0164 REAR BOSTON SREET - TBA-15-11184; .. _ t. F t S N 1 . I O 0 c5 E T.,
The Commonwealth of Massachusetts City oFRea edy
Q - \
State Board of Building Regulations and . Oflice of the Inspector of Buildings
Standards 24 Lowell Street
Massachusetts S[ate Building Code Peabody,MA 01960
780 CMR 3„p t TeL•(978)538-5786
C70 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE CHANGE THE USE OR OCCUPANCY OF,OR
DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING
This Section For Official Use Onl
i Building Pemvt Number: Date Issued:
t Z
Ln Signature . , fC// -'o
Building Commissioner/Inspector o Buildings Date
p. G 1:
SECTiON 1 -SITE INFORMATION m
l.l Property Address: 1.2 Assessors Map&Parcel Number r-rn
9 y .t'T. D o
T
BRmT` - /9 O 0 Map Number Parccl Numbe '
13 Zaning Information: 1.4 Property Dimensions:
w
Zonin Disttict Pro crt Osc Lot Mca sfl Fmnta e ft)
1.5 Buildin Se[backs ft r'I
Front Yard Side Yards Rear Yar.d
Re uired Provided Re uired Provided Re uired Piovided
1.6 Water Supply(M.C.L.c.40.§54) 1 J Flood Zone Intormation: S SewagelDisposal System:l
Public Pnvatc Zonc: Outsidc Flood Zone Municipal On sitc disposal systcm
SEC ION 2-PROPERTY OWNERSHIP/TENANT/AUTAORIZED AGENT
21 Owner/Tenan[:
L s 4'Ic sssf/ N ,5,d1v uc 2,
Name(prmt) Address 1
r J 12 49- I I
Signa rc
1 cPl Inc I I I I I ( ( (
2.2 Authorized Ageut I
hA'_11La ,ur„u Er2 JG n ZS NI I a.ei itioa iNA oi 803
Name Addriss (
Vn 1 I ! s713oo 9s o
S I V/ l I I I I I I tie e hone L/
SECTION 3-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF
ENCLOSED SPACE
Licensed Constraction ypervisor: ( j ` I I ( I I II ' Not Applicable
Au.tES . I fA } ID2 I I ' I V CS -o 2 &49LiccedConstructio(i upervisor. I 1 I I I I I I I pf 3I License Number
I
Add«ss
nl 1l U
V d2 , zo,
Expira on te
Signatur
Registered e Impro , ment,Conaacmr Not AppliCable
Company Name
Regis[ra[ion Number
Address
Expiration Date
SignaNrc Tefephonc
rz v ib — i-E u r t ,v,.ti.
SECTION 4-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152§25C(6))
Workers Compensation Insurance affidavit must be completed and subrttit[ed with this applicatioa Failure to provide this affidavit will result i the denial
of the issuance of thc buildin cnnit.
SECTION 4-PROFESSIONAL DESIGN AND CON5TRUCTION SERVICES FOR BU[LDINGS AND STRUCTURES
SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE TAAN 35,000 C.F.OF
ENCLOSED SPACE)
5.1 Re is[ered Archi[ect:
Not Applicable
Name (Aegistrant)
License Number
Address
Expiration Date
Siguamce Telephone
51 Re is[ered Protessional En ineer
Name Arca of Responsibility .
