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18 BAY VIEW - BPA-12-89 ADD SHED DORMER , . ' � �3 � .e o c c��--� g�� /') � - l'hr Cummonweahh of Massachusctts -- — - - - - //���y "i�� l3oard of l3uilding Regula[ions und StandarJs crry or 4 / � !' Massachusctts State Building Code, 780 Ch1R ti,�L[�t �J`q� Re ri.����J.I lur IO l l 'L.,,N 13uilding Pennit Applicution To Construct, Repair, Renovate Or Demolish u (Air-ur Twu-Fun�ilc D�rrllin.4 Phis Section For ' �'al Use Onl 6uilding Permit Number: Date Applied: - UuildingOlticial(PrintN.une) (Siy� Dule � . ! SECTION I:SITE INFORMATION 'f � ��opert Jdr�sv%� 1,2 Assessurs Map& Parcel Numbers I.I a Is this an ac�epted street?yes_ no h���p NuinFer Purcel Number .r 1.3 Zoning Infonnetion�o� � I:J,�ope�rty Uimenslons: S' 1 �S %aninb District Proposed Usu Lol Arca(sy Il) Pmnlaga�Il) I.5 Building Setbacks(ft) Front Y:vd Sidc Yards � Rcar Y;vd Reyuircd ProviJcd �Reyuircd Provided Reyuired ProviJed 1.6 Water Supply:(M.G.1.c.J0,§Sa) 1.7 Flood Zone Information: I.8 Sewnge Disposal System: Public❑ Pri��ate O Z°°e: _ Ou�iJe�lood Lune? Municipal O On site Jispowl system ❑ Check il' �cs0 SECTION2: PROPERTYOWNERSHIP� 2.� Owner�of Record: T /�i'�C/_ .� _��.��� �!9 i:�O N;mie(Prinq Uty.Slutc.LIP - ��//9 �v.'e�,� 9j8-.��z �6�,' Nu.anJ Strcet �felephone Fmuil Addrcss SECTION J: DESCRIPTION OF PROPOSED WORK=(check all that upply) New Construction ❑ Existing Buitding❑ Owner-Occupied ❑ Repairs�s) O Alteralion(s) ❑ Addition � Demolition ❑ Accessory Bldg.� Number of Units Other ❑ Specily: riefDescriptionofProposed Work': S I�cC / p S' P � t9 Gsf . �kT�+� .� . (�' .P �eX�!?4S F / SECTION 1: ESTIAIATED CONSTRUCTION COSTS ���i�� Estimaied Costs: OfOcial Use Onl �Lnbor and \laterials) Y I. �uilJing $ !� �� i. Building Permit Fee:S Indicate how fee is detennineJ: '. Electrical g O Standard City/To�rn Application Fee ❑Total Project Cos[��Item 6)s multip�ier ___ x � 1. Piwnbing S �. Other Fees: S --�— I �. \Icch;mical 111�':\Cl 5 Lisc,--- --------- It. .\Icch�nic;d 1 Pirc Su�i�a55iun1 S Tutul :\II Fres: S --------------- �' ChccAVu. ('hecA:\muunt: (';uh :\nwunc n. Tol•rl Projcct CusC 5/'S'D�b ❑p;�iJ in Full ❑Outskmding 13al;mce Duc: - - � ;<� .� � 1� 1 ��� �,•� fio ���. m� �� � �;�G-i.� � , ' � SEC'1lON S: ('ONS"PRUC'f10N tiF:NViC'F.S 5.1 Cbnslructiun Supervisor License(CSL) �c��JB' a 'o��-� � ��----------- ------ � --- ����.5 �� I.icenx Numhcr li�pira�iun Dntc �L�-----i�---��---... -- N;mie a(CSI. I lulder �.// I.ist GtiL�(��I�cc b¢luwl_______ �� �j9�-�``--S�-`-�-------- T��pe Dcscription �, N��. anJ titrcet ��. �/ q l lurcstrie�ed 1 BuilJin�s ii io 35.000 eu. il.l j !