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15 WINTER STREET - BUILDING JACKET '� 15 WINTER STREET CERTIFICATE DATA EXPIRES ISSUED CERTIFICATE NO. INSPECTOR O •�. -' ORDERS ^• ISSUED COMPLIED ISSUED COMPLIED 19 19 19 19 19 19 19 19 19 19 19 19 REMARKS STREET & NUMBER 15 Winter Street DATE 5/19/76 OTHER LICENSES OR PERMITS REQUIRED. / 1 OWNER OF RECORD OF BUILDING Ally Realty ADDRESS CERTIFICATE ISSUED TO ADDRESS NAME OR ADDRESS IJAN IFEBARPIRkAAYIJUN JJUL UG PEP OCT INOV EC I USE YEAR 15 Winter Street L-1 76�A 15 Winter Street L-1 76 NAME OR ADDRESS IJAN FEB MAR PR MAV JUN JUL AUG SEP OCT NOV OEC USE YEAR' PURPOSE USED PROVIDE THE FOLLOWING INFORMATION AS APPLICABLE # OF STORIES 3&B CLASS OF CONSTRUCTION DATE ERECTED CERTIFIED CAPACITY: (BY STORY OR TYPE) HOTELS: Y STORY OR TYPE) NUMBER OF ROOMS - HOSPITALS SCHOOLS. 0 ELS: IB 5 0 1st - #1 - 1 room 6 - 1 room & bath IA - 1 Room 7 - 1 room & bath 2 - 4 rooms & B, Common bath 3rd - 8 - 1 room 7 d - 3 - 1 room 9 - 1 room 4 1 rnnm 10 - 1 room,Bath 5 - 1 rnnm P, bath 11 - 1 room NUMBER OF DWELLING UNITS PER STORY 12 - I room & bath ,FORM SSCC-7 7A- EMERGENCY 4 EMERGENCY LIGHTING SYSTEM MEANS OF DETECTING AND EXTINGUISHING FIRE # OF ELEVATORS HOW HEATED Steam by oil "BOILER OR OTHER HEATING APPARATUS HOW LIGHTED HOW VENTILATED - PLACE OF ASSEMBLY: YES NO PURPOSE USED IN WHICH STORY- STANDARD BOOTH INSTALLED LOCATION FIXED SEATING - # OF AISLES AND WIDTH FIRE RESISTANCE OF CURTAINS OR DRAPERIES # OF SANITARIES LOCATION # OF GRADE FLOOR MEANS OF EGRESS DOORWAYS 2 & 1 outside fire escaiJe N OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY # OF APPROVED INDEPENDENT EXITWAYS PER STORY i DAVID F. JAQUITH LETTER, OF TRQNSMMT L ARCHITECTS & PLANNERS 11 OBER STREET DATE: j5 /Au. /9b� JOBNO.:$gp 9D BEVERLY, MASSACHUSETTS 01915 ep TTENTIONzV AQ116 tiA ek?,1S PHONE: (617) 927-3745 ld I " ' l RE:,t, Wt►JTrN fz' 5T SAL-E/A TO: 1>04VID 949.1R,145 F' G e^ >tjIL4H04 DEPT. CITY OF S,`,_ ; ,r„ WE ARE SENDING YOU: ATTACHEDEf Under separate cover via the following Items: ❑ Shop Drawings ❑ Prints ❑ Plans ❑ Samples ❑ Copy of letter ❑ Change order ❑ Specifications Ef� T=II=L,0 C4-,,0FtbvLT COPIES DATE NO. - DESCRIPTION THESE ARE TRANSMITTED as checked below: ❑ FFoor� approval ❑ Approved as submitted ❑ Resubmit copies .for approval Ltd For your uss ❑ Approved as noted ❑ Submit copies for distribution ❑Vi—s requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19_❑ PRINTS RETURNED AFTER LOAN TO US REMARKS: COPY TO: �or�u ��u�aays/u 0 enclosures are not as noted,please notify us at once SIGNE ' trnllu f. 2NIjUlI'Yf jARCHITECT'S OWNER ❑ ARCNITECTS & PLANNERS ARCHITECT ❑ 11 OBER• STREET FIELD REPORT CONSULTANT ❑ BEVERLY, MASSACHUSETTS 01915 AIAIWCUMENT 6711 FIELD ❑ (617) 9273745 PROJECT: J-0-0.)•anl•0S•F-'2'i rX RST �A l.E�-//� FIELD REPORT NO: I 2 CONTRACT: -1 ou IJ S V LJDI–=^ KI ARCHITECT'S PROJECT NO: 8�g0!L DATE 11 Y-FSg % TIME 2.�bF/A WEATHER I�%s, TEMP. RANGE Q•SjSv: EST. % OF COMPLETION [Q 70 . CONFORMANCE WITH SCHEDULE(t, WORK IN PROGRESS PRESENT AT SITE pluln..bt n� ' hcrpj;nj400r5 andfy-e�imcc,. G n1�3o�- bese:me✓k- OBSERVATIONS. ALQ5?