Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
5 WEST CIR - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts �'�t `i Department of Public Safety '•#. '%• NassaChuselts Sl.de liuilJin Curie i8U CT1R /U\A, Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number. Date Applied: _ Building Official: __ _ SECTION 1:LOCATION('lease indicate Block R and Lot p for locations for which a street address is not available) S_v✓d5% r oU ale _07f - - Nu.,I11o1 Street City/'fmvn "Zip Code Nance of Building(if applicable) --- SF.0 CON 2:PROPOSED WORK EJilion o(�IA SLhtr Curie used_ If New Construction check here❑or check all that apply in the two nmt:s below Exist III;13 uild ing Repair Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and subnut Appendix I) Changvof Use Cl Change of Occupancy ❑ Other I1"Specify: Are building plans and/or construction m dta' ttents being supplied as part of this permit application? Yes ❑ No x --- Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed N'ork:-f-eZ r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,AUDITION,OR CHANGE•IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CkiR 34) ❑ Existing Use Group(s): I Proposed Use Group(s)- SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-?❑ Nightclub ❑ A.3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2.0 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ f-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use - SECTION 6:CONSTRUCTION'IYPE(Check as a licable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: 'trench.Permit Debris Remucal: Public Check if oulside Flood Zone❑ Indicate municipal •A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone:_— or on site scstem ❑ required ❑or trench or specify:.-----_---- permil is enclosed ❑ Railroad right-of-way: .Hazards to Air Navigation: �i t i ,i,•i" .u:uis:..,.i:�t, . „ r..• _: . Not Applieahfe❑ Is 5trurlure wilhin airport approach•uea? Is their review CnmpleleJ? or Consent to Build enclosed❑ Yes❑ or No❑ 11•s❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY fidillon of Code: Csr Gr,nlp(s): _ 1\'pe of CunstruCli011 C7CCupant Load per Floor: Ih WN the hu it ding Contain an Sprinkler Sestem?. ___._-_Special St i pu 10 1 lolls. SECTION 9: 11ROPER'IN OWNER AU 111ORIZA'I[ON Namc lmd Address ut Pruprrh Chv ner ,5�J_-A .— Name(Print) No.and Street Cit],/Town Zip Properh'.Owner Contact lnlormalionq:yP itle -- -- - Telephone No.(business) 1'elcphone No. (cell) e-mail address T r If ap�p�licable, the property owner hereby authorizes _l�—Iy�l_LJoerA r s 5-7 - _ Name Street Address City/Town State Zip to act on the pro,erty o,yner's behalf, in all matters relative to work authorized by this buildingpermit application SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) � If buildin•is less than 35,000 cu.it.of endoa•d s lace and/or not under Construction Control then check here IIS:/ nd skip Section 11).1 10.1 Registered Professional Responsible for Construction Control —alp Aw�tiesF 7 Arp No r to(R gi' rant) Tel• o to o c-nt.it a dress 1%I herrot. ddre. ity/ own ale Zi xpirahon Date 10.2 General Contractor T d�K &vA e- Co^P rri�fr o.t IZCyr fcf/r. C'A/_ompal� no J CS 6 (P�S� Z. v��S Name of Person Responsible for Construction / License No. and Tvpe if Applicable Street Address City/Town State Zip 5W.1-6-I21F9K Tele,hone Nu. business Telephone No. cell a-nail address SECTION 11:IWIN H,!, (. �Mri:V5n ru"'� i_-\!;ur_ANtr nrrn l,_Mi f M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be Coil pleled and submitted with thisapplication. Failure to provide this affidavit will result in the denial of theyssuance of the building permit. Is it