� �� /�- �`��/ �l� R Kc�trieteJ I�? Pamil D�ccllin� �� Citylfo��n.titataZlP ��g�� til �I:uunr I� RC Ruulin Cuvcrin W$ N'indow:mdtiidin f��.�7� � 3 tiF tiolidPuc113urningApplianccs d� -� i huiJution 'fcic hnnc Iim:iil;iJJress U Dcmoliti�ro �51 �R/egistcred Ilome Improvemr/nt Contractor(HI ) /08��� 8 ���� p., //rv�tli'1"I � ' �G�d��'� I IIC RcgiAratiun NumFcr lispirntiun Uatc � I IIC Compm �Namc I IIC Re iurum Namu � �S G'�`1�`.�. �i�- N ,md Straet L:mail adJrt.s G�s� /���� j��-ss�/�'3, Ci /Town.State,ZIP "felc hune SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.4 25C(6)) Workers Compensation Insurance afTidavit 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........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE CO�IPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 as Owner of the sub'ect ro e ,hereb authorize . 1 P P rtY Y to act on my behalf, in ell matters relntive to work authorized by this building permit application. �7���„� ��LC., � a>>l/ Print O�vncr's Nwne(Elcctrunic SignuWrc) D'JIC SECTION 7b:OWNER� OR AUTNORIZED ACENT DECLARATION By enrering my name below, I hereby a[test under t ains and penalties of perjury that all of the informatiun contai ' is true and a t o e best of my knawledge and understanding. �— o?� // I'rint O��ncr's ur:\whurizcJ,�bcnt'.Numc 11[�ccvi iic Signawr¢) Dntu ,uo�rEs: � I. :\n Owntr who ubtains a building permit m do his�her own work,or nn owner�vho hires an unragistcred cuntractor �not registered in the Hume Improvement Cun«actur�HIC) Program),will �iot have access ro the arbitratiun program ur guaranty (und undar\I.G.L.c, la_'A.Othcr imponant infbrma�ion on �he HIC Program ran be liiund at ��n�� mu...��,�� ���,i Inform:llion on theConstruttion Supervisor License ean be found at������.iu:�,:.���� �J��, ] \I'hrn substantial��'urk is vineJ, provide the inl'urmatiun below: Tutal Fluor aren 1 sy. ft.l �� _____1 including garage, linished basemenC�tlics,dcrks ur purch 1 Grosi li��ing areo I sy. R.1 --_ ._------__ - Habiiable roum coun[.-__ a--.-.- - \wnber ul tireplaccs--- \umber ol bcdroums --- ---------- �----- -- --. . ._.__- - Vumhcraf'bathrounu � Vwnbcrufhall'h:uhs -- � -- __.. .._._._._ _ ._._. _--�----- ---- _. 1)pc ul hcating iystcm -- - �umbcr uf dccks, purclics-- � -- - - � --��- - � _ . __ .. .._.__ .. 1\pe of ioulin_L' >}sttnt . . .__. ..._ . I�ntlustd __ (1Pcn . . ... _. . ._. ____. . -.-_- I1. "�fnlal Projiet Syu;ve Pu���;ige"ma�� be.ub,tituicJ fitt'`I'oi;d Prujcel Cos�,. J r G� . � � � CITY OF S.�I.E.�[, tiL�SS.