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59-61 HATHORNE ST - BUILDING INSPECTION I �� :�, I'ha C'onunomveald) of Massachusetts W $ hoard of Building Regulations and Standards Cl FY OF b(assachusetts State Building Code, 780 CMR SALL I Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a One-or lira-Pimlih• Dtvellll{\, This Section For Official Use Onl Building Permit Number: Date Applied: 7 t l A I'll (luilding Official(Print Ntunc) Signatu Uate SECTION I:SITE INFORMATION L�I Praperty Addr ss: �S�LEM 1.2 Assessors blap ds Parcel Number )7-G'� NArCI'��2►J� M I.la Is this an acre tied street? 'es V no Map Nunther I'urcel Number I.) Zoning Information: 1.4 Property Dimensions: Zoning District I'rirp..cd tl c Lot Area(sq II) Prontogc(It) 1.5 Building Setbacks(R) Front Yard Sidc Yards Rcar Yard Required Provided Required I Provided Required Provided 1.6 Water Supply:(M.G.I.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Pr(sate❑ Zone: _ Outside Flood Zone? Munici al❑ On site dis ) Check if es❑ P pusul s stem ❑ SECTIONS: PROPERTY OWNERSHIP' 2.1 Owner'of Re o d: . , M�Qer 7 TLEIZi ill977-J Name(Prim) City.State.ZIP 5)-61 97t 9790W11s No.and Street reiephune Frail Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repa(rs(s) O Alteralion(s) O Addition ❑ Demolition ❑ Accessory Bldg.O Number of Units Other ❑ Speciry: Brief Description of Proposed Work=: elm-�fiQu Zi C( SECTION a: ESTIMATED CONSTRUCTION COSTS Ilcm Estimated Costs: (Labor and Materialsl Official Use Only 1. Building 5 I. Building Permit Fee: f Indicate how fee is determined: '. L'lectrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(1trn 6)x multiplier x j ?, Plumbing S 1 Other Fees: S _.--- J. \lecb:usicd III\'.\('I S Lisl: 5. \Icchanical iFire --- --- - - - - tiuiprosion) S Total .\llFees: S_ - - .-_. l'hcek No. ('heck Amuum: lash \m,nmm: o. Tidal Project Cnsl: S Q fl�,�J "IP 6,1 in Full O Outstanding 11.1kmce Due: rtot; � �c7 �Oh/>•G� SECTION S: CONSTRUCTION SF.RVI('FS 22 5.1 Cons tructiun Supers l' r License I('SL) � g9 9 9 p o V.� _ ,O_C 01e W I icolw Number f\pi Wiiul Ualc N;une of CSI. I Iulder 1�� `�/� I Q� � I ixt l'SI. fN Pe(.,cc helawl_�--_--_- ----- 'I'y p; Description N,,. .tnd Street d g a 41 v -LFM1rcslriaeJlDuilJin su Io1S.11llticu 11.1 _ R Ne.+Irictcd 1&2 Famil M%ellin Cil\!I'oen.Slate./III SI Mason R00t.ing Covering \4'S Window and Sidin SF Solid Pucl Burning Appliances I Inwlutiun Tale hone Finail address D Denu,litiun 51 Registered flume Ins t/rJuvJement Cuntr/')Stor(HIC) I�s96� d a �.p ���(��{�fjQ,�r l/Q�� �y IIIC Registration Numher I:s liratir n Date III ' 1 'span) Name or I ti 'Reglsua`r Nume G I�I 1 I q r �6 iCCA211de a-Mor: N id Street Email address City/Town.State,ZIP fele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize o N, 1 cc-oto act on my behalf,in all matters relative to work authorized by this building permit application. MA94 1A��' Print U\sl •r's Nwne(Electrumc Slgnaturc) ate SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print 0„nerb or:\udurciieJ Agenl's Nume I liledrunie Signnlure) Dale NOTES: rl. An Owner\shu obtains a building permit to do his.her own wurk,oran owner who hires an unregistered contractor (not registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration program ur guaranty fund under M.G.L.c. IJ_'A.Other important information on the HIC Program can be found at n1.1" \ 4,1 Information on the Construction Supervisor License can be found al++ \+\ nl.l. g \ III, 2. \\'hen substantial work is planned, provide the information below: l roar area(ey. fl.l _ ____.._I including garage, finished basement attics,decks or porch) Gross it%ing area I sq. it.) __.. Habitable room count I Nstnuber of fireplaces ... _ xuniher of bedrooms .