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39 BELLEVIEW AVE - BUILDING INSPECTION � 2 "4 ' The Commonwealth of Massachusetts j `FtSpi rt�u� t ' Board of Building Regulations and Standards � 'EIVI E'Ei Massachusetts State Building Code, 780 CMR SAL EWI lUl6 JUN v r .�„r zou Building Permit Application To Construct, Repair, Renovate Or,&ettiolish a �� ,09 One-or Avo-Family Dwelling ef This Section For Official Use only Building Permit Number. Date pplieds I DuilJing OI)icid(Print Name)._ Stgaature SECTION Ii SITE INFORMATION` 1.1 Pro erty Ad s 1.2 Assessors Map dt Parcel Numbers r&V,irlc� I.IaIs this an accepted stmet7yes no klopNumber )_) t fit�i)tK??# 1.3 Zoning Information: 1.4 Property DimemtlablivA f(i Zoning District Proposed Use - - - Lot Area(sq ft) Fmfudge I ' ' - LS Building Setbacks(R) . Front Yard - -_ Side YardsRear Yard Rewired - provided -Requirm Provided. .Raquired Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informationi 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public 0 Private O- — _ Qheek i f.- 0_ __. Municipal O On site dtaposalsystera O o. , SECTI0N3r PRO PERTYOWNERSRIPk. 2.1 OWne� / �o'f'e✓a 120u 10 (RFc(Prim) Cny,State,ZIP 39 B /le vi`eri 4,--,e_ No.and Strect - Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WOR1e(check all thatoppl)r)` New Construction 61sting Building 0 OwberrOoeupled O Repairs(s) C 1 Altemtion(s) O Addition O Demolition O Accessory.Bldg.O Number of Units Other 0 Specify: Brief Description of Proposed Works: p v.a SECTION 4:ESTIMATED CONSTRUCTION COSTS- Estimated hcm Estimated Costs: Official Use Only (Labor and Materials 1. Building S Ce�o , 11. Building Permit Fee$ Indicate how fee is determined: 2. Electrical S - 0 Standard Cityfrown Application Fee._ ❑Totair Project Cost'(Item 6)x multiplier x ).Plumbing S 3?Qther Fees: S / ,/I T 4.Mechanical (HVAC) S List: 5.\lechanical (Fire S Su ression) Total All Fees:S Check No4jgj_q Check Amount: Cash Amount: 6.,rotal Project Cost: S 6(� ❑Paid in Full ❑Outstanding Bal:nce Due: Mrs t U N 5P SE bj Z5j • t SECTION 5: CONSTRUCTION SERVICES rn c. 5.1 Coltsird'ction Supervisor License(CSL) ?7C)�7 7 y Z 3 /� License Number Expiration Date Name of CSL Holder Eric`J� Palm List CSL'fype(see below) 1 9—hen steelt -Type" � . _ � � Description . No.and Street Salem MA 01970 - �� U Unrestricted Duildin it Coto 35,000 cu. lt. R Restricted 1&2 Family Dvvclltn zi City/town,State,ZIP M Maso RC RooEn Coverin ` 1VS Window oral Sidin C SF Solid Fuel Burning Appliances I Insulation Telc hone Email address D Demolition 5.2 Re rere 1I e I rove entjCpLp(�ractor(HIC ) g`-�' DR'- - HIC Registration Number Expiration Dale HIC Compan - e 'Csllwiw'"hA •`1f10"I11 No.and Street Email address City/Town Stete ZIP Tel horse SECTION 6r WORKERS'.COfY1PENSATION INSURANCE AFFIDAVIT jlVL!Z.I4a Workers Compensation Insurance o idavit must be completed and submitted with this application. Failure to provide this affidavit will-result in the denial of the Issuance of a building permit. Signed Affidavit Attached? yes.......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED,, OWNER'S AGENT OR CONTRACTt)s[i APPLIES FOII l3U[LDlNG.PERNIIT i,as Owner of the subject property,hereby authorize C ✓l`C ��i /h"t t9 act on my behalf,in all matters relative to work authorized by this building permit application. �z z Print Owner's Name(Ekdronic Si urc) .Date SECTION 7b:OWNERr ORAUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information contained* this application is ue and accurate to the best of my knowledge and understanding. Cso fl (, Print Owner's or Authorized Agent's Nume(E ectronic Signature) Date NOTES:- I. An Owner who