101 BROADWAY - BUILDING JACKET IIII ® $
UPC 10333 z
No. 153L-3
HASTINGS. MN
OP-2001-0082 Building Permit No.: 11/15/00
Commonwealth of Massachusetts
City of Salem
BUILDING,ELECTRICAL&MECHANICAL PERMITS DEPARTMENT
This is to Certify that the Residential Building located at
Dwelling Type
0101 BROADWAY in the CITY OF SALEM
------
Address Town/City Name
IS HEREBY GRANTED A PERMANENT
CERTIFICATE OF OCCUPANCY
Variance occupancy
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires - -- unless sooner suspended or revoked.
Expiration Date
Issued On:Mon Jun 25,2001 --- ------------- - ---
GeoTMS®2001 Des Lauriers Municipal Solutions,Inc.
Citp of 6alem, ftla!oarbuattz
CITY OF SALEM. MA
=t 33oarb of 2ppeaC CLERK'S OFFICE
.per
1000 NOV 22 A 11: 23
DECISION OF THE PETITION OF TAMSIN M. CAMERON REQUESTING A
VARIANCE FOR THE PROPERTY LOCATED AT 101 BROADWAY R-2
A hearing on this petition was held November 15, 2000 with the following Board
Members present: Nina Cohen, Chairman, Richard Dionne, Stephen Buczko, Stephen
Harris and James Hacker. Notice of the hearing was sent to abutters and others and
notices of the hearing were properly published in the Salem Evening News in
accordance with Massachusetts General Laws Chapter 40A.
The petitioner is requesting Variances on Lot A, relief from lot area, frontage, front
setback& side setback, Lot B for relief from minimum lot area, side setback&from the
requirement that no accessory structure (pool area) be located closer than five feet from
rear lot line, also Variance from Section 5-1 is requested as the petitioner parks a truck
used for a landscape business in the garage for Lot B for the property located at 101
Broadway R-2.
The Variances, which have been requested, may be granted upon a finding by this
Board that:
a. Special conditions and circumstances exist which especially affect the land, building
or structure involved and which are not generally affecting other lands, buildings and
structure involve.
b. Literal enforcement of the provisions of the Zoning Ordinance would involve
substantial hardship, financial or otherwise, to the petitioners.
c. Desirable relief may be granted without substantial detriment to the public good and
without nullifying or substantially derogating from the intent of the district of the
purpose of the Ordinance.
The Board of Appeal, after careful consideration of the evidence presented at the
hearing, and after viewing the plans, makes the following findings of fact:
1. Petitioner, represented by Robert T. Ford, Esq. of Serafini, Serafini, Darling &
Correnti LLC, owns a property at 101 Broadway on which there lies a single family
house and a large garage with a second story apartment. Petitioner seeks to divide
the property into two lots, each of which will have a single family dwelling with
adequate off street parking.
2. The proposed division will not require any change to the existing buildings. On Lot A,
where there is an existing nonconforming residence, the variances required are a
variance from lot area, frontage, front setback and side setbacks. The existing lot
will be altered to allow creation of two off street-parking spaces on the easterly lot
line.
�e
DECISION OF THE PETITION OF TAMSIN M. CAMERON REQUESTING A
VARIANCE FOR THE PROPERTY LOCATED AT 101 BROADWAY R-2
pagetwo
3. Lot B is accessed from Pacific Street. Variances sought for Lot B are as follows:
Variances from lot area, side setback and rear setback. Petitioner additionally
requests a variance from the provisions of 5-10 to allow overnight parking by the
owner of a commercial motor vehicle on the property,that no accessory structure
(pool deck) be closer than five feet from rear lot line.
4. There was no opposition to the proposed petition for variances for the property
located at 101 Broadway.
On the basis of the above findings of fact, and on, the evidence presented at the
hearing, the Zoning Board of Appeal concludes as follows
1. Special conditions exist which especially affect the subject property but not the
district in general.
