18 WASHINGTON SQUARE WEST - BUILDING INSPECTION crry OF SALE
PUBLIC PRoPRERTY
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' The Commonweahh t#11assachrr.setts
Department of lnrinstrial:ic•cidirus
Office Of fnl'et'tr�rrtianf
600 H iishhr ,,Yf tr Street
Bo.ctna, MA 02111
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Workers' Compensation Insurance Affidavit: t3uihierslC:oat:actmslElectricutns/Plumbers
Applicant Information Please Print LeLibic
MAXTON Technology,,Inc.
�iitllc i8tt.inc.,ilrtt:mv;luun hxlici;Iuaif:
Address: 50 Easiman Street
City'State;Zip:_ South Easton, MA 02375 I'ltcone : (508) 936-6393
kre}on in employer' Cheek the appropriate boa: fypc of Project (required):
I.Q f ann t employer tt ith 75 ❑ 1 ana a general c tntr rc tar anal 1 l 6. Ae+c oo;lruction
ernplorces(full and or part-tine.I.* hat e hired the ,ub contractors
- liged ill] the:tit tchcd sheet. �` ❑ Kennul hag
-lJ' lain t vole Proprietor or p,umer-
Ship and haee no umptoy.ces Fhc e sub-cams tuor ha%C ti. El Demolition
1 notk n forme to ut} capaul� vcorker. comp msu.uce- y_ 0 Building.addition
[\t, uorken'comp insurance 5. ❑ 1A"e ilve it Corpora[ion and its t
ul(wers here esercl+ed their ii).❑ Electricalrcp;nr.:or additions
rcquirecLi I -
�.❑ 1 m a hon a nconer doim_all r;ork riyh ki
t fexemption per hick-. 1 I:D Plu
Lima mhm,-- repairs of 2ddiliun,
nnrielf, [No tror'scis comp. c. 152.$1(-4). and u'e hate no f 3o Roul'ivpairs
insurance rec aired. employees. [\u ttorkets- r
I i l 1=. Othee �) fk9
i comp. m;uranee rcqun-ed.i t . . r .
-An x+Ical tl nt hcckx F.v 1 t.u�l ah�+fill oix nr- I r toe It K-n Iunru:rL, r. 'ouro t.anon la+L t trtmnwel.
Hour ante. uieo.ulmdl Ih� ..i]la:n it indicesm�thrt m.!!ins.cJl .mkmud Ow"[lire uw.iae a+nb'_non om.,1u'+nxrt-t na++.d:ldut IIMJW rill;ladt-
-1 osP rnUOR clst check ill;,ta,%bast au:mhad an:uldtlioual.heel>Inm ire rLa aunt:oCiF.e sub-tunir5etu6 and their sorkcra'io;un.poh" i,,101nalioa.
t:nn an emplgrer that is pro riding rrnrker:c'caraprasntiorr inkir mnee jar rrq•emplape•es. Reline i.c the polies and jab.Vile
infirrrrratiun. -
lo,untncc Compam Name: United States Fire Insurance Company
Police=or Sell-ins. Lie -: 408-693328-2 _--. I-.giiialiun Dille: 5115,108
hrh Silt Addre ,,: __ Cite.Stste Zip: _
Attach a cop. ol'tbe workers' compensation polies'declaration page (shoving the polic} number and expiration date).
I ailurc to secure roterage as required under Section '_>:\ of kvIGL.C. i�2 can lead to die imposition ofcritainal penalties of u
tine up to S 1.500.00 and or one-sear imprisonment.as.,elf i;civil penalties Ili the form kits STOP U(IRK ORDFWitnd it fine
of IP to S2�0.00 a ciax ageirim the t iolau,r. Be adciced that it copy of Otis aalenunt lna} be li+ruM&LI la the 01iice of
Ime,im-ralions of the DIA for insurance corcrage terit icalion.
t do hereto'rertift'tinder the pe nrr arrd prnatrirs r fperiur t'drat the ir+Jorrnatiorr pe•a tided abate ie true and correct.