• to W -�Yre.lot-r �,,., 2N)o Ito he..re �,t.irvcQ6Lkt!WccXc4 uh vSepC14rg.. Owner ' excerloY a17�ldonei{' cb11YNn!AA r MOLaa 6n `ear+ o-f- 6lr•1p1—Tyoer'S �Y ern acl o{.e • f rarnln� chd `�trtypin!�, ve-r • loot Soc�m�4ti emr�cl dvS�► p In `iaOwn k00%e' u A 1-lar c5n ISr I"• L''AyeF 'r upf/ 5P00770AJ5 A-r- rimg : l -2 3 f 5 !v 7 6 IO / .E.vv PY.v ITEMS TO VERIFY 2 �s1" Uerl 1 er&_tjCdj Lty Of• %q iI( 9�Z5g„o 1-�F OQj N,tIK��i,� lM Li �� _n,4- 6 • INFORMATION OR ACTION REQUIRED 4QX1 hcnt) 4- c,}-(�, exny r Std•, - o , sa�b tom, w E r►c� Vows T slwo l c( 5 ATTACHMENTSLS ' PIeO'eC.-C2jl ry.,G C•-'C' g2'7-3746• REPORT BYAA90" 191. Sac"7— AIA DOCUMENT 6711 • ARCHITECT'S FIELD REPORT • OCTOBER 1972 EDITION • AIA® • ® 1972 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE., NW, WASHINGTON,D.C.2OW6 page 1 of / pages n, UWNPP TAVID F lN1C'iFii ARCHITECT'S OWNER ❑ ARCHITECTS & PLAINNERS ARCHITECT ❑ 11 OBER STR' T _ FIELD REPORT CONSULTANT DEVERLY, MASSACNUSETs AIA DOCUMENT 6711 FIELD ❑ ( [ 9"3745 PROJECT: m vi"ir-?- ST sAup-/A FIELD REPORT NO: t CONTRACT: ARCHITECT'S PROJECT NO: $�}Orj$1104 t DATE 11 IA" f-•r Jap%TIME Z:36 PIA. WEATHER `•I-6AA. 'L•7 TEMP.RANGE 117E 4. EST.% OF COMPLETION 1Z+o % CONFORMANCE WITH SCHEDULE(t, -) �F, WORK IN PROGRESS FP.�e/NN '4' 4 PRESENT AT SITE ;zo%w s cn+m woit"-KS• ��""-� lIJ i�C.0/A.Fg• \YcSf`�.6No.� oY� OBSERVATIONS srrr-s • t n1t'�21�tT 1? �l�I�jJ14 tiu _'C' D aovT' Go/rl.P Lem itrtA' �( e �c� rads �i* ve-- foeSfl jMq�!= Ilk 1 rce,. 15 owWAS4W-ket A/�tx�e�o No tNb�l�oi -36r"'c k e:>n U"rr-N4 ITEMS TO VERIFYy�^I.f?G1 a�Js�SfZCy �+' t�e,�ud' In 1-Ilio.. K•h'IC%� Sto.ar rYt¢8 4"& � t300012 TO +aE VSEO IN �YlNGow eN �� FCt INFORMATION OR ACTION REQUIRED ATTACHMENTS REPORT BY: AA4EM-4 h(--5oe w-A r AIA DOCUMENT 6711 • ARCHITECT'S FIELD REPORT • OCTOBER 1972 EDITION • AIA® • ® 1972 1 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE., NW, WASHINGTON,D.C.20006 page ` of pages DAVID F. JAQUITH LETTER OF TRQNSM rrTh L ARCHITECTS & PLANNERS 11 OBER STREET DATE: JOB NO.: BEVERLY, MASSACHUSETTS 01915 �=o , b�Sa 96 PHONE: (617) 927.3745 ATTENTION:D�uI F�r�Q2_I TO: RE: I S \K 1 t�1�g R ST. ✓Art cis//r �V'11� lF�rt2-12.IS '�v+l�ItJC, DGY�T: WE ARE SENDING YOU: ATTACHED G Under separate cover via the following Items: ❑ Shop Drawings ❑ Prints ❑ Plans ❑ Samples ❑ Copy of otter Change order ❑ Specifications � FIQPO I`Lt' COPIES DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: ❑ F'or approval ❑ Approved as submitted ❑ Resubmit copies .for approval L l /�For your use ❑ Approved as noted [3Submit copies for distribution B"L requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19_❑ PRINTS RETURNED AFTER LOAN TO US REMARKS: COPY TO: `E— r�r-rr �_ 0 enclosures are r=4 ed,-please not � e usTiTon�ce SIGNE a a 6 MICHAEL E. O'BRIEN LEONARD F. FEMINO CITY SOLICITOR 'L 4 ASSISTANT CITY SOLICITOR 93 WASHINGTON STREET �°O+ yD'� 93 WASHINGTON STREET and and 81 WASHINGTON STREET CITY OF SALEM ONE BROADWAY SALEM, MA 01970 MASSACHUSETTS BEVERLY, MA 01915 745.4311 745.4311 744.3363 921.1990 Please Reply to 81 Washington Street Please Reply to One Broadway October 26, 1987 William H. Munroe, Building Inspector City of Salem One Salem