sl'ned Affidavit submitted with this application? Yes;' No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Oa Item andMaterials) Total Construction Cost(from Item 6)=$ 0 ya 2 y, 1. Building $ 30 2 ' ' Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical 5 appropriate municipal factor)=$ V Plumbing $ 4. Nltchanical (HVAC) $ Note:Minimum fee (anitactmunlcl l v) 5. Nlechanical Other 5 Enclose check payable to `< u h.Total Cost (contact numicipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering ntv name below, I hereby attest;under the pains and penalties of perjury that all of the information cont,16led in this application is true and accurate to Yle best of my knuwli•dge and undcrsta u print al d sif;n nan Title - 1'rl ph, to Nr Date Please Street Address City/Town late Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF S.1L.E.NI, AiSSACHUSETTS BLILDLVG DEPARTMENT 120 W.SHLYGTON STREET, Y°FLOOR rEL (978) 74S.959S KI1tBERLEY DRLSCOLL F,Vt(978) 740-9846 .MAYOR THoms ST.PmRas DiRECToz OP PCBLIc PROPERTY/13EMMLYG COMMISSIONER Construction Debris Disposal Atttdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section t t 1.5 Debris,and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of roerty licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: tCrr L -F- (nrme of hauler) The debris will be disposed of in (name of facility) (address of facility) Xs,gnre orpermit applicant ate 1,hr141r4.W JOHN BARNES CONSTRUCTION 46 CEDAR ST MARBLEHEAD MA 978-317-0085 REVISED 8/12/11 To: Mr. &Mrs. Brad Martin 5 West cir. Salem, Ma. E-mail bradmartinm@gmail.com Mbl # 978-979-7473 HM# 978-740-3750 The following is a bid to remove &replace one layer of existing siding,trim, gutters, and ceilings of covered patio& front entry. INSTALL: - Hardiewrap(house paper 900 sq'/roll, 2,rolls) ------------------------------------- $ 200 - Hardie siding smooth pre-painted 7"-7 %"exposure(1600 sq'=240,12' boards) $3,240 - Hardie siding touch-up kit(1 per side) , color match caulking (4per side) ------- $ 340 - Comer boards 4"PVC wht(6, 20') —----------------------------------------------- $ 324 -windows& doors trim 22,1x5 PVC wht$814 + sills wht PVC 74' $440 ----$1,258 - rake boards wht PVC lx8 &4,1x10 —------------------------------------------------$ 352 - rake board trim piece as per other quote 5,1x2 PVC wht —---—----------------- $ 90 - fascia 8,Ix10 PVC wht -------------------------------------------------------------$ 592 -Hardie vented composite soffit panels wht 12 -------------------------------------$ 240 - ceilings of patio over hang&entry Ix4 bead board PVC wIrt -------------------- $ 770 -gutters 5"wht alum with elbows&downspouts,hangers& wht rivets --------- $ 587 - stainless steal nails --------------------------------------------------------------------- $ 120 MATERIAL SUB-TOTAL ----------------------------------------------- $ 8,113 TAXES &HANDELING ----—------------------------------------------------------- $ 811 TOTAL MATERIAL COST FOR SIDING JOB ----—------------------------- $8,924 LABOR COST FOR SIDING JOB -------------- -------------------- $21,500 SI G JOB EXTRAS DISCUSSED Extra Trim . water table, 6, 8" face with cap PVC wht -------------------- - 534 c moldings 3 5/8"white pvc(under eves& along r ---- $ 448 band ding around windows(installed on top of 1 x 51 16' ---$ 550 EXTRA L OR TO INSTALL EXTRA TRIM ----------------- $4,080 5 Extra windows: Kitchen,replace existing wi Vicon awning(A ),.window ------------ $ 350 �I Replace laundry rm win w with Vico g(AWN 31), window $ 298 d (BOTH WINDOWS WILL ME HOUT GRIDS) COST TO REMOVE AND IN L ($200 EACH) --------------- $ 400 p0✓� Q/ ADDITIONAL COST to instal dows MATERIALS; -wht window p, flashing tape,'/< CDX ood, 2x4's, J ca mterior %:" SR,tape,mud, spray insulation) $ 132 ADDITI AL LABOR COST(3 hrs per window) - - $ 390 Office/sun 'ndows,replace existing with 2 wht Vicon casements (3636- South East wall to fill in existing RO ,no grids, ($504 each) ---- $ 71 JOB TOTAL MATERIAL COSTS INCLUDING EXTRAS ----------------- $12,307.00 /e JOB TOTAL LABOR COST INCLUDING EXTRAS ------------------------ $26,370.00 � DUMPSTER FEE $675 +STAGING RENTAL $200 ------------------------- $ 875.00 PERMIT FEES -------------------------------------------—------------------ $ 378.00 TOTAL JOB COST ---------------------------------------------------------------- $3 MATERIAL PRICES SUBJECT TO CHANGES IN THE MARKET EXTRAS NOT LISTED IN BID ARE BILLED DAILY AT A COST PLUS RATE ($65/HR+materials). PAYMENT SCHEDULE: STARTING PAYMENT(TOTAL MATERIALS+PERMIT FEES) ----- $12,685.00 1 ST LABOR PAYMENT DUE AT END OF FIRST WEEK -------$ 9,000.00 NEXT PAYMENT DUE AT END OF SECOND WEEK ---------- $13,500.00 1/3 UPON COMPLETION -----_______________________________$ 4,745.00 Signature of acceptance e// A. Thank you, and God bless. John Barnes CITY OF SALEM PUBLIC PROPRERT'Y DEPARTMENT .i,u::Nf 1 Y:INIV rail \f N,41 12C'Xiol L\111U.\SISkL•T • I'1:1: )7L713'93u3 r I:t.r v)s•11C•vasa 'IYurkers' Cumpensation Insurance AtfidaviC otillders/Cuntracturs/Elec� ) trial)Il•• cells/vant In nrmrllon Pfumben T 1 ,/� Plc• s Print Le 'AI Vi1n)C Illuwnc.yi)r��nv�rimvinJivduull:�/ U Lt vl /'7ol.ln Cl � . Address: Ce�ot l Si_ GIy,Smrc,/.II)' /� /�a. �l9`1S 1'llone0: 77 =3/7—ac/rS I .1re)nu in vuglloycr:'Check the appropriule D I.❑ I ant a empluyer with . 4, I ;fill a general contractor and I I)Pg°Ipr,ijuef(required): ❑ unlpluyc"(114114ndlear pun-lime).• have hired the sub-cuntraclors ('• ,-rd0 Now construction 2. I cal i sole proprietor or partner- listed on the anuchd s cheet u. ) 7. tinoJalinR .-ship cull love no clnpluycc's There sub-contractors have corking titr mo in any capacity workers'comp• Insurance. d. ❑Demolition I No workers"cutup. insurance 5. ❑ We are a corporation and its 9' ❑Building addition ).❑ required.) atTicM lava c!terciecd their 10.0 Electrical repairs fir additions 1 ;fin a homeowner doing JII work right of ea,:mplion per NK)L 11.0 Plumbing repairs or aJditinna myself.(KO trnrkcn'cutup, C. 152,41(4).and we hava no 12.❑Ruul'repuin insurance rcquired.) r cm ces.pluy LNO workers' . // corral) insurancwrcquired.) IJ,QOnler Sry�(rkg '.1 n>."pphcate lhW checb bw el mUs,:Jail Itll,tw Ile. _111.L.I.tmfly lknm wwkess cum 'It Iwmwnwrwn way wa+mil Ohio anla4vit irWlutina they Ju Jilin r+nwli,wt ry,liey mlurmwiwl. •f,.nlnata-s this check this box mum m whW ne aaaitiarwl Al,w a this(lance off lsttb.emrxr ldes ton mass.ulna a now WRaavit inditaie f wick. fin a Monommun� rt Ary wuAyn'tuny ley,fit J"A manue. /urn fin crnployrr thu4lr proridlnx tvurArn'rurnpenm/loll hrsurnnee/or my enpluyera Bel°Iv is the pupsy and/ub sib lu�urrnururn / �qL.1, / Insurance Company Vnme: �/ (�� _..L-t�TV�cI I'ulicyNurSulf•ina. LiC.M:V✓��•f-3�303,�—d�� ` . _ _ ---- • .. . Expiration Date: 2- Jab Situ ,\ddress; W e$� �• �a M C'ity,Slatt/Zlp: !L�e.n-t./ 14" a�97d .\tturc a copy of Illu% workers'gumpe llj&:r n pulley Juclarurlon puke(showing the policy number and ciplrailun date). Palluru w sccuro cuveruge as required under Scdiun 25A ul'MC;L v. 152 cau lead to the imposition of criminal penalties of a tine up et if 910.0f)Jnd/ur une-year imprismuncnt, JN cell Js civil IICnalucs in tha form of a STOP WORK ORDER and a ring ,)fill)rat i 230.MI a Jay Jgainsl Ile vioLunr. Ile advi.