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B-19-1164 - 0062 BUTLER STREET - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards-RECEIVED FOR WMassachusetts State BuildingCode 7$0 ICIPALITY $ # NAI .Sb USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling Z319 OCT I l A Rt 110 This Section For Official Use Only Building Permit Number: Date Applied: sAgyE Cuen--,L,�e2S `® °-17-19 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Q;_ &Z 5 LITLE11 ST i1.1a 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 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: Sqe414 SnVA s9(o'VI &4 b 1 q 70 Name(Print) City,State,ZIP l0 Z l,Ej� I '561 Z33 Wfi$ JTLVA . SAIZA14 fit Z e 6n-A .00 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) $k, 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 $ &-rob 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑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: $ (y��d ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I69 Z35 /it z 1 ��,/��• : (�Q/J License Number Exp' ation Date Nam— a SL Holder I' \l / List CSL Type(see below) V /2� 1 62% b)7;V1 Type Description No.and Street �QN Q/ U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding A� l SF Solid Fuel Burning Appliances �7-xoy�W11 e ��FXX- �dm I Insulation Telephone Email address D Demolition 5.2 Registered Home Im rovement Contractor(HIC) ;WIZ f 6L,60�� C R co d a 8' ZD HIC Registration Number 94iratfon Date HIC Company Name or HIC Regist Name 2q6 6 STf/ �CoIZ C Ml/�6C-OWI3 kwK No.a/Town,State,ZIP gd,St�ON ^^ 0 2177 557_ 237 '7!o`'I Tf Emai address City/Town,% "v' 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 .......... No...........O SECTION jai 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 authorized by this building permit application. Print Owner'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 and accurate to the best of my knowledge and understanding. ZD /7 /117 Print Owner's or Authorize gent'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. ovt? /oca Information on the Construction Supervisor License can be found at www.mass.gov/dus 2. When substantial work is planned,provide the information below: Total floor 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" f le OTY OF SALE MASSA MUSE'1'I`S BUILDING DEPARTMENT 12.0 WASHNGTON STREET,310 FLOOR AL.(978)745-9595 KAMERLEYDRISQOLL FAX(978)740-9846 MAYOR THOMM ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING OOIvIlul HONER 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) r eclf1C�4 (address of facility) Signature of applic nt `d /-7 7 (today's d te) i CITY OF S.�tii, 1�'WSACHUSETTS • BUILDING DEPART%IE.2NT ` 120 WASHINGTON STREET,3"D FLOOR � '0r TEL (978)745-9595 FAX(978)740-9846 KI,\1BFRi EY DRISCOLL MAYOR THomAs ST.PtEm DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COMMSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Leeibly Name (Busim-ssiOrganization/individual): ;Foo� I'JiJ,,9 ' Address: o"A S --- City/State/Zip: �J 04 60 Z 7 Phone #:--'56 7 ' Z 3 7 - -761/6' Are you an employer?Check the appropriate box: Type of project(required): 14 1 am a employer with 4 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,91(4),and we have no 12;n Roof repairs insurance required.]t employees. [No workers' I3.❑Other comp: insurance required.] •Any applicant that chucks box#I must also fill out the section below showing their workers`compensation policy information. t I lomeownets who submit this affidavit indicating they are doing all work and then hire outside coat actora must submit a new affidavit indicating such. t =Contractors that cheek this box must attached an additional sheet showing the name of that:sub-contractors and their workers,comp,policy information. I am an employer that Is providing workers'compensation Insurance for my employees: Below Is the policy and Job site information. Insurance Company:Name: Policy#or Self-ins.Lic.