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10 WHITE ST - BUILDING INSPECTION (11) fib- � y -f3� ,►�C p�r7RECEIVFn The Commonwealth of MassaC111TSeRONAL SERVICES Department of Public Safety Massachusetts State Building Code(780 CMID14 AUG 18 P 1= 09 , 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(Please indicate Block#and Lot#for locations for which a street address is not available) d S \2tn/1Ha(,Akrn No.and Street City/Town Zip Code Name of Building(if applicable) rl m SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ j De olition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Z)ther Specify: 5 fQ& eA- 14 0 - 12 ✓V Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ 1 + Brief Description of Proposed Work: c'P cock)f� �'�-- C� 96 x - �(?rvxn.2 — TP.VI` G r—r n P� J as ` I SECTION 3:COMPLETE THIS SE ON IF EXINUNG BUILDING UNDERGOING RENOVATIO ,ADDITIO O"R CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): 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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ I H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ 1 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 Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SIlCAw P " ` 1B • ggLl , 72, 0 7 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner V--� r f tt l.�t ►.�A aAe �-ry n a r ¢ �C r Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the l2roperty owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor yn L r- �3 Company Name Name of Person Responsible for Construction .- License No. and Type if Applicable Street Address U City/Town (�� 1 `C/-0 ��- \� State Zip Tele hone No. business Telephone No. cell -mail a es SECTION 11:WORKERS'COMPENSATION 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 ed Affidavit submitted with this a lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ ry!7 Enclose check payable to 6.Total Cost $ 15 G (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT . By entering my name 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 t of my kn ledg d underst g. Please tint and sign name Title Telephone No. Date AMIN Street Address City/Town State Zip n Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan tilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ecif 21 Other(SpecifyJ 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State 1p Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date umk ^,Y Y xµ- •. {2a, 4 5" y.. •:r '4v 4,v aY M r 'fi mr „k t .. "rS,.ry"n' .. e i N Y��:�'sY`•.�a 'v,2',�S* a. 'c 7•wy�S°r�+'„�!'r <3'.a 's� ��f.�6��s';w' *� �I�,�' sr �',�,y '� w ts,����'�:t�"„�^.a� U�+.�t% ?; �v".<L�tTau�t�`&..1,��'�,'�9Y �;�Lth:�G.S•e? �,ii .�.;s"��'EBB,.^+�'la'xa'.t ^3.�9..�:.atr�.r.7.�.xa:.r�.t.t`ir:� � ,t sr Certificate of 11ame llkemi!6tlnce PAGE "r Date Manufactured AZTEC TENTS r�r z# 2665 COLUMBIA ST INV NUMBER: 0190421 01/18/2012 =- 3 TORRANCE, CA 90503 P.O. NUMBER: (800) 228-3687 CUSTOMER NO: TAYL018 s This is to certify that the materials described below have been flame retardant "" treated (or are inherently flame retardant). 17 "Yi`e Brvin a MaNi 17 •_•\^Di �44d B•uin Mesh s F2220A •af TAYLOR PARTY PLUS - HAVERHILL cermn aca e. lzn,Te.rz 77,not 77l9Dti'f: c/o True Value - #12424 t DAF eals°Fa°^<e «e,�^v a 209a aeervmv lo,l6gs/zoga F-swD DAF DAF F-59]02 r P.O: Box 31850 rrR tlusloey EWn ly5aleen Dnm J].D, Chicago, IL 60631 t°[? 9 t Fehen 3n190E 01 F:A .. • F<nan r rertl 02 F- OB �Sluai Millipz l'e.l les N,<T¢z liner F-50001 Ywe Tern. De<a Cloth/vean F-50<01 .M W th s^voe, erspa^ F- DD Tr ventage500 F l2,02 x, Certification is hereby made that the articles described below hereof are made To Vensaq Y• from a flame-retardant fabric or material registered and approved by the ,n vameoe va^quaN W¢°Inn FBs9D -rx7... °?.a' California State Fire Marshal for such use. The fabric has been tested and Th va^le9e WeE^^/eoa.rne Foss D, passes NFPA 701 Large Scale. See chart to right for trade name of sex°aq Dures°^51s2],asu F-5]Do v s, flame-resistant fabric or material used and additionally referenced on the label A;h of the fabric panel. _ e THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING David Bradley General Manager-Manufacturing Name of Applicator or Production Superintendent Tile of Applicator or Production Superintendent F ° rm1 5 '4•'+2i s r f44Fd7i' , +>) rs'r'.F7.