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B-19-920 - 0025 BELLEAU ROAD - Building Permit l The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: V Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1� Prop Address: 1.2 Assessors Map&Parcel Numbers, a5- >:LLEAV Rop-j) 1.1 a Is this an accepted street?yes no 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 Requirred= Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 ner1�o1f�Reco;m�T• , A E M P)6 L9 Name(Print) y City,State,ZIP 61-7g60.7177 No.and Street ' Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(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: /� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 10 gdO 00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee ❑Total Project Costa(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: $ �0�.(�/,f 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) y�� 2� ozao \A/TU.-T-Ary\ IWA-111 '1 License NumberExpiration Date Name of CSL Holder List CSL Type(see below) R—C- (�:2-Scy�-?/ ry Type Description No.and Street C V kM 1 1 T 1 PSCo7T M 0i Ll U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 FamilyDwelling City/Town;State;ZIP M Masonry RC Roofinp Coverin WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5E2 Registered Ho mc Im rovement Contractor(HIC) sc, -r �— \,TV4 J11cIOti 7 17 �� HIC Registration Expiration Date r C Com Name or H] Registrant Name d Street Email address 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 Issuance of the building permit. Signed Affidavit Attached? Yes..........Y, No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN I OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT \ I,as Owner of the subject property,hereby authorize A 1y!:L : ►t}M to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and.penalties of pegury that all of the information contained in this application is true and 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 Flome 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 xvww.mass. ovg /oca Information on the Construction Supervisor License can be found at wwwmiass.goy/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished 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" • r � The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ' I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): WILLIAM TRAHANT JR CONSTRUCTION Address:62-SCULPIN WAY City/State/Zip:SWAMPSCOTT/MA/01907 Phone#:781-599-1211 cell 781-307-0848 Are you an employer?Check the appropriate box: I Type of project(required): 1.❑✓ I am a employer with 20 4. ❑ I am a general contractor and I employees(full.and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers'comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions - myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no strip and reroof employees. [No workers' 13.0 Other— comp.comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: CONTINENTAL CASUALTY CO Policy#or Self-ins.Lic.#:6S5PUB2E82980519 Expiration Date:04-04-20 Job Site Address: 25- Belleau Road City/State/Zip: Salem/MA/01970 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an4penalfies ofperjury that the information provided above is true and correct Sicnature: QA Date:.8/22/19 Phone#:781-599-1211 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CITY'01:-SiUE:"[y ' [ASSACHUSETTs "CM-(974)745.0595 FAx(97-9)740-9846 <I.,MERLF-Y OPJSCc7Ei THo.Si+t§Sr. R1aE MAYOR �C��-r` . ?�CCF1..'4;'V6EC31�P VOLICftOffa�'SY�BSt),��eG4:Gfl�L''•St$SCUdi�1L f.onStrltdion Debris Disposal Affidavit. (required for all demolition and rena anon work) In ijewrdance with III sixth edition of the$sate Building C94e,790 CIMR;section 111.5, Debris,and the provisions,of lc3s,c 40, 54; Buridtng Permit# a � � Mtsstteti with the;andition t8:rt th4 ttilbris resulting fmna this work shall be�l sposed vtin a Properly licensed waste'dispoial facility m-4efincd by hf GL c The embris will he transponed by: i (Jumv ,t rlaulerl The debris will be dispos4�tt of in: T__)= 0! s f'v_n-S uG 11.E {ds'r�ss arfa:�latyz aag��ts�rcat`przrn,ra�c;aisc 3 . Q f'• �. ,.y ""�. .