#: 445 Z Expiration Date: Z �� Job Site Address: & City/State/Zip: 50M A14 e/17d ,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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie 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 and penalties of perjury that the information provided above is tr a and correct en t u [)ate: ��1-7 /g Phone#: p�7 237 �Coy� OJfcial use only. Do not write in this area.to be completed by city or tower oJfciaL City or Town: Permit/I.icense# 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#• .l Roof Hub I I A 240 East.M St.Suite 1 Boston,MA 02127 OOFUHB Phone 857-237-7"8 www.m=ofluib.com R . cslw tog= Buyer(s)Name Date L -SAV.49 Sri A Ja l5 /9 Address cry State zip !0 4/97d Cell, Cell Fminifl S57- 233-Ss55 S 5'nVA. SAMM li 1 Z F 6rmt .Com Weather Stopper System`Indudes:GAF Timberline IiD.Shingles installed with 6 nails per shingle,Drip Edge.Weather Waidn ke&Water Shield,Synthetic Underlayrnent, Pto-start:Starur Strip,Snow Country'Ridge Venk Tunbertex Ridge Cap.Shingle,Pipe Flashing,ard.Chinmey Flashing. Z N Color. R W.fa t.. Q&quare Feet: 7S Tear-off Iaye* 7 0 Boot Collar(ay ' To see our shingle colors,visit.myroofhub com/colors Areas to Cover(Circle): All 'd Rear Dormers Garage Drip Edge:(Circle). 'te Almond Brown Areas NOT to Cover: Low Slope Sq.Ft: Color. Wood Rot'Sq Fe Areas: Type of Wood Ledger The Roof Hub replaces up to 3 sheets ofplywood or 6 pieces of board free of charge. Buyer Initials: Any replacement of wood declong over the 3/6 pieces is an additional $70 per sheer.ofplywood or$45 per board The Roof Hub will not be,responsible for any fine tuning of satellite dishes.If Buyer Initials: additional layers over 2 are discovered,it is an additional charge of$0.75 per SF per additional layer. The Roof Hub is not responsible for future repairs of existing skylight issues Buyer initials: /4 Roof Luis ♦� c 'r 1F c{ t 1= .1`Y -1. ♦ t �� ltri � 1 i" Roof Hub Consultant Buyers) Buyers) t Sarah Silva(Oct 15,2019) 1 Contultant Aud6orization Authorization Authorization 1 1 Roof Hub HUB 240 East 8th St Suite 1 Boston,MA 02M7 ROOF Phone 857 237-7640 mmnLm=othub.com A=ement. Scope of fork See Specification'Sheet(s) P>�ng., Total Project Price: gd Deposit Amount(due at signing): Partial Payment(due when project is 50%complete): Final Payment(due on completion): 0(p,J60 Form of Payment(Circle one); Cash/Check Credit Card inane Payment Schedule For all home improvement projects,the payment schedule for non-financed projects or projects that will take more than one day to complete will be; 339.of the total sale price as a deposit prior to the start of work 33%of the remaining balance when the project is 50%complete 34%upon completion of work and acceptance by homeowner and Roof.Hub Types of ftym nt Roof Hub accepts cash,personal checks,and bank checks with zero fees.Roof.Hub also accepts credit.cards at,an additional 3%fee.Roof Hub offers financing through third-party lenders.The homeowner is subject to credit approval before the project can commence and interest rates fluctuate based on homeowner approval and credit rating.If the homeowner chooses to finance they will be required to sign a project completion form upon completion of work and to:contact the third party lender directly within 3 business days to confirm completion. Roo Buyer(s) Buyer(s) Sarah silva(Oct 15,2019) Consultant Authorization Authorization. Authorization Roof Hub OO 240 East 8th St Suite 1.Boston,NIA 0212'7 HUB Phone 857-237-7648 www.mvroofhub.com Instillation The Roof Hub estimates the start date.of your project to begin in,1-8 weeks from the time of completing. this document.The Roof Hub estimates all work will be completed in.a timely manner.All project times are weather permitting.The Roof Hub is not responsible for delays in work due to inclement weather,acts of God,unsuitable;working conditions;delays from inspectional services,or worker strikes.Homeowners or customers are responsible for moving or protecting personal