\umher a1 hadtn+unls . _ - -. . �'umbcr)(half h;ufts I�ItCIoieJ I)pe of heating i)'Iem Number ofdeeks• porches - Open � I\pC Pl cP1+1111L'_ i1 s1e111 i \. "I+dal Project Square Footage"nBn) he suhstiuded ILr"I'otal Project('o)t- CITY OF S.kLaf, �Lkss.kcw'SE-fTs 8LtLDLNG 0EP.1ATntLVT I is 120 W'ks' 4GTON STURr, }iO FZOOI! rM (978) 74S-959f KI BERLEY DIMOLL FAX(978) 740.9844 .MAYOR 7}to..%W sT.PtEtatt DIRECT01t OF Pt.aUC PRoPEATY/at:Q.DLNG CO\Lltluto,.S;Elt Construction Debris Disposal Aff1davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I (1.S Debris, and the provisions of MGL o 40, S 54; Building Permit At is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by AIGL c U 1, S I30A. The debris will be transported by: (nune of hauler) The debris will be disposed of in --- (name oP fudity) tom✓ ltill(� iJudnu or f�nliyj--�' vynanua ofpermir�pphunt JJte Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contactor Registration Registration: 147960 Type: Private Corporation Expiration: 8/23/2013 Tr0 215989 ROBICCO INC ROBERT POCZOBUT - 172 WHALERS LANE L - SALEM, MA 01970 Update Address and return card.Mark reason for change. Address ❑ Renewal Employment ❑ Lost Card SCA 1 0 20M-05/11 ,0 1(�o�ieoruirerzui.1�o� rmGrdriaaCGJ License or registration valid for individul use only Orrice or Consumer Affairs&Business Regulation before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR egistration: 147960 Type: Office of Consumer Affairs and Business Regulation xpiratlon: 8/23/2013 Private Corporatio-S 10 Park Plaza-Suite 5170 Boston,MA 02116 lug- ROBICCO INC ROBERT POCZOBUT - 172 WHALERS LANE g SALEM,MA 01970 Undersecretary Not Afidithout signature i :r tLhacctts D(R`'�n,t(on'. an I St nd trds rd Boa ut'Buildin cialty License ConstYLction'Supervisor Spe, .Lice+nse: OS SL 99699 ' Restnctedto: WS ROBERT POCZOBUT P i -17 BEACH ROAD APT.45 'LYNN,MA 01902 ".: •.... NExp,retion: 2/812o12 "��� - Tr#: 99699 '. Check Image 2/13/12 9:55 AM Check Image Prin ,�y:.a.+rrr•-. ':.�.-.— 'i.-,'„ '-_:-i:,'T_�:_JT_Ji");"fP��Mb* �'M+rrpi� .2315 ';'''...' `: . . ".: . . •' . : ROBICCO INC.` :046 :. a. 2 PRESCOTT RD 1 LYNN,AAA'01902 3 Q/ •': t2 �. :':: .�•: ". ;., . .. .. �,/ DATE; p� CIA, . .. '!u/•�. tF .PAY '/h '..,!10 3{ TO THE l4 --- -- DOLLARS y Citiiens Bank':. :ZssacAusefIS FOR � ------J_!6_J '. _ _-- — ".:. . .� .-... .,:• . �� `t•'' 0002'3i59�; 'i:211070L75!: ,:.u�rai/.��tySa+fidG ti'a':.Ji:\:::�s•�..•u^,tn�4•'•!a)'•:rt-.�..a�a.._r.:ay*f�:,u•w f:/.ar���'wu.•r�ra::i-3>r"�t'n'i 1r.:.t.s•.i�•�+•:�.;- J t�1 1 :,>n_�a oae' sr r ry ' I. ♦ .iu ..3 aao�u��e t ryW O+N 1�0r�9 _ f`I;' € r `s � r � r �Yq J- .. � r a a �.n n� � Q1 F+ O.W w >ao - tr'.Y. � � 1�i Oi,hr - W F•+ rA a f� em °•'u fr i v t- ':.f-', t y 1 ..-+. ♦.r � .. iJ,.r. l .n.;, .:. .a i..n•;rr.F:.t7��:P.is`. !g.J t;.... ,- ..: t' __= � __:-L- �'.0 1 I + � 1/,�>f � - 1:., r -.r J� c i,/Y r Pi o_�r fL .I 'A f•� N .�e -- s .°s8:y t r t !"� 4 3 'r i �• !r .t [g,,� r W ! 1 'n Pam. i rP N O 0 I r - t '✓ 1 .