96 TREMONT - BUILDING INSPECTION The Commonwealth ofMassachusetts
BoarassdouBuisState uilingCok780ons and dards INSPECTRIpNA F�
Massachusetts State Building Code,780 CMR
Bolding Permit Application To Construct,Repair,Renovate Or �MA T 4 Revised Mar2011
One-or TwoFamiTyDweliing MAr A 31
(� This Section For Official Use Only
.0 Building Permit Number Date Applied:
[ liaitdiog Official(MntName) Signature Date .
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
[ - — til 1
l.la Is this an accepted street?yes no Map Number Paru1 Number
1.3 Zoning Information: 1.4 Property Dimensions
Zoning District Proposed Use Lot Area(sgft) Frontage(ft)
1.5 Building Setbacks(ff)
Front Yard Side Yards
Rear Yard
Rempdred Provided Required Provided Required Provided
1.6 Water Supply:(hLG.L m 4Q§54) 1.7 Flood Zone 1nt'ormatioltc 1.8 Sewage Disposal Systeta:
Public❑ Private❑ Zone _ Outside Flood Zone? Municipal❑ On site
Checkifyes❑ P disposal system ❑
SECTION2: PROPERTYOWNERSEHA
2.1 Owner}of Record-
vIo((r m 0 pi
Name(Print) - - Lily,State,ZIP
4` n, It S-(- �zs-z4v. rs� �
No.andSneet Teleplmne Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ IExisting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ terati m(s) ❑ Addition ❑
Demolition . ❑ 1 Accessory Bldg.E3 Number of Units- Other Specify:
Brief Description of Proposed Work:
p Y -
SECTION 4:ESTIMATED CONSTRUCTION COSTS..
Item -gAoar and Af nags Official Use Only
1.Building $ 1, Building PemritFee $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Co'se(Item 6)x multiplier x
3.Plumbiog $ 2. Other Fees: $
4.Mechanical (HVAC) -$ List_
5.Mecbmdcal (Fire
-Suppression) $ Total All Fees:$
6.Total Project Cost: $ Check No'JgJ"-CbeckAmount: Cash Amount
8 a ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5- CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL)" .I 7 b-7—�
UteaseNumlber ExpuationDate
Name of CSL Holder
List.CSL Type(see below) t/f� "
Eric W.Palm
No.and sheet 3 Hilton 3tfeet Desaipdoa .
U Umesttided to 35,000 cu.tt
CAlerrt MA 01970 R RestdctDdl&2F=HyDwdft
City/fown,state,ZIP M Masonry
RC Roofing covering
WS Wmdow and Safio
SF Solid Fuel BumiagAppliances
8 5 "t f ' I Ianiletion
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(BIC) ! 20
Atlantic eathcrizAiivi,, L...
MCRegistrationNimba Exphatiou late
,
HICCompanyNameorHI venue
o:.t asA 017.0 n ° .
No.and Sheet CtR r.vs T Email address .
7
City
/Town,Statc,ZIP Telephone
SEMON6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L r.152.§25C(6))
Workers Compensation Insurance affidavit must1 a completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the.Issuance a building permit
SiguedAZdavitAftached? Yes:.........0111, No...
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WREN
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUIIBING PERMTf
I,as Owner ofthe subject property,hereby authorize &( G �Q/f n '
to act on my behalf,in all matters relative to work authorized by this building permit application.
Prim awnees Name(Eledrvmc Srgnahue) � _ - Date
SECTION 7M OWNEle OR AUTHORIZED AGENT DECLARATION
I ,
By enteringmy name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained ialhis applicatip is to the best of my knowledge and tmderstanding
Prim Owner's orAuthorized AgwPs Name(Electronic sigashue) Date
NOTES:
1. An Owner who obtains abmlding permit to'do hisllter own work,or an owner who hires antmregistured contractor
(not registered in the Home Improvement Contractor QUQ Program),will not have access to the arbitration
program or guaranty fmd phderM.G.L.c.142A.0ther important information on the HIC program tan be found at
www.mass.gov/oca htf mnation on the Construction Supervisor License can befound atwww.mass.eov/dos
2. When sabstaatial work is planned,provide the information below:
Total floor area(sq.I) (including garage,finished basemenUaUics,decks or porch)
Gross living am(sq.ft.) Habitable mom count
Number of fireplaces Number of bedrooms
Number-ofbathrooms Number-ofhalf/batbs
Typeofheadngsystera Number of decks/porches
Type of cooling system Enclosed Open-
3. `Total Project Square Footage,maybe substituted for'Dotal Project Cost'..