�CHL'SETTS ' 81;11�LVG DEP.1R"[�tEVT � I?O W.1.iHLYGTON STREfiT, 3iO EtOOIt ` T�L (97� 7�5-9595 F,�x(97� 7�i0.9&{6 fCI��ERLBY DRlSCO[l. ,�UYOR �+o.+w St.P�ua DIREGTOR OP PCBLtC PROPFATY/Hl'Q.DLYG CO\p1(SS[ONER Construction Debris Dtsposal At'fidavit (required for all demolition and renovation work) in accondance with the sixth edition of the State Buiiding Code, 780 CMR section I l I.5 Debria, and the provision�of MGL c 40, 3 54; Building Permit p is issued with the condition that the debris resulting from thia work shall be disposcd of in a properly licensed wacta disposal facility as defincd by MGL c l 1 l, S I SOA. The debris will be transported by: �i�s'�f�i-�i-�-e s (n�une oChauler) The debris will be disposed of in : ���� ������ � (n me of facdily) �Grol/`I r � �-- /7��o (�ddras of fuility) � � .. siyn�nue olpermit applicant �- � �-/'� J�cr :.nn..if.Lw . � . , __._ __._...- , _....__ __ _. __ ____. 4 . _'___.__.. ..___.__ . ....__. .._.. ._.__.._ ._....._..__. No�: ���. W�. ��8�. MORTGAGE INSPECTION DRfVENlAYS, ETC. DO NOT NEC- ESSARILY REPRE�NT PROPERTY PLAN IN _ �"� SALEM, MASS. N/F REID LANQ SURVEYORS CAMPBELL 365 CHATHAM ST., LYNN, MASS. ��5 � (7B7) 592-28fi0 - plotplans�reldls.com � � � u � 1 CERTfY 7HAT THE DWELLING.IS LOCA7ED ' AS �iOWN AND CONFORMEA TO THE ZO►HNG 3'S•''9 SgT BAf�t REf�UlREMENTS � 7HE qTY OF �-� �m � SALEM VKiEN CONSiRUC7ED, OR IS �/,,, DfEMPT FROM 1dOLAiION ENFatCEMENT � UNDER M.GL TTLE VII CH. �A SEG 7. /� �fk-•.� `�� �y YARD OUNtEDIN�nONI 10.0' 9DE !►� NOtE: YARD U� EXTENDS UP TO ABUTiEiYS � 6ARAGE ENCROACI�NG OVER PROPER7Y I.INE& / + � �s ��, LOT A �'���"- \ �� ��`m. � � 3338f S.F. ,;:: s� ��°°� �G �' � �� � �. � ��r N/F `'o= �_, i°v° su�' � ARENS � �, SPECIAL F�OOD NOTE: WHEN OGFSETS ARE Offf F00T �" � H�AZARD AREA: OR LESS A FULL IIdSTRUMENT SURYEY IS RECOMMENDED. 22.89' � 2� � ZONE A2 COLUMBUS AVENUE ry, HEREer, catm�r TO n� eEST oF Mr KNow�fncE NOTE: THIS PLAN WAS PREPARED fROM A nuT n�E rrtE►nises SHovn� ar 'nns Ptnr+ aRE locnr- TAPE SURVEY AND IS IN7ENDED FOR � m WITHIN A SPECIAL FLOOD HAZARD AREA AS DELWEATED MORTGAGE PURPOSES ONLY. OFFSETS SHONAV �J THE MAP OF COMMlN117Y �150102-8 PREPARED BY h1E � � SCALED FROM THIS PLAN, ARE FEDERAL QdERGENCY MANAGEA�NT AfENCY at1YS SUCCESSORS DATED 8/5/85. PAN0. 2 . 2oNE n2 ' APPROXIMATE ONLY AND SHOULD NOT 8E i FURni� c��r nuT niis ttrsaec� w�s �- USED TO DETERMINE PROPERT`f LINE5. FOIq�tED IN ACCORDANCE 1NTH 'ft� 'TECHNICAL STAND- SCALE: 7" = 20� DATE: APRIL 6, 2011 ARDS FOR MINtTGACE LOAN �NSPEC710145�.AS ADOPTED ± BY THE MASSACHUSETTS ASSOGA110N � L/WD SURVEYORS gppK; 25879 , PAGE: 2 CERT.