2. Literal enforcement of the provisions of the Zoning Ordinance would involve
substantial hardship to the petitioner.
3. Desirable relief can be granted without substantial detriment to the public good and
Without nullifying or substantially derogating from the intent of the district or the
purpose of the Ordinance.
Therefore, the Zoning Board of Appeal voted 5-0, to grant the Variances requested,
subject to the following conditions;
1. Petitioner shall comply with all city and state statures, ordinances, codes and
regulations.
2. All requirements of the Salem Fire Department relative to smoke and fire.safety shall
be strictly adhered to.
3. A Certificate of Occupancy is to be obtained.
4. Petitioner is to obtain approval from any City Board of Commission having
jurisdiction including, but not limited to, the Planning Board.
Variance Granted
November 15, 2000
Nina Cohen, Chairman
Board of Appeals
ti
DECISION OF TAMSIN M. CAMERON REQUESTING A VARIANCE FOR THE
PROPERTY LOCATED AT 101 BROADWAY R-2
page three
A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND
THE CITY CLERK
Appeal from this decision, if any, shall be made pursuant to Section 17 of the
Massachusetts General Laws Chapter 40A, and shall be filed within 20 days after the
date of filing of this decision in the office of the City Clerk. Pursuant to
Massachusetts General Laws Chapter 40A, Section 11. The Variance or Special
Permit granted herein shall not take effect until a copy of the decision bearing the
certificate of the City Clerk that 20 days have elapsed and no appeal has been filed,
or that, if such appeal has been filed, that is has been dismissed or denied is
recorded in the South Essex Registry of Deeds and indexed under the name of the
owner of record or is recorded and noted on the owner's Certificate of Title.
Board of Appeal
13 1'lie C'onumomsralth of Jklassa0lilselti
Board of luilding Regulations and Standards CI'I'1 of
Mas.cachusetls 5MIC Building Code. 7SO CNIR S,\LF.%l
1uilding Permit Application To Construct. Repair. Renovate Or Demolish a
Uue• or Tnvt•fiunsh Urrrllin.l+
This Section For Oflicial se Onl
l3uiiJing Permit Number:
-- Uate:1 plied: ,p
IlulJmy UI►icial(Print N;unu) tiigttalurc '
UI
SECTION I.,SITE INFORMIAT1
1.1 Property Address. SECTION
Assessura Map g Parcel Numben
I.la Is this an acce ted sheet? es no Map Nunsher Futrell Nunib r
1..1 Zoning Informations 1.4 Property Dimensions:
Leniny District I'nrpuseJ Il.wt Lut Area IY ITI 4 Frontage I II►
1.5 Building Setbacks(1t)
From Ywd Site YwJs
Required Front
Reyuircd Provided
Reyuircd Ruar Y:wdI'roviJeJ
1.6 Water Supply.-(M.G.1.e. JU.§1a) 1.7 Flood Zone Information: La Sewage Disposal Systems
Ihubllc D Private D Zone: _ Outside Flood Lune?