Massachusetts Home Ira rovement Sam le Contract
MM
tom 1111 regem seekIs oftheatvice Home Lnprovemeul Contract a Lmv11GL chapter1I ,k),outdoes not include standard
languagean homeowoea. Seep legal advice if"Ce tury. A°YPerson plmning home improsements should fire obtain a capy of"A
senter Guide to Home improvement-beforeag drg manywmrkm Your
r Affairs and Business Ro@ulanen's Consumer Y residmm You any obtain a in,copy by calling the
Ltfonhaton Hotline en 617-973-9787 or 1-888 283-3757 or on omwebai,
meOW ner information
Contractor Information
Name
Company Name ♦/���. t (/�
Street Addns(donotmeaPmt Officello<address) Add W�LLC
Cmuaztm/Sdespvsmd Otwer Name
City?own - �I R Avem
State Zip Code Bmmess Address
�^/^� �� (mmiuludea street ddress)
AN,. C> 7fl
Deytene phone Erring Phone
Ciry/fown Same Zip Code
MaihnB Address Pt diRercm from shove)
emnaw Phone FedandE 1
%er 7D or S.S.Number
Iawrmovnftc nmaaeme ifomelopormml4mavvme¢NmepQ a ,am.
(mpnnmmr amnrmnaan L
...aanssrnm„umae /"
The Contractor agrees to do the following work for the Homeowner.
(Describe in detail me work to complamd,sPecifymg the type.brand,and grade of mnaiats tobe^ , rued,pseadd'tio I,�h 'f �)
`(1I0 AA., CA-(l U lace-
Required Permits- v'e9 y the clmma building permits are carped Proposed Stnrtand Completiot Schedule-Tnefollowing scbedule will
and will be secured by the Contracror as the hom manes agent be adhered to unless Cma rnstaoces(Owners who secure their own permits will be beyond the mntramot's mmrol raise
excluded from the Guaranty Fund provisions of
MGL chapter 142A.) —(0—fie when Wnvacmrwill begin conUWW work-
f
_�E-L_CYetc when"Mounted work will be substmhally completed.
Total Contract Priceand Payment Schedule �
The Contactor agrees to perform the work,famish the material and labor, 7 C
specified above for the torsi
Payments will be made according to the following schedule:
S upon signing contract(not to'ezceed la of the total Contact price m the cost ofspecial orderitemg whichever is greener)
S by /_�/_or upon Complanon of
S ,�,�qq by y_/ ([�or open completion of_ '150 f a l
SRO UCX/. AJ Ce -�'pAJ
upon campleti000fthe centrism. (laav forbids.dmtanding fuB Pa mt mtl coma is completed to bath parry's satisfaction)
The following notarial/equipment mac bespecial s
ordered before the demanded work Paid far
to ram the completion scbeduk(•• m in order
$ to be paid for
NOTES:(•)including all finance charges(••)[.awrequins that my "tadown
notercedta'socamof(a)onmthidofthemadeontram pritem(b)meactaal cost of my
cmuaclwbeforeawrkbegiamay
whch mac be special ordered inadvance to men the and raceleam schedule. my special equipment or cannot made material
ffic,t
isan e:rs-Themntiamm agreestoutilizedby the cmtram u th"pmnce-UpsigningthfIlot imply shot any Tien or otherseauiry interest has hem placed on the residmm Review the following tautens and notices
carefully heCore signing this card",
• Don't be Pressured into signing the contact Take tote to read and fully understand it Ask questions if something is unclear,
• eke sure the cantram hasavalidH111 elmmov®rat Contaam Registration. The law requires most homei
mbcoutrectors to be registered mth the Drremor crd mpm areas wunamm and
SUbcaatien lmprovemmt ConuMorRegismfion. You ma in by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or calling617-inquire aboutContractor
• Dues the Contractor have filmmoce? Ask the Contractor for his insurance Companyh 9dera co 7 or 88&283-3757.