Siunmulc; .((� �� .— _____ Date: . .__ -- _
Phone.-. (508) 936-6393
OjJirial rrse salt. Do real rrrile ire this area, to he completed ht'ritr or tun-n offc•ial.
( its or Toil it: PenuiULiceose _ _-- _
Issuing Authorit}- (circle one):
.1. Board of health 2. Buildin„ Department 3. Cit)lfortn Clerk J. Electrical Inspector 5. Plumbing Inapet'tor
6.ether
(milact Person: _ Phone fr:
ACORD CERTIFICATE OF LIABILITY INSURANCE 5/14/2007
PRODUCER (781)681-6656 x217, Fax(781)681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Driscoll Agency, Inc. ONLY HOLDER.N THSOCERTIFICATE NFERS NO RDOES NOT IGHTS O AMEND,N THE CERTIFICATE
DAOR
93 Longwater Circle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 9120
Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC III
INSURED INSURER A:Admiral Insurance Cc
Maxton Technology, Inc. INSURERS Employers Fire Insurance
50 Eastman Street INSURER G:United States Fire Ins.
INSURER D:Illinois Union Insurance
South Easton MA 02375 INSURER ERAGES
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
REG kTE LIMITS SHOWN MAY HAVE SEE 4 REDUCED BY PAID CLAIMS.
UISR IIIDWL TYPEOFINSURANCE POLICY NUMBER DAVIT EFFECTIVE E�AITE MMIIDDNON LIMITS
GENERAL LIABILITY CA00001115101 05/15/2007 05/15/2008 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMI T Ee ,ante E 50,000
A CLAIMS MADEFXI OCCUR MED EXP An are $ excluded.
PERSONAL S ADV INJURY S 1,000,00
GENFRALAGGREGATE $ 2,000,000
GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY Ex-1JECOT LOC
AUTOMOBILE LIABILITY FBIE04605 05/15/2007 05/15/2008 COMBINED SINGLE LIMIT
ANY AUTO (Ea arriEent) $ 1,000,000
B ALL OWNED AUTOS BODILY INJURY $
(Per X SCHEDULED AUTOS Parson)
X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Pe,ameen0
PROPERTY DAMAGE $
(Pu&;o a t)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA A $
AUTO ONLY: AGG $
EXCESSUMBRELLA LIABILITY EX00000567901 05/15/2007 05/15/2008 H RR s 6,000,00
X OCCUR CLAIMS MADE AGGREGATE $ 6,000,000
A DEDUCTIBLE $
X RETENTION 0
C WORKERS COMPENSATION AND 408-693328-2 05/15/2007 05/15/2008 y WCSTATu-
oTH
-
EMPLOYERSLIABILITY 1,000,000
ANY PROPRIETOR/PARTNER ECUTIVE EL.EACHACCIDENT $
OFFICERIMEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE$ 1,000,000
IO in
SPECWL PROVISIONS Below EL DISEASE-POLICY LIMIT $ 1,000,000
D oTMER Pollution/Profession COOG2189925 001 05/10/2007 65/15/2008 Poll: $5,000,000/claim/agg
al Liability Prof: $2,000,000/claim/agg
DESCRIPTION OF OPERATIONS/ OCATK)NSA(EHICLESIEKCWBIONS ADDED BY ENDORSEMENTISPECUIL PROVISONS
Evidence of Insurance for work performed within the Insureds scope of normal business operations. Notice of
Cancellation provision is 30 days except 10 days applies for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SKWLD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEPORE THE
.sample EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEK NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIAMUTY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORMD REPRESENTATIVE �P• _
B. Drisco]VJMT �-�
ACORD 25(2001108) 0 ACORD CORPORATION 1988
92.77 '[9antn[axtdfa(L/l.O�llRJJ¢US![ilC�
Board of Building Regulations and Standards
Construction Supervisor Lloense
License: CS 88703
V BirBniete: 10/9t1967
Expiration: 101912009 TO 5154
ResWction: 00
KEVIN CUNNINGHAM
` 29 HALE RD
STOW,MA 01775 Commissioner
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