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19 GREEN ST - BUILDING INSPECTION (2) 5 2S nD CK �g23 The Commonwealth of Massa gam. d, a J Department of Public SafeA ,C TC10 W TMassachusetts State Building Code(780 CMR) Building Permit Application for any Building other th O -TjwKagpWvvelling V its Section For Official Use Only) Buildnig Permit Number: Date Applied: Building Official: r 1CTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ct,(evIA O(CC70 No. k :i! SEreD� 5 City/Town Zip Code Natne of Building(if applicable) ( S r:CTION 2 PROPOSED WORK n� Editionof MA State(.o.,�used 11:Jew Construction check here❑ or check all that apply in the two rows below 1 Exist' if;Building❑ Repair Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Cha:sc of Use ❑ Ch-----of Occupancy ❑ Other ❑ Specify: Are`wilding plans and/or construction document:;being supplied as part of this permit application? Yes ❑ No Is an_adependent Structural Engineering Peer Review required? Yes ❑ No Brief Descri.lion of Proposed Work: 1-d�s'1-C(_`I G(.'t'4a� ©� CDJa- C ,At PfiR[1'f Gi(I Yt C� c9f\ `�t2t oC D� O� .'C� tatrt OP-QrtS SEk.TION 3:COMPLETE THIS SECTION IF i4XISTING BUILDING UNDERGOING RENOVATION,ADDITION,.OR CH'iN'GE IN USE OR.OCCUPANCY Check nera if an Existing Building Investigation:,;.d Evaluation is enclosed(See 780 CMR 34) ❑ Existir 6Use Group(::): _. ._ Proposed Use Group(s): _ SECITOr74:BUILDING HEIGHT AND AREA Existing Proposed No. of Floors/Stories(include basement levels)e( '% ea Per Floor(sq. ft.) Tota' Area (sq. ft.)and Total Height(ft) _ SECTION:5:USE GROUP(Check as:applicable) A. Axserubly A-T. ❑ A-2❑ Nightclub ❑ A-3 Cl A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Fattory F-1 ❑ F2❑ 1 H Ml h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: iOercantile❑ R: Residential R-1❑ R-2❑ R-3❑ F-4 ❑ S: Stv-•zge 5-1 ❑ S-2❑ U: T :i14y ❑ Special Use❑and please describe below: Sped,.; Use. _ SECTION 6:CC,DTSTRUCTION TYPE(Check as applicable) IA G IB ❑ IIA ❑ if , ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ qfc`{,ON 7:SITE INFO.RPL.ATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Zone Information: Sewage Disposal: Trench Permit: Debris Removal: P.iblic❑ Check if outside Flood Zone❑ (rtdicate mwticipal ❑ A trench will not be Licensed Disposal Site❑ required❑ or trench or specify: P:ivete❑ or indenaiy gone: or on site system❑ permit is enclosed ❑ I _ -1- Railroad right-of-way: IIa zcds to Air Navigation: MA Histo:is Comm issio n Peneese Process: Not Applicable ❑ Is Structu >v ithin airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑ SECTIONS:(C'7E ENT OF CERTIFICATE OF OCCUPANCY Editico of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does building contain an Sprinkler System?: _- Special Stipulations: GQl t COl\fr ' F ;7 �/3_ 1,C SECTION 9: PROPERTY OWNER AUTHORIZATION. Nadi anti Address of Propert Owner �� 7� c:ct✓� 1M� Nk� l L-I C/f�(an�1 5� Sc���JUI -Name(Print) No.and Street City/Town Zip Property Owner Contact Information: c ✓ °(7p J8 6 S ``vt--� All Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Mckcc- L.o e° vyL%A 7 UCc.vu;, L CL`FCc� G 4�p l"I� c oq-T Name Street Address City/Town State Zip to act on tM.roperty owner's behalf,in all matters relative to work authorized by this building permit application. SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (II buildiut;is less than';5,000,u.ft.of en osed s pac.e cr d,/or not under Construction Control thou check here O and skip Section 10.1) 10.1Registered Professional.Res on 'bl for Construction Control Name(Registrant) T - No. e-mail address Registration Number t Street Address ity/ own State Zip Discipline Expiration Date 10.2 General Contractor e _ CTowv\ 64a� ��' 1���cnc��Mitovt l Cf��2s2 ��To►'L CZL Company Name �,. CSC (p t,v�I e5tf Clad CSC, Mt;r� C. _ v��r� g[z Q Name of R.—son Responsible for Construction License No. and Type if nA�p�licable 7 c9rGvtc6' CurG[Q �e( b L.2(—c ,k `i 0lCl6fy Street Address City/Town State ip 7#'2-Y 307 cre"V\ SL�I,�P q G✓i.tti.l Cc� Telephone No. (business) Telephone,No. (cell) e-mail address SECTION 11:i4r7RKFR5'CUM,MI h':9AT1;7N tNSURANCSAFFIDAVIT M.G.L.c.152.§ 25C 6 A VV,,rkers'Compensation hssuaance A]Hdavit frm,., the MA Department of Industrial Accidents must be completed and subrnit!ed with this application. Failure to provide tl-a of will result in the denial of the issuance of the building permit. Is a signed Affidavit subm,itte_,l with this application? Yes❑ No ❑ SECTION 12:CONS-9:UCTION COSTS AND PERMIT FEE l tom Estimated Costs: (La',or and Materials) Total Construction Cost(from Item 6) _$ 1. Buildin;., $ 6 _ Building Pernit Fee=Total Construction Cost x (Insert here 2. Electric,,. $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechan:i�of (HVAC) $ Note: Minimum fee=$ (contact municipality) \J'� 5. MechaNcal (Other) $ Enclose check able to - payable 6.Total Cosl $ bar- (contact municipality)and write check number here SECTION 13:SIGNATJRE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pants and penalties of perjury that all of the information contained in this application is true and accurate to the best o and understanding. Please print and sign name Title Telephone No. Date Cf Street Address City/Town 1te Zip Municipal.Hispector to fill out this section upon zpplic,,Aion approval• Name Date Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill. out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for r Construction Documents* Mark "x"where applicable No. Item Submitted Incomplete Not Required 1 _ Architectural 2 Foundation 3 _ Structural 4 _ Fire Suppression 5 , Fire Alarm (may require repeaters) _ 6 HVAC 7 Electrical 8 ( Plun+ing(include local connections) 9 1 was(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities, Wetland,etr 1 11 i Specifications 12 + Structural Peer Review 13 Structural Test &Inspections Program 14 Fire Protection Na.:;ative Report 15 Ezi sting Building Survey/Investigation x 16 ! Energy Conservation Report }� 17 _ Frchitectural Access Review (521 CMR) X 18 _ Workers Co ensation Insurance _ 19 i-',ezardous Material Mitigation Documentation 20 I Other(Specify) 21 Other(Specify) _ 22 Other(Specify) `Areas of Design or Construction for which plans are;:ot complete at the time of application submittal must be identified herein. Work so identnied must not be commenced until this app],L,tion has been amended and the proposed construction document amendment has been proved by the authority having jurisdicticr:. Work started prior to approval may be.subjected to triple the original pemrit fee. Registered Proiessional Contact InformationKca- / y( (�,ury7Phe4o1 CS �1�01 eVi�tco Z---- Jo7� Nam; (Registrant) Telephone No. e-mail � Registration Number GSL 2a,�Q r�rC�taaf� Ct�rct,¢._ ��let� a dr ,s olY4 Street Address City/Town State Zip Discipline Expiration Date Registration Number Nanw. (Registrant) Telephone No. e-mail address Street Address City/Toe :t State Zi Discipline Expiration Date Re"istration Number Name (Registrant) Telephone P!t e-mail address Discipline Expiration Date Street. Address Citv/To.rr: State Zip Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connectio s are roperl ddressed to ensure for public safety. Please fill in the i m below an i apper Ix with the building permit application. The buil g permit app an; attests under the with and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot # for locations for which a street address is not available) No. and Street City /Town Zip Name of Building (if applicable) For the bove described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shirt Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Ye- ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ )ther (if applicable) ice'• Clary OF SM-Em, %LXSSACHLSETTS • BUILDING DEPARTMENT tt 120 WASHINGTON STREET, 3-FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KINIgERI EY DRISCOLL MAYOR DIRECTOR ST.PtEula DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO`tN1ISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App,icant Information Please Print Legibly Natrie(0usiness"Urganization Endividual):S(12 1/V(C/AGcC2 CON5 r-rcC t,L44 �7 p Address: rr ! City/State/Zip:tAW' l.ttiead /1 W r f9Y5 Phone #: 2 � ` �- 'T 1 Arse, vo au employer?Check th appropriate box: Type of project(required): i.L`,"1 am a employer with 4• El I am a general contractor and 1 6. ❑New nsttuction 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• emodeling ship and have no employees These subcontractors have g. Demolition working for me in any capacity, workers' comp. insurance. 9• 0 Building addition (No workers* comp. insurance 5. We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.Ci 1 am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions myself. (No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.)t employees. [Ato workers' 13'E] Other comp. insurance required.) *Any upplicam that checks box or must also rdl out the sectfgn below showing their workers'compensation policy infurmuuiom. t 1 totttetw:nxs who submit this affidavit indicating trey are doing all work and then hire outside=ntracturs most submit a rmv affidavit indicating such. -Conva:wn that check this box most anached an additional sheet showing the name of rho sub-ewntractan and their workers'comp,policy information. --a I am n n employer rhtsi?;,nruviding workers'compensation insurance for my employees. Below is the policy and fob site information. (' I p Insu:trice Company N::me: C_,gfp'l •�'yt Src,' C�� G. C3✓� y � I'oltr.y 4 or Scl / f-ins. Lie. ti: C `�L Uo'_165( Expiration Date: P— 2d— Za 14 Job^ire Address:_ S i City/State/Zip: Sit I <2l A4 1C>/`?Zo Attach a copy of the workers' compensation pulley 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 foe 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. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of the DIA for insurance coverage verification. /do hereby certify adder the"ns grad petrah�erfu r that the iuformadon provided above is true and correct S_lgn_nµrc; phone 14. —7_ �: O,11rial use only. Do nor write in this area,ru be completed by city or town offic•iaL City or•rmvn: Permit/1.1cense# Issaing Authority (circle one): ----- ----_.___ 1. hoard of Health 2, Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. *Other ..__...__ LCu:itact Person:_ _..._..____.____,. Phone#: Office of Consumer Affairs&Business Regulation w License or registration valid for individul use only - ME IMPROVEMENT CONTRACTOR I before the expiration date. If found return to: - egistration: 119813 Type: '- Office of Consumer Affairs and Business Regulation - xpiration: --9L14[201S-. LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 CROWN PROPERTY MArU'GEMENT &CONSTRUCTION LLCTV , MARC LIEBMAN 7 ORCHARD CIRCLE MARBLEHEAD, MA 01945' - Undersecretary Not valid without signature � 7`' s'achatsetts -Department vF€'uCkc Safety Board of Building RegzAaforts arr: haodaids t¢ C01151mcdofn Supervisor License: CS-108128 ' MARC LIEBMAi Marblehead MA b19 Cornrnissioner 09J20�2o18 Uri eS,,ricte 1-Buij"gS.ofany use group,uhich contain less that5,000 cubic feet(991m)of enclosed space.. 3 + Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license, For DPS Licensing information visit w .Mass.GoWDps Sally Murtagh Kristen Boffo <kri tenboffo1984 From: s @gmail.com> Sent: Tuesday, July 12, 2016 11:23 AM To: Sally Murtagh Cc: Carmel Harney Subject: 19 Green St. Hello, I am writing to inform you that the 19 Green St Condo Association is aware of the work being done to install a railing on the second floor on Wednesday 7/13. Please feel free to contact me with any further questions or concerns. Sincerely, Kristen Boffo 19 Green St. Condo Trust t DoouSign Envelope ID:95CF21C7-B689-4334-9667-A07CB05CFF2B Crown Propert Management & Construction LLC CONTRACT FOR WORK Client Name: Brian Mccarthy Date:7/11/16 Address: 14 Oakland St Salem MA 01970 Phone: 978-994-3180 Description of Project: The following entails the scope of work for completing Installation of railing on exterior of door to roof. • Construction of railing. o PT 2x4 top and bottom rail o PT balusters 0 42" in height o less than 4" between balusters Exclusions: • Additional work required or requested Grade of Materials: • All materials to be standard grade unless otherwise specified. Required Permits: The following building permits are required and will be secured by the contractor as the client's agent: • All required building permits • Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A. Proposed Start and Completion Schedule: The following schedule will be adhered to unless circumstances arise beyond the contractor's control: 7/13/16 Date when contra for will begin contracted work. 7/13/16 Oate when contracted work will be substantially completed, subject to change because of change orders, delays in material availability and delivery, inclement weather, and other unforeseen circumstances. Total Contract Price: The Contractor agrees to perform the work and furnish the material and labor specified above on a time and materials basis at a labor rate of$60 per labor hour and 10% markup on materials. Estimated time and materials: $600 plus the cost of permit 1oft DocuSign Envelope ID:95CF21 C7-8669-4334-9667-A07CB05CFF2B Crown Propert Management 8 Construction LLC CONTRACT FOR WORK Payment Schedule: 100% payment due immediately after inspection. Change order policy: Any deviation from these plans or scope involving an extra charge shall be agreed upon in writing. • The dollar amount for such extra work shall be determined in advance if possible. Change order payments are due upon receipt of change order. • In limited cases, a change order may be charged for actual worker-hours accrued at an hourly rate ($xx/worker-hour) plus materials purchased. Warranty: The contractor warrants to the client(s)and all subsequent owners of the property: • All of the work, including all materials, hardware, and fixtures utilized in said improvements, will be free from all defects caused by faulty workmanship and/or defective materials independent of whether such workmanship or materials were in r. ,^oliance with building standards, for the one (1) year time period after the date which the work is completed. Contract Acceptance: Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Resolution of Disputes by Contractor: The Home improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The contractor and the client hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm for resolution by a single arbitrator which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. oocuslgnetl by: p j�V1AIn' �LC�AY��AAf 7/11/2016 Marc Liebman Date Clients Igna ure Date 2of2 A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD 4/12/2016 16 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 endorsement(s). PRODUCER CONTACT Marcia Thompson Charles River Ina. Brokerage, Inc. PHONE (508)656-1400 A/C No:1508)656-1499 5 Whittier Street ,,RESS:mthomp eon®charlesriverinsurance.com ADDRE 4th Floor INSURERS AFFORDING COVERAGE NAICN Framingham MA 01701 INSURERA-till Insurance Company INSURED INSURER B Guard Insurance Company Crown Property Management 6 Construction LLC INSURERC: 7 Orchard Circle INSURER D: INSURER E: Marblehead MA 01945 INSURER F: COVERAGES CERTIFICATE NUMBER�GL 3/2016 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER IIMIDDY/YEYYY MMNDIYEXP YYY LIMITS LTRJUSEL MD R COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 RE A CIAIMS-MADEOCCUR PREM SES Ea oocurrence $ 50,000 TBA 3/10/2016 3/10/2017 MED EXP(my one person) $ 11000 PERSONAL B ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PROJECT- 1-1LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Employee BeneflLs $ AUTOMOBILE LIABILITY CEaOMBINED SINGLE LIMIT $ accitlent ANY AUTO BODILY I NJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accitlent UMBRELLA LIM OCCUR EACH OCCURRENCE $ EXCESS LIM CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOWPARTNER/EXECUTIVE YE N/A B E.L EACH ACCIDENT $ 3.00,000 OFFICERIMEMSER EXCLUDED? (Mandatory In NH) CRNC604658 B/20/2015 8/20/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD IN,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Swampscott THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 22 Monument Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Swampscott, MA 01907 AUTHORIZED REPRESENTATIVE T Vocatura/MARCIA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 oIHAnn CERTIFICATE OF LIABILITY INSURANCE DATE(MMA)D YYYY) 4/12/2016 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 endorsement(s). PRODUCER CONTACT Marcia Thompson NAME: p Charles River Ins. Brokerage, Inc. PHONE (508)656-1400 uc No: (508)656-1499 5 Whittier Street E#AIL mthompson@charlesriverinsurance.com ADDRESS: 4th Floor INSURERS AFFORDING COVERAGE NAIC 8 Framingham MA 01701 INSURERAEaseX Insurance Company INSURED INSURER B Guard Insurance Company Croern Property Management & Construction LLC INSURERC: 7 Orchard Circle INSURER D: INSURER E: Marblehead MA 01945 INSURER F: COVERAGES CERTIFICATE NUMBER:GL 3/2016 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE JH=MD POLICY NUMBER (MMIDDNYYYI IMMIDDIYYYY) LIMITS R COMMERCUILGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGETORENTED PREMISES Ea occurrence $ 50,000 THA 3/10/2016 3/10/2017 MED EXP(my one person) $ 1,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY[::] PRO-JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Employee Benefits $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-0WNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA Use OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DIED RIFTEN I I $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STAT YIN UTE ER ANY PROPRIETOWPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICERIMEMBER EXCLUDED?(Mandatory In NH) ❑ NIA CRWC604658 8/20/2015 8/20/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 Dyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Marblehead THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 188 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. Marblehead, MA 01945 AUTHORIZED REPRESENTATIVE 7- T VOCatuTa/MARCIA "'o L Z --��- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO251>D14nn