Check iY esD MttniclPd D On site Jispusul s).stmn (3
SECTION I. PROPERTY OWNERSHIPt
2.1/OOwnerrofReco/^r�ds A 4t
1LLL},y�" lire �F `e r•M /L44 OI S7J
Millie lPrint) Coy. Wta.I.IP q
Nu.,mJ Strcet / L
elephant Email AJdnss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction CIE.viatiny Building D Owner•Oceupied O Repatnla) O Aheration(s) D Addition D
Demolition D Accessory Bldg. D Nuns-erof Units Other I Speeity: n
Brie fDescripiionofProposedWork
SECTION Jt ES LATE CONSTRCICTION COSTS
hens Evinsated Costs:
f l.ahur and Materials) OMCIAl Use Only
I. Building f J� I. BuilJiny Permit Fee: f Indicate how fee is determined:
'. Electrical f D Standard CiryTown Application Fee
I'lunihutg f D Tulal Project C•ov'(Ilens 6)x multiplier
'. Ulher Fees:
J. Meihenic.d ill\ \(') j List:__ .____
1u ..rai.umt j fatal \II Fees: S
n fatal Prnject Cmst: i ('had Vu, ____( heck .\maunC . . . .0 \mount:
O PaiJ m Full C3(hustmJing Ilal.mee Due:
('1)NtiI Rl ( flON SFRV'1('F.S
bZ� /z/2
S,I ('unstrue.lion Sullenisur License(C'SLI -- �. j. ur;alou I),lm
TT / I iecllw Nuulher I
.. _o_n._
\,unto CSL Iloldarntl'SL I'�pcf•echelu.sl.__._-- —.._
I)pc I7csaripliun
N o. and Street tl I�nreiRielcJllludJin ili 10 11.I111U cu. IL1
It It.>lri.tcd I:C? I.and) D"0111101
j\...n.S(.ltc./II' µC RIKIII lilt crimit
µ'S µ'inflow.mJ SiJin
• --' SF .tioliJ pucl Ilurniny Appliall"s
ti.
1 Inmdution
T 77 1�_ Pm;ul addrus U Dmnniitiun
1'elc hone
5.2 Registered Ilunte Improvement Contractor(HIC) IIIC' I clikiralion Nuill If —I`'`7P'sr"�tlr"n Dalc
I IIC C'onlpan)N.ono or IIIC cgistmnl Nano
):)nail aJJnss
Nu. Z3 Suva
Ci liown. State ZIP
7cic hone
SECTION 6t WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 1!].1 2�C(
Work en Compensation Insurance oMdavit must be completed and submitted with this application. Failure to provide
this atlldavil will result in the denial of the Issuance of the building permit.
Signed Alfldavit Attached? Yes ..........
No...........O
SECTION Tat OWNER AUTHORIZATION TO BE C0111PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Dula
Print U,�ucr's Nulna(Elcctrunic Signuluru)
SECTION ?b: OWNER OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the inrormatiun
contained in this application is true cura o the best of my knowledge and understanding.// Q
Data
,wib 11'.Icclrunic SignaWnt)
Print oenei sur:\ulhon gc VO'f ESt
I, �n egistdr J inblal—the builing
hnpruvcnlenterinttCumm lctur(HIC) program),will = have access tolihe arbitration
tracwr
pmgnilllor guanult)i ull m u un M.. Conlstructioa Supervisor Lim Othcr important information
nse c� n be found at
C Program c,n`bal';ound at
Wien iubslnnlial Iwrk is planncJ, prusiJe the inlormaliun below:
I including garage. linished bascnlcnt attics,decks or porchu Total (lour area 1 iy. t).1 _ --- Habitable room.aunt
Groii 11%ing area I iy. 11.) ._. .. Number of hcdroonts .
\unlhcr of lini,la.es --- .. \unlhcr of hall'hathi
i \unlhcrofhalhnw°Is por.hei
I\pc of hc,lting i7 item I'nao•cd llpal
I �pc, l':oohngi�itam
1 ..1,d.d I'f.,IdCt \,III:IfC l.pn.lyc Illl1\ h¢ •Ilh.11lllled lar"I Jlal I'roj"t(o,l'.
`y
:� •4 i- �2S �K- �`�S �
One or Two Family Dwellin'
The Commonwealth of Massachusetts °,,� D
Board ofBuilding Regulations and Stancj�'gQ3ECj;j��� "���e
Massachusetts State Building Code-780 CMR
8
T}us'$ecLiniiTSr Ofiieia1 Use Only
60
6 Building Permit Number - Editi of 780 CMR Date of application
nSignature Z� `h �!/✓Z 7/�1
`j B Coaanissiancr/Local Date
SECTIONI:' SITEINFORMATIOIV-"`. `..
i
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
/ a / ✓��om d/w 57�.