belongings in the attic or away from the construction area before construction begins..Roof Hub is not responsible for any damages due to homeowner negligence of personal belongings or third party partners of Roof Hub including,but not limited to material delivery companies or dumpster companies.Roof Hub is not responsible for future. .issues of unforeseen problems unrelated or potentially related.to the scope of work uncovered during,or after construction or perceived to be a result of the construction. Change Orders Any additional work or modifications to the work.listed in the attached scope of work shall require a change.order.A change:order is a formal document listing the materials.and'labor required for services not. listed in the original home improvement contract or specification sheet and must be signed by both the Homeowner and Roof Hub representative.Additional expenses may be incurred due to unforeseen problems not recognizable at the.time.of the estimate or when the original agreement was drafted.If such circumstances arise,work will be postponed until the homeowner or agreement holder approves any additional charges. Rescission Homeowner can rescind on this agreement within three days of signing with no penalty.If homeowner cancels following the allotted three days,then there will be a 15Y penalty of the sale price assessed to the homeowner.Roof Hub reserves the right to cancel any project prior to work starting for any reason with.no penalty..In the event of a Roof Hub rescission,Roof Hub will return.any payments received prior to the work starting.If the project is rescinded on after work has commenced,Roof Hub reserves the right to maintain any payments received to cover reasonable costs incurred and will return the remaining balance to the homeowner. Dispute Resolution Both.parties agree to take reasonable measures to resolve any conflicts or issues before,.during,and after the;home improvement project:ln the event that a satisfactory conclusion to any conflict cannot be reached,both the Homeowner.and Roof.Hub agree to seek a resolution.through a neutral arbitrator,and agree that the decision of any such.arbitrator shall be considered final and unappealable, Permits,Licensing, &Approvals Roof Hub shall obtain all required permits,,including local residential.construction permits.Roof Hub will also pay any fees associated with licensing or inspection of completed work. Property Access Homeowner agrees to provide Roof Hub.representatives and workers with reasonable access to the property where the home improvement project:is taking place..Roof Hub agrees to make reasonable efforts to prevent disturbance or damage to the property or surrounding areas. Roof �Cotj�jjt �! Buyer(s) Buyer(s) Sarah si Iva(Oct 15)2019} Consultant Authorization Authorization Authorization Silva roof 62 Butler St 01970 10-15-18 Final Audit Report 2019-10-15 Created 2019-10-15 By:. - TAYLOR FERGUSON(taylor@myraothub.com) Status Signed Transaction ID f .CB4CHBCAABAAuAHHcKKMhOFvY_nTgOwZO-ML9FPtMp "Silva roof 62 Butler St 01970 10-15-18" History f) Document created by TAYLOR FERGUSON (taylor@myroofhub.com) 2019-10-15-11:20:05 PM GMT-IP address:73.119.54.254 24 Document emailed to Sarah Silva(silva.sarah1112@gmail.com)for signature 2019-10-15-11:21:44 PM GMT Email viewed by Sarah Silva (silva.sarah1112@gmaii.com) 2019-10-15-11:21:50 PM GMT-IP address:74.125.210.31 FS� Document e-signed by Sarah Silva(silva.sarah1112@gmail.com) Signature Date:2019-10-15-11:27:52 PM GMT-Time Source:server-IP address:172.58.231.130 Fi Signed document emailed to Sarah Silva(silva.sarah1112@gmail.com)and TAYLOR FERGUSON (taylor@myroofhub.com) 2019-10-15-11:27:52 PM GMT i Adobe Sign I F&BRE-1 OPI ACORL7® DATE(MM/OD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/27/2019 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 terns 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 endorsemen s. PRODUCER 508-829-7100 CONTACT Kathy R.Smith Pi