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B-20-709 - 0081 BARSTOW STREET - Building Permit The Commonwealth of Massachusetts � CITY OF Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 0— Building Permit Application To Construct,Repair,Renovate Or Demolish a oOne-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 5ctE�41_1 Building Official(Print Name) Signature Date 1 SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Q�on s W s4 5)41�,11 1.1 a Is this an accepted street?yes no r Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ame rint City,State,ZIP I l Sew f ? •3/3 - YO/� No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units ! Other ❑ Specify: Brief Description of Proposed Work2::Zj 4 4, a// 05-e— 1,aA - 8/ow i CPI(ti low �3 I Ga 1 u SECTION 4's ESTIMATED CONSTRUCTION COSTS Item Estimated.Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: r. ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ �(�(}(� ,bd ❑Paid in Full 11 Outstanding Balance Due: JUL $ Am11:47 ro tWD t N s AS e TC� S SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date ♦� Name of CSL Holder Eric W. PalmList CSL Type(see below) U�`�' 3 Hilton St No.and Street Salem, Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R. Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin Q SF Solid Fuel Burning Appliances 7+, "(1 Y3 Insulation Tele bone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I 0 kq%Adant:e Weather,j,LC HIC Registration Number Number Expiration Date HIC Company Name or HIC Registffttl erson Avenue A1,710 1 � CC �L� No.and Street dem, O Email address 9&-9VY- M City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 IssuancSpKe building permit. Signed Affidavit Attached? Yes .......... No...........1 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work uthorized by this building permit application. M C a�{l <<r9 4,14 1A.W-1 y- lap Print O ner's Name(Electronic Signature) Date SECTION 7b:OWNEW 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 an accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.g_ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,fmished basementlattics,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"maybe substituted for"Total Project Cost" f CITY OF SALEM, MASSACHUSETTS J BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR F TEL: 978-745-9595 K OERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING CON MESSIONER Construction Debris Disposal Affidavit (required for all demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40,S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) s 0 6,�T t (address of facility) , f Signature of applicant (today's date) Home r, revemment salisffes an bas , ample rojmt , bats �°fthesta>tseamslmmm'tan D C�mwGuidettEr, eeca An3'P eat 1:0arI.aw(f�1 ii; I ,fRt sarsIImcarAi;i p,md�az�ov=ev"bat'o,, gto pig memtgT°y�entsshould nottitdtrdestaad i0 4etbrgga R atr°a's;Caasmneiinfofm;di�warLOnyom•�id�Yoamayay9am�°btaiu2CWQf°A 1I,2#OLpR� Eatlinaat62T1373,g7t;T ar o-�g82$33T57 ozoa g the e C® Namae a• 04 t;7BNOR, street A - dnnotuseaPyrta�&� l . C!Dirona O , CoaOr�etor! $ •as ' SCae apCcda Husla ( = ddic�s � rnard� DagtimeFltoa A (y t, P 197Q�- Cityl3•oyro Mailing Addfmmm tiereet above) state; apCade B�Pkone „-. 117amer' .NmnBs L-air.7Um1L^Sa�rl^� -----•- ia3-NC3? 4'Ite won_ tractoraY�fudotite t tDescnheind-tailih--wmkto f°t6 gwOTk for LbeHb /coiaptetcyt aPs±ifi+nSthef}�-.kmfl,aadmadeo (`v� •� s( W (�• n made of t�ials W b:�O rued,rse.+ddIi /1 t J i,J^ .