Is this an ac=tnd street? Yes ❑ NO ❑ Map Nimbc(s) Passel Numb¢(s)
1.3 Zoning Information 1.4 Property Dimensions
z0aia9DLqtflCt pmposcd Use LotArra s ff Fina ft
15 Building Setbacks(feet)
Front Yard Side Yard Rear Yard
Regrmed Provided Regrmcl Provided R=pmd Provided
1.6 Water and Sewer 1.7 Flood Zone Information 1.8 Conservation Commission
Private ❑ Municipal 13 Flood Zone N/A❑ DEP Number 40- N/A❑
19 Old&Historic Commission 1.10 Site Plan Review 1.11 ZBA Special Permit
COANumber N/A❑ Date tiled N/A❑ Data filed w/Tuwa Clerk N/A❑
SE CTI0N2:'.`PR0PERTYOWNERSHIP`
21 erofRecord
1 h I blroan(uxwl, c Ca I ern �A �/970
(plB SI ao - n58
Tdeph—
'SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
DdstingBuilding ❑ NewConshuction ❑ Accessory Bldg. ❑ 1 Addition ❑ Alteration(s) ❑ Repair(s) ❑
Demolition ❑ Owner-Occupied ❑ Number of Units CD+Other ❑ Specify:
Description of Proposed Work: S L✓ Dfs— J'K d ' � U l b /o
SECTION 4: ESTIMATED CONSTRUCTION COST.-.BUELDING PERMIT EE
Item Estimated Cost This Section For Official Use OnIY
Gabor and materials) -
1.Building $ Buildmg.$10/$1000
2.Electrical $ Building+Plumbing:$1=1000 Building+Eleciricah$13/$1000
3.Plumbing $ Building+Electrical+Plumbing combined:$15/$100�
4.Mechanical (HVAC) $ Total project cost(labor and materials)$
5-Fire Suppression $ Fee multiplier from above$ ' /$1000
6.Total Project Cost I-(d • 0 O Permit Fee$ Receipt Number _
SECTION S CONS�XRUCTION SERVICES:
5.1 Construction Supervisor License,(CSL) „
License Expfi...on Date
Name of CSL - Type Description .
U UmcsuicRd to 35000 Cb FL
Address .Z I ""f^+ 1 I t1uFl Ulk" , . R ResWcted1&2F
M Masaary only
Side RC ReadcotW Rao
WS Mddcffielwmdow and Sid-mg
SF Remdenhd Solid Fod
Tdeph— D Resklca[3l Demolf9m
5.2 Home Improvement Contractor Regiala-atiou(HIC)
Registration Expiration Date
HIC Company Nerve rn HIC R.eg84mtNmre
Address
Tdcphaae
SECTI.0 N*6_--=WOB-CER'_s CONTENNATIONINSURANCL:AF,FIDavrr OLg4t c-152- §29C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit
Sipped affidavit am&he? Ya ❑ No O
SECTION 7a1;'""OWNER ADTHORI7.ATTONTO BE COMPLETED WBMN OWNER'S AGENT,OR
._
CONTRAC�T�O(RAPPLIFS,$ORBIIILDINGPERMIT:
I �X1'/� } as Owner of the subject property,
hereby authorize be rye'- rQ)( �Q,t,��.:." to act on my behalf in all matters relevant to work
=- by emit application. sli�Dare
SECTION, 76: . OWNER OR AUTTHORMED AGENT DECLARATION
1, Rp y C.W Irj - /c,� as Owner or Authorized Agent,hereby declare that the statements
and info 'on on regoing application are true od accurate,to the best of my knowledge and belies
SignafmcofOwnerm Authmimd (Sigwdmd¢ pa aadpmmlbmofpeljmy) Date
YM
SECTIONS: DEBRISDISPOSAL ' `
All dumpsters of six(6)cubic yards or more are reamed to have a permit from the Marblehead Fire department call 781639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work perfinmed shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL el11,§
150a.