see a ca'y Ofa'yroofOfinsurance"document informatoB so that you can co all COveraMoraskto
• Knowww rights and responsibilities. Rend the important information an the reverse side of this form and get a copy ofthe Consumer
Guide to the Home hnprovement Cmaactor f.aw. -
You may cmcel""so
ementifithasbcan signed at apiamotherthan the c°ntmaoesnormal ace Ofbusio
cmtmetor in wrung at his/her main of m m branch office ass,provided you notify the
third business Se ordinary mail posted,by telegram seen m b deli day fallowing the signing of this agreement See the anached notice of y delivery,not loterthan midnight of the
'I SIGN THIS CONTRACT IF THERE ARE ANY orm exploration of this BLANK SPACES!!!right
rr.o meacem roper oroe.mua7mmrbeaomgema®d
1 nsaad oaerovs raeawgamwe 7aecacropraaeyld b<"`°'a,�'__"
I r f s
HamCo er Srbmemre�
Cootmctor's Signature
Dares
Vase
Contractor Arbitration* - - - - -^
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an -
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to
contractor,however. The contractor would have to resolve any dispute he/she has with a homcoivnei in court unless -
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home improvement Contractor Law.
The contractor and the mco,,,FrPereby mutually agree in advance that in the event the contractor has a dispute -
cbrl�4=4e lh� 'b a'aotor may submit the dispute to a private arbitration firm which has been approved by
thet � iifJS Office of Consumer Affairs and Business Regulation and the consumer shall be required
to su s ly
Rio suchA arbitration as provided Massachusetts General Laws,cba 142A. n n
HoWownee S� Contraemes Signature
NOTICE:The signatures 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 signed by the parties.
Homeowner's Rights., ` .
A homeowner's rights under the Home improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,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 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 contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and finless for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowners basic consumer rights.,If you have
questions about your consumer/horneowner 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 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/berself 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 fonds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal 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 hnprovemenP'
contact: . . -
Consumer information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston.MA 02116
617-973-8787.888-283-3757 or visit the OCABR website at JIUTV N�%%V.nras5 vov00br:
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law,contact:
Director of Home improvement Contractor Registration
Office of Consume Affairs and Business Regulation
10 Park Plaza.Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at htm:,`.hr�l�c.massso�/ocabd
Go online to view the status of a Home Improvement Contractor's Registration:
htt?:ild'ostate.ma.usthumeimnrotemenylicenseelistasn -'
For assistance with informal mediation of disputes or to register format complaints against a business,call:
l Consumer Complaint Section
Office of the Attorney Genera(
617-727-8400
AND/OR
Better Business Bureau
508-652-4800.508-755-2548 or 4133-734-3114
vasi.31-❑PJ2010
The Commoniveaith of massitichuseft
Depardneat ofIndustiW Accidents
Office oflnvestigadons
600 Washington Street
Boston,MA'02111
rvtirrn niass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electrician/Plumbers
Apalleant Information ♦��asts� `y! i i Please Print Lembly
Name(BusincuJOrganizatioMndividual): Adak neon,LLC
Address:
City/State/Zip: Phone#:_ 97$-70Y- 910
Are your employer?Check the appropriate boa:
1.dam a employer with�+� 4. 1 am ageneral contractor and 1 Tie°few cons project(required):
):
employees(frill and/or part-rime).* have hired the subcontractors 6' New cortstrtiction '
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7- 0 Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in-any capacity. workers'comp.insurance.
[No workers' 9. 0 Building addition
comp.insurance 5. ❑ We are a corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c.152,§1(4),and we have no 12.n gn frepai s
insurance require .]t employees_(No workers' ='IO'T_
coup.insurance required.] 13.L hcr_IZLSUIpL,
*Any applicant that tbaks box al mug also an Daum=fion bdm shaving theirwmisea'cmnpsmafioa policy inro®ation.