+ di"IFJ,wr �uc, �� � afftih�r /xarn �aft4 { , aryr� A srnvls� a } xarcl L 1z s. A<I' rA 3r^-',' Fa :s „�':„ 9 :a• t � �t, �r�f. e�/>�..,A,:-,�'a2 � of � ?, s i'z''2_ " �?ti:�•�$. •a a' +, s` /4Ox4O ITEMS MANUFACTURED TYPE PRODUCED 2pc Std Top Only UW S 1 TC Style Lace -Blockout White ,,XOx20 Std Middle Top Only UW S 3 ATC Style Lace -Blockout White 20x20 ATC Canopy Top Y/W S 1 Yellow Translucent/ White Translucent Tie Downs & CP Jumper Attached To Top 20x20 ATC Canopy Top UW S 1 Blockout White Tie Downs & CP Jumper Attached To Top 2000 ATC Canopy Top UW S 1 Blockout White Tie Downs & CP Jumper Attached To Top 2000 ATC Canopy Top Y/W S 1 Yellow Translucent/ White Translucent Tie Downs &CP Jumper Attached To Top 20x40 ATC Canopy Top UW S 1 Blockout White Tie Downs &CP Jumper Attached To Top 20x40 ATC Canopy�op Y/W S 1 Translucent Yellow/White Tie Downs & CP Jumper Attached To Top 531 Broadway 4 7AYIOR77 . Haverhill, MA01832 978-374-0136 status: Quote Quote#: g539-1 Fax 978-521-5669 Quoted To Date: Fri 8/22/2014 9:OOAM www.mypartypius.com Operator: Rich Hassell ustomer# 78586 Brewer Hawthorn Cove Marina 978 740-9890 10 White St SALEM, MA 01970 Qty Part# Items Rented Agreed Return Date Status Each Price 1I TENT 40X 60 FRAME 8/23/2014 9:OOAM Quoted $1,395.00 $1,395.00 a� s Quote valid for 30 days. RENTAL CONTRACT Rental: $1,395.00 Damage Waiver: $0.00 Sales: $0.00 Delivery Charge: $0.00 Misc.Charges: $0.00 Subtotal: $1,395.00 E 11 Sales Tax: $87.19 TOTAL: $1,482.19 0 m SIGNATURE: PAID: $0.00 m a Brewer Hawthorn Cove Marina AMOUNT DUE: $1,482.1.9 0 Printed on 8/18/2014 11:32:43 am Mon-Sat 7:30am -5:00prn Closed Sunday Modification#1 oe Software by Point-e-Rental Systems WW W.POINT-OF-RENTAL C C bract-P4rams rpt(7 Store Hours: Mon. - Fri. 7:30 AM - 5:00 PM • Sunday closed Aank you for your busi'ness�! TERMS AND CONDITIONS 1.INSPECTION.Customer acknowledges that Customer has had an opportunity to personally 14.COLLECTION COSTS. Customer agrees to pay all reasonable collection,allorney's and inspect the equipment,and finds it suitable for Customer's needs and in good condition,and court fees and other expenses involved in the collection of the charges or enforcement of that Customer understands its proper use. Customer further acknowledges Customers duty to Dealer's rights under this contract. inspect the equipment prior to use and notify Dealer of any defects. 15.REPOSSESSION. Upon a failure to pay rent or other breach of this contract,Dealer may 2.REPLACEMENT OF MALFUNCTIONING EQUIPMENT. If the equipment becomes unsafe terminate this contract and take possession of and remove the goods from wherever they are, or in disrepair as a result of normal use,Customer agrees to discontinue use and notify Dealer and Dealer and his agents shall not be liable for any claims for damage or trespass arising out who will replace the equipment with similar equipment in good working order, if available. of the removal of the goods. Dealer is not responsible for any incidental or consequential damages caused by delays or 16. INSPECTION OF TRAILER HITCH. Customer agrees to inspect the trailer coupling otherwise. mechanism and safety chain before leaving Dealers premises. Customer also agrees to 3.WARRANTIES. THERE ARE NO WARRANTIES OF MERCHANTABILITY OR FITNESS, inspect the equipment periodically(every 100 miles)and to maintain the coupling and chain in EITHER EXPRESSED OR IMPLIED.THERE IS NO WARRANTY THATTHE EQUIPMENT IS a safe and secure condition. SUITED FOR CUSTOMER'S INTENDED USE,OR THAT IT IS FREE FROM DEFECTS, 17.SEVERABILITY. The provisions of this contract shall be severable so that the invalidity, 4,POSSESSIONITITLE.Dealer owns the Equipment,and title in and to all of it will remain unenforceability or waiver of any of the provisions shall not affect the remaining provisions. Dealer's at all times.Customer is entitled only to use and possess the Equipment for the 18. LOADING AND UNLOADING EQUIPMENT. Customer is responsible for loading and Rental Period;subject to the terms of this Contract.If Customer retains any of the Equipment unloading equipment. If Dealers employees assist in loading or unloading the equipment, beyond the agreed Term without Dealers express