�G��rt tp� _ ../l 4 w i/S t and u&ada��-Tnefoltoangbar7dia / s�in2dblthecoatraatnrast;i hpatmitsarcrtq ps,�gosedShun (0svfogs Who Secure their aaeavmfesa attd e e�e9t4C7e>��s�MeCL ct��F39�t5e� betdherdtotmtesso�ttey��-Te1'efotiosvmgsCherlalea� J h er✓e a f s 2t�� a a04,ED13 ®3sof zcaahactox'scemtral�H . .. atewh -� rwMba&cOnftctcdwvdc , P eC on a dl'aee2$bEyaie Dale irzc ed want vl be sobs antiailY leterL Perorrtttheivo , ,comp .. finzti tflert>:t�alaad7aboe F4,mcatswilibarode tathefaU m��cvemrthettizl� �(� OV 3eb �g,ahadOle: (t, lkmm sing costa (oat ro afihe ro a]rnatrist the cast ofspetl order b3' z or/ or Upon completion of ` tc6eir�y4 gnat ? t'Y j totJL(—�J upon ecmiiictioa oftkeconbp` T-acfollc-ingiaa�-„1/ "`(laYfnrbidsdemaadat _ gfaltp��eatIDo �fnrt Lha iQlp b=spcaai § _ , +. C3a$2rd35 olItobothpmVsp_ti�cdoa ordmcd ceat+a-red H , to meet th,.cainpi�a,7�citedat�)ems fit a:de; - ��--- to id£ ) PtGai$:(°)lncladingalt. for not t��('°)Tarr.-R.•• � tvhicli must&:�?of(a)6+e tki d oftly fetal watrrany�F�cc ar paet ttke actual re9arsxf by W3 ea x-aaJ ordamd in advai atr r?ar heFote w i;ars Y;srhazins may r.11-jn -isa lOmtompletioaschitte � G?t+tpmeafarcrttommadeerial Subcontavrtor-hainhreide tMsarrs irn ntrS�m.i nao esc�itri-�rotLrafacrtoii caatrarrPmrycon �a nt tgena�arrzfvmr trtJhl�3blrecon sesno4aolfr � ° tIIcampieaonafnew nmatetialsndtar haa- Y ��fntiw_�at�erl connrrectR �zesiobe�tei t'` �eyaftke atiaasnfaaythlrzt�•ocz-IJpoGsig �ads do Y FmisFolef-ailPayzatnto all—sub ca!fi babe, fog tmplpthatnit;lieuarotbers t dm eaa , actor:far r1 3 IT=underiaYr. &uaig tins caotuct. !�acad as the Zlnt= eir�ise muted tuft>;a ibis dacaroent;tbo ° Baa't bep •r j >ffidatce Revlerit}iefollcwiagpn8mtsandao8ias 4al'. esuathc tttasigingth coaaac�i p+m�to.- �adHame- itmefatz2daitdfull;>nndess�aaiL 9 onsif gisnaciear. i cni s to be mgastW d tsztb fhe ent nt2aorP,eastr fan T- Ask arsh somet>ziA �soatioabyw�� Di2ctorof$o,ne ue,taw. ° Daesthec_tr Stoffier�,�tara'tilP2ii P1- lDQ mtCotmactrir �it►m-mosthntaeimPrarremeaLeo ec a Ca;+ ctar n,z m nee?A Roam 5170,BO-S.a may in aaactats aad �sn'�aa.Yau a darn•��fofn�r� �iiactoria:itis�,-tatmcecamp 6z orbS'ca%g617473��g38�?53-3�57 lnasyotirrfg$tsrad, dacum Y aimaffonsolhLhejtojWT, atYoccaztw Guide toineiiomei,y��c�ioi7itirs. eidIiormannnthcrzvtusesitteoftbisibrmaad pnl-umcover-„ge,or�:to Piayemert Caattactar You ma'cancelt;:isa getaco ofthcConsitmer contactor in writ q teatifitirIsbe=s, Mirabsinms gotta laeraaut office arii1r`place ot'sa , othth�the caatr�ct d.3 at7oumg the silPtiag rdiamy mail of laic c rh�rhe p �bY'tetn mPeof ar ceded ycc aotifjrr§e ` ydiednatic�aftnce!)alioafwatFiaaa 'notlaierthanmirinightthe „ ARB .r aPlaaatioa oftitiS ng'nt_ r 1 C t WtY q°a fr t 1�, fi '!� Cj$S4 - . �L-ptb 1�OIDWp. -fig$i J T • _ i 5 / �O?ni?aCjWS$IgtjieaECi, Date i i Contractor Arbitration •- ' The Home Improvement Contractor Law provides homeowners with the right to initiate an arbi rition action(as an alternative to court action)if they have a dispute with.a contractor. The same right is not automatically`afforded.to a contractor,howev"ei-. The contractor would have to'resolve any dispute he/she has with a homeowner in court unless .. both parties agree to the optional clause provided below.This clause would give the contractor the.same right to 'arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. . The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute = concerning this contract,the con to e e dispute to a private arbitration firm which has been approved by the Secretary of tEj.eF1 �31 Aonsarrser Affairs and Business Regulation and the consumer shall be required to submit to su6h'arbitrahF j6jnWW§achusetis General Laws,chapter 142A. Horn er's S gnature Con ac s .ignature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is notpioperly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described In a timely and worlartanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. 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 enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be'executed in dualicate and should not be signed until a copy of all exhibits and referenced documents have been attached, Fatties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired; Accelerated Payments - A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure, However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the signatures of both parties. 