Hum
auvmrea wbo submit We affidavit iudicaVng dtey amdoing aU work and urea him onuideeonuamaamost submit a new affidavit Mceavgsuch.tConuamoa that cbxk this box must anachcd an additional sheet showing the ma eofthe mbsotmacmrs and their workers'comp.policy inteattion
!amen employer that ispmvid*wrkers'compeamnon immunceformy our
information. tokyem Below isthepolicy andjob sire
Insurance Company Name: Z(A rl t
Policy#or Self-ins.Lic. Expiration Dater$/10/16
Job Site Address: City/State/Zip:
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 MOL c. 152 can lead to the imposition of criminal penalties of a
lime up to$1,5W.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.
I do hereby certify wader the pao/s fad pea ofperJury feat the m ornranon
f prot+tded above is true and correct
Si
anamre: -' - +�._.. . -: Date:
Phonett: q7k- 7j�V- Fl(lo
Official use only Do not refire ice ads area,to be completed by city ortmtm ojfrciaL
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
Contact Person: Phone p•
Accol
14l CERTIFICATE OF LIABILITY INSURANCE IDATE(MM'D°" M
THIS'CERTIFICATE IS ISSUED A3 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD015
ER. THIS
3/3/2015
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 holler is an gDDR10NAL INSURED,the policy(ies)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 corder rights to the
certificate holder In Ileu of such endorsement(s).
PRODUCER
N MEAD COnatPIlCt].On
Eastern Insurance Group LLC PHONE
233 West Central St . %000)333-7234 FAX
ED AIL
Dil
Natick MA 01760 INSURE AF FORGING COVERAGE NAIL®
INSURED INSURER AArbella Protection Ins. Co. 1360
Atlantic Weatherization INSURERB1Tautilua Insurance Co
61 Rear Jefferson Avenue INSURED 1:
INSURER 0:
Salem MA 01970 INsuRERE:
COVERAGES CERTIFICATE NUMBER>m BTER 20I INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES U INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N All NNU ABOVE ISION FOR THE POLICY PERIOD
INDICATED. NOTVURE I SUE MAY
ANY REpUIREMENT, 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 E ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPEOFINSURANCE PMO/UDCY EFF IID CLAI
GENERAL LIABILITY POLICY NUMBER UMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A CLAIMSMADE ®OCCUR 500042816 /20/2015 /20/2016 PR MISES Ea oaurrer� $ 50,000
MED EXP Arty one parson) $ 5,000
PERSONALS INJURY $ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
POLICY X PRO- LOC PRODUCTS-COMPIOP AGG S 2,0011
AUTOMOBILE LIABILITY $
COMBINED SINGLE
A ANY AUTO Eaamda I LM 1 000 000
A J-OISNNED X SCHEDULED 020015B71 BODILYINJURY(Perprvson) $
X AUTOS
/20/2015 /20/2016 ( accia
HIRED AUTOS X AUTOS BODILY INJURY Per ) g
PROP DAMAGEer $
X UMBRELLA UAB X OCCUR PIP-Basic $
A EXCESS LAB CLAIMS4MOE EACH OCCURRENCE
S 1,000,000
DED RETENTIONS 600058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'LIABILITY $
ANY PROPRIETOR/PARTNEREXECIJTIVE YIN WC STATU- OTH- .
OFRCER/MEMBER EXCLUDED] ❑ ryIA
(Mandatory In NH) E.L.EACH ACCIDENT S
DESffsCRIPTION OFF OrPERATIONS below
E.L.DISEASE-EA EMPLOYE $
B POLLUTION LIABILITY E.L.DISEASE-POLICY LIMIT S
PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE
$1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPT OPERATIONS ON OF OPERONS'LOCATIONS/VEHICLES (Attach ACORD T01,Addlgonal RemarNs SWadUle,Bmom space is mquirer0
:ERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF BALM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.93 WASHINGTON STREET
BALM, MA 01970 AUTHORIZED REPRESENTATIVE
John Roegel/Pb4l -- � �
CORD 26(2010/O6)
isn251�mnnslm 01988-2010 ACORD CORPORATION. All rights reserved.
