78A WEBB ST - BUILDING INSPECTION � . R
- � I 7 5� G�G C 2Z
� The Commonwealth of Massachusetts � � ���u�.�. �
� � ° Boazd ofBuilding Regulations and Standards � � - '>�rC�T t�t$Q'S �- . (��^�
� Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demo��a��� 2� ,P ,z: � �j
One-or Two-Family Dwelling
� This Section For Official Use Only
Building Permit Number: Date Ap ied:
� � �-.� 7 � �
� Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
� 11 Property Address• 11 Assessors Map&Parcel Numbers
� 7� � wt,�f Ji` 3s- o,�qo-o
� l.l a Is this an accepted street?yes_ no Map Number Parcei Number
13 Zaning Information: 1.4 Property Dimensions:
//R�
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Reaz Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.4Q§54) 1.7 Flood Zone Informadon: 1.8 Sewage Disposal System:
PubticJ Zone: _ Outside Flood Zone?
L�J Private❑ Check if yes� Municipal L9�On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner�of Record•
Tnn,r w� �.t'1� T�- .S,�lin , .�`7�a, f�!Q?o
Name(Print) City,State,ZIP �r// G�7�- a 93- y�sG�
�t; �sn.Sd�n- ...j,� �78 - 71t�i-G$f� ��ofr.l�a2,/,col�.y9vs�,zo.e , cr
No.and Street Telephone ° Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Conshvction ❑ Existing Building� Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ � Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descriprion of Ptoposed WorkZ: v �wo � n.,/ u u tn sJ i� v: �y.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ � !�L�ypP�, -- I. Building Permit Fee:$ Indicate how fee is detemuned:
❑Standazd City/Town Application Fee
2.Electrical $ ZG,a0!!. ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ Z(/,Ubv. z, Other Fees: $
4.Mechanical (HVAC) $ �/��/jps List:
5.Mechanical (Fire $ '
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Z�U,(y/�G� ^ ❑paid in Full ❑ Ouutanding Balance Due:
�'�u 7/ 2.�
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SECTION 5: CONSTRUCTION SERVICES
5.1 ConstrucHon Superviso�License(CSL) CS- ��q�2� � �r i?
+ 3�yi( �/ sq p 1 License Number Expiration Date
Name of CSL Holder
/� ( r! List CSL Type(see below) (/
�13 pJ��•rhory d /—
No.and Street Type Description
�.(�a�Zi'I� Y f.6'N �l�Z� U Unrestricted uildin s u to 35,000 cu.ft.
Ci /Towq State,ZIP R Restricted I&2 Family Dwellin
tY M Maso
RC Roofin Coverin
WS Window and Sidin
/ / SF Solid Fuel Burning Appliauces
G/>- ZY3- �ufrG_ ,��afulsow��/Go/2�`f-�✓e��/ZGw� I Insulation
Telephone �� Email address wy/- D Demolition
5.2 Registered Home Improvement Contractor(ffiC)
Q.��crr<dn,�/ ioo�.., `a.vr��c�•i �i�, i /627G6 y/G />
HIC Registration Number Expiration Date
HIC Com any Name or FIIC Regishant Name /
�s.r �n.�uiu �� tr(torr� roorH l/avi7u.z, wt
No.�nd Street Email address
.�ld/ro . /7e<r O/$7� �� 2$¢ -�88If
Ci /Town, State,ZIP Tete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this applicatioa Failure to provide
' [lus affidavit will result in the denial of[he Issuance of the building permit.
Signed Affidavit Attached? Yes .......... L9� No........... ❑
SECTLON 7a: OWNER AUTHORI7.ATION TO BE COMPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDINC PERMIT
I,as Owner of the subject property,hereby authorize
tp act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER`OR AUTHORIZED AGENT DECI.ARATION
By entering my oame below,I 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 unde�tanding.
..�" i,v 1'�x. �✓ d�l/�
Priut Owner's or Authori genYs Name(Electronic Signature) Date -
NOTES:
1. An Owner w o 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(HTC)Program),will not have access to the azbitration
program or guaranty fund under M.G.L.c. 142A.Other important informafion on the HIC Progratr�can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) �G6v (including garage,finished basemenUattics, decks or porch)
Gross living area(sq.ft.) /4Uv Habitable room count 7
Number of fireplaces D Number of bedrooms 4
Number of batltrooms � Number of half/baths O
Type of heating system /�� Number of decks/porches �
Type of cooling system Enclosed a Open o
3. "Total Project Square Footage"may be subsrituted for"Total Project CosY'
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� .� '(,f �,�o�.{m�,ra CITY OF SALEM� MASSACHUSETTS
�� �/� � y ���, BOARD OF APPEAL
) 1 2 �' 1 20 WASHINGTON STREET, 3RD FLOOR
' y { � SALEM, MASSACHUSETTS 01970
�n� —. ^'��' TEIEPHONE: 978-745-9595
. �Do� Fax: 978-740-9846
KIMBERLEY DRISCOLL �
MAVOR
2010 P!Olr -3 P 2� 3l
i'.