4 Additional In€ormation ~ If you have general questions or need additional information about the Home Improvement Contractor Law or other- consumer rights,or ifyou wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information-Hotline Office of Consumer Affair and Business Regulation IO Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,808 283 3757 or visit the OCABR vmbsite at httn:/h«%nv.mass.aov/ocabr/ . If you want to verify the registration of a contractor or if you have questions or need additional information specifically ' about the contractor registration component of the Home Improvement Contractor Law,contact: Directorof Home Improvement Contractor Registration „ Office of Consumer Affairs and Business Regulation, 10 Park Plaza,Room 5170,Boston,MA 02116 - - 617973-8737,888-283-3757 or visit the HIC tvebsite at lid:/h«vtiv.mass eox,/ocabr/ Go online to view the status of a Home.improvement Contractors Registration: httn://db.state.nia.usiibmeimprovement/licenseelist.aso For assistance with informal mediation of disputes or to register formal complai=aaninst a business,call: r Consun omplaint Section - � a - Of c Attorney General ' a 617-727-8400 ANDIOR Better Business Bureau 508-6524800._508-755 2548 or 413-734-31 i4 Version 2 1-I I/TV2010 The Commonwealth of Massachusetts t Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114 2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le"bly Name(Business/Organization/Individual): Abli is Weatherizadon,LL 1 R Jefferson Avenue Address: swe n0170 City/State/Zip: Phone#: appropriate box: ArA�youemployeO Cbeck the a roType of project(required): ployer with employees(full and/or part-time).• 7. El New construction 2Q I am a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t , [] 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. [will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.instaance.t • 14. Other 6.Q we are a corporation and its officers have exercised their right ofexemption per MGL c. [� 152,§1(4),and we have no employees.[No workers'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. tCont mctors 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-contractots have employees,they must provide their workers'comp.policy number. I am an enptoyer that is providing workers'eom pensaion insurance for my employees Below is the policy and job site information, d I Insurance Company Name: /,/ l�Cc..,1 ZL✓1 I c 5 _ Policy#or Self-ins.Lic.#: �J ` �z a ,,.. Expiration Date: Job Site Address; 54� /W17 O'l,9 7 t „�,�� .City/State/Zip; , Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance i coverage verification. _ I do hereby certify and pains and pens 'es of perjury that the information provided above is t5r a and correct: Sianature: . Date:- Phone 22 7L 2V q`5 Y3 _ 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 S.Plumbing Inspector 6.Other t Contact Person: Phone#: TEOFAXPI GMT 3/18/2020 11 :20:32 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDlYYYY1 TkQ,QeKTIFICATE 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 FICATS HOLDER. IMPORTANT:If the certificate 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 and endorsement. A statement on this certificate does not confer rights to the. certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL ST (A/C,No,Ext): (A/C,No): E4ML NATICK,MA 01760 ADDRESS: 22ML'W INSURER(S)AFFORDING COVERAGE NAIC III INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHBRIZATION LLC INSURERB: INSURER C. INSURER D: 61 REAR JEFFERSON AVE. INSURER E: SALEM,MA 01970 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,EXCLUSIONSANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS, INSR