written consent.Customer will be deemed Customer agrees to assume the risk of,and hold Dealer and/or its employees harmless for any to have materially breached this Contract.Customer will not take,grant or permit the taking property damage or personal injuries,including damage and personal injuries attributable to of any(and Customer hereby waives any and all)liens or other similar claims on any portion the negligence of Dealer of the Equipment,and Customer will take such actions as may be necessary,at Customer's 19.PROPERTY DAMAGE. Not responsible for any damage whatsoever as a result of on-the- sole cost and expense,to ensure that any and all such liens are released as soon as possible. job deliveries or pick up by Dealer. 5. HOLD HARMLESS/WDEMNITY. Customer assumes all risks associated with the 20. FEES, LICENSES, PERMITS, TAXES AND FINES. The Customer shall be solely possession,use,transportation and storage of the Equipment.ACCORDINGLY,CUSTOMER responsible for payment of any fees,licenses,permits,taxes or fines,required by or resulting HEREBY WAIVES ANY AND ALL LIENS AND CLAIMS ARISING FROM OR ASSOCIATED from the Customers use or operation of the vehicle/equipment&Tents. WITH, AND AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE DEALER 21.UNDERGROUND FACILITIES.Customer agrees to have all Underground Facilities,in the FROM AND AGAINST,ANY AND ALL LIABILITIES,CLAIMS.DAMAGES,LOSSES,COSTS vicinity of the Equipment installation,clearly marked prior to the arrival of Dealers work crews. AND EXPENSES(INCLUDING WITHOUT LIMITATION,ATTORNEYS'FEES,CLAIMS FOR Customer assumes full responsibility for damage to all Underground Facilities.To identify BODILY INJURY(IES)(INCLUDING DEATH),PROPERTY DAMAGE,LOSS OF TIME AND/ Underground Facilities,Customer must call one week prior to installation. OR INCONVENIENCE) RESULTING FROM OR ARISING IN CONNECTION WITH SUCH 22. EQUIPMENT FAILURE. In the event any of the Equipment fails to start, breaks, POSSESSION, USE,TRANSPORTATION AND/OR STORAGE, REGARDLESS OF THE malfunctions, becomes unsafe or is in need of maintenance or repair,Customer agrees to CAUSE AND INCLUDING ANY INJURIES AND/OR DAMAGES SUFFERED BY CUSTOMER, immediately discontinue use, notify Dealer, and if directed to do so, return the Equipment CUSTOMER'S EMPLOYEES ANDIOR ANYTHIRD PARTY(IES),EXCEPTTOTHE EXTENT to Dealer.Customer further agrees Customer will not repair or have anyone else repair any DIRECTLY RESULTING FROM DEALER'S INTENTIONAL MISCONDUCT. Equipment.Failure to timely notify Dealer will result in Customer being charged for all Time 6.ASSIGNMENT AND SUBLETTING.Dealer may,at Dealer's sole option,assign all or any Out, portion of Dealer's rights and/or remedies under this Contract without Customers consent. 23,FUEL SURCHARGE.Equipment with gas/diesel engines must be returned full of fuel or CUSTOMER MAY NOT ASSIGN CUSTOMER'S RIGHTS OR REMEDIES UNDER THIS Customer will be charged at the current Dealer's rate. CONTRACT,NOR MAY CUSTOMER SUBLEASE OR LOAN ANY OF THE EQUIPMENT 24,SITE PREPARATION.If Dealer has agreed to deliver any Equipment,Customer agrees TO ANY THIRD PARTY WITHOUT DEALER'S PRIOR WRITTEN CONSENT ANY SUCH to have the Site clean and ready for the delivery and installation or dismantling and retrieval, ATTEMPTED ASSIGNMENT OR SUBLEASE BY CUSTOMER WILL, AT DEALER'S and Customer agrees to pay an additional charge for any delay incurred,or additional labor OPTION,BE DEEMED VOID AB INITIO. performed by Dealer resulting from Customer's failure to timely do so. 7.ASSUMPTION OF RISK.Customer acknowledges that the possession,use,transportation 25. INSURANCE. If any of the Equipment is to be used for a commercial purpose or is and/or storage of the Equipment may give rise to the risk of personal injury and/or property otherwise designated as"Customer Insured"on Page 1, Customer agrees to maintain (a) damage.CUSTOMER VOLUNTARILY ASSUMES ALL SUCH RISK AND RELEASES AND property damage and casualty insurance on an "all risks" basis for the full replacement DISCHARGES DEALER ANDTHE EQUIPMENT FROM ANY AND ALL LIENS,LIABILITIES cost of the Equipment (including without limitation, all risks of loss or damage covered by AND CLAIMS ARISING IN CONNECTION WITH THE SAME, INCLUDING, WITHOUT the standard extended