Address Rcgistration Numbcr
Sig ature Ielephone Expiration Datc
Name Area of Responsibility
Address RegisVation Number
Signatuce Telephone Expication Date
Name Arca of Rcsponsibility
Address Registration Numbcr
Signature Tcicphone Expiretion Datc
Name Area of Responsibiliry
Address Registration Number
Signamre Telephone Expiration Date
5.3 General Con[ractor
d.11C RAtL uG.rfE.21ti.L"
NotApplicable
Company Name
t4it*Iv2 ITc.KWkS
Responsible In Charge of Cons[ruction
2s C(AU.. tZa u2LINGT A C Ik'Q3
Address
lnll \ 77 - 72(a '
Signawre Telep one
li
SECTION 6-DISCRIPTION OF PROPOSED WORK(CHECK ALL APPLICABLE)
New Construction Existin Buildin Re airs Alteration Addition
Accessory Bldg Demolition Other o Specify:
Brief Description of Proposed Work
t ec..SN OLD fniT aio2 Cgoc.a.A 60 itwi /n S Lc_ A
NE J Coo,Te.2 goX 7 LI +a2- L1UE CeN6ifL JG'l O J •
SECTION 7-USE GROUP AND CONSTRUCTION TYPE
Use Grou Check as A licable Construction T e
A Assembly A-1 A-2 A-3 lA
A-4 A-5 1B
B Buslness 2A
E Educational 2B
F Facto F-1 F-2 ZC
H Hi h Hazard 3A
I Insritutional I-1 1-2 1-3 3B
M Mercantile 4
R Residential R-1 R-2 R-3 SA
S Stora e S-1 S-2 SB
U Utili S eci :
M Mixed Use S eci :
S Special Use Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS AND/OR CfIANGE IN USE
Existing Use Group: Proposed Use Group:
Existin Hazazd Index(780 CMR 34) Pro osed Hazard Index(780 CMR 3
SECTION 8-BUILDING AND HIGHT AND AREA
BUILDING AREA Existing(if ap licable) Pro osed
Number of Floors or Stories Include
Basement Levels
Floor Area Per Floor SF)
Total Area SF)
Total Hei ht
SECTON 9 STRUCURAL PEER REVIEW(780 CMR ll011)
Inde endent Structural Peer Review Re uired Yes... No...
SECTON l0a—OWNER AUTHORIZATION—TO BE COMPLETED WHEN O WNERS -
AGENT OR C OR APPLiES FOR BUILDING PERMIT
I as owner of the subject property
j
herebyauthorize L Ql71L'. 72a NG/wl 'rEn./A Cn toacton
my behalf,in all matters relative to work authorized by this permi[application.
Signature of Owner Date
SECTON lOb—OWNER/ UTHO D AGENT DECLARATION
I, as owner/authorized Agent hereby
declare that the sta[emen[s and inFormation on the foregoing applica[ion are true and accurate,to[he best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
e 9 Zelb
atur ner gen Da e
SECTION(ESTIMATED CONSTRUCTION COSTS
tem Estimated Cost(Dollars)to bc Official Use Onty
c m leted b eQnit a licant
I.Building a)Building Permi[Fee Multiplier
2.Electrical p
b)Estimated Total Cost of
5 739. Construction from
3.Plumbin N A Building Permit Fee
a.Fire Protection p SO. a a)x(b)k
o
5.Mechanical HVAC Check Number , ..,, t. , SD
6.Total=(1+2+3+4+5 S .-6
µ.Y
All Building,Wiring,Plumbing,Fire uppression and Alarm Permit Fees will be paid by the general contractor or owner }
at the time of issuance.
THIS SECTION FOR OFFICIAL USE ONLY
PERMIT FEE BREAKDOWN
ESTIMATED COST: NOTES:: }.. . . . ; „ .
y , '. y •
k"YS .fre.n rt,2 ., & _ s'#'
I
I TYPE MULTIPLIER FEE
s ,y :+
Building
K. . sr ..
Electnca] a s s. ,T;
y3. . 2 t Y3S . " t v s .i:;
Plumbing s#. ;.: ,t? ; x..
Gas 4 Y
w
Sprinklers
f 3 .,
Mechanical t ""' ' `
Total t
The Commonwealth ofMassachusetts
Depanment of Indusbra!Accidents
Office oflnvestigatrons
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
R'orkers'Compensation Insarance Affidavit: Builders/ContractorslEleMricians/Plumbers
Auplicant Information Please Print Leaiblv
N8i11C(Business/Organi ation/Indrvidual): ALTC a-- .N<<h --.N..