obtains a building permit to,do his/her own work,or an owner who hires an unregistered contractor not re eistered in the Home.Improvement Contractor(HIC)Program):will n r have access to the arbitration — - - program or guaranty fluid under M.G.L.c. IJ2A.Other Important mForm—aho`n on th—HM-Program can be to0ad�-- — _- www.m:rss.cov'oca Information on the Construction Supervisor License can be found at wwtv.masssovlJns . - 2. When substantial work is planned,provide the information below: Total floor area(sq.R.) N (including garage, finished basernent/altics,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 coolingsystem C•neloseJ Open j. "Total Project Square Footage"may be substituted tur"Total Project Cost" Massachnaetts Home Im rovement Sam le on 71ds tine saasi all bcrWtdt®mtsofthe �[SOAge in,W tWr..._____ statesHpme e Mn.�a.a-_ w:ts Seek/eg¢(advimif �9���ter 14ki O&ceef GledemH�eRT bill � �workm admty Yaguts¢ shord wn° aeapyamnA erAffahsandBo.� � tO mayo6�a¢a S r HOIDEOWner7HfOlIDRliOH Coostmand'mmation HoSme 617-J73VS7 or I-M2833737 or®ate the Nam ConpactorFnfoematio- 8t Addirea(do not veeal lfiallo dd�G(. 0 Conuamd Chi Jeffer x� Av ie ' Stam Zap Code Huti�AddRs }pp�B Daytime Phone, 1970 • :3�.-=. Evmingphme _� City?mw � Sum Zip Code Mailing Addm®(adlBcytt6wg above) ' Bi pheae padad raophgerIDar3S.lVumbe Q��ncb ea' ' The Caatraporaee¢�mdo the =.,vemeta,.u�,� /���(/ 9 -. 7�'. (Decribe in detaD Oe:wwk ro eamp)�mH�g workiorl6e Aammwner. apa+fYW,Weeype,band,andgrdde Of !omadsm6e vssd.pteadtin_„m�y_sF-�yy-�,�� rox /2 s ptjmm�Pvf ermits-7'hefoD secmed by We mlimemgoined ProposdStertmd ehmmw¢a's who secure their°%u Pe•'HIIL47ei1ibefrom the Guaranty EOud pterl42A. Ptm'ISioncof �Datef®eantraaorm7t Negro Commeted wodc mPr$eand DatewhmOOni n ted workwdl be stb9anliaDY a®oe,,a nreglm Payment Srhedale lmrfmm mewmltf f.,h]be laatedal end l abor ed Paymmts will be rude s�S abomforWemtal stow of _(7 aOmNmB m WefoDowiaBmkadalr. 8 upon signm8c¢ntraOr(¢ot m mi 113 oFthetmal una $ 'Y / f Wpmi p+ice ar Wemstof�eciai atderitem.whicher�.ria&earu) 5 �P men of by! muponcom i p etim of 3 ____io-A / py)�upon rum Idivn P ofWeeoattact aI fniidsdenandm mdeWOb�e[n���'QU1PmrotmmthespeoN s Sfidi l+sYmmt® rnnaaet to bnWpartyrssetis[iretioa) m mztthcampimm'mt�a,hmedd�(sa�°rmmdv t^ -tlf is Plated S bo NOTES(`)1a�«ecdthe Ce�r®e('9 LM1wmpmes tivp mg, / B>eteraf(a)meibud of depasi[m ^-Yaam whim met ye - thet°ta! 'r4aiad by t�eommam s7uwd mtlacd" de enetimaw(tr 1M hefwe wwa.k m adv®a m mat de avgletim a:treddeBebal eon afaay��eiPmmt ar mrom nmde martial S bmatract a 7l. � ""°'' awtb naeaY+ ❑a,,,n Partyfsubmnuactnrukkad a!¢eesrobemldymypops-hle mr °r tr a1 d r d bYW CO°�� n'eccet+amrfmWem ofWeworkderonLedmganBes ofWero Contr¢et Acre a al;<es to be solely efmdl aeaottaofmythint centmct shall notimy thmPoogay. ar�dmammtbemmesabrodingeontmetander P¢Ym®tsroall m6contraotorsfur carefully 6¢fore sig®gthis mntmcG O'mtaest hashemldacedm Werevd®UNessoWmwdsedoted with@thisdommeaS We R ReviewlhefoDowiog®uonsendDOBca ° DoaY hepressmed(am si ° Mi"'snnW mo SmnSWecontrgp,Take tiIDtmread . �' r raidH - IDdY>mdcstandit Askgnationsifmmetkin is®d m110th wmW H,--x-�_- Thelawr�rewhnme•S ear. Dneaorof a._— c D�strWdnmtce6ywntmgm WeDireepr et lO wa®t ContredorYou e�°�mt°oaaaelorsand seeacopyofua`ipmf f msmaoce7 AsictheCo¢6agarNoam 517q Boston,MA 02I1R�6 en'Yob mWilig8irvidu787 org8mne.UOr Knowhtoofofrnemanca^doC�mG m�a�°OmPan3'mfam om so thazyon on 283-3757. ° Guide Yourrill mthelfMaj.