+ca-shut a copy of this.matemem may be Io to the Ullice uY llv�allgJllntla ill ;Ile DIA for nl,ur:fi'ce ctivcrJgc\criticJltun. /du hereby t crri/y under 1/se pains find pennh/er ujprr/nry Ihut r6e inluronuNon prvvided ubuv irr true rind correct. gin•: : liar — Jplcial lire yn/y. pis not,)•rile in 1h1T urrn, to be cunrpletrJ by city fir/turn a//IriuL i ('itv or 11nrT _ Perinitil.lee•n/C 1,vuing Alahurily (circle nnc): II. Ih,JrJ of IlcJlth ), Iluddim; Ileparuneut 1, Cit): uan Clerk 4. Llectricdl Inyrccrur 5. Plumbing In,peeror 6. 1)Iher _ llutl.td I',nun: _..__ 1'hunc Y: Information and Instructions Lon in the service of anther un,ler any contnet of him, �Lusachusctts licneral Laws chapter every i2 teyutres all anploycrs to provide workers' compensation lift their cmployeea. Pursuant to tilts>wtue, an emplos•rr is defined as"...every fN' %press or unplieJ, oral or written." �n ampluyrr is defined as"an individual, paRnershlp,assoetamon,corporation ter other legal e er any two r t more ,,I the foreg,nog engaged in a joint enterprise, and including the legal rcpresatly ivas tit i gemdeceased employer,or the eccrver or trustee of.tit indivtJud, paRaershtp,assoetativa or other legal entity,employing employees. However the owner of a dwelling house heving;not more than three APM111119fits employs persons w do nainicnun and unhuor ioneurhepuu work serein,or the uch occupant house dwelling house of an shall not because of such employment be deemed to be an employer." t thereto ' ,a appurtenant pp on the grounds or 1, or o Issuance or �IGL draper 152. E25C(6) also states that"every star or local tract buiing ldings I shall withhold ea Oaaee with the Insurance coverage required: renewal of a license ter permit to operate•business or to eonstruet buildingf la flu commonwealth or say iliall applicant eho has not produced acceptable evidence of sump A plicant"Ise IGIL draper 1 Sl, §,5C(7)states"Neither the commonwealth no any of its political subh the ios rant Am ter into any contract for the perfotnsnnre of pu o work the contract g authority,til acceptable .Jance ufcunlpliustce with the insurance requirements of this chapter have been p ,applicants to our situation and.if please rill.wt the warkors' compensation affidavit completely,by checking the bongs witthah apply Y necessary supply workers ctor(s)name(s),addrees(es)and phone nutnber(a)slang with the certiticrte(el of Insurance. Limited Liability Companies(LLClvofketa'imitcompensatioed Liability o ituurance,`If an LLC or LLP does haveLLP)with no 9MPIOY%'Vs than the members or partners, are not required ro carry be submitted to the Deportment t of Industrial employees,a policy is required. 8e advised that this affidavit re t \,.ride,for contlrmaiion of insursneo coverage. Also permit sure to sign a is dote the u requested. l the°ttl�m`"t of shouw he rentrncd to the city or town that the application for the permit of lice, f befog requested,not the lit p Industrial Acuidents. Shaul)you have tiny yueadoos regarding the law ter i.you ire required to obtain u workers' compensation policy,please call the Depttsameni at the number listed below. Self-insure)companies should enter their scif•insuranett license number on the a ro riute line. City or Town Ofnciats the applicant. Pcnu he sure that the affidavit is complete told printed legibly. The Department has provided u spars at the bottom of tie affiduvit for you to till out in the event the Olfice wi ll eau ed asa has to contact you reg addition,an arding 111:use be sure to till in the permit/licanse nunebtr whiions t hanill be n ee t need only csubmitoner. laffidavit indicating current that must submit multiple ssary)'andtin tinder