Address: ZS IMfFLL oaA
City/State/Zip:$RuNGrDn W A o/S 03 Phone#:$7 ,300- (p9 Sa
Are you an employer?Check the appropriate bos: Type of pmject(requ'ved):
I am a em lo er with 4. t am a general coMractor and Ipy 6. New consuvction
employees(full and/or part-tvne)." have hired the sub-contracWrs
2. I am a sole proprietor or par[ner- listed on the attac6ed sheet.I Remodeling
ship and have no employees These sub-contractors have 8. DemoliHon
working for me in any capaciry. workers'comp.insurance. 9. Building addition
No workers'comp.insurance 5. We are a corporation and irs
0.Electrical repairs or additions
required.] officers have exereised the'v
3. i am a homeowner doing all work right of exemption per MGL I 1.Plumbing repairs or additions
myself. [No workers'comp. c. 152,§l(4),and we have no 12.Roof repai s
insurance required.]t employees. [No workers' 13.0 Other
comp.insw ance required.]
Any eppliemu tha[checks box pl mwt alw fill out ihe section 6dow strowing iheir workers'eampeaufian poliry infomuuon.
t Homrowners who submi[this affidavit indiwtin8 they are doing all work aod ihen hire outcide contracrors must submit a new affidavit indicuting such.
Comwctas thet chak[his 6oz must atroched an addi[ional sheet slwwin8lAe name oflhe sub<ontractors azid ihe r workas'comp.policy infoimatloo.
7 am nn emp[oyer that ls providing workers'compensation insurance jor my employe¢s. Belmv is tke poticy and job site
injormarinn.
A
Insurance Company Name: ryC0 1`f7
Poticy#or Self-ins.Lia p: A 2 C Ca O 7 34 I k O I Expiration Date: I Z .3,ZO/S
Job Si[e Address: OW l.Y .ST• r . .,. . . :_CiTy/State/Zip:17(LA(y l la 0 9(pa
Attach a copy of[he workers'compensation policy declaration page(showing tAe policy number and ezpiration date).
Failure ro secure coverage as reqwred under Sectio 25A of MGL c. 152 can tead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year'unprisonment,as well as civil penalties in the fo.n of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of Ihis statetrtert may be forwazded to the Office of
Investigations of the DIA for insurance wverage verification.
do hereby cerli ie pains an rjury that the injormadon pravrded above is trye and conec[
c r r)ate 9 6/lv s
Phone#f I 7) (/77' 72.(o Z
Officia(use onty. Do not write in this area,to be comp(eted by city or town ojJiclaL
City or Town: PermiULiceuse#
Issuing AutLorfty(circle one):
1.Board of Health 2.Building Deper ent 3.City/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Peraon: Phoee#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for theuemployees.
Pmsuant to[}ils statute,an emp/oyee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An emptoyer is defined ac"an individual,paitnership,association,corporation or other legal entiry,or any two or more
of[he foregoi¢g engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or Wstee of an individual,partnership,assceiation or other legal entity,employing employees. However the
owner of a dwelling house having not more[han three apartments and who resides ffierein,or[he wcupant of Ihe
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurteaant thereto shall not because of such employmen[be deemed to he an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a ticense or permit to operate a buslveu or to construct bufldings in the commonwealth for any
epplicant who has not produced acceptable ev(dence of compliance with the insarance coverege required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of iu potitical subdivisions sfiall.
enter into any contract for the perfom ar ce of public work un[il acceptabie evidence of compliance with the insurance
requirements of this chapter have been presented to the contrneting authoriry."
Applicants
Please fill out the workers' compensafion affidavit completely,by checking the boxes that appty to your situation and,if
necessary,supply sub-conuactor(s)name(s),address(es)and phone number(s)along with their certi8cace(s)of
insurance. Limited Liabiliry Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parfiers,aze not requiced to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted m the Department of Industrial
Accidents for co rmation of insurance coverage. Also be sure to sign eud date t6e affidavit The affidavit should
be retumed to Ihe ciTy or town that the appfication for the permii or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regazding the law or if you aze requ'ved to obtain a workers'
compensa5on policy,please call the Depar[ment at the number listed below. Self-insured companies should encer their
self-insurance license number on ihe appropriate iine.