�o�bt7ities.Read thelmpmund m COn�CO Sq mask to Prowemmtcommoorlaw. lnfnrmatiQum WemversesideofWisfm and ' . Sd a copy ofthe Consumer YOu may cancel Wisegteaamtifitheshe c m Signed ataphtceoWer mttacrorin writmgarhis/hermainoffine a¢dtof ¢eby than Wecmtradoysaptmal p) ofbosa third 6usmess dayRrBowmg Wesigom of °�amYmmT l+asWd,byteIe .Provided ytwnotdj.the FDO)V�T 8 WaageementSceWemmrhadnericeof &am smtorbydaDve} totlatcthmaddaSktofttre T�idm� �SFGNTHFSCON RACTIF emOdmdonformfivanemkmee®ofWsran ` ten°®pxxmad,e olAREANYLANdt� rrr and n Vest 7 "07 �D Zi� Ccntrutar's Stgnsna¢ Dam �C' Z Z Contractor ArbitrationThe Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration.action(as an alternative to court action)ifthey have a dispute with a contractor. The same right is not automatically afforded to a contractor,however, The contractor would have to resolve any dispute be/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 homcownerby the Home Improvement Coutracmr Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contrpcmor3�t le dispute m a private arbitration firm which has been approved by the Secretary o! W fC o urger AfTairs and Business Regulation and the consumer shall be required m submit to I 7tlattl�o�a % �achusetts General Laws,chapter 142A. Homeowner's signature ' d 'J - Con c r lgnafure �'� NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resoalternativeon initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. e 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 not properly registered as prescribed by law. Homeowners who secure their own building permits ate automatically excluded from all Guaranty Fond provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike 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 yourconsumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a.copy of all exhibits and referenced documents have been attached Parties 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 otherkept by the contractor. Any modification to the original contract most 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 1 ._. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems himtherself 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 fiords from said account would require the signatures of both parties. Additional Information 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: - Coasmner Information Hotline - Office of CousumerAffairs and Business Regulation _ 10 Park Plaza,Room 5170,Boston,MA 02116 - 617-973-8787,888-283-3757 or visit the OCABR website at httl)://xH%v.mass.eov/ombr/ 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: Director of Home hnprovement Contractor Registration Office of Consumer Affairs and Business Regulation . 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at htm:/Ayxyw.mass.EOV/ocabr/ - Go online to view the status of a Home Impivement Contractor's Registration: http://db.state.m&usthmeimpm%,ementAicemeelist.asp For assistance with informal_mediation of disputes or to register formal complaints against a business,call' omplaint Section ,4 Olga Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652.4800,508-755-2548 or413-734-3114 Version 2.1-112=010 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ff 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Atlantic WCdUiraLati nl, LLC 61 Rjeftersov Avenue Address: Salem M n '11970 City/State/Zip: Phone#: gJ79-- 7-/1W- F/tr/3 Are yo n employer? Check the appropriate boa: Type of project(required): I EXam a employer with Z _)"� _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El 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 working for in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. ❑ Building addition 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 I LEI Plumbing repairs or additions myself. [No workers' com right of exemption per MGL t p c. 152 1 4 , and we have no 12.0 Roof pairs , insurance required.] § ( ) 13. ther �i,/54 G/i dLJ 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. 