Y tt y Ycations in cat or to Policy informati1'f ha ulflJuvirtyth+t has been offtc ally stamped or marrkedtb `I eucit write rtown nay bo provided to they y y Y town)."A copy A now alilJuvit must applicant as proof that a valid affidavit is on rite for future permits or licenses. tilled out each y car. Where a home owner or citizen any business or commercial venture n is obtaining a license or permit not related to (i.e. a dug lice,or permit to burn leaves cte.)said person is NOT required to complete this affidavit.operation and should you have;rnY 4uesuons, t 1 he Mice of In Its would [Ike to thank you in advance for your co please do nut hesitate to give w a call. fhe u:p:ttneeot's aJdre'S, telephone aThrax number: Commonwealth of Massachusetts Department of industrial Accidents of ce of Invesdgadons 600 Washington Street Boston, MA 02111 'raj. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617.727-7749 <.+u.us www,man.gov/dia U�� CGNS�JL7�t Uri cf WOR1aRS L1 uIYINSURANCE . Liberty aR [ep PAGE Mutual:. 't �: liberty Wwl Group M BerlmlWy Street Boston,MA 02117 Issued3rJ Ilr33fE -ENSURANCE 16586 Rob: 3 =353035-011 Issuing Office 181 REtiEmLQs 9n 331;-363 0 3 5-010 Issue Date 07-27-11 A J,-,J$393&6,. `, Sub Account 0000 1. FEIN 026582763 I3�. .1 ) CISiSTRIICTION 46•Vgh 2 RISK ID 681351 JW70I945 k Suds O3 -;INDIVIDUAL nW shown above: SEE ITEM 4. PREMIUM-DCENSION OF INFORMATION PAGE 2. PoiyPenoek The poky period isfrom 07-24-2011 to 07-24-2012 12:01 A.M.standard time at the InsuredsmaTEg address. 3. Coverage A- Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states Wed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A - D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this polity will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information P e Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 510 Premium will be billed ANNUAL Producer 0004-145031 ROSE INS AGENCY 66 LORING AVE SALEM MA 01970 Sales Representative 3000 Sales Office Name WESTON 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 A All Rights Reserved Ed.071 01/2011 Inwre Copy - �-' ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/15/2011 PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'.MERCHANTS INSURANCE GROUP Havens, Michael dba Under Construction INSURER B'.Alm 28 Harris Street INSURER C'. INSURER D' - Marblehead MA 01945- 1 INSURER E: COVERAGES 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MWDD/YY DATE MM/OD/YY LIMITS A GENERAL LIABILITY CCPI044602 04/22/2010 04/22/2012 EACH OCCURRENCE $ 1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 300000 PREMISES Ea occurrence $ CLAIMS MADEOCCUR / / / / MEO EXP An one rson S 5000 PERSONAL B ADV INJURY 3 1000000 / / GENERAL AGGREGATE 4 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 3 2000000 17 POLICY JECTPRO- LOC / / / / NOWND AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) S HIRED AUTOS / / / / BODILY INJURY NON-OWNEDAUTOS (Per accident) S PROPERTY DAMAGE (Per accident) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 3 ANY AUTO / / / / OTHER THAN EA ACC S AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ 3 DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND WC60137550 07/28/2011 07/28/2012 X TORVUMITS Ea EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 3 100000 OFFICER/MEMBER EXCLUDED? / / E.L.DISEASE-EA EMPLOYEES 100000 1(yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 - OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT John Barnes Construction FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHPIUZED RE ESENTATIVE ACORD 25(2001108) ICJ ©ACORD CORPORATION 1988 INS025(oia% B Page t of