . __. -_ Phone 4:
[
Information and Instructions
Massachusetts General Laws chapter I j2 acquires a I I employers to provide workers' compensation 6)r their enployees'.
I'ursual)f to tills slamle, an employee is defined as"...every pet-son in the service of another under ally contract of hire,
apress or implied.oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
a the loreloing engaged In a joint emerprlse,and including the legal representatives of a deceased employer.or the
I CCelvef Jr traslCe UI .I71 ❑hdhvhdual,parmcrship,alaoctauoa or other legal cnnly,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, ¢25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant .who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally. SIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
' enter into any contract for the performance ul'public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(.$),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confimtation of insurance coverage. Also be sure to sign land date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insurcd companies should enter their
self-insurance license number on the appropriatc line.
City or Town Omelets
Please he sure that the affidavit is complete;md printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant.
['lease be.sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant
that must submit multiple pertnitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I lie 01IICc of Invesriganons would like to thank you in advance for your cooperation and should you have ally questions,
please du nut hesimre to give us a call.
the Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCS of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-WSSAFE
Fax #617-727-7749
www.mass.gov/dia
L/Ls/LVll 11 :t:J: 11 API PAUL zlvuz rax server
�j
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM DC:YYYYj
,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 ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER.AND
THE
CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(tes)must be Endorsed. It SUBROGATION IS WAIVED,subject to the
terms and
conditions of the policy,certain pollcies may require and endorsement. A statement on INS certificate does not confer tights to the certificate holder
In lieu of
such endorsement(s).
PRODUCER CONTACT
NAME:
PHONE FAX
VEAVTON IN�LJRANCE ALUNCI Y' (/VC.No.Ext.: FAX
(AC.No):
66 1YERSON LANE E-MAIL
ADDRESS:
PRODUCER.
N ENVIDN,NIA U2451' CUSTOMER ID A:
SSRLG IMURER!S;I AFFORDING COVERAGE NAM
INSURED INSURER A: TRAVL:I.ERS DIRECT ASSIGNAIEN'1'
INSURERS:
ROWL tiRD ROOFINGS_CLADDING LL(.' INSURER C:
INSURER D:
26 LINCOI N STREE I SL Ii 1-8 INSURER E:
BOSTON.VIA 02135 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERPFY THAT THE POLICIES OF INSURANCE LISTED BEL"HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PRRIOC INDICATED.NOTWITHSTANDING AN'
REQUIREMEN'.TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTC WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY�SRTAIN THE INSURANCE AP°CRDED
eY
THE POLIMES DESCRIBED HERON IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CUNDITIONS OF SUCH nO'JCIES. LIM:TS SNOWY.NAB HAV E EE EN REDUCED BY PAID CLANS.
INSR AOOLSUSR POLICY EFF DATE POLICY EXP LATE
TYPEOFINSURANCE POUCYNUNEER (MN'0DIYYVY) iMM'.DD,YYYY) JMRS
LTR NSR WVG
GENERAL LIABILITY EACH OCCURRENCE S
COMMERCIAL GENERAL LABILITY
DAL•1AGE TO RENTED S
C'_AIMS MADE OCCUR. PREMISES(Ea almn!renvo)
MED EXP(d•q-ono persnc) S
PERSONAL SS AU'J INJURY .$
GEN'-AGGREGATE LIMIT APPLIES PER GENERAL ACG9EGATE S
POLICY PROJECT LOC -ROCUCTS-CCM°/CPAGG $
AUTOMOBILE LIABILITY r-OMBINEU SINGLE }
AINY AUTO LIMIT(En acobUnlj
ALL OWNED AUTOS BODILY INJURY 5
SCHEDULE AUTOS !Par perso`0
HIRED AUTOS EODILYINJU'H'Y -
(Purxcidert)
NON-OWINEDAUTOS FROPERTY DAMAGE p
(Pw a cklen:)
1 UMBRELLA LIAR OCCUR EACF OCCURRENCE
EXCESS LIAO CLAIMS MADE AGGREGATE $
DEDUCTIBLE S
RETENTION S S WORKER'S COMPENSATION AND WAY=AIUfUrvtiN:IS JIF$N
EMPOLYER'S LIABILITY VIM Ue 4-aUPW?11) (17!132010 (I7.1312011
YIN E.L EACH ACC!UENT S x'.,50f_C00
YPI'!OPEPII(x!PAHINEREXECUTI`:ti N
Or-F10ER06EM9EPEKCLUDEDP N E.L.DISEASE-EA EMPLCYEE S �'.SOC.COG
(YanOamrYin NH) El O'SEASE -POLICY LWIT $ 50C'.000
OY DIf C.MP
Sf.PoP❑ON OF:ffRA'IONR-sl;w
DESCRIPTION OF OPERATIOW tOCATIONSiVEHICLES+RESTRICT10NSr5PECtAL ITEMS
'[PIS ILEFLACES ANY."PWR CFRTff1CA1E 155U-1)TO THE CFRI^CATE HOWER.t-FECIIN(i W ORFaas COMP CC]'RAOc.