# AND dVIL ENdNEERS. � ' 7HI5 CERTIFlCATION DOES NOT �NCLUDE SHRUBS. WALLS, CONTROL �:P71-�092 �B FENCES OR DRIVEWAYS AS THEY DO NOT ALWAYS INpICAIE C&C �2b1O179 PROPERTY LINES. . • • ti � G= . � , � ` � , �✓ � � �"' � � �) -� - . , v� .c� " . c � r-- ,..,. - �' �'� CITY UF S ;� .� . �LEi�[ �;�'��.l' 1�UBL[C 1'RUPRERTY � '=�"� DEPA ����4 MII Y:iNl4,��� RT�IENT' \�11�M Il: 1VM111A�f lu.\j1yCk7' � j.\ll'N, (e�. n47ii�ify �I��x ,MK,�.��.u� a�i nJl��l: ►�'urk�ry' Cumpenaation (n�urunca �i1ldu�it: Uulldcrs/Cuntnctur�/Elr trlclynyPlumben \ i ilicant In unnuflo PI • � f e 'AI ViIIT�{:IUIIuiK�Yl)IAy�iN1lnNInJl�nluull: ��k-(��/-� / /g- / c� h 1 ��lilr�s.v: � G�.2�ti--� s�, c��y,sr:���.i��•Cl/ ���� �� Phuna i/r ?�'— �'3 2 /./"3 S � .�w�ou�n .mplorcr7 Ch��ek tA�apprnyrlu� bui: I � I:�m a�mpluyur wiih 0. ��)M��I praJart(ruyWrrJ): ampluycc�pull�nJ/ur par�,• O huva hir�vd�ha.�uh'a etra�u i1 R. ❑Kew cu���ructiun �•O I.m��yulo praprieaw nr p�nnur• liar.d un rhe.macheJ.�hece � ship;�,i�l hava no mn lu cvy �� ❑Rc�nod�lin� ��orkin� �i�r ma in Jny�p�ciiy. ��urkrn'bo nO,�nyure e�� M. ❑ntmoliriun I Kn wi�rkca'cwnp. iuyuranh 1. Q W�a�v o ea�pon�ian anJ its 9� ❑OuiWin�adJi�iun nyuircJ.J ,�fttcen have,;t,M1i.��y�ihcir 10.0 Elaerried«pain ut aJditions 7.O 1 :m��homcowner Join��II work riyh�ufuaemprion pur hICL 1 LQ 1 lumbin rt inywlf.��b worMun'cum ' 1{ Iwirs u�aJJitiort� p• c. 1 Jl,¢I(�).anJ wt hnvv rro in.ur:ucea rcyuimd.J r .mpluyvcM. (�'o wohen' 12.�]Ruul'mpuin cmnp, incur�ntv myuintil.J 1).Q Uq�rr , •�1 n�.yrpLc.ul q„�I cMcY�Oo��I mu4:Jw tlll uw iM�ahan 41ur Jwruq'IMir wwY�i�vmpmuqluw '�^,^�"•�.�.,.iw��m�w�n'..rnd.�i„wk.��.r�M+�.aw����.+urt aM i Iwlicr inhwwuiw� �l�,�n�n.wnihM�A����Y111�1SYTWI�IIiI'11��illLIJII• h1111WWI1�Mt�IMl�lifp�T wryl.hwl du�in�iM na�M o/tlb w�►MM� wr.ulw��a nw�IRJ�vil inJlavlin�.���. /aNr un r�nployp rh�f lr prVvlJlnX�rarAnt'ruinprnmdsn liarpnine��uriMy� xtun aMl��w ruhm'rviy.p�lKr�n�brmaiw. i��/�nnwG�� p���cp Br/ury ls�M pu//�y unJ/a1.�it� Inwr�ncu Cump�ny Name� $GC / �Y�S`� . Pulicy 4 ur Svlf•ins. Lic.Ik 7 l���j _ . . ^. -�---- ` �p- � EApirutiun D,rtc��`�_ J�b Si�� �\ddres.rLLL/��7 `/l/��T�vr .J�.1,�,4 \tt�eh u cuyr uf�h� �rorkan'.umpvm�No�pulley Juelrrallun puX�fshowl K rM'polley nu bu ��1 q dYf1�. I�,,�lura w,ccure cu�eruy�,y rrquireJ u�iJ.r S�c�i�n:!A ul'�IGI a I71 tau lead�o rlu impwition or trimin�l panalriea of a rin.„�� i,�11.Ju0JM�nJ/ur uua•year linpri.rumncnr, �� �vcll.��ci.il pcnulliu in ihu lunn ul'a �TfJP 1VURK UROER anJ a fin� ,�/up rn i?SQ��1 tldY.I�yllql Illf vi�)I�Ifqf. IIt i�IYI.K'J fAYI J CU I�n�.