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.4:: :r6 a 7 O /Z / Expiration Date: 314-0b -7 Job Site Address: 3 / 1�e2 ✓i CGo - A,_ City/State/Zip: -15-1l-eh-r 11,14 ✓4 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 certif&under thepains and penalties ofperjury that the information provided above is true and correct. Signature: ({� Date• /ZZ Phone#: 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#- i �. vva rax Server -- CEiR3I IFICATE ®F LIABILITY INSURANCE " ` DATE(MM/DDNYVY) IFIT ATE D TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS THIS CERTIFICATE DOES NOT INSURANCE 0 LI'IOR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE U l INSURANCE DOES NOT CONSTIME A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR P ROD CER A D T E CE CATE !OL ER. IMPORTANT:if the certificate holder is an DITIONAL INSURED,the the terms and conditions of the policy,c POlicy(ies)must be endorsed. U SUBROGATION IS WAIVED,subject to the Certificate holder in lieu of such end ertain Policies may require and endorsement A statement on this certificate does not confer rights to orsement s. PRODUCER CONTACT EASTERN INS GROUP LLC NAME: 233 W CENTRAL STREET PHONE FAX (A/C,No,Exq: (A/C,No): NATICK,MA 01760 E-MAIL 22MLW ADDRESS: i INSURER(S)AFFORDING COVERAGE NAIL lF INSURED ATLANTIC WEATHER[ZAT[ON LL INSURERA: AMBRICANZURICHDNSURANCH C COMPANY INSURER B: i INSURER C: 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 j INSURER E: INSURER F: COVERAGES CERT09 'TE NUMBER: CERTIFY MATT POLICIES OF SUfl LISTEDSELOWH Van EN ED TO THE INSURE-NAMED 4BOVE FOR THE PoLICYWSPERIOD WDICATED.010T1ffHSTANJDWG 4FF RDEMO YTHE OORESCRIBEONOFANYCOMR4CTOq OTHER DOCIMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTIW.THEINSURANCE AFFORDED SY THE POLICES DESCRIBED HEREe!EIS(IBJECT TO ALL THE TERMS,IXCLUSIONS AND CONDITIONS OF SUCH PoLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. WSR LTR TYPE OF DISURANCE ADD a POLICVEFFDATE POLICYa11PDATE L q POLICY NUMBER (MRSOOIYYYY) (MIADO\WYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CH OCCURRENCE $ CLAIMS MADE ®OCCUR. ( DAMAGE TO RENTED S PREMISES(Ea occurrence) ED EXP(Any one Person) S GEN'L AGGREGATE LIMIT APPLIES PER- PERSONAL a ADV INJURY - ®LOC ENERAL AGGREGATE POLICY ®pgO,IECT g AUTOMOBILE LIABILITY PRODUCTS-COMP/OP AGG $ ANY AUTO II COMBINED SINGLE $ ALL OWNED AUTOS j LIMIT(Ea accident) SCHEDULE 0.UT05 BODILY INJURY $ HIRED AUTOS (Per person) NON-OWNEDAUTOS { BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EXCESS LIAS CLAIMS-MADE EACHOCCURRENCE $ DEDUCTIBLE i GGREGATE $ RETENTION S S $ A WORKER'S COMPENSATION AND $ EMPLOYER'S LIABILITY Y/N U"8270121-16 032012016 03/20/2017 X WC LIMITS rORY OTHER ANY EMBERIEXCLUDPoEXECIITIVE I (Mmdavory Ir,NIU EXCLUDED? N/A (MenealPry in NH) I E.LEACH ACCIDENT S 500.000 0 ySCRIPvlbe OFF E.L DISEASE-EA EMPLOYEE $ 500,000 OESCRIPITON OF OPERATIONS beim { DESCRIPTION OF OPERATIONS/LOCATIONSNEHICII ESTRMTIONS/SPECIALITEM$ E.L DISEASE-POLICY LIMIT $ 500,000 THIS REPLACES ANY PRIOR CER71F(CATB ISSUED To TTIE CBRTDTCATH HO[DBR A e FPELTIY0 WORKERS COMP COVERAGE � I CERTIFICATE HOLDER CITY OF SALEM CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINGTON ST ? BEFORETHE EXPIRATION DATETHEREOF,NOTICE WILL BE DELIVERED I IN ACCORDANCE WITH THE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZED REPR ACORD 25(20IDI05) The ACORD name and logo are registered marks of ACORD 998a=2010 ACORD CORPORATION. All rights reserved- i I A CERilIFICATE