The Ar`nan namn>nrl Innn aro roniat.rod nraelrc of atlnp T
ran UU1 Vct -
CERTIFICATE OF LIABILITY INSURANCE
T DATE(MM/DD/YVYY)
IFICATE 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 BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIME A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
O UC C C
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the poncy(les)must be endorsed. If SUBROGATION IS WAIVED,subJect to the
terms and conditions of the policy,certain policies may Nquira and endorsement A statement on this certificate does not confer rights to the
tcertificatend holder in lieu of such a,certain p s.
PRODUCER
� CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET' PHONE LFaAX
NATICK,MA 01760 (AIC,No,Ext): (AIC,:No).__:::
EMAIL
22MLW ADDRESS:
INSURER(S)AFFOgDING COVERAGE NAIC#
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHER[ZATION LLC
INSUgER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
0 TO FYTOM OR POLMESOF NSURANCE UST®ego NAVE BEEN 159U TXE NSURED NAMED pVE FOR THE REVISION NUMBER:
AFFORDS IflEMEE TERM OR CONDITION OF ANYCONiflACT OB OTHER DOWMENTYIRX PEflIODNOICATFD.NOTWITHSTANDNG
PADCL CLAIMS.
THE POLICIES DESCmSED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCHPO 0eES.LBE ISSUED OR MAY SHOWN MAY PERTAAVE EENRE INSURANCE
PAD CLAm3
UCED
NSR
LTR TYPE OF INSURANCE ADD B POLICY EFF DATE POLICY EXP DATE
L R POLICY NUMBER (WADMYYYY) (MMOMYYYY)
GENERAL LIABILITY LBdR6
COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $
CLAIMSMADE DOCCUR. AMAGE TO RENTED
REMISES(Ea occurrence) $
ED EXP(Anyone pereon) $
GENt AGGREGATE LIMIT APPLIES PER ERSONAL&ADV INJURY $
POLICY PROJECT Q LOC ENERAL AGGREGATE $
AUTOMOBILE LIABILITY RODUCTS-COMP/OPAGG $
ANY AUTO COMBINED SINGLE
ALL OWNED AUTOS LIMIT(Ea acciden)) $
SCHEDULEAUTOS BODILY INJURY $
HIRED AUTOS (Per person)
NON-OWNED AUTOS BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per acciderd)
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMSaHADE EACH OCCURRENCE $
DEDUCTIBLE AGGREGATE $
RETENTION $ $
A WORKER'S COMPENSATION AND $
EMPLOYERS LIABILITY yM WC STAIVroMY OTHER
ANY PROPERITo1WagTNER/E)(EC(lfNE U83B270121-15 03202015 03202018 X
OFFICERNEMBER EXCLUDEDT WA UMrTS
(Mandatory Fl NMI E.L EACH ACCIDENT $ 500,000
Il yea,dnalbe unov
DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE $ 500,000
DESCRIPTION OFOPERATIONS/LOCATIONSIVEHICLESREESTRICTIONS/SPECIALITEMS E.L-DISEASE-POLICY LIMIT $ 500.000
THIS REPLACES ANY PRIOR CERTIRCATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION
93 WASHINGTON ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE TFIERE OF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS,
SALEM,MA 01970 AUTHORIZED REPR " A. ' E
ACORD 25(20T0/05) The ACORD name and logo are registered marks DI ACORD C w
1988=2010 ACORD CORPORATION. All rIgMs.rewmed_
Massachusetts-IDepa'=tnent of Public Safely
�( Board of Building Raguielions and Standards
Construction Supervisor
License: CS-087977 ;
ERIC W PALM _ 4
3 HILTON ST x
Salem MA 01970= ~;
1' fa
J.�w..� ter. . �rrfff: '•`
�dL�. F;.p;ratian
Commissioner 04123/2016
` Office of Caosumer Affairs&Business Regulation -
MEIMPROVEMENTCONTRACTOR Type:
osepiration:
istration: 142089
-_311212016 Ltd Liability Cotpo-.k
ATLANTIC WEATHERIZATION-LL.C.
ERIC PALM
61 R JEFFERSON AVE �. -• "' " -
SALEM,MA 01970 Undersecretary -