TFDi[NSLnLED'S DL\R'nF KFI.S CO:.Il'FNSA"ION W?1JC}'AIQD ITS i ALRPL'TITTER STATYS F;.DOR.•'8_NtfNT AI_THORIZES THP 1`AY"JfF.'NTOP BFIJ_F[r5 POR Cf.S.Tei�
At.li)E E}TICS INSUREDS AL1�-}1PI U]PYS IN iIA^,b'S O7F�k:Tt aN AtA. NO AUTHORIZATION 15(AVFN TO PAY:T,,IMS FOR BF14EMIS IN.STATES OTHER
TfiAN Lin IPTHF.LVSiIRE0 H1RE5.OkH.\SHI.3F7 PAfF[J.IYE°S Ot.TS/':E:'FAI,\. �SPOIJC}"70 aN1'/!'7RO\T.)E�'VVERAL/P.!+rR rtil"STATE IY[F�k 7FI?:J D4i.
RIP CeH1GHi.iNi):R StI(1FY1VC FLA�A.SALY?L YU
CERTIFICATE HOLDER CANCELLATION
HIGHLANDER PLAZA SHOPP[>fG CENTER AND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE
HI(iHIANDER PLAZA.LP WITH THE POLICY PROVISIONS.
uIC OLD YORK RD AUTHORIZED REPRESENTATIVE
JENKINTOWN.PA 19�)46 Charles T Clad:
ACO RD 25(2009100) 1988-2069 ACORD CORPORATION. All rights reserved.
I
i:FR-4-2011 03:54P FROM: T0:16175625'04 P. 1
®R� CERTIFICATE OF LIABILITY INSURANCE
j 6/3/1_1
THQS CERTHFiCATE M ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFFRR NO RKHHTS UPON THE C£R(IRCATE HOLDER THS !
W"FICATE DOES NOT AFFRSMAT(VELY OR NEGATWELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POIJOES
BELOW. THLR CFROFICATE OF INSURANOE DOES NOT CONSTlTU E A OONTRACT BETWEEN THE MSUNG 11$IAiEM). AUTHORIZED
R 84MBEMAWE OR PRODUCER,AND THE CERORCATE HOLDER. `
IMPORTANT. Nths cortlfleaLs holtlor to an ADUnKW4L INSURED.the e)(is)ameE he endure". U SUBMAMON 16 M—"-eulyaet to
the(arms and eau lids a of the Polley6 certain pokim my fsgdre an endorsement A>rel8meld on tide tertlflale does not embr rights to the
certideete holder in Wu of such ermlarsormnllc4.
rnaollcla -
Newton Insurance Agency 7 9Fi5_515 . (617) 327-5609
66 Myerson Lone
Newton, MA 02/59-353 pAmmumy. 2050
9Bvas aauxswc,4aQ_ttedalq_ITieuranc® Co___�-__. _
Rowland Roofing 8 Cladding LLC asllsme-Citaticn Insurancs Cc .1
26 Lincoln Street rj
eRe:the Travelers
Suite 8 Heaton, Mh 02235 Hli: _ --
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
TICS!S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISG EO TO THE INGMED MAMED ABOVE FOR THE POLICY PE O
INDICATED. NOTIAnTHSTANDNG ANY REOUIRENE r.TERM OR COa)ITIM OF ANY COPoTRACT OR OTHER DCCUWNT WITH RE VECT TO WHCH THIS
CERTFICATE MAY BE ISSUED OR MAY PEFTAW. THE WSURANCE AFFORDED BY THE POLICES QESMSED HEREIN IS SUBJECT TO ALL THE TERMS;
EUCLIMIOM ADCONOTIOHM OFSUCH FOUCES.LEBFS SIONAA1t MAY HAVE BEBJ(EDUCED BY PAID CtAhS.