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT
. 'NOTE
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(MQ Program)will not have access to the arbitration program or guaranty fund under NLG.L.
c. 142A.Other important information on the HIC Program and Consroction Supervisor Licensing(CSL)can be found in 790 CMR
Regulations.
t4, The Commonwealth of Massachusetts
Department of IndustrialAccidenis
Office of Investigations
Ulf 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Ptint Leeibly
Name (Business/Organization/Individual): 46VeKh �ar JL
Address: Yk y LB-w e W V r
City/State/Zip: Pi>�e B10phone
A,r�e,you an employer?Check/th<e�ppropriate box:
1:I(�'L am a employer with 4• ❑ I am a general contractor and I [8.
of project(required):
employees(full and/or part-time)-* have hired the sub-contractors New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet, Remodeling
ship and have no employees These sub-contractors have Demolition
working for me in any capacity. employees and have workers' Buildin[No workers'comp.insurance comp.insurance.: g addition
required.] 5. ❑ We are a corporation and its . Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myselj,[No workers'comp. right of exemption per MGL 12❑ of repairs
insurance required.]t c. 152,§1(4),and we have no �LHIf
employees.[No workers' 13. er
comp.insurance required]
*Any applicant that checks box#1 mart also fill out fire section below showing their workers'compensation policy infomnatioa
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such-
:Contractors that check this box must attached an additional sheet showing the name of the soh-cortmetms and state whether or not those entities have
employees. If the sub-contractors have=Tiny=,they must provide their workers'comp,policy number.
I ant an employer that ra provrdmg workers compensation h urance for my employees. Below is the policy and job site
information. r�
Insurance Company Name:_ 2 'do-
Policy#or Self-ins.Lic.#: W L 70 — C 42 — rf,�T'— Q Expiration Date:_1t p41
(p
Job Site Address: O/ 50.OAA14 y City/State(Zip: :Q eu, D/f 70
Attach a copy of the workers'compensation p licy 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 DLA for insurance coverage verification.
I do hereby certify" der Ih and penalties ofperjury that the information provided above is tr and correct,
Date lG/
Q
Phone t
#: / 7 '�� ,�— ra
Official use only. Do not write in Otis 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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or.the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07
www.mass.gov/ilia
NORTH-4 OP ID: BC
CERTIFICATE OF LIABILITY INSURANCE DA04/19/20016Y)
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 endorsements.
PRODUCER CONTACT Elizabeth Saville
DPS Insurance Group Inc. PHONE NAME:
500 Granite Ave.,Suite 2 WC,N E,T;617-479-5500 FAX Np;617-479-8761
Milton,MA 02186 ""p'E�,ESaville@dpsinsurancegroup.com
Daniel P Sullivan
INSURER(S)AFFORDING COVERAGE NAIC!
INSURER A;Nova Casualty
INSURED North Shore Rental Inc. INSURER B:
Chris Leblanc
464 Lowell St. INSURERC:
Peabody,MA 01960 INSURER D:
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.