coverage endorsement) with such deductibles, if any, as may be LIMITATION, ANY AND ALL CLAIMS ARISING FROM OR IN CONNECTION WITH acceptable to Dealer in Dealer's discretion;and(b)commercial general liability insurance with DEALER'S NEGLIGENCE(OTHER THAN DEALER'S INTENTIONAL MISCONDUCT). minimum limits of$1,000,000 per occurrence.Such insurance shall cover all operations and 8.PROHIBITED USES. Use of the equipment in the following circumstances is prohibited, contractual obligations,as well as any and all damage or liability arising in connection with and constitutes a breach of this contract. (a) Use for illegal purpose or in illegal manner.(b) the handling, transportation,maintenance, operation, use or possession of the Equipment Use when the equipment is in bad repair or is unsafe.of Improper,unintended use or misuse. during the Term,and shall name Dealer as an additional insured and loss payee on a"closed (d) Use by anyone other than Customer or his employees,without Dealer's written permission. clause"basis.All such insurance shall be primary,without any self-insured retention,and shall (a) Use at any location other than the address furnished Dealer without Dealer's written waive subrogation against Dealer.Customer agrees to provide to Dealer copies of the proper permission. (Does not apply to mobile equipment.) endorsements for the above coverages specifying that they will not be cancelled during the 9.ASSIGNMENTS,SUBLEASES AND LOANS OF EQUIPMENT. Dealer may assign his Term.Any insurance Dealer carries will be deemed to be in excess of Customer's insurance. rights under this contract without Customer's consent,but will remain bound by all obligations 26.DAMAGE WAIVER. It Customer pays the damage waiver charge(DWC) as specified, herein. Customer may not sublease or loan the equipment without Dealer's written permission. subject to the limitations and exclusions below, Dealer agrees to modify the terms of this Any purported assignment by Customer Is void. contract and relieve Customer of liability for accidental damage to the rented items) on 10.TIME OF RETURN. Customer's right to possession terminates on the expiration of the this contract,and for loss due to fire,windstorm, upset and riot. Dealer excludes from the rental period("Due In"date&time)and retention of possession after this time constitutes a waiver,however,any loss or damage due to theft,burglary,collision,misuse or abuse,theft material breach of this contract. Time is the essence of this contract. Any extension must be by conversion,intentional damage,mysterious disappearance or any loss due to Customer's mutually agreed upon in writing. failure to care for the rental item(s) as a prudent person would his/her own property,such 11, LATE RETURN. Customer agrees to return the rented goods during Dealer's regular as proper lubrication. In addition, if the item(s) rented is a truck,Customer is not relieved store hours,upon expiration of the rental period("Due In"date&time). Customer agrees that of liability of accidental damage for the truck container(box)caused by striking a stationary if the rented goods are held beyond the expiration of the rental period("Due In"date&time) object. If any such loss tends to Indicate a crime may have been committed,a further condition as designated in the contract,the daily rate as indicated on the contract shall be the agreed of this waiver is that Customer must file a report to the proper law enforcement authorities and contractual rate for the entire period,notwithstanding any lesser periodic rate. furnish Dealer copy. In addition,if Customer has insurance for the loss or damage,Customer 12.DAMAGED,DIRTY, OR LOST EQUIPMENT. Customer agrees to pay for any damage shall exercise,and shall empower Dealer to exercise,all Customers rights to obtain recovery to or loss of the goods,as an insurer,regardless of cause,except reasonable wear and tear, under insurance,shall cooperate with Dealer to obtain recovery and all insurance proceeds while the goods are out of the possession of the Dealer. Customer also agrees to pay a shall be given or assigned to Dealer. reasonable cleaning charge for equipment returned dirty. Accrued rental charges cannot be 27. WAIVER OF JURY TRIAL. Each party waives its right to a jury trial of any claim