L TY/EOFIra1N(Id/CE ADm LIMITS
Ras PaUcy I E LL*ARD CHC� rWdM�E -_�.!-sE._1-i01-0G00-�-0O0C-1O?
X A -7
ONSIERCIAL GENERAL Lvalu" X CPS1186132 7139/10; 7/19/il�_ CIADMAOE00MUR
-
- i 1 I I �Mc80Pi/ugoroDeeml {,S 5
I ,PalsoHt_sAOVNHIORr E 100,000_
iJ 1 � j I (;Er(ERaLAccREeATE s .2.,cao._o�6
am%ADGROMTELrRTAPPUE8 PER ! ! RLOIR;CrB-DOrPA1PA00 E OQQ OQU
X I
.L.. �T r ac 1 s
�AUTOMDa.9.81NNMUTT mLexrED a:NSLE1xRrt 1.000.000
IEaysagvq)
4MTAVN)
L 8 _ I LOVAEDALTDS I1SIX968 7/19/IO� 7/1$/31 BOOZY LNAIRY!PTr ixeon) s
AL
l ®li i aoa r INJURY aadMI) S
_j ecHtEOaUTos i i Ems,DAMAGE
UTGa
.__
X,HIFEDA
XONa NVJWD AUTOS S
eNeAEu.U,uas Oman I ((..rraloccuRRalce Ia 5,G00.000 __
A I X ENGBaUgB__ i XB80009423 i 7/19/20 7/19/111AjW_CA_M,__ 5,CO0s0 0_
ire Offmcna1E 1 1 -- ------
REI9ITION E
�DO1UR.rLL1 arCSTAitL Orl4
MoB7Lovew Lwmam YIN I
C ANY PROPREFORPMINERE71EOITE NiA ORI]SI(ED F'ROfT EL.:&CH ACd CEHr ';
OFFICE��yyeeqq �%E�E#11OE07 ITN6' TRAT/ELBRE 7113110 7/13111 E-.m3EAjz.EAEmFLaY
DEauir�7gN OPERsn(Ne mbr I EL.OS •PWUC'U L91rt "�
I
�9diPiN1NOFOP9NONIMettD4nar181VENC1�(A16eq AfAlo�aI.MR1biW Mm,b BTLgerq.xaaq qpe N,gq,rM
Highland Plaza Rea1tV Trust and Jager Management, Inc. are added as additional insureds
For iob at Highlander Shomina Plaza, Salem. MA
CERTIFICATE HOLDER CANCELLATION
I NOU1D ANY OF THE ABOVE DE36RffED POLICES BE CANCELIBO BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DEUVERED R i
Highland Plaza Realty Trust AMORDANCE 01I711 TICE POLCY PROVISIONS.
c/o Jager Management, Inc.
610 Old York Road AUMORIZEDREFResENDILI e
Jenkintown, PA 19046
d TON4009 ACORD CORPORATION. AN rights reserved.
ACORD 26(2009109) The ACORD name and logo are regletered marks of ACORD
Massachusetts- Department of Public Safet%
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 104308
THOMAS LAWLER
49 ROCKAWAY AVE
MARBLEHEAD, MA 01945
Expiration: 6118(2014
(1nmds.hmrr Tr#: 104308
0043640
r
201A O6 1 =`1
a n'IfG r dixi+;
i A0o KAWAYA '2'
m
b ,
019g8LEt1EAD 6U � �i _
r
t
, 4
WORKICONSTRUCTION AGREEMENT : Roof Replacement T 3 Max/ Sally'S
JINp1WNER Highlander Playa Realty Trust
CONTRACTOR Rowland Roofing&Cladding LLC
CONTRACTOR'S ADDRESS 26 Lincoln St suite 8
Boston,MA 02135
PH 617 562-5703 FAX 617 562-5744
CONTRACTOR'S FEiN NUMBER
DATE OF AGREEMENT April 1,2011
NAME AND ADDRESS OF PROPERTY Highlander Plaza
17 Traders Way
Salem,MA 01970
In consideration of the mutual covenants herein contained,and intending to be legally bound,Contractor agrees to perform the Work hereinafter
described,and Owner agrees to pay the amounts hereinafter described,all on the terms and conditions heminafter further set forth.