INSR RDOLr
TYPE OF INSURANCE POLICY NUMBER POLICY
MN YEFF POLICY
MN YUP LRdffS
LTR
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE T OCCUR RNT-CL0010436-2 04o1/2016 04MI/2017 PREMISES tFaoxunence $ 300,00
MED EXP(My acre person) $ 10,000
PERSONAL B ADV INJURY $ 1,000,0001
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
POLICY❑ PRO- ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,00
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
Ea accident
A ANY AUTO RNT-MH-0010007-2 O"IJ2016 04/I11/2017 BODILY INJURY(Per Person) $
ALL OWNED )t SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY D
AMAGE $
AUTOS �dAMAGE $AUTOS Per t ax,d
X UMBRELLA LIAS X OCCUR EACH OCCURRENCE $ 1,000,00
A EXCESSIJAB CLAIMS-MADE RNT-UM-0010271-2 04/01/2016 04/Dl/2017 AGGREGATE $ 1,000,00
DED I X I RETENTION$ 10,000 $
WORKERS COMPENSATION PER
COMPENSATION STATUTE OTH
LI ER -
ANDEMPLOYERS' ASILTY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICER EMBER EXCLUDED? N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
K yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$
A Equipment Floater R7736-2 0401Y2016 04/01/2017 Equipment 800,00
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD101,Addhlonal Remadrs Sehedul%maybea chedNmorespaceisrequired)
Rental of Goods
CERTIFICATE HOLDER CANCELLATION
SAMPLE-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
g ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENIATNE
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
10/28/2015 10:05AN FAX 603 $64 1484 MIEGIANY NGffr CORP 19 0002/0002
CERTIFICATE OF LIABILITY INSURANCE r °ATEfgN+IDAYr»
1fL' a=15
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE )$SUM INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the eartiscale holder is an ADDITIONAL INSURED.the pcdWv(hm) must be endorsed. If SUBROGIATION IS WANED,subject to
the terms and Conditions of the policy,certain policies may raestire an endorsement. A statvrnerd on this certYBeaea does not confer tights to the
certift"te holder in lieu of such
PRODUCER
Tom Henan do Hays Companies of Now England �o� 61 773-7775 FAX 617 1
55
133 Federal Street
Second Floor
Boston,MA 02110 MSUFMIM AFFORDING 0e31 NAtC a
w: - Ir�arl.ce Cmr�i--- t6536
INSURED vanwaRg
Aliegiant Management Corp. - ------
300 Lafayefte Rd. ------
Rye,NI10387MOO sesuvERD: —.--
I arstnuete:
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COVERAGES CERTIFICATE NUMBER.ISNHOO27SOM REVISION NUMBER:
THIS 0 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIM
INDICATED. NOTWITHSTANDING ANY MQUIREMENT,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,LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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CITMERIMEMBEREXCEDT I�INIAI WC50.9073&07 = 111Dt12093111/0112016
(NenDTNlry m NH) I E.L DdhASE-EAR w.D a 1,000,000
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:Location Coverage Period: i 1 110 1 12 01 6 i Tiro9120-16 Ci*n* 621
PESCRWTON OF OPERAIMM I LOCAnONEI VEHICLES (ACORO 181,ACIIIMnm FROM"Seeemde,-MY be awVhW if pSpa is mque,ai
Cmersge is pro wed North Shore Rental,Ire.dba:Events for Rent
for oAy Ihme c empwyeee 4B4(:Dwell St
of.bUt M aebrarmxwIS Peabody,MA 01960
to:
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ADM MSCFMW POLICIES DE CANCELLED BEFORE
TILE EXPIRATION DATE THEREOF. NOTICE MALL BE DELMERED IN
ACCORDANCE WTTH THE POSIT t IONS-
I AVT"CRRED REPReWWAYNE
0193&2014 ACORD COPYORATIDN. AN riatits reserved.
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e ®1 ��G111� �'G�7IJ�Gi��� PAGE 1
Date Manufactured AZTEC TENTS
2665 COLUMBIA ST INV NUMBER: 0179791
r 03/24/2010 TORRANCE, CA 90503 P.O. NUMBER:
(800) 228-3687 CUSTOMER NO: EVEN019
This is to certify that the materials described below have been flame retardant
treated (or are inherently flame retardant).
hSn-i ruin : -
r`t
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t Allied Financial Solutions Events for Rent
T :r 7103 Turfway Rd Ste.306
Florence, KY 41042
r 464 Lowell Street
>a Peabody, MA 01960 «r eap F s
swc.r W.ther°n.n a-im of xyJ
Ft{.'� nU9n c_3 pnc
Certification is hereby made that the aracies aescribetl below hereof are made
*"vame9e Big Tw r-i2l w
from aflame-retardant fabric or material registered and approved by the °Ee°
?s California State Fire Marshal for such use. The fabric has been tested and r." °9e rr,^^ ``"'
t"" �nnssrs Fsa9u ?
passes NFPA 701 Large Scale. See chart to right for trade name
rr flame-resistant fabric or material used and additionally referenced on the label
E➢ of the fabric panel. c '
si
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING ' 'r �=.
