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3 WINTER ST - BUILDING INSPECTION (2) 1��� l og �l -l Z+{3 Commonwealth of Massachusetts RECEIVED INSPECTIONAL SERVICES Sheet Metal Permit Date:1�// Permit#UL 25 A 48 �J Estimated Job Cost: $ Permit Fee: $ Plans Submitted: YES , NO_ Plans Reviewed: YES_ NO_ Business License# y ` J� Applicant License# Business Information: / Property Owner/Job Location Informations Name:A� L'QY__���/�����r//Q,/�J�> Name:///lf��fi/�4/ £��GU^�9rCGliY� JzCYf UBIi/Ali Street: �p� ��=L7llJ/��7' �3 Street: City/Town: ��l rL�l City/Town. e Q Telephone: 97t� ��_ �� Telephone: Photo I.D.required/Copy of Photo I.D. attached: YES_ NO_ Staff Initial J- /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family_ Multi-family_ Condo/Townhouses Other_ Commercial: Office _ Retail_ Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft.� over 10,000 sq. ft.— Number of Stories: Sheet metal work to be completed: New Work: Renovation:_ HVAC, . Metal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing_ Provide detailed description of work to be done: 4 / ) rn�,L.Q ,1 zz INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meats the requirements of M.G.L.Ch.112 Yes No❑ If you have checked Yes,indicate /the type of coverage by checking the appropriate box below: A liability insurance policy pp Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are tme and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑Master The ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted Fee$ License Number: Check at www.mass.gov/dpl Inspector Signature of Permit Approval The Commonwealth of Massach useto Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): ��/� 4 � (� Address: y(p/ , 5 g& �43 City/State/Zip: J� S �e 92 Are you an employer?Check the appropriate box: Type of project(required): 1.IX I am a employer with 4. ❑ I am a general contractor and 1 employees(full and/or part-time). + have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp,insurance corn insurance.' 9. ❑Building addition p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] -Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractots that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name:. � �s�'�� Policy#or Self--ins.Lic..#: l� ez Z40 / _�Ll Da Expiration Date: �O Q/ /'// Job Site Address:C Gf/`�/ G� �q` # , 3 City/State/Zip�_A4e&z 9�o 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 under thepains andpenalties ofperjury that the information provided above is true and correct. Signamr i(jt Date Phone. #: Official use only. Do not write in this area, m be completed by city or town official 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#: i-- PREFE-2 OP ID: KS1 .4llft o CERTIFICATE OF LIABILITY INSURANCE DAT10103 DIYYYV) 10103113 -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 781.914-1000 NAME PRODUCER Kelly Sturtevant_____ _ TGA Cross Insurance,Inc. 401 Edgewater Place,Suite 220 PHONE OON,FnI; '81-914-1000 FA,An, No): 781 Chris Hawthorne @tg -224-9490 Wakefield,MA 01880 -�'MaL ksturtev across.COm-noorsEss: _ ant INSUNERI51 AFFORDING COVERAGE - NAIC p INSURER A:Arbella Protection ins.Co. 41360 INSURED PrBferred AU,IOC INSURER e_ T 461 Boston Street, Unit A3 — ------ - - - -- - Topsfield,MA 01983 INsursErs c: INSURER 0: INSURER E: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR-----____—__ —pDDLSUBRr -----. POLICY -F -1 POLICYEXP - - - - LTR TYPE OF INSURANCE I I POLICY NUMBER MWO I MMID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TORENTED -- - - - -- " A X COMMERCIAL GENERAL LIABILITY I8500026668 08/01/13 08101/14 (PREMISE$(Eacccunerce)_ $ 300,000 CLAIMS-MADE X OCCUR I'� MED EXP(Any one Person) ; $ 5,000 PERSONAL B AOV INJURY $ 1,00000 GENERAL AGGREGATE $ 2,000,00 G_EN'L AGGREGATE LIMIT APPLIES PER: PRO- i n PRODUCTS-COMPIOP AGO $ 2,000,00 X POLICY T ILOC I I E AUTOMOBILE LIABILITY COMBIawNED SINGLE LIMIT 1,000,00 (Eaiden_t)_ E A - ANY