OF LIABILITY INSURANCE DATEIMMIDDAWY) THIS CERTIFICATE IS ISSUED AS A iV1ATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 3/9/2016 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: conditions the certificate holder i 90 ADDITIONAL INSURED, Ule polfcy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and 0 of the policy,��rtain Policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such Endo rsement(s). PRODUCER COME Construction Eastern InsurantM& I.LC PHONE (800)333-7236 FAX cT 233 West Centra c Na: EMA L i OUR NatickINSURERS AFFORDING COVERAGE NpICd 01760 INSURERAArbella Protection Ins. Co. 1360 INSURED � Atlantic Weatherization I INSURER B Naut1lus Insurance Co 61 Rear Jefferson Avenue INSURER C: INSURER D Salem NA 01970 INSURER E- COVERAGES INSURER F: CERTIFICATE NUMBERMaster 2016 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 PO�.ICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR NPE OFINSURANCE - POLICY NUMBER MO�pCY EFF &OU, YEXP GENERALLABIUN ILIMITS X COMMERCIALGENERALUABILITY EACH OCCURRENCE S 1,000,000 A CIAIMB+dADE ®OCCUR EA O I ES aoc In P e oe S 50,000 500042816 /20/2016 /20/2017 NED EXP(Anyonapeonr) S 5,000 X CONTRACTUAL LLAB11; I X C PERSONAL a ADV INJURY S 1,000,000 GOOOI 10/01 FORM GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,000 POLICY X PRO- LOC PRODUCTS-COMPIOP AG G S 2,000,000 AUTOMOBILE LIABILITY S COMBINED SINGLE UMU Ea aetitl A ANY AUTO ent S 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Perperson) S AUTOS `Y AUTOS I 020015873 /20/2016 /20/2017 BODILY INJURY(Paraccidanl) S X HIRED AUTOS X NON-0WNED AUTOS PROPERTY DAMA S P rami ent a X UMBRELLA UAB X OCCUR PIP-Basin S A EXCESS UAB CIJUMS.MADE EACH OCCURRENCE S 1,000,000 (OED RETENn NS 10,00 600058654 /20/2016 /20/2017 AGGREGATE S 1,000,000 WORKERS EMPLOYERS, LSAnON S AND EMPLOYERS'IJABI RI WC SI'ATU- OTH- O ANY YIN FRCERI PME BER EX CLUDEO??EC��❑ NIA (Mandatory in NH) EL EACH ACCIDEM S Ifyes,tlasnoeN'nFdar EL DISEASE-EA EMPLOYE S DESCRIPDON OF OPERATIONS 0alow B POLLUTION EL DISEASE-POLICY UMTT I S L200378614 0/1/2015 0/3/2016 EA POLLUTION CONDITION $1,000,000 GENERALAGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS/LOCADONS"Ha"CLES( Nash ACORD 101,Additional Renod¢Sphetlute,if mate Spamis MQUIretl) CERTIFICATE HOLDER ) CANCELLATION C I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SALEM ' ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET .SALEM, 11A 01970 ! AUTHORQIDREPRESENTATNE John T[oegel/SME � ACORD 25(2010/05) I INS0251?n,nns,n, Tndlarnlan D�.a,o�n�I^^^�.e roD ©A r,-f A t-ARnORD CORPORATION. All rights reserved_ Massachusetts Department of Public Safety Construction Supervisor - $�� - Board of Building Regulations and Standards Restricted to: 977 - Unrestricted-Buildings of any use group which contain License: CS-087 Construction Supervisor 3 less than 35.000 cubic feet(991 cubic meters)of - pe enclosed space. ERIC W PALM 3 HILTON ST .. . ' SALEM MA 01970 _ F.1,,,to possess a current edition time Massachusetts Expiration: State Building Code is cause for revocation ofNris license. Commissioner 0 412 3/2 018 OPS Licensing Information visit UIWWMASS.GOV/DPS JfI .iCo)N,NflNN«rttft n!L f/Ps rr./srr�G License er r.&tratioia valid for individul use 61119 7� O ice of Consumer Affairs&Business Regulation _ before the expiration date. If fond return ter . j fp'Dt E IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Bnstuess Regulation jagtion: 142084 Type: 10 Park Plate-Suite 5170 £xplrallon: 3/12/2018: Ltd Liabilly Carpor Boston,lt9A 0211E ATLANTIC WEATHEROATION LL.C_ ERIC PALM - �a� . 61R JEFFERSON AVE SALEM,MA 01970 Undersecremry Not valid withoot signature I i