Novembec3,2010 Cii"Y t'-__f�.:! . .�..�: , i � ,: ;
ecision III I II III I III I IIIIIIIIIIII IIIIIIIIII I II IIII III
Ciry of Salem Zoaing Boazd of Appeals SOZ ESOEX #643Bk 34418 Pg4480
Petition of JAMES SHEA,seekiug a Special Permit and Variances to allow the
demolfition uf ihe ezisteag noneo'nforming steucture at 78A 'J✓E�B STREET and to
construct a new building containing two residential dwelliag units with two parking
spaces [R-2].
A public hearing on the above Petition was opened on Odober 20, 2010,pursuant to Mass
Generel Law Ch. 40A, § 11. The hearing was closed on October 20, 2010 with the following
Zoning Boazd of Appeals membecs present Robin Stein,Richazd Dionne,Annie Hazds,
Beth Debski,Becky Curran,Bo�ie Belau (altemate), and Jimmy Tsitsiaos (altemate).
Petitionez seeks a Special Permit pursuant to 333,and Variances pucsuant to Section 4.1.1
� and Section 5.1 of the City of Salem Zoning Ozdinances.
Statements of fact:
1. Attomey Scott Grover Lepresented the pedtioner at the heauug.
2. In a petition dated September 29,2010,petitione=requested Vatiances from the
number of pazking spaces cequited per dwelling unit and the maximum number of
stories permitted, as well as a Spec:ial Pem�it to reconstruct a nonconforming
structure.
3. T'hz cureat use of the property Iocated at 78A Webb Street is a garage,curxendy
used to store equipment
4. Petitioner proposes an addition above the gr�.�e that would contain two residential
dwelling units,with the eacisting garage used f�parking.
5. At the heuing,Attomey Gcovet clarified that the request was to add on to and
renovate tl�e existiug gazage structuce,not to demolish it, as indicated on the
application form.
6. At the 6eazing,Attomey Gcover stated that because the building occupied almost the
entize lot,there would be uo place to put additional packing spaces;thetefoze,
meeting the requitement of three.pazking spaces for a tcvo-family home,which is an
allowed use in the R2 zoning distzict,would constitute a hazdship.
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7. At the hearing,Attorney Grover also presented a petiuon of approximately 40
neighbors in support of the project.
8. The Board of Appeals received a letter prior to the hearing in support of the projec[
from Ward One Councillor Roberc McCarthy, 153 Bay View Avenue, stating that the
renovation and change in use would be a positive improvement to the
neighborhood.
9. At the hearing,several residents, including At-Large Councillors Steven Pinto and
Anhur Sargent, spoke in suppon of che project, saying ic presented an opponuniry co
redevelop an unattractive sice, and chat the shift from a commercial to a residential
use would be positive for the neighborhood and for properry values.
iC. Ac the hearing,several residenes spolce in opposition to the project; ci"ting concems
abou�traffic, density and appropriatencss to neighborhood character.
11. At the hearing,Board membexs stated their concems about the parking relief
requested, indicating that ehey would be more inclined to support the project if three
parking spaces were provided. In response, the petitioner agreed to change [he plans
for the interior of the garage strucmre in order to provide three spaces.
12. At the hearing,Board members indicated that they did not have concems abouc
allowing relief from the requirement for number of stories, since the height
requirement for the building was being met.
The Board of Appeal, after careful consideration of the evidence presented at the public
hearing, and after thorough review of the plans and petition submitted, makes the following
findings:
1. Special conditions and cucumstances exist affecting rhe parcel or building,
which do not generally affect ocher land or buildings in the same district;
2. Literal enforcemenc of the provisions of this ordinance would invblve
substantial hardship, financial or otherwise, to the appellan�;
3. Desirable relief may be granted without substantial detriment to the public
good and without nullifying or subs�antially derogating from the intent or
pucpose of the zoning ordinance,a� rhe project provides an opportunityto
redevelop an unattractive,underuti!�ed site and to change the cunent
commercial use to a residential tue in a residential neighborhood. .
4. The applican� mayvarythe terms of the Residential Two-FamilyZoning
Discrict to allow for the proposed addi�ion and renovation.