AUTO _ _ 1 I1020003133 108/01/13 1 08/01114 I BODILY INJURY(Per person) s ALLOWNE X D - SCHEDULED AUTOS AUTOS II BODILY INJURY(Per accident) E _ '. NON-OED PROPERTY DAMAGE X HIRED AUTOS . X AUTOS (Per 1 (Per acodent) E S X :EXCESS DAB_ x J OCCUR EACH OCCURRENCE _ S 2,000,000 UMBRELLA LIAB A �CL4IMS=MADE 14600037647 08/01/13 08/01114 [AGGREGATE - .,E 2,000,00 DIED X ,RETENTION$ t0,000 5 WORKERS COMPENSATION WC STATU OTH AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE Y I N E L EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? NIA - -. (Mandatory In NH) E L DISEASE EA EMPLOYEE S If yes describe under I ---- - - 0SCRIPTIONOF OPERATIONS below EL.DISEASE POLIC',LIMIT E ICI i I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarries Schedule,R more space is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street,3rd FI. AUTHORIZED REPRESENTATIVE Salem, MA 01970 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD a,. �R� ' ; , CEt1Fl`CATE O� (LIABILITY INSURgCE3 �:- 4 ,�Y_kfa. -.,'fir4y �>�zw :u��s.,x•�„��.+t��`6-���,,ng��M,+,� �,b�L.3 N,rt�asa�Ls���.�c��.t��`d. ,��J,� 1...0/3/2013 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 C ortificate does not confer rights to the certificate holder in lieu of such endorsements(,) PRODUCER CONTACT NAME TGA Cross Insurance, Inc. (ac Ho.Eae (781)914-1000 (AICNO-) (781)224-5577 401 Edgewater Drive, Suite 220 E MAIL ADDRESS: Wakefield, MA 01880 PRODUCER _CUSTOMER In tt ' INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 Preferred Air., Inc. INSURER B. INSURER C: 461 Boston Street, Unit A3 INSURER D: Topsfield, MA 01983 INSURER E: INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR Vjve DATE(MMIDDIYY) DATE(MMIDDlY1') IInounf.od) GENERAL LIABILITY LN OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISESEe—enae) § CWMS MADE ❑ OCCUR O❑ ED E%P(Any one Pe,san) $ PERSONAL B ADV INJURY S ENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-dOMPIOP AGO § POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ee Aeelden0 § L ONMEO AUTOS BODILY INJURY ALL Person) $ SCHEDULED AUTOS BODILY INJURY 5 fee Amcem) HIRED AUTOS PROPERTY DAMAGE S NOR GANGES AUTOS E.Arsv,len0 NYORELLA ❑ OCCUR LIABILITY EACH OCCURRENCE 5 EXCESS LIAR❑ W CMS MADE AGGREGATE S �•'� DEDUCTIBLE S S RETENTION E AfORKERSCOMPENSA MPLOYERSUABILITY ANO WCV00971102 08/01/2013 08/01/2014 X STATUTORY OTHER HITS MY PROPRIETORPARTNERR%ECVTIVE YIN OFFICERIMEMBER EXCLUDED' 7 Wq Policy Coverage State: MA EACH ACCIDENT S 1.000-00Q M-0.1 in NH If yen.despite under SPECAL PROVISIONS beox DISEASE-POLICY LIMIT 1.000.000 5 DISEASE-EACHEMPLOYEE § L000,000 OTHER ❑❑ DESCRIPTION OF OPERATIONSROCATIONSNEHICLES(MRCP ADDED 101,AddMbnal Rm,M,Schedule,A mom ePxe H mlubNl CERTIFICATE HOLDER b 11"1�` w 5 -'.i i k,p- ^`+ i2C rk t'".q id T CANCELLATION'^ s 4 q A s 1: -..._ .,.,... ..-.- ,. ..w. ✓- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 120 Washington Streeet,3rd Floor 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Salem, MA 01970 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTHORIZED REPRESENTATIVE ACORD 26(2009109) Page I of CERTIFICATE HOLDER COPY 01988-2009 ACORD CORPORATION. All fights reserved. Mt4SSACHUS) 1TTS` t _ _ DRIVER'S --� as ,,06 4tl NON xuxaEP az z0 s S19539973' ^' m '" zU78 09-101959; D -s3 ft"< s cuss.r�iz�PEsr is sa M° ]PPsr 5-10 zROBERTV of # s 19 LE9tlE RD R6WL£Y,MA 07969$318 SDDOB-06M1]0.av011SM09 Ov4u'"COMMONWEikLf OFM gs/Ab'[AET • • • •]1=6:1.1 L• jjj 'BOARWOF w SHEETO.f 'A'L WORKERS ISSUES THE FOLLOW Ik Li DENSE f ,, (` p5 A1NASTER UNRFSTRIC-.TOD hM< �' i ROBERT V SMITH x st 15 LESLrjE D > ra`�+�A ROYILEY' a-MA 01969 1633 , s *9J'Y2 /1,5, 105771 MBANK 1568 AMERICAS MOST CONVENIENT BANK PREFERRED AIR, INC. s3-iasam01 P.O.BOX 648 - BEVERLY,MA 01915 7/24/2014 (978)750-8282 _ - x PAY TO THE City of Salem I $ **159.00 ORDER OF a One Hundred Fifty-Nine and 00/100****..*..***,*****.......********...*:......*.