City or Town Otficials
Please be sure ttiat the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to£ill out in the evrnt the OfSce of Investigations has to contact you regazding the applican
Please be sure to fill in the permitAicense number which will be used as a reference number. Tn addition,an applicant
that must submit multiple permitAicense applications in any given year,need orily submit one davit indicating cusent
policy infom ation(if necessary)and imder"Job Site Address"the appficant should write"all locadons m_(city or
town)."A copy of the atfidavit that has been officially stamped or marked by the city or town may be provided to the
appiicant as proof that a va]id affidavit is on file for future permits or licenses. A new davit must tie filled out each
yeaz.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
i.e.a dog license or permit to tum leaves ctc J said person is NOT mquired to complete this affidavit
The Office of Investigations would like ro thank}rou in advaoce for yo a cooperation and should you have any qvestions,
please do not hesitate to give us a call.
The Depanment's address,telephone and fax number:
The Commonwealth of Massachusetts '
Department of Industrial Accidents
Oflice of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-OS
Fax#617-727-7749
www.mass.gov/dia
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8 h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title:S7 P &S wP `k OOS Date:
Property Address: /9 w E. ST. R J_//.q 2(OD
Project: Check one or both as applicable: New construction Existing Construction
Project description:
I MA Registration Number: Expiration date: am a
registered design professionol, and I have prepared or directly supervised[he preparation of all design plans,
computations and specifications concerning:
Architectural Structural Mechanical
Fire Protection Electrical Other
for the above named project and that to the best of my knowledge, information, and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documenu.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of constnaction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding tha provisions of 780 CMR ]07.
When required by the building official, I shall submit field/progress reports(see item 3 J together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a`Final Construction Control DocumenY.
Enter in the space to the right a"weY'or
electronic signature and seal:
Phone number: Email:
Building Ofliciel Use Only
BuildingOfticialName: PermitNo.: Uare:
Version Ob I I 2013
I
Required Inspections and Site Review Document
As a condition of the building permit the following Inspections and
Site Reviews identified by che building official are required for work per the
8`n Edition of the
Massachusetts State Building Code, 780 CMR, Section 110 and Chapter 17
i
Project Title:SrOP L° S+bP 00 S Date:
i
Property Address: 19 ll c.EX_T,A@onY //A OI q(Q( Building Permit No.:
Re uired Ins ections to be erformed b the Buildin Official ',6
Ins ection X Ins ecGon X
Prelimin rior to s[att Roofin S stem/Attachment
Soil/Footin oundation Smoke/Heat/Fire Alarm S stem
Concrete Slab/Under F7oor Cazbon Monoxide S stem
Flood Eleva[ion/Certificate S rinkler/Stand i e/Fire Pum '
Framin -Floor/Wall/Roof Fire/Smoke Dam ers
La[h and G sum Board Witness S ecial Ins ec[ions
Fire/Smoke Resistan[Assemblies Accessibili[ (521 CMR)
Ener Code Ins ections Manufactured Buildin Set
Sheet Meta]Ins ections Other:
Emer enc Li hfi it Si na e
All Means of E ss Com onenets Final ins ection .
Required Site Review and Documentation for Portions or Phases of Construction 'fi'
to be crformedb the:a rt ria e re is[ered tlesi n.- ioCessional or his/her desi ner or M.G.L.c 1 l2§81 R cunimetor)
Site Review and Documentadon X Site Review and Documentation X
Soi]condi[ion/anal sis/re ort Ener Efficienc Re uirements
Foo[ing and Foundation Fire Alarm Ins[allation2
includi e reinforcement and foundation attachmenQ
Concrete Floor and Under Floor Fire Su ression Installatiod
Lowest Floor Flood Elevation Field Re rts'
Structural Frame-walUfloor/roof Carboo Monoxide Detection S stem
La[h and Plas[er/G sum Seismic reinforcement
Fire Resis[ant WalllPartitions frartiln Smoke Control S stetns
Fire Resistant Wall/Partitions finish attachments Smoke and Hea[Vents
Above Ceilin ins ecfion Accessibilit (521 CMR)
Fire Blocking/Sropping System O[her:
Emer enc Li htin xit Si na e
Means of E ress Com onenets Other Special Inspections(SecSon 1704):
Roofin ,co in S stem
Ventin S stems(kitchen and cleanouts,chemical,fume)
Mechanical S stems
1.li is ihe responsibility of the pamit epplicant to no ify he building officiel of requ'ved irepecuons(x).Inspection of 780 CMR Poe promclion syetems may be wimessed by the fue officiel and
ins allafion permiu are required from Ihe fire departmem per 527 CMR.