�II�Jllulb JI ;Ily UTA tor m.,�aicc¢:,,�.•rr � � . PY�dihu.iutc�ncm inuy b�Iurw�rJ¢J w iha Ulli.n�!' d ulli��l;uq. /�/u/q•rrAr�.vn%y ni�Jw rG p� Niw-u . f�7�e'�//��' ihw 'i/'urrnrNow proriJr�ubuv�it iiw��i�J��onvc4 11.� i Ilq_���. V I).�... �" � �— i r -I'1�, � . �i � �)j�l��iu/u��on/y. /)o nn��rriu ii��hlr urru. �u A�ruu�y/ri�d Ar ci�r ur im.n u/�lrirL � (if�,�� 1'�nrn: �, � --__, Pcnnitd.lh•n�a Y � I 1�.uinq ,lwhuri�r (circlo ona�: � 1. II�,.�rJ .� � � (Ilr.�lib 2. Ih�dduiy p���.�ri„��.��1 I. Cil�.'1'����i� C'IcrM J. L•7c�'fric.d hi�l�•crur i. I 6. i)rtier I Pfwnbin� In�ycerar i �'„�u.�.� I'���uu: . ! --'----_.. I'A�iiiv 1• . . i [nformatian and Instructions � � �I.ui.�chu:aus G.nar�l L��vs:h�yce[ li2 reywre�.+ll ev��pW)°ion in ihe�se�'ice oi anoihertumfer my.�inct of h ro.+. I'unu.m� io mir ,utwe. an rmplurd n dctined+s"._e uY f*' ..r«,y�� ��„���„�. ,�,i or �.niron." ura�wn ur u�her Ic�{al�nnry.or�ny two or mort �n .,�npluyri�•dcrincJ �s"�n �ndrviJuol. P urtnenhip.,itsocwnao.�o�D lu �r or �ha wni en�crpr�s�. +nd incluJin�{�ha t¢gal rcpteytu�ativm 1u��^�`n�'lo)te� Nowaver �h� ,�� iha (J(lyJlll� CfIVJVC�I �n +1 �umenh�y.+�+��auuu ur o�her Ie�{al enoiy.�mP Y. � � ol� iecervef ot�(ua���ul'.u1 iudiridurl. D ,,wner ui a�wellin�{houye I+avin�na mara �+va�hra �p�ro^en���who reai�e��+erc�n•ur ih�acu of wcA amploym¢n�be�aameJ tu br�n a�npluyer.,• .I..rll�ny huus�of anoihar whu employ�(+�r+on�tu do muin�enunce.cun+vuc�ion ur repuir wuclt un sw�h Jwellin�{ u� .�r,,i��hs eruun�la or builJin�+ppurten�++t ihercto shrll no��c��t �IGL chapwr I52. �=SC(6) also s�°�°+���"�v�ry�tat�o�lo<al Ilemslar+µ�ety shaY wi�4huld�h� I�� utr�d or ft�tW III U��IICCA31 Uf P�fNI/fY U�Nfif��DYfIA�f�Of (0 CO\uYqC,N'IIY 1I1�Imuranc�ov rv{'�QVa' ,or • VP rnduad�SCIv►•b�`�r!Nai her ht ommonwc�l�h n�c�^y o�iu poli�ic+l subJivi�ion�ih+ll � Ilcunl �I�o hu! nol p i 1�Jiuonully.�IGI- clwptar I S: 0 u61ic wurk uNil uecptable avidanN ul'eun�pinm�e"ith the msuron ,n�er inco�ny�un�rrct t°r th�pertumwnc� u1'p rcquinm.ni�t of�hir.hupi��1»w heen p�•e+enceJ ro�hs coneractino awhoti�y." I ,�yypcan�f checkin{th�boac�ihat uDV�Y�oYuw yiwaiion an4 if i a��i�rion aPflJavit eamplatelY�M nwnbuU)v1O^�witb the'u un�cv��)�� _ Pla:�++ IiU uut �he wurkart' ao�mP' n�a(s),+���n�)°°d p r�w �(LLP)wirh no employ���u�hsr ihan�h� II su I +ulseontrrc � 1 Limitad Liabillry PaNu P LLP J�+h�vo , D Y . or , or necu�yyY� P Cmr �nia�(LLCI insuruna. limiie�l li a bi li t y P workan'eomp���ion u n u r a n a�. I f a a L L memb�n ut puM+h. rr�not requiraJ tu curY y�yubmimtd to�� nep°r�n�t of Industria l empinyaaf.u�wliey ia raquirad. 