****........*............*.,......:.***.*. - DOLLARS ;�. . City of Salem a g LL MEMO Sheetmetal Permit Kernwood Country Club UTHORZED SIG NA URE n'001568o■ 1: 2113705451: 82507 0751u' PREFERRED AIR,INC. - - 1568 City of Salem 7/24/2014 5000 Cost of Goods SoId:5011 Job Pe Sheetmetal Permit Kernwood Country Club 159 00 TD Bank-Operating Sheetmetal Permit Kernwood Country Club 159.00 Commonwealth of Massachusett&EGE1VED Sheet Metal Permit INSPECTIONAL SERVICES Date:�y 'A%)gL 25 A Q148 , o� Estimated Job Cost: $��� Permit Fee: $ Plans Submitted: YES NO_ Plans Reviewed: YES_ NO Business License # y 3 Applicant License# A`�/ 3 3 Business Information: Property Owner/.lob Location Information: �y Name: / � /�+ //c? Name: /w,Gl'7/ Street:��� j�J` J-fi Street:f_lt�I'll 6,90,od �(fi , City/Town: e 0.-? City/Town� IgZewl !/lL D& '76 Telephone: Telephone: 9 =�L�/ J�/Q Photo I.D.required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 /6�ted ticeuse J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family_ Multi-family— Condo/Townhouses Other Commercial: Office— Retail— Industrial— Educational Institutional— Other -,< t—.L Square Footage: under 10,000 sq. ft._ over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work:_ Renovation: _ HVAC Metal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing Provide detailed description of work to b�el done: Y INSURANCE COVERAGE:I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes���—No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy )6 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑Master Title ❑Master-Restricted City/Town ❑Joumeyperson PermR k Signature of Licensee ❑Jou rneyperson-Restrictetl Fee 3 License Number: Check at www.mass.gov/dpi Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Leeibly Name(Busiin/neesLss/Organization/Individual): . Address: City/State/Zip: Phone #: Are you an employer. Check, h the appropriate box: Type of project(required): LINE am a employer with� 4• ❑ 1 am a general contractor and I ////// employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.t 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152,§1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers''compenvation insurance far my employees. Below is the policy and job site information. G Insurmice Company Nainc;A'T— /&/Y/7C., Policy#or Self-ins:Lic.#: �(�Q�q �J1O�- Expiration Date: !�gw L �� Job Site Address:../ '/ /� �� el f)1 0 �"�" / i�t City/State/Zip( / V Attach a copy of the workers compensation poliey-declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 c of under the pain and penalties of perjury that the information provided above is true and�correct. Si nature: /J p ry p Date: Q �y Phone#: Official use only. Do not write in this area, to be completed by city or town official 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#: PREFE-2 OP ID: KS1 CERTIFICATE OF LIABILITY INSURANCE DATE1010DOIYYYY) 0103113 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMAT)VELY 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 TGA Cross Insurance,Inc. 781-914-1000 NAME: Kelly Sturtevant__ __ 401 Edgewater Place,Suite 220 j�j u, Wakefield,MA 01880 E Eny,781-914-1000 _ _ja Rog 7.61-224_-94.9.0_ Chris Hawthorne ADDRESS:katurteyant@tgacrOSS.COm_ _ INSURERS)AFFORDING COVERAGE NAIC N INSURER A;Aroana Protection ms.Co. 141360 INSURED Preferred Air,Inc. INSURER B: 461 Boston Street, Unit A3 — ----- - -- - ---- -- - --- _- - -- - Topsfield,MA 01983 INSURER C:____— INSURER O: INSURERE: NSURER 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR! ADD WWDI POLICY NUM POLCY EFF POIJCY EXP LTRI TYPEOFINSURANCE MAID �MM/p LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAIAAGE'TO RENTED ------ A X ' COMMERCIAL GENERAL LIABILITY 8500026668 06I01113 OBI01114 PREMISES Ea occurrence $ 300,000 (Any person) E 5,00.0 CLAIMS-MADE X OCCUR MED EXP An one _ PERSONAL 8 ADV INJURY E 1,000 00 GENERAL A_GGRECyATE jS 2,000,00 