� N Hl' r 7�/ r / � W r ,' L ..:1:.:"• / :6 �. - i J � � er`I rr I� r 4 t�r � rrrl rt x- ! � �� .a i a � �1 dt• r( s 1 1` r ✓> � e� �.of th 1 ' V _ j W f• y : CLOSE This is an image of an item(check, substitute check, or debit memo)which has posted to your account. Items resulting in a non-sufficient funds situation may not have been paid. Unpaid items will show as a credit item in your account history on the business date following the date the item was presented. https://www3.citizensbankonline.com/efs/sewlet/efsonline/imagejsp?TranslD=13059379341201202010000001 - Page 1 of 1 CITY OF S:ULE.NI, NWSACHUsETTS t BUILDING DEP.\RT>lF_NT 120 WASHLNGTON STREET, 1-FLOOR TEL (973) 745-9595 F.+x(979) 7•149946 KI\IBERL.EY DRISCOLL 1NLAY01 THO\IAS ST.PIEARa DIRECTOR OF PUBLIC PROPERTY/BUILDMG CO\LUISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorr/Electriefans/Plumbers A t \licant Information Please Print Legibly .Name Inuaitx,.e Urglnnndon,lndividuaq: ) Ct.� PC, i%ddress: �� V r//ITV'I t%1' J I nt/1 / City/State/Zip: cs/� �4 _ Phone N: _ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with - 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subeontractors 2.❑ I am a sole proprietor or partner- listed on the attachcd.shect.t 7. ❑ Remodeling ship and have no employees Then subcontractors have V. ❑ Demolition working for me in any capacity. fvorkers'comp. insurance. 9. ❑ Building addition (No workers.comp. insurance S. (J�We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions ).❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself.(No workers'sump, C. 152,$1(4),and we have no 12.0 Roof repairs insurance required.] t employees.[No workers' I3.❑Other comp. insurance mquimd.j �nny uppli,w1 dw vhvcks box tl must also fill am the uwliva below showing chair waken'mmpsn"dun puliry infumurion. 'I4vseo% a-rc who whmil this atnMvil indicting they am doing all work and than him wnide contractors mtut mhmit a now alltdavil indicting ruck $'.�mrxtun thol ohak this box must aaachvd un.Iddillurud'hart showing the nwno or the subrunimtom and their work'"'wmp.policy infamwtlon. l con an employer that is providing worker'c umpruraNun brsurance for my employees. Below/s the policy and Job site hifutmatlon. Insurance Company Name:_?d]M- —7—n/,f 5 un o to ee Policy U or Self-itu. Lic. d: -S� S Expiration Date: (+ Job Site Address: �j '6/ �/J /"r0 JCg/p Cily/SlatdZip: —?(&/F/t, IVA Attach a copy of the workers'compensation pulley declaration paks(showing the policy number and expiration data). I'Auns to secure coverage as required under Section 2JA of MGL c. 152 can lead to the imposition ofcriminal penalties are line up to S1,500,00 and/or one-year imprisonmcnq as well as civil penalties in the forth of a STOP WORK ORDER and a tine Of up to S230.00 a Jay against the viulnmr. Re advised that a copy of this statement may br: turwurdcd to the Otlica of Invesligaliuns of(he DIA for insurance coverage verilicatiun. l do hereby certify rurde le all',and penaltlex of pet%ury that the iufonnatluu provided above i.r trot surd ej"eclL wry-�y{��/� D,ttu: Q�.