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28 GARDNER ST - BUILDING INSPECTION 25�% o0 The Commonwealth oftbiassachusetts Ca,u. Ytu Board of Building Regulations and Standards 5 � W Massachusetts State Building Code, 780 CMR 1' ed,lk rr22011 Building Permit Application To Construct, Repair, Renovate Or Demolish a JJ One-or Tivo-Family DiveUing �Ti This Section ForOftial Use Only.. BuildingPemiit Number Date A � - ( "Building official(Print Name). Signaltrre' • : _ - Date - SECTION L SITE INFORMATION"` ~` " 1.1 Pro�tertyM d�es� �-Ss 1.2 Assessors Map&Parcel Numbers f� I.lalsthisanacce tedstreet?yes no 1161apNoinberi ; , , t,::tth" 1.3 Zoning Information: lA Propertyj.Dlmensiaas tr,rhl `. )t) Zoning District=' Proposed Use Lot-Area(sq R) "F7ontoge(R) 1.5 Building Setbacks(R) . Front Yard - - Side Y" Rear Ywd - - Required - Provided Required - Provided. .Required .. ._ Provided 1.6 Nater Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information- 1.8 Sewage Disposal System: Public I Private O.- Zone: Outside Flood Zone9 Municipal O On site disposal system O -. SECTION Z:"PROPERTY ONNENSFIIPr ' 2.1 Ognerr of Record: / �DGI'S'w �ifli Z4 I .�cs��"�-7 5me(Print) / . . _ City,state,Zip - ITh r�li9"Prr Sf . (al (!0 0070 No,and Street - Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED NORK=(check all that apply)`" New Construction O 1 Existing Building 1 Owner-Occupied O -Repairs(s) O Iterations) O 1 Addition O Demolition O Accessory Bldg.0 Number of Units_ Other Spedfy Brief Description of Proposed work=: g/ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and,Materials) y 1. Building g 1. Building Permit Fee:s" . Indicate how fee is determined: 2.Electrical S ❑Smndard Chy(fown Application Fee- O Total Project Lose(Item 6).%multiplier s 3.Plumbing s 2N Qther Fees: S 4.X hanical (H VAC) s List 5.M1lechanieal (Fire Suppression) s Total All Fees:s Check No. Check Amount: Cash Amount: 6.Total Project Cost: S .� ❑Paid in Full O Outstanding Balance Due: l M rte- t UE�D iJ STA S SECTIONS: CONSTRUCTION SERVICES &I Construction Supervisor License(CSL) T -7 ?1 -7 of/Z LicenseLicense Number Expiration Date" f N:IfileofCSl Holdei Eric W.Palty I.IstCSL' (see below) i HIM'Q'- d Type Description No.and StiedSaIeM MA 01970 U Unrestricted Duildin a "to 35,000 Co. Il. R Restricted I,q<2 Family DvveE Citylru�m,Swte,ZIP -M Maso - .. RC Rooli Covedri WS Window and Sidin SF Solid Fuel Burning Appliances Tele hone Email address D Demolition mproembet:nTt17CAot1n0tB,ctor HIC) tCCYtS.2 Rcgistered.11ome IZ )' HIC Registration Number Expiration Date HIC Company Name o. _ � Email address No.mrd Street Ci /row State ZIP Tel hone SECTION 6r WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.I::.e.151 g 2$CM Workers Compensadon Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will,result in the denial of the Is§uance ofAiltintilding permit II, Signed Affidavit AttnchedT Yes.......... No...........D SECTION lap OWNER AUTHLPX 2.A10N"TO BL.COMPLETED.WHEN':-,;'" 01VNE1('S AGENT OR CONTRACTORAPPLIES FOR BUllibiNG.PERMIT i,as Owner of the subject property,hereby authorize ev's-G Palm t act on my behalf,in all matters relative to work authorized by this building permit application. 