8�aJvlred iha����+tn�vit may �m,;nt of e cov.re�{�. AIN 0����10 rI�M�pJ Jul�th�uanu�"n��»�pJ°vit xhou �ccidenu Por con0m+a�iun uf inauran� nni�at licerw is b`ina�q uu�to obmin u worken' h� ,.��umed iu�h�city or town�u h•av�uny14��or°�re4 rdin�{�M luw ur if yuu un K4 �ie��hould entt��ha'u InJuxaiul�\c�i�ents. Shauld y �tlnt�t du nwnbar IIamJ balow. Salf-in�ureJ eomp ��in��enciun polfay. pla�eall�h� DeP I .alf-in�urana lieann�numbK�n th�a ro ute lina. (�Iry ot'foM�OMe1rU �r�ant hw provided u�p�a rt�hu�w� rinted le�{�bly. The Dep the applinnt, Plca.c hc *ura�h�c ihe af8duvit i�cmnpleu ;u�d p �n r licant ��P�hs�ifiJrvi� tur yuu m IiU ou�in�he avent �h�Oitle�uP lnveati�rtions hur to cuNaet yuu rcYardm� I'I:�s� ba +uro�o NII in iho p�:�++iUlicen���w»�r which will been�e���eedeonly�ubm�t�^u'ndldovit udicwPn�earteuf dc�t muat sub�nit multipb penni�'lica�u�a �PVlicu�ions in any�{ Y �J ur mark�d by di�aity or wwn moy 6�providuJ ro iht �alicy iul'orm+�ioe lil'nacesiary)+�J undar"lah 5iu AJJreis'the�pplic•rnt.+hauW write";dl locmiun+in ' 1 euwnl,"�\c�py°f�ha utTlduvi��hut hai b��n offleiully Y�mp' buyinas�or commereiel van�urt P�hat a vuliJ uiflJuvi�ii un fil� 1'or N+iun Pe�mit�ur licensa�. A n�w a�TlJuvit nwat b� Alled aut eae �pplieant;u ptoo annU not relotcd�o�ny I areun i�VOT required ro camploee thi+:+Nldovit. ya�r. ��'hem+hum+own�f uf ci�izan i�ub�ainin��Iic�ma ur i i.e. .i du�{liun.0 or permit w burn Irove�ete.)�aiJ p Y y uwuan�. II I hc i)I li�¢ UI Ii1vi�11L�IW�y ��JuW IIM IJ �1YIIM )'�lY IO 7�IV:IOC� �Uf Y�Yf COUP�fitl011 1111�ahuulJ uu hu�o,�n 4 ple�+t Ju nu� htdicarc to yrv� u� +��II. I fhc U:p.�r��n�"�'"J'�i��' 1°Icphuns:+nJ Eu nua'Q^wealth of MauachuseKs The Comm Deparvneet of Industrial Accidenu 011ta of[srad4adons 600 Wa�in4ton Street goaton, MA 021 I 1 'fal. q 611•72�F�617 702 o7�J971-�SSAFE , • ,..� 5.���.��s www.m�tf.�ov/ti� '`��� CERTIFICATE OF LIABILITY INSURANCE °"TEFM""°°"""", , z�,..c�i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATIVELY AMEND, EXTEtJD 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. IMPORTAN7: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to I 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 e�dorsament(s). PROOUGER NAMECT AS2110}� H18IIC0 $7: Stevena Company� 211C. PHONE E (�81)322-2324 � No:(]81�39'I-]6')] E�MAIL 389 Main St. aooreEss:ashleyb�eastevensins.com P. O. BOX 18B PROOUGER pOOOO1SO Malden MA OZ�.QH INSURERS AFFOROINGCOVERAGE NAICq INSURED �NSURERA:A.LS America 2ozzz iNsuaene:Central Mutual 20230 ADD IT NOW DORMfiR CO - INSURER C: 