Green Salem, Massachusetts 01970 Re: 15 Winter Street Dear Mr. Munroe : Please be advised that after reviewing the material furnished by Mr. Suldenski and after your personal inspection of the premises, it is my opinion that the use of the above entitled real estate was a lawful twelve unit use prior to adoption of the Zoning Ordinance on August 27 , 1965 . Accordingly, it should be afforded the protection of Section VIII (E. ) of the aforementioned ordinance relative to non- conforming uses and, thus, rehabilitated use as a twelve-family is permissible. jVermy ygurs, Michael E. O' Brien City Solicitor MEO/jp 21 March 1988 Mr. David Harris Salem Building Department One Salem Green Salem, Ma. 01970 Re: Renovation of 15 Winter Street Salem, Massachusetts Dear David: We have inspected the rough at 15 Winter Street, Salem, Massachusetts and believe that to the best of our knowledge the rough inspection meets the Massachusetts State Building Code. If you have any questions please give me a call. Sincerely, David F. Jaquith R gistered Architect cc; John Su n i 27 April 1988 Mr. David Harris Building Department City of Salem 1 Salem Green Salem, Massachusetts 01970 RE: 15 Winter Street, Salem, Massachusetts Dear Mr. Harris, On April 26, 1988,1 reviewed the work performed by John Suldenski on the above referenced project. I certify that, to the best of my knowledge, all the work performed by Mr. Suldenski on the project was executed in accordance with the State Building Code of the Commonwealth of Massachusetts with only two exceptions. The boiler room door and frame assembly is not UL rated "C" label door and the provision for combustion air for the boiler has not been provided. Mr. Suldenski will be sent a copy of this letter and I am sure he will take the necessary corrective measures in a timely manner. As you know, in a partial rehabilitation project such as this, there are many gray areas in regard to the applicability of certain aspects of the Building Code. I feel that Mr. Suldenski has,in general, taken the necessary measures which provide for much greater public health and safety. If you have any questions or comments. please feel free to contact me. Best, Thaddeus S. Siemasko Registered Architect l 1 JAQUITH & SIEMASKO, INC. J ARCHITECTS & PLANNERS 8 ENON STREET,BEVERLY,MASSACHUSETTS 01915 J I The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY (f !1 Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM l i Revised Junuury f �I Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section F fftcial Use Only Building Permit Num r: J I D to Applied: Signature: c Building Commissioned I for of Buil Date SECTION 1:SITE INFORMATION 1.1 PI.roperty Addlreu: \\ �+ 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownerr of,Record: DC_ fof. m-r //F4f`i 5- Name(Print) ss Address for Service: Y clrGT�lY�9n /52 1 -t-g�— 01$a yr{�S Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK(check al apply) New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) arl Alteration(s) ❑ 1 Addition ❑ 3 Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': a 2r,7 r , r -o� Jt I� SECTION d: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S