5. In pemvtting such change, the Board of Appeals requires certain appropnate
conditions and safeguards as noted below.
,
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,� . � 3
On the basis of the above findings of fac� and all evidence presented at the public hearing
including, but not limited to, the Plans, Documenrs and testimony, the Zorung Board of
Appeals concludes:
1. A Variance £rom the number of allowed stories is granted to allow for the
proposed renovation and addition to Che structure on 78A Webb Street.
2. A Special Permic to alter a nonconforming stnicture is granted to allow for
the proposed renovation and addition �o the structure on 78A Webb Streec.
In consideracion of the above, the Salem Board of Appeals voted, five (5� in favor(Scein,
Curran,Debski,Dionne and Harris) and none (0) opposed, to grant peduoner's requesu for
Vanances and subject to the following terms, conditions, and safeguards:
1. Petitioner shall comply with all city and state sta�utes, ordinances, codes and
regulations.
2. All construction shall be done as per the plans and dimensions submitted eo
and approved bythe Building Comrnissioner.
3. All requiremenu of the Salem Fire Department relative [o smoke and fire
safetyshall be strictlyadhered �o.
4. Petitioner shall obrain a building permit prior to beginning any cons�niction.
5. Eacterior of the building is �o complywich che submitted plan. I
6. A Certificate of Occupancy is to be obtained.
7. Petitioner is to ob�ain approval from any City Board or Coinnussion having
jurisdiction including, but no�limited to [he Placuwig Board.
8. Unless this Decision expressly provides otherwise, any zoning relief granted
does not empower or authorize che Petitioner ro demolish or reconscnic�the
suucmre(s) locaced on the subjecc propenyto an excent oi more than fifry
percent (50%) of i[s floor area or more than fifry percent (50%� of its
replacement cost at the time of destruction. If the strucrure is demolished by
any means to an eattent of more th__�fifty percent (50%) of iu replacement
cost or more than fifry percenc (�0":�� of i[s floer area at the time of
destruction, ic shall not be reconscructed except in conformity wich the -
provisions of the Ordinance. '�`
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, �R�tem, au-
Salem Board of Appeals
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� A COPY OF THIS DEQSION HAS BEEN FILED WITH THE PLANNING BO�RD
AND TT-�E CITY Q.ERK
Appeal from this decision, if any,shall be made pursuant to Section 17 of the Massachusetts
General Laws Chapter 40A, and shall be filed within 20 days of filing of this decuion in the
office of the City C1erk. Puxsuant to the Massachusetrs General Laws Chapter 40A, Section
11,the Variance or Special Permit granted herein shall not take effect until a copy of the
decision bearing the cenificate of the Ciry Clerk has been filed with the Essex South Registry
of Deeds.
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TINTI, QUINN, GROVER & FREY, P.C.
27 CONGRESS STREET, SUITE 414
� WILLIAM J.T1NTI SALEM, MASSACHUSETTS 01970
.finti�tivtilaw.com ' WILLIAM B.ARDIFF(1965 - 1995)
WILLIAM F. QUINN TELEPHONE
(978)745-8065 • (978)744-2948 MARCLA MULFORD CINI
WilliamFQuinnQaoLcom oe CoUNSEL
SCOTT M.GROVER , TELECOPIER JOHN D. KEENAN
� smgrover@tintilaw.mm (978)745-3369 OF COUNSEL
IvtARC P. FREY www.cineilaw.mm JERALD A.PARISELLA
mpfreyC�eintilaw.com oF CouNSE�
JONATHAN M.OFILOS
j o fil os0[intilaw.to m
THOMASJ. HOGAN
ej hoganOti nti law.e o m
MARCY D. HAUBER -
m h auber�tinti I aw.co m
CHRISTINA M.MIHOS
cmihos�tintilaw.mm ' -
October 28, 2015
James Shea
45 Dearborn Street
Salem, MA 01970
RE: 78A Webb Street Zoning
Land Court 10 MISC 443245 (JCC)
Dear James:
Based upon the ludgment of Dismissal entered recently by the Land Court in this appeal of the
Salem ZBA's 2010 Zoning Decision, I have obtained and recorded an attested copy of the Zoning Board's
original Decision dated Nov. 3, 2010 granting your Special Permit to allow demolition of the existing
structure and construct a new 2-family dwelling at 78A Webb Street in accordance with the conditions
of that Decision and the plans submitted. No further appeal can be filed as a matter of law.
This means that you should now be able to now pull your demolition and building permits to
construct the project. You have one year from the recording date (today) to pull the building permit and
begin construction, as all Zoning decisions expire after one year(that period can be extended by 6
months provided that you file for such extension before the decision has expired). Please consult with
Salem 8uilding Inspector Tom St. Pierre on all such permitting and construction matters.