GEN L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOPAGG ' E 2,000,00 X POLICY 11 PRO- i—_IECTLOC -- $AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT I 1,000,00 A �ANY AUTO _ 1020003133 08101113 08101/14 BODILY I NJURY(Per person) E T AUTOS NEC rX SCHEDULED BODILY INJURY(Per amment)AUTOS E X HIREDAUTOS rX, NON-0WNED PROPERTY DAMAGE S I X ! UMBRELLA UMB I X OCCUR EACH OCCURRENCE __' S 2,000,00 A EXCESS UAB j-1 CLAIMS-MADE 4600037647 08101113 08/01/14 AGGREGATE E 2,000,00 DED I X i RETENTIONS 10,0M S WORKERS COMPENSATION I WC STATU- OTH AND EMPLOYERS'LIABILITY y I M _-_TORN LIMITS-,_-.,ER ANY PROPRIETORIPARTNERIEXECUTIVE E LEACH ACCIDENT E i OFFICER/MEMBER EXCLUDED? ❑,NIA - (Mandatory In NH) E.L.DISEASE EA EMPLOYEE E I ll yes,deaclib9 under DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT I $ ET DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,U more space is reQulred) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 120 Washington Street,3rd FI. AUTHORIZED REPRESENTATIVE Salem,MA 01970 4 I 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ,�'« r.c;.mu F + z .y_ '0'^w y• r.. w: .,. LI71(�11lSURANGE k v 10/3/2013 wx. msea.afiEGu�+ s�nr.AsT i�.e'A�dn1 '�n .t,._' 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 INSURERIB),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policyllea must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this c Drtificate does not confer rights to the certificate holder in lieu of such endomements(s) PRODUCER CONTACT NAME TGA Cross Insurance, Inc. (A((C Nio.Enr (781)914-1000 (AICNO-) (781)224-5577 401 Edgewater Drive, Suite 220 ADDRESS: Wakefield, MA 01880 PRODUCER CUSTOMER ID a' ' INSURERS AFFORDING COVERAGE NAIC# INSURED - INSURER A: Atlantic Charter Insurance Company VDAC 44326 Preferred Air,Inc. INSURER 8: INSURER C', 461 Boston Street, Unit A3 INSURER D. Topsfield, MA 01983 INSURER E. 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBP POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR NNO DATE(MMIDDYY) DATE(MMIOOM/) (In M..Mi GENERAL LIABILITY EACH OCCURRENCE E COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES ❑ Ee m ECLAMSCMB MADE ❑ OCCUR ED E%P EXP((Myone pereonl E PERSONAL A ADV INJURY E ENERALAGGREGATE E GEN'L AGGREGATE LIMIT APPUES PER: PgOOUCTe-COMPKIP AGG E POLICY ❑PROJECT ❑LOD AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E ANY AUTO (Ea Ameen0 BODILY INJURY ALL OYMED AUTOS (P."..) E SCHEDULED AUTOS ❑ BODILY INJURY E (Ee Attldenll XIREO AUTOS PROPERTY DAMAGE E NON-DVINDED AUTOS (Ea MaGenl) NMBRELLA ❑ OCCUR LIABILITY EACH OCCURRENCE E EXCESS LIAR ❑ CLAIMS MADE AGGREGATE E DEDUCTIBLE E-1❑ E E RETENTION E WORKERS COMPENSATION AND WCV00971102 08/01/2013 08/01/2014 X' STATUTORY OTHER A MPLOYERS'LIABILITY LIMITS ANY PROPRIETORNARTNEREXEOUTIVE YIN E OFFICERMIEMBER EXCLUDED? a — ❑ Policy Coverage State:MA EACH ACCIDENT I,000.000 MaMak,N NH nrn.aesarbe umm SPECIAL PROVISIONS bald-., DISEASE POLICYLIMIT s 1,000.000 DISEASE-EACH EMPLOYEE E 1,000,000 OTHER ❑❑ DESCRIPTION OF OPERATIONShOCATIONSNEHICLES DBF&Ih ACORD 101.AdOabnal Raplerks ScheduM,d MM sNce Is nqubad) rdNCELLATION'�'ry',{ ..emJV. A7 M�la � �fx.al k+.✓M. 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 120 Washington Streeet,3rd Floor 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Salem, MA 01970 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTHORRED REPRESENTATIVE �1 - ACORD 36(200&09) Page I of I CERTIFICATE HOLDER COPY Q 1988.20M ACORD CORPORATION. All dghb;reserved. 1 - MASSACHUSETTS ;DRIVER LICENSE 2 zo 3 "O+E Sl953997374 0 20'18 09=10:4959. a;i�M to-MT 5-10 r.1 B t Ts ITH 1 E 21— ERTV - at a15 LESUE RD , t$t 1 5 W OB-06M1J Ibv 0]-0SA09 ' 1 �z-2w4 £OMMONWEALTH OF MASSACHUSETTS • • • - - • • SHEEt M`tTXhL. WORKERS% e x ISSUES .THE ,FOLLOW IN4 L4CENSE A A MASTER fflESTRI CT.ED 6 a � Fp y�°�'fLx ,ROBERT V SMITH ip 15 LESLlE t`,ROWI.EY . MA 01969 23TB:10 ., 1633H'D9/28/a5x 10577