9 n Date Print Owner'9 NaM944ftlecumilo Signature) SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION 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 best of my knowledge and understanding. E� � D Print Owner s or r udrorizcd r c Icctronic Signature) Date NOTES: L A n 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 r r have access to the arbitration program or gumurtty fund under VKG.L.c. 142A.Other tmporta—o-tnforma on on—Ui"e HIC Program can a ou www nmss eov'oca Information on the Construction Supervisor License can be"found at AAA• �ls " t 2. When substantial work is planned,provide the information below: "total floor area(sq.ft.) 3 _(including garage,finished basementiattics,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 9qu:ire Footage"may be substituted for"rutal Project Cost" mm s�"'un�maotsafineyam'sxnme7mpmae I E Ic uor Ma M�r>• °mmr✓ems sr¢ul iaavi�Hn"'Engr. O15ceofC¢mvCm�sA®ffearoGsuainddegto�Ha�moR7�egttdpavd�w®fPCoB¢as�t'amtetgaP�Sn�e_O1�Im4 "o" s-d2tsA?.hatdt7na3si75[ombttaimndauwdPeshntfa^dA wy617m1734,8 18 $ m rl ara omxxbv2Sthe �Oe7iBUF/tte�jr�aJ�{p�18dQII �'03ififlr20P�OP[il8210ii Street Addrea(da ao aPast 016caFae , Ciry/{ d CState J�i AvMue �a! �Pa� Dam�Addnss(mat' 1970 Erxtdug Ptd- Cih75eav 7-- G/0. Qt77 Sole F+P Code Malting Sad+ Ridifiemt6am4:, Bmmm Pmrae Fatrcni F.mP/oyrrIDarSSI.`®thY rwrm�c ani �4 mar�ur�,rcesz r� yzG _ 77ie ronL-actor¢ za fa do lteeA llliggwarkfarCoeH L /r+ (Drsciee in dehtl lir xwk tucoap7em/7,�aPc3.Sy�the4R,tcaQmdgrrdey 1.�/�w� netsra[SNbe¢ed.taadd'rix/�ys6'f ) psecered bptho ma bmidmSPnmtiSatnrequired Pmos¢d SYartand The a;tbehameovra�agent hea ' Compohon SdtedWo_ FppawiDova g� cs aosy^e 11*OEM iw�„ pdae'odowlessmeumdvt�b�dthecwt-,atots c=_c4ueed -�aMoGvematyFD©® 6 ,3/ [:SUv_r:37�i2d'Ffty-LL3 �+1°Vl9fiD505 Ihte:�dt® '°nwrxm'm71 berm wnasctW�vorlc Total Conrriu?:dmand era a.- $�/ e ®�weted iWdcvn7i bei'msfanG¢11Y camP76W. Th.Contrauo,-a�;n Bsm�m�i'LeaNe '°d:,f`a°'it'aumatedaland)ah-S) abovsfoa t8em�].� c i Pa}Tieats twill bemadencw °L —lo�_� rd+g o6efollovdagseLedul� ' upw si�dng oaau'ect(n¢tta c'xa:diCa ofthem:at cwbaatpdae or dtewstoFspecinl onler S of/ frums.wldchetaisgrcatc) �'f�� � °r'arm campledan of 5by—/—I— Or ��j�� upw wmaletiw oF�_�- ! / S-�upon comeledw oFihe coawry p/67"3 UPJ (fsw i'nddds d®andmSfnll PaS'm eat w Taa PoNmvingmmyi;,F�am�watba cwaamis pletedto hnlhpmt3lssztisFacdan) - atdacdnefemilmeam.�-,-+cvrrba -tdf to nct fiNeWmplyW�aaN¢(��) a%der @+'s:f)ledudiag Jifiamcf¢rgc; n P9Eaw S 6c far xhichma„3 b: a)w�etidra arde., r., ¢dattn'tr+Yrnvu.-eq,trr:3 bylFa a®tr xab:Iaa wud: .esiv-.dvaco tomes Zb at- iedmor(b) t...bd�Y ofrmy jf Pa¢nt arr�°mmadav�lmel - unn -ez nn Snbconfrnerors-The nt•b^^en`nmgy trr R:emntrrc}°A L�(;:°f�; P'-nS)sWremttn„etor• �o-ie`m'a'aesco he�tetYr.�oaable" 'c rnn nrt6nac�nt,m,cxtr.