Very truly yours,
,
��� ��
William F. Quinn -
cc. Thomas St. Pierre, Building Inspector
,
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COMIVIONWEALTH OF MASSACHUSETTS
LAND COURT
DEPARTMENT OF THE TRIAL COURT
ESSEX, ss. 10 MISC 443245 (JCC)
KEITH C. WII,LA,
Plaintiff,
v.
ROBIN STEIN, RICHARD DIONNE,
ELIZABETH DEBSKKI, ANNIE HARRIS, ,
and REBECCA CIJRRAN, as they are
MEMBERS OF THE ZONING BOARD OF
APPEALS OF THE CITY OF SALEM, and
JAMES SHEA,
Defendants.
JUDGMENT OF DISMISSAL
On September 29, 2015, this court issued a fourteen-day Order for Plaintiff to file an
affidavit showing good cause why he failed to appeaz at the Status Conference held on
September 28, 2015. No affidavit has been filed. Accordingly, it is hereby ordered that the case
be DISMISSED, without prejudice.
SO RDEREA
y the Court(Cuder, C.J.)
Attest:
Deborah J. Patterson, Recorder
Dated: October 14, 2015
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a Citv of Salem �
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� W 120 W ashington St,3rd Floor Salem,MA 01970(978)745-9595�v5641 ��� ��
Retum card to Building Division for Certificate of Occupancy ��
Permit No. B-�s-7�o
FEE PAID: $1,�50.0o P E R M i T T O B U I L D
DATE ISSUED: 7I20/2016
This certifies that SHEA JAMES
has permission to erect, alter, or demolish a building 78-A-A WEBB-STREET Map/Lot: 350590-0
�.�
as follows: New Construction - 1-2 Family CONSTRUCT A NEW, TWO FAMILY HOME OVER EXISTING
BUILDING WITH ZBA APPROVAL ON FILE. �
ti
Contractor Name: JAMES W. SHEA
DBA: PROFESSIONAL ROOFING CONTRACTORS
Contractor License No: CS-019729
�
� � 7120/2016
Building Official Date
� This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within�six months after issuance.The Building Official
may grant one or more extensions not ro exceed siz months each upon written request \
t
All work authorized by this permd shall confortn to the approved appiication and the approved construction documents for which this permit has been granted.
All construction,alteraGons and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible trom access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
H�C#: "Persons conUacting with unregistered contractors do not have access to the guarenryfund"(as set forth in MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
I �^`°N°`T" Commonwealth of Massachusetts �
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� Citv of Salem ��
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. � W 120 Washington Sl,3rd Floor Salem,MA 01970(978)745-9595 r5641 '., �\, '
` Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT °''
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Excavation PERMIT TO BE POSTED IN THE WINDOW -'��9�
Faoting INSPECTION RECORD
Foundation
Framing
Mechanical ~ ' a ~ ���'�
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�nsu�ation INSPECTION: BY �� DATE
Chimney/Smoke Chamber ,
Final ' � ���,, c
,�� Plumbing/Gas � +
�. Rough:Plumbing . � �
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Rough:Gas
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Final � ''r
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'�'"=_� Electrical � �
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Service , ���~.� r
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Fire Department
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Preliminary
Final
�'\ The Commonwea[th ofMassachusetts
— � DepartmentoflndustrialAccidents
,� 1 Congress Street, Suite 700
_; (: Boston, MA 027I4-2017
'��y�y www.mass.gov/dia
Rorkers' Compensation 4nsurance Aflidavit Builders/Contractors/Electricians/Plumbers.
TO BE FILED VV[TH THE PERMITTING AUTHORITY.
Apolican[luformation Please Priot Le iblv
N2IDC (Business/Organizatiou/Individual):�(j��F r(�( � ' �r ��(; ���f��.�-l�Y �� ��
Address: �G • �p ;k �-[. ;t ��6 ,
City/State/Zip:, j ls!!� p Phone #: cj Z�- 7yy-G �F,i�'
Are you an employer?Check t6e appropriate box: ' - 'fyP¢Of PfOJ¢Ct(1'¢(�Ulf¢d):
L�I am a employer with�employces(full and/or part-time).' 7. ❑ New cons[ructiw
2.❑1 am a sole proprietor or partnership end have no employees working (pr me in g. �Remodeling
aoy capaciry.[Nu workers'comp.iatwmce requ'ued.J
l.D I am a homeowner doin�all work m sdf No workers'com r 9. ❑Demoli[ion
6 Y [ p.insurance requ'ved.]
4 I am a homcowner end will be hinn contracroa to conduci ell work on m ro e �0 � Building addition
'❑ g Y P P rtY. 1 will
ensurt that all rontracrors either have workers'compensation insurance or are sole 1 1.�Electrical repairs or additions
proprietors wi[h no employees.