�J �,+„ eR r s xra'u�' t„+�i 7 t Page No ,$ot Pages . � - - - ' j y' tt � S f./✓� cam.. WM.TRAkW JRr C , 4TH GENERATION ROOFING -Swampscott,MA 01907 : CSL g101220 !` (781)599-1211•(718)8444551.,FAX:(781)581'©855 LIC.•(1178945 ��,t��� s PRCKQ AL Sl6KiTF010 - -, 'N DAiE°" d` r#�; �`f x r x t ✓i Sri„ �a7: —t u�t sit i crn. �rc.arrcox toDtaarq+v. /vim€ ©I c1�O 1 n•n bey I P-S 1 9'� <o Cc3T f1 - ,#R -Atlaa oereby:submil soecificaLons and esCmates for: Vio hereDY Submit specifkation`s and e�tima2es for:a. ".y:;� t r " 'a 10'Strip entire roof C CD Reshingle D Sweep entire roof t IrRepiace any bad boards up tc 00 linear feet _ ❑$Uip entlre root „ �, j; ,is GAF Stormguard first� feet up roof e ❑Mechanically fasten doom lS0 beard nnsufahait ' r f fnstap GAF Stormguard to an valleys and along dormers CI Install Ob0 Rubber Roofing on enLre roof , I _4i � . IrutaG secure grip synthetic un0lertayrnent on remainder of roof p Install metal fla'shing around perimeter of bu,fdtng- �` t instatl eight inch drip edge �ite 0 Black O Min O Flash chimneys) ptpeis]antl wdlf(s] . . _ M Cl Edge caulk all y1� R.7 a lw, or r&flash chimney(s)S y k� '3G J jx` '� xFs }s xGtY.s',� *✓} X� r �. y ) p Install new coppe rcenter drams > "_ installj[new p�-(me,flanges O Other � .t�§ tlT�it 1 rl '/ •_ - 1 a. z` '`'G F #r a2 t-?' 7w'"�'{xra..a ,s�p gi Ins 1 e time shin L(7 3 e z 3 tt vi m u + r 5 a g Color L p Clean up all debris s `+" t ° x�, # 3 i ate' 0 M Will gutters and downspouts L tabor and materials guarafftLei lO(b96 t�azfive years " R .` 4 CD InSLall irrm CWl _•a i 3 ?r �t . rsr+ X r'3{ L n p -d ' 5V ,tnWr d°^k�' 0 lw1 vtah nevi fascia boards � r Install new rake boards ❑Ins tag Sky fight(s).. _ '� - - i +�a,..K �t��F j'�•s:r �.:`a-�' _ar�,C't^�+�"'�at"r s Sa.''�,',yy,.'.!P�ti? (' '0�IerC ' �' _ --•-_ � sy `^ r rt .._4,. 5.� _uQ all detNts t R # t �'� wa{+ -.,, t{, x„9•»`xr- r• 't+ ' 3#€ - f ,R.r.`^' -.:" •„,"wt ,`+.ra'u..41a...-.�s"``"'�i*_..• ,.'Ps?may ,ys' *s.F. "3 ,ay, y' S tJ Laborand materials guaranteed i0(]%far free yeais , yi' �'a �^t, E k t '* i!x,hingle roafs,are mailed by hanC r CJ ' z ; a!t r Y+.� G-.a eat.*,•.-.�'.rt'r,�+ry � x.$+k,�.", `i r±: ka :.. :�k , r r nsr'�hereby to fwmsh-maternal and labor � �t a •,� t .� ra p i dbOV@:Sp¢Gt'ICat10n5 d '' C�. p�a 'IF .Gkf+ 'w? pp��,Ea 'F' t.�" .�'. ,S.r z._.. �z,}$f �{t0 �]leSlllYt?;day - .�y _ . Yi KtM �C'�C' � j� SAT y}F k pia sxr rr t" TOta1 �.F •3,. -. �.. r *� 3•e ^�',.:: t' r; -�Ot �i'�, PrIV'E#is of YOtf RE'HAVING YO1fR ROOF STRIRPED, PLEASE RCOVER'ALL;VALUAE.LES"_IN ATTIC S r r ' ' F s iv y � + � r.. kVAL Y�iID -V �"rr K'_}' •r,.,,,rm ' Wig` ._tWk HAVE NO CONTROL:OVER DEBRi5`THATIAAY FALLS�T!l�IROU�GyH tR00E-:80ARDS '* �4 j .� v'rlsYz,Pr6irr� a7"` � �4.sisCs�' *�x'"� ` xF.�p_ ' `��str`A� 1 > ✓ ..Y C*- -^s.r ems- N;frurarai e-suar"'to�be as`" s n>arrrer yecnrOnp standard pacUce3 yAf�w.orlt M be cosnpiGed h"e workmy�q +i� D �yv y tffl #7Qxni tluA{ o.owr and wi!be�ealted mA,{40�,wdten ads .x AuthDrr.>t�edly; T� 4 � P� xs£4y F 43 3 `JOGd!lttS Or lliyb tlW?bo"LDr ft 82f a�Y$rNatfat9 QAi` ., Te .�.ltpDa Stf41tR5-err- T f1511artCE.ait+ iltl�j COYErIQ yyp�p�j�` �a�OS11lr j...i�j 'ht4 as ,�y �'M E'W�+ % F 4.,:* ,� yr+.rit {- � ) i' 'Fi`x•{A'S< .Q`,t-'r,i-nt7,�„x "� ' }'l� G .-YK'„j w ..4,•-, e::x'• :'.".i f vt -s ; t' -iw�',.t' 4 -„-.'k,''a^ .,r.Y �"�' � M .1p • _` ,n { _?a •'mod x' �� v y r ra.t M,,`M!' .� �- xp �stt! The shwa � �mnE �, �� �� • tt t tlor�sRk , 4� � r" st cr. an4= tlorrsaresabsw r y, � afld_"be/ +,y C•n Z.i:'s- '" h ryR xG f' +ty • [d[d e r do the woyk as specrbed Pwflriwt wil be ?Pted You aria aaUtonzed too Si x V . , % r.` n1ade as OU% d above, hex + 5 r i4� e.mi l r aWE . " 1r€a ax�a 5 lk Dill:dJkCtDdaBt!`• r x*' t � ^�' '-'°�` 'ldya4�' �?"�-,,sr�� �, ' ,� �1rw.a'b.:apn+eowaeisasi ti r..'. � .� ..,�.d�,.,,;'*.;•�C�.,tf�a�°T{x „� .� �, �..• -:� ..