-:crate m¢tcri is 3rd mb rnrdhi �r�eemn�- laeeantr�tar �a7epon oFtbewadct7smPedm l:n tb_ry,.,eawl Yal�sm hemldyrmPonaNeior�cs oftbeanlnasoFmiythird ioanectLaD notimpiythm aa} oradtero¢amea[bccomaabhrdm3cmGattaadslavi�( F.9rmmhmaFl m[n'oaasraorsfill canlmcL+ enrafal7}'hafore sipviug this contract � tYmteaYl�s6eeaplaredw drereddmce cssadieniisenotedmThia lbisdncumeas the Reviawtfiefnitm•(mgcv6a�avdnotieez ° i?a¢'t be pn�Wed iany��gaStyema�Tz?;e i�eis tnretho c¢nr rh-c a*rlidHome' hmeo:�daadfid(Y�d�dii Ask . a�bcennacEosmhn:egish'redritb ihCD, enrCw�.gnr.esss¢ygon.roelav,4 mcifsemndmgisnoeiear . Meisratioa b}+wdtingolheDiriff"te:ID—ofbmmelmpravemem Cowutcs "W mosthomeim2+avammtmovactarsmd � Dc�dtecwtragar'rava' aza,geamii7t],Bw, ReSisa¢Na¢.Yau maYo4iiaeahaut sea a wry af¢`Sre¢fofh,— 7 ';`YlbcC®uactm'fo:bism, X216 o:hycaflmg 617A73-E7S7 or8D8�2S3ri7. ° I:n¢=:po¢rip;tsyda mm m"doctmeut Panyinfoapagw sotbstyoopnvnfnmw Guide to d!exoeeua-.F bifidp-=tend tue haoanant' v" °•arto r•avemrntCnana"ad Eh". raformadan w fh000 —Sdeoftuisiam:wde tac ¢pYofthcConsnmer emtrcor nttvrihis [l--tifa:hnghe�9gnedm<P1a2ad14 Iticd busiae�dy 7ouing Wes SWor""Mcla�cebyoN� man tea'` tnaw„IP),?vof5miaeq WovidadY¢aaotifythe gnxment See thnytn armed nhti�oF�e��arbyd.7iazty,natlasdma add6tofthe nMj NOT%C-LIT h� COMT1"q_a,�rL+a 5", -Ilatioaf�fotan 'rn�o;e=�,im15P1aoatim oFthisriSht ^�rl�s_crb:sn»na � t�.3vrC BICCs�S� �Slar Cwaantm-"s$ippi-,tam ry Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The sameright is M automatically afforded to a contractor,however_ The contractor would have to resolve my dispute he/she has with a homeownerin court unless both parties agree to the optional clause provided below. This clause would give the contractor the sane tight to arbitration as is afrnrded m the homeownerby the Home Improvement Contractor Lav- The contactor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this croaoract,the conuq��igllhe dispute to a private arbitration firm which has been approved by the Secretary oftEmFd'e'eonsumerAfTahs and Business Regulation and the consumer shall be required to submit to siicii" rtrati asrp#o7/dit�I�acitusetts General Iavrs,chapter 142-9. %1MARP, los. & Homeowner's S atute C c i rgnature NOTICE:The signahnes of the patties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is notsepamtely signed by the parties Homeowner's Rights A homeowaers rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(Le.MGL chapter 93A)maynot be waived in my way,even by agreement Howeve,homeowners may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits am automatically excluded from all Guaranty Food provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanldce manner Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty fur workmanship ormaterials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumerationof othermatters oa which the homeowner and contractor lawfally agree maybe added to the temts of the contact as long as they do not restrict a homeowttees basic consumer rights. Ifyou have questions about your consuaherfiomeownerrights,contact the Consumer information Hotline(listed below). Execution of Contract The contract must be executed in dmhcate and shouldnot be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in ormarked as void,deleted,or not applicable. One original signed copy ofthe contact with attachments is to be given to the owner and the other kept by the contactor_ Any modification to the origival contract must be in writine and agreed to by both parties_Contacted work may not begin until both parties have mceived a fully executed copy of the contracS and the three day rescission period has expired Accelerated Payments A contractormay not demand payments in advance of the crates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contactor deems him/herself to be financially insecure,the txtmhactormay require that the balance of fiords not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted wore withdrawal of fiords fivm said account would require the signatures ofboth parties. Additional Information If you have general questions ornmd additional information about the Home Improvement Contractor Law or other consumer rights,or ifyou wish to obtain a free copy of "A Masachuseas Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation - 10 Park Pura.Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at httm:/h:viv.ma�s goy/ocabr/ If you want to verify the registration ofa contactor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 03116 617-973-8787,988-293-3757 or visit the BIC vrebsite at him:/Awvrv.mm-atordocabr/ Go online to view the status of a Home Improvement Contractors Registration: httn://db.state.mnus4tomebnprovement/licenseelistasu For assistance with informal mediation of disputes or to register formal complaints against a business,rail: Cknsmj �omplaintSection ' Offteeih Attorney General 617-7275400 AND/OR Better Business Bureau 503.6524300,503-755-2548 or 413-734-3114 Vasim 2l-Im2r olo The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe (Business/Organization/Individual): Ir1"tIbmtt& l/�etlicfl[aattull,LLC # ct',,, Avenue Address: SsleFn \4 A '11970 City/State/Zip: Phone#: Are yo n employer? Check the appropriate box: Type of project(required): 1. am a employer with Z< 4. 0 I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. EJ Remodeling 2.El a sole proprietor partner- shipip and have no employees These sub-contractors have yees 8. E]Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions Iofficers have exercised their 1 I.❑ Plumbing repairs or additions ;.ElI am a homeowner doing all work per exemption of MGL myself. [No workers' comp. right P p 12.13. ther0 Roof r pairs insurance required.]t c. 152, §1(4),and we have no 1 employees. [No workers' comp. insurance required.] *Any applicant that checks box#I 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'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: Z-C4 r r G G+ Policy#or Self-ins.Lic.#: /+r6,2 7 O /Z 1 Expiration Date:�,// 7/nen Iob Site Address: �c� Ga rd el-e,- �7 City/State/Zip: 3-- le III Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). o secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Failuret s q g as well as civil penalties in the form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one-year imprisonment, p 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 certift under thepains andpenalties ofperjury that the information provided above is true and correct. J, = y Signature: :. (/ Date: 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#: rax 5eraer CERTIFICATE OF LIABILITY INSURA T_ 1 FIC TE D'O E IS ISSUED 0.S A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAYE HO DER�Ty[3 Wn CERTIFlCATE DOES NOT AFFIRMATIVELY'OR NEGATIVELY