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SURETY BOND FOR SIDEWALK WORK © m G ® Y r D Y r p � J F Y f f• Y 4 J J J Western Surety Y F tl G 9 f Y G Y CONTINUATION CERTIFICATE F F Y Y f J h 7 4 Y F J Western Surety Company hereby continues in force Bond No. 63185267 briefly described as DRAINLAYER CITY OF SALEM for MARBLEHEAD MASONRY LLC as Principal, in the sum of$FIVE THOUSAND AND N0/100 Dollars, for the term beginning May 03 2018 , and ending May 03 2019 , subject to all the covenants and conditions of the original bond referred to above. This continuation is issued upon the express condition that the liability of Western Surety Company under said Bond and this and all continuations thereof shall not be cumulative and shall in no event exceed the total sum above written. Dated this 11 day of April 2018 WESTERN URETY COMPANY (35 By Paul T. Br at,Vice President _ G � F F �,✓ <fi D µo 5��,�UV' F F G F J f Y F Y F Y F , I Y n Y F g J THIS "Continuation Certificate"MUST BE FILED WITH THE ABOVE BOND. F W , F F F r Form 90-A-8-2012 F g F q Western Surety POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That WESTERN SURETY COMPANY,a corporation organized and existing under the laws of the State of South Dakota, and authorized and licensed to do business in the States of Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin,Wyoming,and the United States of America,does hereby make,constitute and appoint Paul T. Bruflat of Sioux Falls 4 State of South Dakota its regularly elected Vice President as Attorney-in-Fact, with full power and authority hereby conferred upon him to sign, execute, acknowledge and deliver for and on its behalf as Surety and as its act-and deed,the following bond: One DRAINLAYER CITY OF SALEM bond with bond number 63185267 for MARBLEHEAD MASONRY LLC as Principal in the penalty amount not to exceed:$5.000.00 Western Surety Company further certifies that the following is a true and exact copy of Section 7 of the by-laws of Western Surety Company duly adopted and now in force,to-wit: Section 7. All bonds,policies,undertakings,Powers of Attorney,or other obligations of the corporation shall be executed in the corporate name of the Company by the President,Secretary,any Assistant Secretary,Treasurer,or any Vice President,or by such other officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint Attorneys-in-Fact or agents who shall have authority to issue bonds,policies, or undertakings in the name of the Company. The corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation. The signature of any such officer and the corporate seal may be printed by facsimile. In Witness Whereof, the said WESTERN SURETY COMPANY has caused these presents to be executed by its Vice President with the corporate seal affixed this 11 day of April , 2018 . ATTEST WE N SUR COMPANY By !: - - L. Nelson,Assistant Secretary Pau4. Bruflat,Vice President �. STATE OF SOUTH DAKOTA Ss COUNTY OF MINNEHAHA � b� On this 11 day of April , 2018 ,before me, a Notary Public, personally appeared Paul T. Bruflat and L. Nelson who, being by me duly sworn, acknowledged that they signed the above Power of Attorney as Vice President and Assistant Secretary, respectively, of the said WESTERN SURETY COMPANY, and acknowledged said instrument to be the voluntary act and deed of said Corporation. +yyhhyh��yyhh���hhhh�hyhh f s J. MOHR s Ss S AE NOTARY PUBLIC SE SOUTH DAKOTA s Notary Public +y�yyy�,yyyyyyyyy�yyyyyyy + My Commission Expires June 23,2021 To validate bond authenticity, go to www.cnasuretycom > Owner/Obligee Services > Validate Bond Coverage. s� If Form F1975-1-2016 « CITY OF S� tiI, �L'�SS.'�CH[;SETTS BUILDING DEPARTMENT ' 130 WASHINGTON STREET,3110 FLOOR TEL (978) 745-9595 FAx(978) 730-9846 KIZSBF.RIEY DRISCOLL T �Yolt t-to>`Ns sT.PIERA$ DIRECTOR OF PUBLIC PROPERTY/aL'ILDNG Cow OSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information J Please Print Legib1Y tsh" Name(Busitts.Organization/individuaf): AbkhedA Ua4T)l/1.c1 ,1.61-- Address:-- Am,,) FA City/State/Zip: OCAA kcad 11r1A OR44 Phone!#: 78/ &31 Are yo an employer?Check the Appropriate box: Type of project(required): 1.;WIam a employer with Y 4. ❑ 1 am a general contractor and 1 6. ❑New construction e,nployccs(full and/or part-time).' have hired the sub-contractors 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. 7 Remodeling ship and haVC no calploycm These sub-contractors have li. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.C3 Electrical repairs or additions required.] 3.Q I am a homeowner doing all work right of exemption per MGL 1 t.❑Plumbing;repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.)t employees. LN`o workers' 13.dOther C Ilrtl/d &,Qzy2 comp.insurance required.) Any applis-artt that ChMICS box tel must also till out the section below Showing their workers'compensation policy info... ion. t I lotth:ownlTs who submit this affidavit indicating they are doing all work and then hire outside contractors aunt submit a new affidavit indicating suck =Contractors that check this box must attached an addititwW sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that Ju providing►vorkers'compensation insurance for my employee& Below Is the policy and Job site information. Insurance Company Name: /`f —ri an Zurich �/M-lu ante Co . Policy 4 or Self-ins.Lie. #: t9-2F'173 I�d-�"f Expiration Date:: ,,/ Job Site Address:� XYIa&_ `St. City/State/Zip: %km = 0(q'ta ,%ttach 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 STOP WORK ORDER and a tine 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 ol'the DiA for insurance coverage verilication. I do hereby certify wader the pains and penalties of perjury that the information pruvided above is true and correct Siimtture• Date: Phone#: 33q tV 7 70 Oficial use only. Do not write in this area,to be completed by city or town off elak City or Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: _ .._._—_ __ Phone#:,-- VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-9F77374-2-18) RENEWAL OF (6ZZUB-9F77374-2-17) INSURER: AMERICAN ZURICH INSURANCE COMPANY 1 NCCI CO CODE: 17965 INSURED: PRODUCER: MARBLEHEAD MASONRY LLC DBA AHMED INS AGCY INC MCLAUGHLIN MASONRY PO BOX 449 6 AMES ROAD SALEM MA 01970 MARBLEHEAD MA 01945 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 06-15-18 to 06-15-19 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B a� ,= D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 06-08-18 RP ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: AHMED INS AGCY INC 29P5Y 017307 VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-9F77374-2-18) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 1741 NAICS: 238140 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 6710 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 24 TOTAL ESTIMATED PREMIUM 7072 TAXES AND SURCHARGES 306 DEPOSIT AMOUNT DUE 7378 A/R (WCIP) # Minimum Premium: $ 500 ST ASSIGN: MA DATE OF ISSUE: 06-08-18 RP OFFICE: ZURICH-ORLAN 809 PRODUCER: AHMED INS AGCY INC 29P5Y