1. DATE TO COMMENCE WORK April 15,2011 weather permitting
H. DATE TO COMPLETE WORK:
IN. CONTRACT PRICE: $113,600.00
The Contract Price shall be paid in full within 30 days after the Work has been completed,lien releases and affidavits of payment have been provided,
and the other requirements set forth in Addendum A Paragraph III,have been complied with(except that any installment payments,less retainage
amounts of ten percent 110%],shall be made as partial lien releases,affidavits ofpayment,and other items required under Addendum A,Paragraph III,
are provided in accordance with the following schedule;if no installment payments are to be made,leave blank):
IV. DETAILED DESCRIPTION OF THE WORK
Contractor shall perform the Work as described and as further described in Exhibit A,attached hereto. (Also,attach any architectural drawings,
engineering specifications,and a site plan,and/or floor plan[s],if appropriate,as Exhibits showing areas]involved,and fill in Article VI of this
Agreement). The Work includes all items described herein,or in any Exhibits or Addenda attached hereto,or contained in my change orders or
modifications signed by Owner and Contractor,or reasonably inferable from my of the same.
V. DESCRIPTION OF MATERIALS APPROVED FOR USE BY CONTRACTOR(e.g.,band,style,color,quality and Other aspects of items such as
paint,carpet,wall coverings,roofing material,etc.):
As noted in Exhibit A.
Vi. INTEGRATION
This Agreement,together with Addendum A through Addendum B and Exhibit AJland D constitutes the entire agreement betwem the parties and
supersedes all previous written or oral agreements,if any,relative to the subject matter hereof. In the event of my inconsistency between this
Agreement,the Addenda,and my Exhibits,this Agreement shall control over the Addenda and Exhibits. In the event of inconsistency among Addenda
or Exhibits,the Addenda shall control. in no event shall any proposal or contract form submitted by Contractor be pan of this Agreement unless attached
and referred to herein as an Addendum,and in such event,only the portions of such proposal or contract form consistent with this Agreement and the
other Addenda and Exhibits shall be part hereof. -
IN WITNESS WHEREOF,the parties hereto have each approved and executed this Agreement as of the date set forth above.
The persons executing this Contract on behalf of Cmlractor represent and warrant that they are duly organized or duly qualified,and are authorized to
do business in the state where the Property is located;and that the persons executing this Contract on behalf of the Contractor are officers of such
Company and that as such,are authorized to execute this Contract.
CONTRACTOR OWNER -
Highlander Plaza Realty Trust
Rowland Roofing&Cladding LL/Cn� Managing Agent: Jager Management,Inc.
All
By: --J O !�, By:
Name: 110n1A5. ZAalgizz' Name: / �+
Tide: )(F:6.i GCT MghtA011, Title: \via �
fir
tip
g.W4
,�' ��
r 1 B' q t r
. fl a�'.� a �qr Ie R
1 Rq �^" a e$ pp� � rI to u
I jr
°,� 9 a Ada �R A `Agot
eA a m
p lit
� B tit ' It,° tell
ti
t&
4IL
[ ti
U111
a .� t
g � 41
aa e
;Lill
IF T It
�ArPIS
rya-
= fix a A q .t H' @ �9qeI
�' � � t• �• R � q �. A m 8
lit
it
� �. � �•a�Ag, ��� �� �� �' q� �' L( �� �,� . 9 �� �, �e, �� � SLR
I.
eRF
H.
B�
it forHER
� 4 I �Q a � � Et "
gIt aso-
55
�^ 6i � @� 9,gg g• g •�
lot
s t g
aLt
tr
Ob
�
a
Oi e
k
' C
y
mw Exhibit B
3 -
f'
t
f e � f
9