+�.:, �,{�r? ��,' ,gav�az? s-• - �-}`,�i. L. ✓r X� F "fit- _ ',� �s=� - NMW _ ACORO CERTIFICATE OF LIABILITY INSURANCE -Ir mmuU,rriT/ ( 08/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOSES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE:OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and congditions 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 NAME: Mike Conlon DIVIRGILIO INSURANCE AGENCY PHCNN . (781)592-5220 Al No: E-MAIL ike ADDRESS: mike@dfgedge.com 270 BROADWAY INSURERS AFFORDING COVERAGE NAIC A LYNN MA 01904 INSURERA: CONTINENTAL CASUALTY CO 20443 INSURED INSURER B: WILLIAM R TRAHANT JR CONSTRUCTION INC INSURERC: INSURER D: 62 SCULPIN WAY 215 VERONA STREET INSURER E: SWAMPSCOTT MA 01907 INSURER F: COVERAGES CERTIFICATE NUMBER: 438631 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MPNO�UCY EFF MPO DCD EXP LIMITS LTR COMMERCIAL ENERALLIABILnY EACH OCCURRENCE $ DAMAGE TO RENT D CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA 6S59UB2E82980519 04/04/2019 04/04/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits tip employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool atwww.mass.gov/lwd/Workers-compensation/investigationsf. . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Cro�y,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved at,mmn 9S/9MAB111 Thu Ar r1Rr1 name anrf Inn^aru runiaturorl mar4c of arnp 1 • -. � �. uw�c lmnuutnnr rl. A CERTIFICATE OF LIABILITY INSURANCE . 08J05/2019 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 have ADDITIONAL INSURED provisions or 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 certiffcaste does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Michael Conlon NAME DiV rgilio Insurance Agency,Inc. a"c°Nr u Ext: (781)592-5220 qic No: (781)'598-5957 270 Broadway ADDRESS: mike@dfgedge.com INSURERS AFFORDING.COVERAGE NAICH Lynn MA 01904 INSURERA: American European INSURED INSURER B: Allmerica Financial Benefit 41840 William Trahant Jr Construction Co INSURER C: lit SCUlpin My INSURER D: ` INSURER E Swampscott MA 01907 INSURERF: COVERAGES CERTIFICATE NUMBER: CL198501079 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. - IOUC LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDY EFF MMIDD EXP - LIMITS COMMERCIAL GENERAL LIABILITY _ - EACH OCCURRENCE $ 1,0D0,000. C iAIMS-MADE I OCCUR - - PREMISES Ea occurrence $ 100'000 MED EXP(Any one person) $ 5,000 A CPP 120488210 08/05/2019 08/05/2020 PERSONAL&ADV INJURY. $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ - GENERAL AGGREGATE $-2,000,000 POUCY PRO- LOC 2,000,000 JECT PRODUCTS AGG $ OTHER: $ AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT $ 1,000,000 - - Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED AVVNA117991 09/25/2018 09/2512019 BODILY INJURY(Peraccident) $ AUTOS ONLY AUTOS - - HIRED NON-OWNED - - - PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY - Per accident AUMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EJCCE;S LIAS CLAIMS-MADE AGGREGATE s DED RETENTION$ - - - - ' $ WORKERS AND EMPLOYERS'LIABILITY YIN .N ISTATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑, E.L.EACH ACCIDENT $ OFFICER/MrMBER EXCLUDED? (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ If yes,Aescri ae under - - DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) - CERTIFICATE HOLDER CANCELLATION '� _ _ --w --- - "� -�'•^•'^" rtp"'"�V-T � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF,NOTICE WILL.BE DELIVERED IN s ACCORDANCE WITH THE POLICY PROVISIONS. .AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ecnan�s Ian�amzA rtio ernan��me a«1 1«««�.e.o«I�to.r,w..,>.r,a«s ernari'_, b , r' Corntnonwealth of Massachusetts ® e"livtsion of,Professional Licensure Board of Building Regulations and Standards Cpt"Structto t-Su pervibor spftlatty CSSL-101220 Expires:02110t202t5 �.I WILLIAM R TRAHANT,JR 62 SCULPIN WAY SWAMPSCOTTMA 04907 . r Commissioner ✓fir`�.'nu�ir�n«urz��;�,�T'ro�ir1r�,.��s Office ofConsumer Affairs&Business Regulation Expiration License ar regislrittion valid for individual use onl y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: $ggisfrtltiprt TYPE:Ctxftor Ofticr uf'Consumer.Adhirs and Business Regu6tIion "• - � - 178945 0610Q020 10 Farlt Plus-Suite 5170 Boston,NIA 62116 WILLIAM TRAHANYJR.`CONST.INC. WILLIAM R.TRAHANTJ2 (} 215 VERONA ST _ T LYNN.MA 01904 Undersecretary Not valid without signature