APREND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTtIE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERT CATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject b the Perms and contlitlons of the policy,certain policlas may require and endorsement A statement on this ceetificate does not confer rights to the certificate holder In lieu of such endorsement s- PRODUCER CONTACT EASTERN INS GROUPLLC ( NAME' 233 W CENTRAL STREET ! PHONE I No,Ex (ASC, tp FAX (A/C,No): NATICIC,MA 01760 EMAIL 22MLW ADDRESS: ;i INSURED INSURER(S)AFFORDING COVERAGE ATLANTICA }NSURERA: ANTMEAYEtZATIONLLC ZURICH INSURANCE wNCs COMPANY INSURER B: ii i INSURERC: 61 REAR JEFFERSON AVE INSURER D: SALEM.MA 01970 ' INSURER E: COVERAGES -. I INBURER F: OCEIRIFYT Ai THE POLICIE&pFOSUR4NiCEL SUPABFR- TEP ELpW pgyE BEEN ANV gEOUIREP.16Yr,TERM OA CONpp10N OF4wY CDIiTR4Cf ORREVISION NUMBER: 4FFORDEO eY THE POLICIES DESCRIaEI HEgEe165UBlECT TD �p /n ATO THE@ISUREp NA/Am ABOVE FOR THEPDUCVPERfOOMOCATEpPAp CLAIJAS. ALL THE TEgMS EXCL1151flD5PANO CON PIOTE3AVIpyppilfgrgpnBO 4YOlTHIBCEEMyg y9v� VE LTR TYPE DF e1SUR(WCE 4DD SUB POLICY�pATE PpLtGY EXP DATE L R POLICY NUhIDEfl (L�1AUDIYVYY GENERAL LIABILITY ) (MMApD1WYY1 LOUIS COMMERCIAL GENERAL LIABILITY CH OCCURRENCE CLAIMS MADE �OCCUq. S DAMAGE 7p RENTED S ( PREMISES(Ea occuvence) GEN'L AGGREGATE LIMIT APPLIES PER: ED FXP(Anyone Person) S POLICY 17PgOJECi PERSONAL&ADV INJURY S ®LOC GENERAL AGGREGATE AUTOMOBILE LIABILITY S PRODUCTS-COMP/OP AGG y ANY AUTO ALL OWNED AUTOS COMBINED SINGLE S SCHEDULE AUTLIMIT(Ea aeddenqODILYINJURYOS B HIRED AUTOS (Perperaon) S NON-OWNED AUTOS BODILY INJURY S (Peraccident) PROPERTY DAMAGE S LIAR (Per accident) UMBRELLA OCCUR EXCESS LIAR CLAIMSMADE ! EACHOCCURRENCE DEDUCTIBLE $ i � AGGREGATE RETENTIONS S A WORKER'S COMPENSATION AND S EMPLOYER'S LIABILITY $ ANY PROPERITO"ARTNER/EXECUTNE Y� U13-58270121-1603/2020 8270121-i6 WCSTATUTCRY j OTHER OFFICERMEMBER EXCLUDED? N/A 16 03rZ02017 �' ,CLEARS p It It Yes'Ill in Ind E.L EACH ACCIDENT Dyes, IPTION unser S 50D,ODD DESCRIPTION OF OPERATIONS beJmr i EL.DISEASE-EA EMPLOYEE S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICFES/gE E.L DISEASE-POLICY LIMIT PHIS REPLACES ANYPRIOR CER STRICTIONSISPECIAL ITEMS S 500,000 TIFICATE ISSUM TD THE CERTIFICATE HOMIER AFFECTING WORKERS COMP COVERAGE .ERTIFICATE HOLDER 4 CITY OF SALEM CANCELLATION 93 WASHINGTON ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES E CANCELLED e BEFORE THE EXPIRATION DATE-HEREOF,NOTICE WILL BE ELrD l IN ACCORDANCE 1MTH THE POLICY PROVISIONS, SALEM,MA 0]970 THE REPR --- } ri VE :ORD 25(2D1D/05) The ACORD name artd to 9n; are registered marks of ACORD 788820T0 ACORD CORPORATION. All rights reserved- : - CERigF9CATE O LIABIL6TY ONSU ANCA DA„E""�D°'YYYD THIS CERTIFICATE IS ISSUED AS A M)1T 1 11 OF 1PIFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOIf LDER.CERTIFICATE DOES NOT AFFIRMATII/ELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TH15 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;clan ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the polendor,certain polie'as may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerd(s). PRODUCER Eastern Insurance GroupT•Tl•I