2.Indude NFPA 7Y rest and acceptonce documenw ion
3,Include applic le NFPA 13,13R,13D,14,I5,17,20,241,ac.-lesl nnd acfep ance documenlu ion
d.Include NFPA 720 Record ofCompletion end Inspenion and Trs Portn
5.Include feld ropons and relelod daumentation
6 W wk shnll noI promed,or be concealed,unlil Ihe mquimd inspection hav been appmved by the building official,and rwlhing wilhin conswction conwl shWl have Ne eHect o(weiving a
limiling Ihe building official's euNorily lo mkrc<Ihis code wilh respecl lo exeminetion of Ihe contrecl dacumenls,imluding plons,cwnpulelio a M specificetions,andleld inipeclions.
7.Rough enA/or finish inspectiow of elecMcel.plumbing,ar shea metal shell be irepec[ed prior ro rough end fiNsh i upections by he building ofGciel.
1(type or print name) Q'MV 2 LE.KY-Jt S am the building permit applican[and by entering my name below I
attest under the pains and penalties of pery'ury Ihat I have received this checklist of required inspecdons and approvals and will copy all
individuals with 780 C ponsibility.
Signatur Phone No.:(aQ 7_0 EmaiL•RT!„4.LTc AI'C S/aAui c_t8,ljg_.(N
Signawre rype neme i elecironic signnmre
Building Of}'cial Use Only
Building Ofriciel Name: Dnte:
Version 06 1 I 2013
Massachusetts.-Department of Public 5afety , j Unrestricted-Buildings of any use goup wlnch
Board of Building Regulations and Standards contain less than 35,000 cubic feet(991m3)of
Cons[r c6on Supen-isor CIlC10SCa SP3C0.
License: CS-072849
r.rrc ..
JAMESEHAIdAjtAPi ' '',. I
202 COUNTRY CY.iI r ;
IPSWICfIMA OP/38'.. '-' y . .
Failure to possess a arrent edition of the Massacbusetts .4.:.'`"
rin' State Building Code is cause for revocation of this license.
Expiretion .
Commissioner U2/17/2016 FwDPSLicensinginformationvisit: www.Mass.Gov/DPS
I
Ii
A`o CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/D IYYYY)
5/5/2015
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 AFFOR ED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiTcate holder is an ADDITIONAL INSURED, the policy(ies) 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
certiflcate holder in lieu of such endorsement s .