45 GARDEN ST � INSURER�: INSURER E: WEST NEWBIIRY MA 01985 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION.NUMBER: THIS IS TO CER7IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IND�CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV 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. �j� TYPEOFINSURANCE POIICYNUMBER MM/DDTYWY MM/O�/YYYP9 LIMITS GENEftNL LIABILITY EACH OCCURRENCE g 1�OOO�000 X COMMERCIAL GENEftAL LIABILITY DAMAG TO RENTED � PREMISES Eaaavrrerice $ lOO�OOO A CLnIMS-MADE � OCCUR LP 7923868 /aa/2010 /22/2011 MEDEXP(Myonepereon) $ 5�000 PERSONAL 8 AOV INJURV $ 1�OOO�OOO . GENERALAGGREGA7E_ $ 2�OOO�OOO �rGEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 3.000�000 X POLICV PR� LOC � a i AUTOMOBILE LIA9ILITY COMBINED SINGLE LIMIT a , ANY AUTO (Ea accitlent) BODILV INJURV(�er persan) $ ALL O WIJED AUTOS BODILY INJURV(Per acciEent) $ SCHE�U�EOAUTOS HIRED AUTOS PROPERTV DAMAGE (Paraccitlent) $ NON-OWNE�AUTOS $ $ �__ ❑MBREILALIAB OCGUR EACH OCGURRENCE g I EXCESS LIAB i __ _ CLAIMS-MADE AGGREGATE S . ._ __ ..___ ._�_—«__ __. __—"._-..__._ __._.. _ '"__ "'._ .._—"_ __ ' _ �' ' . DEDUCTIBLE ' $ ftEiENTION $ - $ $ WORKERS COMPENSATION � WC STATU- OTH- � � AND EMPLOYERS'LIABILITY Y�N X � ANY PROPRIETOFIPARTNERIEXECUTIVE EL.EAGH ACCIDENT $ (ManCaWryinNH�EXCL0�E0? � N�A C 7959740 1/31/2011 1/31/2012 � 10���00 ELDISEASE-EAEMP�OYE E lO0 O00 I/yes,tlesa�beuntler E.LDISEASE-POLICVLIMIT $ SOO OOO DESCRIPiION OF OPERATIONS below �ESCRIPTION OF OPERATIONS/LOCATIONS I VEMICLES (Attach ACORU 101,ptltli�lonal Remarks Schetlule,it more space is requlreE) :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESBRIBED POLICIES BE CANCELLED BEFORE � THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Add It Now Doxmer Co ACCORDANCE WITH THE POLICY PROVISIONS. � Thomas Leonard 45 Garden Street AUTHORIZEDREPRESENTATIV � West Newbury, MA 01985 /� Thomas P Cares ".�. ,'�'ESC M�'�'� .CORD 25(2009/091 n�ona_�nno er.non rnoonon .� n�i.:_�._ _____._� 1�� � � � `?��-o/T�.� �:,� ��� .�, � �-_��� -����{1 � �' � U"� `�i `�'` / t � �� l/i' �/'"-E � � ��r�r�! �°r�, � � r���� t�����^' �iYY1 t.�°` c' , � � � � k � � { lf - i� � ! nl���, U Q.✓! + `I 3 J� �j e � � I ,r�, ��� 0 3 " : + ��L- �sr /`' 6 � ��ovf3le ��Z� � ���E'� # � :�- � xio CJ�,��'e�-s �� ��.'. � t � \� � � Ta��T �'�'��� /n�u�" > -' a X/� R/����'i'a i� ' �;e` , ._-- — "a'` °� � LG,�Lf s � _ _ . ,� a ,��' C���;� ,��,,��� - - -- i, % � s�wea�� � y o��6 Si�� • ;,- � � �X � \ a // „ ;,y � � - � ��_ // L° 1� X � y � t, � �% �. 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