Lombardo Insurance Agency PHONE 508-829-7100 Pax 508-829-0689 789 Wachusett Street A/c No,Ede: A/C,No Holden,MA 01520 Eo 1 s .kathy@pjlombardo.com HOUSE ACCT INSURER AFFORDING COVERAGE NAIL# INSURER A:Western World Ins Group FErB r ODr: ING,LLC INSURER B: dbe h0 o0 ub INSURERC: ayylEr Fergus 40 t eSt�n 2tr27 INSURER D os on, 0 1 INSURER E INSURER F: OVERAGES CERTIFICATE NUMBERs 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 DDL BR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRpIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR NPP8458651 02/24/2019 02/24/2020 DAMAGE TO RENTED 100,000 MED EXP(Any one rson $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 21000,000 POLICY❑2& LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea ace'dent) ANYAUTO BODILY INJURY Per arson $ OWNED SCHEDULED AUTOS ONLY ANUUTT Ep BODILY INJURY Par accident) AUTOS ONLY AUTO ONNLY PReOr a deTMid AMAGE UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR HCLAIMS-MADE AGGREGATE DED I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN TATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT CFFICE.,y.ng R EXCLUDED? N/A (Mandatory m N E.L.DISEASE-EA EMPLOYE $ If yes,describe under DES RIPT O P I EASE-POL LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddMonal Remarks Schedule,maybe attached B more space Is required) Workers Compensation information to be forwarded under separate cover from assigned risk carrier. , CERTIFICATE HOLDERANCELLATION GAFC012 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN k GAF 1 Campus Drive ACCORDANCE WITH THE POLICY PROVISIONS. Parsippany,NJ 07054 AUTHORIZED REPRESENTATIVE HOUSE ACCT ACORD 25(2016f03) ©1988-2015 ACORD CORPORATION. All rights reserved. ,. a The ACORD name and logo are registered marks of ACORD T ® DATE(MMIDDNYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 02/28/2019 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 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 endomement(s). PRODUCER 05226-001 E24 ACT Branch 5226-1 P J Lombardo Insurance Agency A/C.No.Ext: (508)829-7100 No.: 789 Wachusett Street ; Holden,MA 01620 NSURER(Sl AFFORDING O INSURER A A.I.M.Mutual Insurance Company 33758 INSURED INSURER B: F & B Remodeling LLC Roof Hub INSURER C• 240 East 8th Street Apt 1 INSURER South Boston, MA 02127 INSURER E [INSURER F, COVERAGES CERTIFICATE NUMBER: 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. IN TYPE OF INSURANCE A,NDf NSR We POLICY NUMBER MMIU F MPIO� Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY E� Eloc AUTOMOBILE LIABILITY COMBINED SINGL LIMIT $ Fa ac ident ANY AUTO BODILY INJURY(Per person) $ ALL OWNF17 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB [::17OCCUR EACH OCCURRENCE $ EXCESSLUIB CLAIMS MADE AGGREGATE $ DED I I RETENTION$ C g 7 $ AND E MRRAPS"LIIABILQT, X TORY LIMITS OERH- A P� FIP ��iLEJCECUTIVE Y/N E.L.EACH ACCIDENT ER $ 10O 000.00 A o Ic ❑Y NIA AWC-400-7034062-2019A 2/24/2019 2/24/2020 ((rMandatory in NH)) E.L.DISEASE-EA EMPLOYEE $ 100 000.00 D SC d ccn1g g OPERATIONS below E.L.DISEASE-POLICY LIMB $ 600,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,B more space is required) No Member is covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION City Of Boston Attention:Inspectional Services SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1010 Mass Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Boston,MA 02118 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD . A Sir.. t';> ..," :r.a+..*ts.xa.,,,""`.$,Ka�.,.>:. �,.r... ,h... ...............".;. �,...w,..,.. .�. ...:._.,.,....._.�- xw ..;x r^' was,• z - _';<,2 sxY'n.• . w x ,,:_ % mot � r �, c " .. '£).::y^1 - .> x. ±._... .< r: :.,1>. r , o ,.. z s tip.,? ,tn .,:r-F: ,$` Nr,.�z,W, r's....f+ €.:..t . .r; ".,, - :. -;.- r,.;'y :: .., :>W r �,V'Y :.NSF -.- ' * �s v.3 a..-rk.. , � -e;:,. .. _. :., t ,.h, ..x. y ;z „:. ........ y:..,Ry. � '�';.„ k, " Y` - b, .-%,-.. 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