or applied against the purchase or cost of repair of damaged,lost or stolen goods. Equipment cause of action based on or arising out of this agreement or the subject matter hereof. This lost,stolen or damaged beyond repair will be,paid for at its current list price.The cost of repairs waiver pertains to all disputes that may relate to the subject matter hereof,including,without will be borne by Customer,whether performed by Dealer,or,at Dealer's option,by others. limitation,contract,tort,breach of duty,and all other common law and statutory claims,and will 13.TIME OF PAYMENT. Accounts are due and payable at the termination of the rental period. not be subject to any exceptions. Each party(A)understands that this is a waiver of important A carrying charge of 1.5%per month(ANNUAL RATE OF 18%)will be charged on all overdue legal rights and S)acknowledges that helshe/it has had a reasonable opportunity to discuss accounts. this waiver and its effects with legal counsel. Accordingly, each party knowingly,voluntarily, irrevocably and unconditionally waives its jury trial rights. A LARGER FONT COPY OFTHESE TERMS AND CONDITIONS IS AVAILABLE UPON REQUEST. NOTICE w NOTICE TO o TO EMPLOYEES EMPLOYEES ' V 0,9M Svg The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (XEUB-4195T29-4-14) 01 -01-14 TO 01 -Ot -15 POLICY NUMBER EFFECTIVE DATES USI INS SERVICES LLC 29A TECHNOLOGY DR STE 100 _ IRVINE CA 926182302 NAME OF INSURANCE AGENT ADDRESS PHONE# BROADWAY RENTAL, INC. 531 BROADWAY DBA: TAYLOR RENTAL CENTER HAVERHILL MA 01832 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT e The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 038353 W20PIG02 TO BE POSTED BY EMPLOYER Client#:415474 TAYLOREN22 *CORDTa CERTIFICATE OF LIABILITY INSURANCE DATE A 03/01120141/2014 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 A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)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 confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: USI Rental Specialties PHONE C No,Exl: C,No g00 854.3298 949 790.9222 AI P.O. Box 53310 E-MAIL ADDRESS: Irvine,CA 92619 INSURER(S)AFFORDING COVERAGE NAICIs 800 854.3298 INSURER A:St Paul Fire and Marine Insuran 24767 INSURED INSURER 5:Travelers Indemnity Company,of 25682 Broadway Rental Inc. INSURER C:Travelers Indemnity Company 25658 dba: Taylor Rental Center INSURER D 531 Broadway INSURER E: Haverhill, MA 01832 INSURER F COVERAGES — _CERTIFICATE-NUMBER:' - -- --" - - ---REVISION NUMBER: - - THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AlM 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADD EXP ILTR TYPE OF INSURANCE NSRL WVD POLICY NUMBER MM%01 OY EFF MM/OUY/YYYY LIMBS A GENERAL LIABILITY ZPP12S514051447 3/0'l/201403/01/201 EACH OCCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea NTIED nce $100 000 CLAIMS-MADE 7 OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2,000,000 X POLICY PRO LOC $ C AUTOMOBILE LIABILITY BA3B71642814GRP 3/01/2014 03/01/201 EeaocideDtSINGLELIMIT $1,000,000 X ANY AUTO NH.Auto and BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ZPP12S514051447 3/0112015 03/011201 BODILY INJURY(par accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS MA Auto Per accident A X UMBRELLA LIAB X OCCUR ZUP12S82351447 3/0112014 03/01/201 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1000000 DED X RETENTION$1000Q $ B WORKERBCOMPENSATION XEUB4195T29414 1/0112014 01101/2O1 X WCSTATU. OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $SOO OOO OFFICERIMEMBER EXCLUDED? � N I A .. __ IMandatory In NH) __._______ —_— _.. E.L.DISEASE-:EA.EMPLOVEE $500,000_. If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5001000 A Inland Marine ZIM12S8234A1447 3101/2014 03101/201 Limit: $604,000 Equipment Floater Deduct: $1,000 Wind/Hail 2%-Min. $7 500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) **Workers Comp Information** Officers Excluded: Rich Hassell,Jill Hassell &Dave Hassell **Supplemental Name** Broadway Rental Inc. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Richard Hassell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 531 Broadway ACCORDANCE WITH THE POLICY PROVISIONS. Haverhill, MA 01832-0000 AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD Alc.ulealaorral.r+calnn rVIMALJ