Fs „ {-
< ,� David Bradley f�eneral Manager- Manufacturing "K:*.
�x
"'� ,�E Name of Applicator or PrpAurtipn Supe nfen Aent Ltle of Applicator ar Protluction supenntentlent �.''
�� �-� ."ati � �w�'Y PP"`y r✓+'���j�y�P .,1�,+'if:S`'at' r`,�i�'!� '+S��Ar�r ;,�;Yt"5�'�Y T�,t�4,� _« F R'�(, a�`s�',��'F+�r.'s�'�i ,�+ ,e�.�5 ✓c'>rr t�^,. � t�tt ry rt rs:ITEMS MANUFACTURED TYPE PRODUCED
15x15 Ipc Festival Top UW S 1
w/ Rope Tensioners & Flag
with secondary valance
15xl5x8 Festival Frame Only S 1
15x30 1pc Festival Top UW S 1
w/ Rope Tensioners & Flag
with secondary valance
15x30x8 Festival Frame Only
(2Peak) -
20x20 1pc Festival Top UW S 1
w/ Ratchet Tensioners & Flag
with secondary valance
20x2Ox8 Festival Frame Only S 1
20x30 1pc Festival Top UW S 1
w/ Ratchet Tensioners & Flag
with secondary valance
20x3Ox8 Festival Frame Only S i
(2Peak)
20x40 1pc Festival Top UW 5 1
w/ Ratchet Tensioners & Flag
with secondary valance
20x40x8 Festival Frame Only S 1
(2Peak)
o ae esos ance PAGE: zwilcate arse .;
Date Manufactured AZTEC TENTS
03/24/2010 2665 COLUMBIA ST INV NUMBER: 0179791
TORRANCE, CA 90503 P.O. NUMBER:
1800) 228-3687 CUSTOMER NO: EVEN019
s
This is to certify that the materials described below have been flame retardant
treated (or are inherently flame retardant).
Y.
e wnn ras F zzz.oa �'
Allied Financial Solutions Events for Rent GWOM4c„m° J;, ' ;�;;>dia° F29.Q1
7103 Turfway Rd Ste.306 02
464 Lowell Street
OFF Gea,V11116.120ga I 0,01
' Florence, KY 41042 oFF oFF F.,,,.o,
Peabody, MA 01 960 E.d°s.eyE.n° 4y5alaM ^eF o=
Recm1am50z F.Ka.ol �¢
a Fenian FRc tmia 702 14e406 t µt
G111up:Taal_ 1111,cne. I-soo m
WCTepi, pec°p°[^=Velm F5o001
5ny°Pa Weallcerspan F100o1 fV�t
Certincatiion-is-hereb made that the articles described below hereof are made Tn°°"`°9° °°"°mo z oz
Y h VM-v 77 ,069.01
from a flame-retardant fabric or material registered and approved by the "'� 1". 0,T.pbWe°1m F.osv.ol '.
California State Fire Marshal for such use. The fabric has been tested and T^°an=a,e 1.06901
` passes NFPA 701 Large Scale. See chart to right for trade name of 40RB'°°9 ^°a..1n ale,=.els=s F_sTo.ol
•. flame-resistant fabric or material used and additionally referenced on the label -
of the fabric panel. +y
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing '
Name of Applicator or Production Superintendent Title of Applicator or Production Superintendent
0
ITEMS MANUFACTURED TYPE PRODUCED
***8x20 Grand Panorama Wall- 15oz UW S 25
Qty 4 P5 Window per wall
Lap and Snap "Indiana Style"