CONTACT
PRODUCER NAME:
Alliantlnsurance Services, lnc., PHONE , 617-535-7200
FA" . 617-535-7205
131 Oliver Street,4th Floor E MAIL
Boston MA 02110
INSURERS AFFOROINGCOVERAGE NAIG#
INSURERA:OICi R2 ublic General Insurance Cor 24139
INSURED INSURERB:EO(IUf8f1C0AfT12fIC80If15. 00. OE4
Baltic Trail Engineering, LLC INSURERC:N9VI ators Insurance Com an 42307
72 Sumner Street
Milford, MA 01757
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:600833152 REVISION NUMBER:
THIS IS TO CERTIFV 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 DESCRIeED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
rypE OF INSURANCE
POLICV EFF POLICV EXP
LIMITS
LTR INS WVO POLICVNIIMBER MMI DM/ri MMIOD
A x COMMERGIALGENERALLIABILITY V A2CG07341401 12/37/2014 17/31/2015 Ep,CHOCWRRENCE 1,000,000
AMAGETORENTED
CLAIMS-MADE X OCCUR PREMISES Eaoccumence $100,000
MED EXP(Any one pereon) $10,000
PERSONALBADVINJURV $1,000,000
GEMLAGGREGATELIMITAPPLIESPER: GENERALAGGftEGATE $2,000,000
POLICV jE PRODUCTS-COMP/OPAGG $2,000,000
OTHER: PeroCwffence Ded.50,000
A AUTOMOBILELIABILITY Y q2CA07341401 12/31/2014 12/31/2015 accOeD IN EL T $p00,000
X ANVAUTO 80DILVINJURV(Perperson) $
AUTOSNE qUTOSULED gODILYINJURV(Peraccitlent) $
NON-OWNED PROPERTY AMAGE
HIRE AUTOS AUTOS Peraccitlent
S
B UMBREL nuAB X OCCUR EXC70004487301 12/37/2014 12/31/2015 EnCHOCCURRENCE 10,000,000
C X EXCE35LIA9 IS74EXC7659551V 12/31/2014 1Z31/2015
CLAIMS-MFDE AGGRE6ATE E 0,000,000
DED RETENTION$
q WORKERSCOMPENSATION A2CW07341401 12/31/2014 12/31/2015 X PER OTH-
AND EMPLOVERS'LIABILITY
STATUTE ER
OFFIGER/MEMBER EXCLUDEO?ECUTNE
Y
N A
E.L EACH ACqDENT 1,000,000
Mantla oy in NH) E.L.DISEASE-EA EMPLOVE $1,000,000
If yes,describa untler
OESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICVLIMIT $1,000,000
A Auto Physical Damage AZCA07341401 12/3V2014 12/37/2015 Comp Ded 7000
Coll Ded 7000
OESCRIPTION OF OVERATIONS I LOCATIONS/VEHICLES (ACORD 101,AddlHonal Ramerks Schetlule,may be attachetl H more space is requlretl)
Ahold U.S.A., Inc. and Its Subsidiaries and A liates are included as Additional Insureds as required by written contract and executed prior to
a loss, but limited to the operations of the Insured under said contract,with respect to the Automobile, General Liability and Umbrella/Excess
Liability policies.
CERTIFICATE HOLDER CANCELLATION
SHOULU ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ahold U.S.A., If1C. ACCORDANCE WITH THE POLICY PROVISIONS.
c/o MAC Risk Management, Inc.
P.O. BO%ZOOOO AUTHORIZED REPRESENTATIVE
Woodstock, GA 30189-0400
O"_."` g'' ..,,t".r
OO 1988-2014 ACORD CORPORATION. All rights reserved. ,
ACORD 25(2014101)The ACORD name and logo are registered marks of ACORD I
li ..
j anoia usA
The Stop & Shop Supermarket Company LLC
October 2, 2015
Mr. Alberf Talarico
Building Commissioner
City of Peabody
24 Lowell Street
Peabody, MA 01960
RE: Super Stop & Shop #0005
19 Howley Street, Peabody, Massachusetts
Deaz Mr. Talarico:
The undersigned, The Stop & Shop Supermarket Company LLC ("TenanY'), is the tenant
of the entire property containing the above store and associated parking pursuant to a
Lease dated February 12, 2001 entered into with Ahold Lease U.S.A., Inc., as landlord
Landlord"). Tenant has contracted with Baltic Trail Engineerin ("Contractor") to
perform the replacement of an interior freezer/dairy box in the Premises. Tenant has the
right to make such replacement pursuant to the terms of said Lease, and has the right
to apply for any and all federal, state or municipal permits, approvals and the like
required to perform such work, in its name or, if required, in the name of the Landlord.
This will confirm that the Contractor has our consent and is authorized to file
application(s) for any and all permits necessary to perform the interior freezer/dairy box
replacement work to be performed by Contractor at this location.
Should you have any questions require any further information, please do not hesitate
contact our representative, Linda Camara, at 617-689-4126.
Sincerely,
The Stop & Shop Supermarket Company
LLC
By:
Name: ,(//ot CQ/1QIK.
Title: Q 7 GCy /1I 1LJ,„ /y tf/!i/Q/!CL
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DATE REVISION 12.10.98