O'Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S a. Mechanical (iIVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees:S a Check No._Check Amount: Cash Amount:_ +/ 6. Total Project Cost: S o2Sr OCR ❑Paid in Full ❑/Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) D-2403G ff-- �/---2- I.icense Number Expiration Date Name of CSL-I lold S4Zr1J11-*1 Ust CSL rype(mv below) rs Description Address %/ 0 1) -i-Inm-stricted(up to 35.000 Cu.Ft.) estricted 1&2 Family Dwelling M Masonry Only RC Residential Routing Coven.ng WS Residential Window and Sidi r Sl n 7-�L SF Re-idential Solid Fuel Burnin Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) / , 2-c� tQ ts,,,�J Registration Number int:Comeany Name Q0IIC R s stnut" J Address Expiration Date Signature Ul-ephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.11 25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached? Yes ..........0--' N............C3 SECTION 7&:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. signaturc of Owner Date SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION S �P",Jj.as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf Print Nam �--1gnjturCof/0wJcrorAuih�A I Date -LSixned und�r IV pains and penalties of perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will Mul have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11016 and I IO.R5,respectively. 1. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. -Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SM-E.`I, ANSSACHL-SEM BuiLDLYG DEDART1EINT 120 W.tiNINGTON ST RM, 1r FLOOR TgL (978) 745.9599 FAX(973) 740-9646 KIMBERLEY DRISCOLL THOE W ST.P�gJuti MAYOR DIRECTOR OF Pl:91LIC PROPERTYAUI DNG CO-%L%RJSIO-%ER Wurkers' Compensation Insurance Algdavit: guilders/ContraCtorslElectr(c(nnsiFlumbere > a Ileant Information e all- NaineIguame+sOryrnrarionlrahvndud) `1�- vim ��^"yb �M C L C Address: H n,-k C1 City/StatdZip.�Y✓/�T� One N' ,%re yo a employs'Check /ropriase has: Type of project(regrlreft I. I am a anployer with 4. ❑ I am a gmenl contractor and 1 6. 0 New construction employees(full an pan-norV have hired the adt•carnractora 2.❑ I am a soM preprietar all portneo- Iisted an the attach"Aida: 7. �Remodeling :hip and love no employe a Then sub-contractors have V. Q Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition INo workers'comp insurance J. ❑ We are a corporation and is 10.0 Electrical repairs all additioos required.) officers have ereetcised thekt 1.❑ 1 am a homeowner doing all work right of exemption per MOL 11.Q Plymbing repairs or additbro myself.[No workers'comp e. I3Z 41(4).and we have no 12 repairs insurance required.]t arnpkryees.LNo worker' comp insurance required.) _ -Any APPYaae tti aaocha but el mow atw fi0 w Ina ratio•babes lawiq tWr warMn'ownywe060 PDbL7 irrdwntrka 'I I.wwawrew who ruin,%this anldwn ieelodua'MY ara Joint A oak and thin him arraib asroed"mar Ad"M a new ambvil indiraiq nwR i'.mrr _wM nhr cheek iW boa mull arlathd an 3"IiWW.iat arwiq tlta MOM d fill ab4w4twa lad that crarbea'raq.PWKs isrernrtloa /use eve rWp/syo rho b yrorldGrE rwrAers'cowpwsedsa Insrrsstes jot sq erapleyoes QNow b rAe Pe/lq rwd�el sGr injornrWlaa Insurance Company Name: Policy s ur Self-ins. Lie.N Expiration Date: Job SireAddnse: w''" kci cSh--(L Ltle+2.([44 City/StatrJZip: 5�y. e� 4* ,%clock a copy of the workers'compensation policy docimelse pop(showing the policy number and expiration dote)6 Failure to secum coverage as required under Sectloo 2JA of MOL a 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a tine of up to s250.00 a day apinst the violater. Ile advised that a copy of this statement may be forwarded to the Of0ce of Invcsugations of ilia MA for insurance cowrap vc:1169atiaa. 1,10 hereby C Air the ins nd yenahles a/per/uq that Ad,informarlow provided above is true and averred P. a J. _ LA)ihcr . Sd o,0ot wrife in this area,W be rerny/rtd by City all telww a//lridt i n: _ PrrmiN.lcrnse e__. hunty"circle line): Ileallb 2. Ruildlne1)epirimcal ).City/rows Clerk J. Electrical Inspector S. Plumbing Intpecter.rton: _ . _ Phone e: CITY OF SALEM j PUBLIC PROPRERTY PDEPARTMENT .1'.1 G: MI hl '•slw '•11 I'FI:',;a•Ni:,iNs •IC\s:979.N47946 Construction Debris Disposal Affidavit (required 1'ur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit !f _ _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: �<J _cC C III me of hauler) The debris will be disposed of in L \� . (name ut aci tly) (address or facility) I�Il:llur If f 'r111It al7Nhl'a 9V dale Irlu i.�l( :w DDNYYY ACWD CERTIFICATE OF LIABILITY INSURANCE DATE 09/ 2010051/2010) 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 INSURERA Nautilus Ins Co. Serven Construction Company LLC INSURER B.Guard Insurance 14 Griffen Terrace INSURER C'. INSURER D. ,Lynn MA 01902— 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 MMIDDIYY DATE(MMIDOM) LIMITS A GENERAL LIABILITY NNO07523 03/16/2010 03/16/2011 EACH OCCURRENCE a 500000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SOOOO PREMISES Ea occurrence a CLAIMS MADE ❑ OCCUR / / / / MED EXP(Any one person) $ 5000 PERSONAL B ADV INJURY a 500000 GENERAL AGGREGATE $ 1000000 GEN1 AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 1000000 POLICY JECOT LOC / / / / NOWND AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) 5 ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) a HIRED AUTOS / / / / BODILY INJURY NON-OWNEDAUTOS (Per accident) s PROPERTY DAMAGE (Per accident) 9 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT s ANY AUTO / / / / OTHERTHAN EA ACC a AUTO ONLY: AGG 5 EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE _ 5 OCCUR CLAIMS MADE AGGREGATE S a DEDUCTIBLE / / / / a RETENTION $ $ B WORKERS COMPENSATION AND SEWC131747 04/01/2010 04/01/2011 WC STATU- OTH- EMPLOYERS'LIABILITY TCRY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT a 100000 OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPLOYEES 100000 IT yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I a 500000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS r ATE 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 Brian Heath FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 15 Winter Street INSURER ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE(2001/08) ©ACORD CORPORATION 1988 ).os Page 1 of 2