cgrnra�Construction 233 West Central St PRONE c f 800)333-7234 Al EMAIL AIC No ADORE Natick Md. 017;60 INSUR S AFPoROING COVERAGE MA{!;p INSURED - wsuRERAArbetla Protection Ins, Co- 41360 Atlantic Weatherization `I INSURER autilus Insurance Co 61 Rear Jefferson Avenue 'I INsuRERc: �� wsuneeo: Salem 1+8� 01970 INSURER E: COVERAGES INSURER F: CERTIFICATENUMBEROastsr 2016 THIS IS TO CERTIFY THAT ICIES OF INSURANCE LISTED W HAVE BEEN IBSUED TO THE INSUREDD NAMREVISIO ABOVE FOR THE POLICY PERIOD INDICATED_ N IMUR98ER: NOTWDTiSTANDING ATHE POLNY REQUIREMENT, BELOTERM 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 LTR TYPEOFINSURANCE GENERAL UAINUTY POLICY NUMBER MM11 EFF pOUCY uams X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 i A CLAIMS-MADE �OCCUR ;j 500042816 EMI$ aENTEO 5 50,000 X CONTRACTDPy L1AB1L1Ty '1 /20/2016 /20/2017 MEDEXP(AnYnnePerson) S 51000 X CG0001 10/01 FORM PERSONAL& INJURY 5 1,000,000 POLICY GEN' GATELIMITARI PER: GENFRAI GREGATE 5 2,000,000 POLICY X PRO- LOC :i PRODUCTS-COMP/OPAGG S 2,000,000 AUTOMOBILE LIABIUtt 1� S A ANY AUTO COMBINED SINGLE UM ALL O'AMED Es acCd.t SCHEDULED '� S 1 000 000 AUTOB `Y AUTOS 020015871 BODILY INJURY(Perparson) S `X HIRED AUTOS X NON-OWNED .I /20/2016 /20/2017 BODILY INJURY(Peractidan0 5 Pe TY AGE S AM X UMBRELLA LIAR X OCCUR PIP-Ba9e S A EXCESS LNB CLAIMSAdADE EACH OCCURRENCE 5 1,000,000 DED RETENTIONS 10,00 600058654 AGGREGATE 5 1,000,000 WORKERS COMPENSATION /20/2016 /20/2017 AND EMPLOYERS,UASI S ANY PROPRIETORPARTNER/EXECUIIVE YIN WC STATU- OPRCER/MEMSER EXCLUDED? ❑ MIA (Mandatory In NX) EL EACH ACCIDENTg DESGRBpsT�jON OFOPERATION$bouiv EL OIBEASE_Eq EMPI S B POLLUTION EL DISEASE_POLICY LIMIT S 00378614 0/1/2015 0/1/2016 EA PoLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEX; GENERALAGGREGATE $1,000,000 CLES(I eh ACORDt01,AddMonal Remarirs SdhWuie,Blndresparnis required) 1 CERTIFICATE HOI DER CANCELL,gTiON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SALEM THE EXPIRATION DATE THEREOP, NOTICE WILL BE DEi tvPRPn IN ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET 'SEM, LJp 01 970 AUTHORQEDREPRESENTATNE CORD 25(2090105) John Xoegel/SNE ISD2s Ilmnnsl n, ©9988-2010 Aan CORD CORPORATION_ All rights reserved. nrn Massachusetts Department of Public Safety Construction Supervisor E Board of Building Regulations and Standards Restricted to_ License: CS-087977 Unrestric93ed-Bwldings of any use group which cor¢ain Construction Supervisor less than 35,000 cubic feet(991 cubic mdeis)of Pe enclosed space. � n ERIC W PALM 3 HILTON ST - SALEM MA 01970 fl4 �'� � raiture to possess a current edib-on oftheMassachuselts C& - Expiration: State BuddngCodeiscauseforrevoca6nndrthisVicense- Commissioner 04/23/2018 Ops Licensing information visit imm-MASS.GOU/DPS t '• - License or re$iamlian valid for individal ese only . 1 .. _OfliceofConwaicrAffeirs&BodnessRepla6on before the expiration date. Iffo�dreturn t0- ^ iu ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business gegvlation YP T e: 10 Pa rkPtm-Suite 5170 142089 piratlon: W1260-1e- LM UabHHy Corpor - Boston,MA 02116 - ATLANTIC WEATHER17-40N LLC- ERIC PALM j blR JEFFERSON AVE - p - a'{'•`�-�""�— Not valid without sr mime SALEM.MA 01970 Undersecretary