12.�Plumbing repays or additions
5.�I am a general convacior and 1 have hired[he sub-wmracturs lis�ed on[he auached sheet.
Thcsc sub-contramors havc cmployccs and havc workcrs'comp. insurance.� 1 J.�RoOF IOpeu'S
6.�We are a rorpora�ion end i[s officers heve exercised their nghl of exemption per MGL c. �4.❑O[I10!_ __.
IS2,§I(4),and we have no employees[No workers'comp.insurance required.]
� 'Auy applicaut t6at checks box#I must also fi0 out[he section below s6owing Ihev workers'compensalion poGcy information.
t Homcowncrs who submit this afiidavit indica[ing they arc doing ell work and[hcn hirc outside con[ractors must submi�a new a�davi�indicaeing such.
�Convac�ors that check this box must ettschcd an additiooal sheet showing the name o(the sub-contrac[ors end state whether or no�thosc emities have
employees. Ifthe sub-contractors have employees,they must provide Iheir workers'camp.policy number
1 nm an empfoyer that is providing workers'compensation insurance jor my employees. Below is fhe po[icy and job si[e
injormatioa �/" '
Insurance Company Name: G.[J(�f��.}� .Z�J �
Policy H or Self-ins. Lia #: 6 ZZ U L3 - O4 O NO �—� / Expiration Date: S�/// 7
Job Site Address�� A• E �Pj. J � � � City/State/Zip"f/+'�M���g v�C(7�
Attach a copy of the workers compensation policy declaration page(showiog the po:icy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criurinal violar�on punishable by a fine up to$I,SOOAO
and/or one-year imprisonment,as well as civil penalties in [he fortn of a STOP WORK ORDER and a fine of up lo $250.00 a
day againsY the violatoc A copy of this statement may be forwarr>d to the Office of Investigations of the DIA for insurance
coverage verification. ��—
/do hereby certify under the pains and pena[ties ofpery'ury that_'a,�yformaJirn provided above is true and co.rect.
SiQnature� �fPBa��� /"�'LL.l/�Bir.o� Date: � �' Z-�^ / (o . '
Phone#� fi� � '.-,�y � -- �/G �G � .
O�cia!use an[y. Do not write in thrs area,fo be comp[eted by city or town o�ciaC
City or Town: Permit/License p
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.CiYy/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Coutact Person: Phone#:
�'1 9PROF02 OP ID: DP
ACORv° CERTIFICATE OF LIABILITY INSURANCE °"'�M"�°°"""'
�� 10/77/2016
THIS CERTIFICATE IS�ISSUED AS A NATTER OF INFORMATION ONLV AND CONFERS NO RIGHTS UPON THE CEk71FlCA7E HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMA7IVELY OR NEGATIVELY AMEND, EXT�ND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFiCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER(5). AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcate holder fs an ADDITIONAL INSURED,the policy(les)must be endorsed. If Sl18ROGATION IS WAIVED,subjec[to
the terms and conditions of the policy,certaln policies may requlre an endorsemenL A sWtement on this certiflcate does noF confer rights m the
certiflcate Hoider In Ileu af Such endorsement s.
vrsooucEn NpMEp� John J.Walsh Ins.Ag� .,Ine.
John J Walsh Ins Agency,Inc
P O Box 4407 � a°Nti E,a:9�8��45J300 � No:978-745-9557
Salem,MA 01970-6407 E+�N�
John J.Walsh I�s.Ag¢y.,Ine. aoonEss:
INSURER S AFFORDING COVERAGE NAIC•
waursEn a:Admirel Insurenee
IN6URED Professional Roofng INSURERB:ZUfICFI
Contractors Ina ixsuaeac:Cammerce Insurance Company 34754
P.O.Bdx 262
Salem,MA 01970 INSIIRER :
INSURER E:
IN9URER F:
COVERAGES CERTIFICA7E NUMBER: REVISION NUMBER:
THIS IS TO CER7IFY THAT THE POLIGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P6LICY PERIOD
INDICAlED. NOTWITHSTANDING ANY REpUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
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EXCWSIONS AN�CONDITIONS OF SUCH POLIGIES.LIMITS SHOWN MAY HAVE BEEN REOUCED BV PAID CIAIMS. �
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE
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Inspectional Services ACCORDANCE WITN TNE POLICYPROVISIONS.
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