DDL WRAPOLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE NSR NVID POLICY NUMBER (WADDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY PROJECT a LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY OMBINED SINGLE $ ANY AUTO IMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) ROPERTY DAMAGE $ Per accident) UMBRELLA LIAR []OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTIONS $ A WORKER'S COMPENSATION AND X I WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB562T0121.2D 03/20/2020 03/20/2021 LIMITS ANY PRDPERITORMPARTNERMEXECUTIvE NIA E.L.EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? MN '(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000 I yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT. S 500.000 DESCRIPTION OF OPERATIONSILOCATIONSNEMICLESIRESTR(CTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR450ITP SALEM,MA 01970 ACORD 26(2010106) The ACORD name and logo are registered marks ofACORD 19884DIDACORD CORPORATION. All rights reserved. ACORV CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) `� 2/25/2020 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(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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Steve Eckles NAME: Eastern Insurance Group LLC PHONE (800)333-7234 p/cNo: 233 West Central St -MAIL seckles@easterninsurance.com ADDRESS: .INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURER B Nautilus Insurance Co 17370 Atlantic Weatherization LLC INSURERC: 61 Rear Jefferson Avenue INSURERD: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER:HASTER 2020 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 ADD UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE [i]OCCUR PREMISES Ea occurrence) $ 50,000 X CONTRACTUAL LIABILITY 8500042816 3/20/2020 3/20/2021 MED EXP(Any one person) $ 5,000 X CG 0001 10/01 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JEC El LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Employee Benefits $ 1,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1.,000,000 A ANY AUTO BODILY INJURY(Per person) $ A O X SCHEDULED 1020015871 3/20/2020 3/20/2021 BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident) $ PIP-Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3 000 000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED I I RETENTION$ 4620091948 3/20/2020 3/20/2021 1 $ WORKERS COMPENSATION PER T AND EMPLOYERS'LIABILITY y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B POLLUTION CPL200378618 10/1/2019 10/1/2020 Easch Pollution Condition $1,000,000 t Aggregat $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) RE: EVIDENCE OF INSURANCE 4 , .Y CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 93 WASHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS. SAIMM, MA 01970 AUTHORIZED REPRESENTATIVE John Koegel/PMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025Om4011 Office of Consumer Affairs and BusinG- ss Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts. 02118 Home improvement�Contractor Registration V _ Type: LLC ATLANTIC WEATHERIZATION L.L.C. `, ... } F=F Registration: 61 R JEFFERSON AVE Expiration:(03/1 2022 SALEM,MA 01970 " k , b :.Y 1 w SCA 1 0 20M-05/17 Update Address and Return Card. �� So�rrroir..ae��/-c�✓%Imr:�c�v.-;ell-i - __—._- _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Regi Commonwealth of Massachusetts TYPE:LLC befo Division of Professional Licensure BgM gairation Offic `Board of Building Regulations and Standards. 742089 03/11/2022 1000 Constr+il>kt' �tSp�rvisor a ATLANTIC WEATHERIZA-VON-LL.C. Bost f, CS-087977 �pires:04/23/2022 ERIC W PALI1W 4 r ERIC W.PALM /' 3 HILTON STD i C 61 R JEFFERSON AVER t �°'`�� "�'� SALEM MA Oiip70 SALEM,MA 01970 Undersecretary- - - -- - Commissioner Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl r