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4 HARRISON RD - BUILDING INSPECTION I23`E '� 4 XN The Commonwealth of:Massachusetts �� WRtA1. q Board of Building Regulations and Standards � CITY OF / Massachusetts State Building Code, 780 CMR As EM jr 2011 Building Permit Application To Construct, Repair, Renovate offish it (n One-or Avo-Family Dwelling r. This Section ForOfrkial Use only Building Permit Number. D . _pelted: c�J 611 Building Official(Print Name) - - Srgzmture, Date SECTION I.SITE mottiviAT10N% I.l Property A ress: / 1.2 Assessors Map St Parcel Numbers � �m I.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Uime'0516nst''' 'r`)"x alil t l!fi �isn;�:A, raurvc�tl:�1. Si 6i1 Zoning District Proposed Use - Lut Area(sg it) t;K-,7 i{Fmnte 1.5 Building Setbacks(R) . _Front Yard - - - _ Side Yartls Rear Yard - Regytenl .Providal Requhed P.rovided.. . . Required ` !'mviJed 1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone. Outside Flood Zone? Public Private�. Municipal 0 On site disposal system O Check if estD.. SECTION2: PROPERTYOWNER$RIPk- 2.1 err J of Reco C` Grp G tan .. �Llu,S ,e(r�`i ' Gt lme(1'rinq /-'- City;Slate ZIP y C/Lt✓Yl s� �- �yy-SSL/y/ No.and Street - Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all thatapply), New Construction 0 Eztsting Building 0 Owner t9aeupied O Repairs(s) O I Alteration(s) O Addition O Demolition O Accessory Bldg.❑ Number of Units Other 0 Sped Brief Description of Prop Work-: S. ti. SECTION 4:ESTIMATED CONSTRUCTION COSTS Clem - Estimated Costs: Official Use Only Labor and Materials) I. Building 1 S'76W I. Building Permit Fee:S- - Indicate how fee is determined: �. Electrical S O Standard Chyfrowa Application Fee O Total Project Cost-'(Item 6)x multipiter x 3. Plumbing S 2?91her Fees: S 4.&Icchanical (HYAC) S List: 5.\[Lehanical (Fire S Suppression) Total All Fees:S CheckNo.42j,9CheckAmount: Cash Amount: 6.Total Project Cu st S 9'W ❑Paid in Full ❑Outstanding Bal:mce Due: (P l m FULL-r_S-n I t'3 S P , `'ua SECTIONS: CONSTRUCTION SERVICES 5.1 ConstructionSupervi"' License(CSL) $7Ll'� 7 Z L ( - License Number Expiration Date er v. Name of CSL Holder =ldJ List CSL Type(see below) Frio W Pal g Tye Description -. No.and Street - 3 Hilton Eueet U Unrestricted(FB­ujltrings up to 35,000 cu. It. n ' R Restricted M2 FamilyDwelling Cityfrowa,Swte,ZIP Salem � M Maso - RC Roof Covcrin - WS WindmvandSiilin SF Solid Fuel Buniing Appliances 9� .�yy-friy3 I Insulation Telephone - Email address D Demolf6on 5.2 Registered Home Improvement Contractor(HIC) �N2d G� 3 Ilk HIC Registration Number Expiration Date FIICCompany g�g,Qr. : egtstntltlV�a� - . No.and Street SaleihAA.Ot970 i Email address city/row cityrrown.State ZIP Telephone SECTION 6:WORKERS'.COhIPENSATION INSURANCE AFFIDAVIT04q L e.152.§2SC OY Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Isivance o building permit. i Signed Affidavit Attached? Yes .......... No...........0 SECTION7atOWNERAUTHORIZA,TIONTOBE.COMPLETE�_WHEM r; OWNER'S AGENT Olt CONTRA&dIIL APPLIES FOR BUILDINd PERMIT'' 1,as Owner of the subject property,hereby authorize rr r P AIn tg act on my behalf,in all matters relative to work authorized by this building permit application./ . Print Owner's Name(Electronic Signature) , Date SECTION 7b:OWNEW OR'AUTHORIZED AGENT DECLARATION - By entering my name below,i hereby attest under the pains and penalties of pedury that all of the information - contained inasupplicads tru n accurate to the best of my knowledge and understanding. c Print Owner's or Authorized Agent's Name(Electronic 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 registered in the Home.lmprovement Contractor(HIC)Program),will LLgl have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Otherimporttant information on the HtCYrogram can bo and aT tvww mass eov'oca Information on the Construction Supervisor License can be found at www.mass.eov.'dtgi . 2. When substantial work is planned,provide the information below: 'total tloor area(sq. ff.) `+ ,(including garage, finished basement/attics,decks or porch) Gross living area(sq. it.) 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 cooling system Enclosed Open .i. "Total Project Square Footage"may be substituted tor-Total Project Cost" 1vlassachnset( g®me rovemeat Sam Ie Contract i litegmeetopeter baah� � loftf- Home lmptovemmt OmcoamorGwdero a ®tf'aybf" Auy p)>e� e 'I .rmghme [dcea aoredodesf Shouldaodard (r �itIDeOwuer .110, on§Cons>®e oa MA eatat617mA7� YUIRMM—MBWobtamei a m8the �nf0r®a�On 3,8787 m 1-88&283_3 757 oron oartve�t�Nm°e Conhaetor7nfnrtnatidn � k FZ�d,mAdd�(..n. mea8mt0 A l"'C {ri�,,�{, amraddaa) lf,eatheriieiwii LLi. Av�ue Stme?� Zip Cade F'•-� Daytime Phd'p'e'^„ 7 Evettmg Py®e - SO - MailinsAddmse(h g. elate®Phone 6 l�/,�— B��Cod` Fetvat r>ON°yQIDmBs.Hmnba �� +tst°a°'®.emnmaatrmt4 7'he Coatractorn;,teE rodo the Poll e� ��e�lJ O 9 .'� ��i/(Dev(be in decal the wmkrornmPlead.owin8warkforWe emaowaer. ` �(p '>'�fYmS iherype kA gm&.f(e,+imctobe taed.2�additi Re9oireaP /7' S a and will bes�m ytb o8owiogbndt(�BPeanilsme r (Owners w�urecePhOia athehom t� P^°Posalsmrt—dd o &sebedulewaj Mcluded,n theta atan[y Fund Winhhe be aditetedmtmt aar�,µ®���do�e��m aol a se — Dzfe whm Caaaecm W begin conbsded work Total Co arractPeim and P49m®t SdtedNe � 1)ate"bee eooaagod wmk WW be mhs ,ZtjttrCoeWetrA e Contractorogtem roperfmm dmw dale themat®ar andlabm .aymeots will bemrdeaccoad(n8to thefollowtn spedfied ahtrvefmlhetota)s®oE upon sigttiagcoahact( .aotm S e1/3 ofthetntard 63' ) ) truce or dte Ctnt ofaronfm' S ''ampttpjnn of �s.wMehewatsgeatu) by S m upon cemptetioa of - f Th eai upon completion oftheCO°hact (fawfodtids md,mdjvth, d/egaiptpmt Meet III d�d°tSfoll eat®h7''oahartis mbe rm eOmPtemambom Patty'asetisfie6aa) Includin8 yl S10 nmm�t Smnmtlwge4(•a)ym,manitrs t(m �(�--K °/ a which mart be'q-mWwdeed etluN afthetaEd 'm md°w*'Wymmt rr-0m-dby dm m �+ mntracam adwy;eemmertrhe R)theaeaulemt of be1mewpdr bepm e°mPtefrm se6 °^y rPxml equi °taY &a reaa •e edvle t�menemcmt°m made _ s mateial Sohroaeradms-7}m C°° O2 i'mesto—be sot Otto pmry/subcontractoray(i$d g,themo ��T°0blefmu® I aced smtd la and his baetw, 7h '"Potorfefm petion efthe me ° be me Cnneraet Accepmaoe-U al7eesrohe sol 9aespoas3tetm��ofrheacdays ofany dtud U-ktoad rnohnct shnil aotiml Pon stgmn&this d°Cummtbecemgabin ' PaYmmtsroaa cebCoatraemmfor Pgtharan beamathv be8c�nastuada.law camtitlly hefine s8ning lhFs canbam, cemII1h' Chas placed on 0te"'idm Rmaogwtseamed"i0tm thisdo''nment the ° Doa'the ihef°Den'in8�t6o¢sandaoa the Iwo a8orogaN cra ° M—as_ va0C"` TaMdmetomadaodruU 9 oat ifszao ms to-be —heDkm wear Yuadrya°d tt�k tegtstmhan bywahoB two Wei mme DaoctoroMeelC tr�."-rR an 7Lelaw'ettoltesmast 8isnndear. lhttstnrg l0 fmPmvmt®t Co home' ° De f �rhaveinstvancev�hp��No®5170,Batton,MBA 02116R 6wby You mayi(PIM �� 7a'm0f =d Raow ghtsand mice^d '+etatMa 57. aam WS&SQ93-3 yem�llitim.Read the lmponmtt you Call''°°flat oovmapS orask to You mby eaacelthis matchub"t,Law. htfotmatioo oe tbetevers "deofthisfmmaadgetaeopyofthecens w Ceaaactorin�foD31 tom 8 9guedaap7�otber0taa the 111111 third business g ,&tameaLceSee thole ml'ttw7 cea �de8mm Gelall �en1 P+ovidedyonnotifydm r°v rDn®a eraoNOT SIGN T'HYS�O1V]$�y�mm�ed noticeofmoodtariottf— f&r Vp�l�atim �mtdmghtoftha eAm W7HERE th sr g)u `e 'mu�a .OacmPrrLwlda°n, ANY BH,ARI[£SP:t g!!! lipaBi be metimnc gnatrae Do. 17 C. C®aaC1m's Signaaae Contractor Arbitration ' 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 same right is not automatically afforded to a contractor however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless t both parties agree to the optional clause provided below- This clause would give the contractor the some right to arbitration as is afforded to the homeowrierby the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the"cut the contractor has a dispute concerning this contract,the ", " 't10 t�lF1'R he dispute to a private arbitration firm which has been approved by the Secretary of the Forerun-i4ece of o Affairs and Business Regulation and the consumer shall be required to submit to such arbikutipj;aSt¢1it7ra�1f9 sachusetis General Laws,ch er 142r1 1. Ho corer's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resotutioh even where this section is not separately signed by the parties. Homeowner's Rights ` A homeowners 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 p',rvscribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund 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 your consumer/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 conractor. Any modification to the original contract must 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! Accelerated Payments ' A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the ,r homeowner deems hinAerself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractormay require that the balance of fiords 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. I Additional Information -. If you have general questions or need additional information about the Home hmprovement Contractor Law or other consumer rights,or if you wish to obtain a five copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline , Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCA13R website at htm:/hvww.massgov/ocabr/ t 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 i Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 j 617-973-8787,888-283-3757 or visit the HIC website at httn://%"nN.mass.2oi,/ombr/ i . Go online to view the status of a Home Improvement Contractor's Registration:- _ bttv,//db.state.ma.us/homeiuxm%,ement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: onsum_ er plaint Section - f6 orney General '. 617-727-8400 AND/OR Better Business Bureau 508-652-4800.508-755-2548 or 413-734-3114 version 11-1IMM10 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 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): Adatic Wtathct LAititl, LLC e rror- Avenue Address: Salem M h 111970 City/State/Zip: Phone#: 7 k' 71'IW- Fl q-3 Are yo n employer? Check the appropriate box: Type of project(required): 1. am a employer with Z< 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑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 me in any capacity. employees and have workers' comp. insurance.t 9. ❑ Building addition [No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself o workers' com right of exemption per MGL y t p c. 152, 1(4),and we have no 12.❑ Roof pairs t insurance required.] § 13. ther�/1✓Si.�/4 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 time of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: �C4 1"r GG, J Policy #or Self-ins.Lic.#: ��'5/ 6 a7 O /2 / aa Expiration Date: .3/Z_011 -7 Job Site Address: q l`lZlr 1 tsar t �A • City/State/Zip: Sl/-2h1I /I14 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 certi under tlrepains and penalties ofperjury that the information provided above is true and correct. Sijznature• N ,� Date: > of 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 i Contact Person: Phone#: v. vvo rax aerver i " CERTIFICATE ®F LIABILITY INSURANCE DATE(RIIBf/DD/YVY1) T. . IFICQTE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TNIS CE RTIFlCATE DOES NOT AFFIRMATIVEL''OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER A T E CE C TE ODE . IMPORTANT:If the certificate holder is an(ADDITIONAL INSURED,the pOlicy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Cerialn policies may require and endorsement. A statement On this certificate does not confer rights to the certificate holder In lieu of such endorsemen s- PRODUCER f CONTACT EASTERN INS GROUP LLC NAME: 233 W CENTRAL STREET PHONE FAX (A/C,No,EXt): (A/C,No): NATICK,MA 01760 EMAIL 22MLW ` ADDRESS: INSURED INSURER(S)AFFORDING COVERAGE NAICp INSURER A: aAthRICANZURICH INSURANCE COMPANY ATLANT[C'NEATIiER[ZgT[ON LLC � INSURER S. i INSURER C: i 61 REAR JEFFERSON AVE j INSURER D: SALEM.MA 01970 INSURER E: I INSURER F: COVERAGES CERTIICATE NUMBER: CEMENT. ER THE POLIES OF WSUAgNCE DSTm BEL WHA BEEN ED TO THE WSUR®NAMm ABOIAi FDATHE PoLICYPEgppNNDICATED. NOTWRHSTANDIYG ANY REQUIREMENT.TEAM Ofl CONDITION OF 4NY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAa1THEWSUAANCE AFFORDED BY THE POLRJES OESCFIIBED HEREIN 6 SU9JC-Cr TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LBA IS SHOWN O MAY HAVE BEEN HE INSURANCE CED N PAID CLAIMS. i ' WSR 4OD B LTR TYPE OF WSURANCE POLICYEFFDATE POLICYEWOATE L R PODCYNUMRER (NAA\pDIYYYY) (MNMDIWVY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CH OCCURRENCE $ CLAIMS MADE ®OCCUR. DAMAGE TO RENTED $ PREMISES(Ea occurrence) D EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ POLICY ®PROJECT®LOC ENERAL AGGREGATE $ AUTOMOBILE LIABILITY PRODUCTS-COMWOP AGG $ ANY AUTO COMBWEDSINGLE S ALL OWNED AUTOS LIMIT(Ea accident) SCHEDULE AUTOS BODILYWJURY $ HIRED AUTOS 1 (Per person) NON SOD INJURY -OWNED AUTOS $ (Peraccident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EXCESS LIAR CLAIMS-MADE ' EACH OCCURRENCE $ DEDUCTIBLE l AGGREGATE $ RETENTION S $ A WORKER'S COMPENSATION AND $ EMPLOYER'S LIABILITY YIN ! U6�6270121-16 05/202016 % WC STATUTORY OTHER ANY PROPERITOlVPARTNERlEXECUTIVE OW2012017 LIMITS OFFICER"MEMBER EXCLUDED? NI (Mandatoryin NHl I E.LFACH ACCIDENT $ 500,000 R yes,describe uMer E.L DISEASE-EA EMPLOYEE $ 500,000 0 SCRIP ION OF OPERATIONS belmY j DESCRIPTION OF OPERATIONS!LOCATIONSVEHIC /R ESTRICTONSISPECIAL ITEMS E.L DISEASE-POLICY LAM? 5 500,000 LES THIS REPLACES ANY PRIOR C6RTiFfCAT6ISSUED TO'i'HE CERTIFICATE ROLDER AFFECTING WORKERS COMP COVERAGE CERTIFICATE CITY OF SA LEM HOLDER 1 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINGTON ST BEFORETHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED INACCORDANCEWITH THE POLICY PROVISIONS. _ SALEM,MA 01970 I AUTHORIZED REPR ...._ A_yE _�. ACORD 25(2010/05) The ACORD name and logo are " V 9 registeretl marks of ACORD TBSB=7A70 ACORD CORPORATION. All rights reserved. A CERTIFICATE OF LIABILITY INSURANCE 01ATE 91 MmDumYt THIS CERTIFICATE ] 2016 S 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,AN THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder ii l ADDITIONAL INSURED,the policy(ias)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COMA ME: COIIBLLIICt10II Eastern Insurance Group III! PHONE (g00)333-7234 PA% 233 West Central St i EartAB. "� Me, i AO Natick t1A 017�60 INSURER AFFORDING COVERAGE NAICg INSURED INSURERAArbella Protection Ins. Co_ T41360 INSURER B fTa.O Insurance Co Atlantic Weatherizati.on 61 Rear Jefferson Avenue i INSURER c: WSURER O: Salem INSURER E- NA. 01970 INSURER F: COVERAGES CERTIFICATENUMBER44aster 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 REO(IIREMENi, 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. NSR TYPE OF INSURANCE POLICY NUMBER MMNCy EFT POLICY EXP LIMITS GENERAL UABI'TY I EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAWABILfrY � A CLAIMS-MADE ®OCCUR PR AISEB 500042816 /20/2016 /20/2017 MED IXP(Airy one parson) S S,Opp X CONTR&CTOAL LIABIISTY X C00001 10/O1 80RAI ! PERSONAL S ADV INJURY S 1,000,010Q GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE S 2,000,000 POLICY X PRO. r. PRODUCTS-COMPIOPAGGS 2,000,000 AUTOMOBILE LU181UTY ] S COMBINED SINGLE LIMB A ANY AUTO Ee accident s 1 000 000 ALL OWNED X SCHEDULED 020015871 BODILY INJURY(Perperom) S AUTOS AO ON-OWNED /20/2016 /20/2017 BODILY III(Paattiaed)X S HIRED AUTOS X AUTOS PROPERTY DAMAGE er acdden S X UMBRELLA UAB X OCCUR 'y PIP-13I S A EXCESS UAB CLAIMS-MADE I EACH OCCURRENCE 5 1,000,00Q AGGREGATE S 1,000,000 DED RETENTIONS 10,00 600058654 /20/2016 /20/2017 AND EMPSCOMPENSAnON S AND EMPLOYERS' ARTN R YIN WC STATU- OTH- ANY PROMEMBER/EXCLUDRIEJ(ECUTIVE O andatoM in NH)EXCLUDED? ❑ N/A EL EACH ACCIDENT S (MYyaaan4tlatory in under OF OPERATIONS btlmv EL DISEASE-EA EMPLOY S B POLLUTION E.L DISEASE-POLICY UMR S L200378614 0/1/2015 0/1/2016 EAPOLwTIONCONDITION $1,000,000 GENERALAGGREOAI'E $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS)VEHICLES( Raeh ACORD tlule,101,Additional Remarks Sche if mare space is required) CERTIFICATE HOLDER I ( CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE �I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 93 WASHINGTON CITY OF S ACCORDANCE WITH THE POLICY PROVISIONS. TON STREET SAT+1''M, I1A 01970i AUTHORIZED REPRESENTATIVE i John Roegel/SNE ACORD 25(2010105) INSO2511n,nna,a ©121135 �OACORD CORPORATION. All rights reserved.n Massachusetts Department of Public Safety I Construction Supervisor Board of Building Regulations and Standards Restricted to. License: CS-W977 Unrestricted-Buildings of arty use group which ao>1Eain Construction Supervisor less than 35,000 cubic fed(991 cubic mders)of . ate: enclosed space. ERIC W PALM . 3 HILTON ST Y , SALEM MA 01970 � n,..a CA— Expiration: state��� Failuretoposs''ssa'eur�reediKon oftheMassacflussus Commissioner 06723/tion eIs�se for revocation 61thisBcense. OPS Licensing inforrrtation v>st VUM MASS_GOVFDPS _ %57 License or registration valid for mdividoi use enly .t Office of Coasnm=Affairs&Busmes R%,Ia0oa - _ before the espirstion date. 7f found rctnrato:. t - - a' ME IMPROVEMENT COKMCTOR � - office of Consumer Affairs and Bosmes Regutahon - d . ._ on: 142089 Type. -10 Park Pt=-suite 5170 lraHoa: .tFF72FZD1fr Ltd tSaaiGty Corpor Boston,K Aa 02116 ATLANTIC WEATHERIZATION L.LC_ ERIC PALM 61RJEFFERSONAVE SALEM,MA 01970 Underseeretnry Not valid without signature