� �-•U/ ch nnC,'7 V v / O/ 571,e/,7 Ojlh ial ase only. Oo nor rvrile in Ilrik area,to be completed by city of town.jjjj i j City nr Town: _ _ Pcrmiul.lcemse iIsuiug,\W a hurily (circle rse): iI. hoard of health '. Iluildin,Ucpartntem I. Cityi fawn Clerk J. Electrical Inspector 5. Plumbing Inspector 0. Other Cu niuct l'crtun:_ _ Phone•l: I 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 ajoint 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." t. MGL chapter 152, §25C(6)also states that"every state or local licensing agency shalt 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)nume(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 he 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 till in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in (city or town)."A-copy of the affidavit that has been officially stampeai 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 or permit to bum 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 0Mce of favestigadons 600 Washington Street Boston, MA 021 t I Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE Fax All 617-727-7749 ;ie;ised 5-'6-115 www.rnass.gov/dia ROBICCO 12VC Siding and Windows Company 4 . Robicco INC Job No: 6 / ` wome No CS sL 99M Location:.Q G� 17 8eae11 rd un to 45,LYNN,MA 01902 Flow:781 9135136,Fax:761 6238111 SIDING MC r Ic .3 %—C:/ %Fu_1_641ri7e' Name y t �'"�'+" Phone: es. Bus. Address-� -A 7y//7 O,�NE' S'T City_y-�/1 r State Zip O 9 9 t-1 Me, the owners of the premises described below, hereinafter referred to as"Purchaser" offer to contract with ROBICCO INC hereinafter referred to as"Contractor", to furnish, deliver and install all materials necessary to imppup the premises located at: MF (Street) (City) (State) (Zip) According to the following specifications: INCLUDED NOT SPECIFICATIOTVs INCLUDED PREPARATION: 1. �f ❑ Obtain all necessary permits and insurances. 2. L/ D Inspect surfaces in work area—renail loose wood, replace CJ rotten surface wood where necessary in work area excluding roof, decking or rafters, and structural damage. 3. O Remove Existing Siding: Type: 4, Q Fir out walls on brick, block, metal or stucco areas: Location 5. Caulk and seal around all windows&doors in work area as necessary. 6. Q ❑ Install approved starter strip. (/ DISULATION: 7. �/ ❑ Ve I insulation on flatwall areas to be sided with`X4'or xtruded poly-styrene insulationL117, 1® m aluminum fascia: Color L1 t• CUSTOM TRIM; Lll 9. CY O (Remove&Reattadv�1e046mtters-fever f 10, C�. 0 Cover Soffa areas with vinyl soffit Color it, 11. ,la 0 Custom wrap fascial frieze boards Color tA.-1 12 l;,t� 0 Custom wrap windows&doors Color Custom wrap garage doors sing*Jdoubte Color,,_ 14. ' Remove and reinstall existing storm t'1 winclows/awnings/shtttters 15 Remove and relrutall storm door. 16. ❑ Comer Posts Color TYPO 17. u Lip locking system Location /J ❑ Install Siding Type_S y Color SIDING , Is ❑ 19 Porch Ceiling Location Color ❑ LY Color ❑ 20 � Porch Posts 21 / Porch Beams COIOf /.✓k CLEAN UP 22 �/ ❑ Clean up and removal of all job related debris 111111JJJ"' ❑ Special Items: WARRANTY NOTE: ROBICCO CORPORATION GUARANTY LIFETIME WARRANTY FOR WORKMANSHIP AND MATERIALS OF THE ORIGINAL OWNER. 70 The TOTAL PRICE for all Labor& Material is $ 6)047 0' L t Contract Price $ Down Payment $ 1 0 State Sales Tax $ Balance Payable $ , . OJ ✓ (if applicable) Total Contract Price$9c��✓ Terns: Credit ❑ (Subject to the approval of the Credit Department) Cash ❑ (Final payment to installer upon completion) S3iI1 7 Date Pwchaser D +trf?5£O B'f//qJ,�r/lam_ 5�ase fu ROMCCO INC Dale PwChas" Date 4 J� '`'tea 4...�'' 11/301/30 CERTIFICATE OF LIABILITY INSURANCE /2011MDIY 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(iss) 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 House Account NAME: David E. Zeller Insurance Agency, Inc. �°NE . (781)595-2071 NC.Na: (781)823-1852 370 Lynnvray ADMESS INSURE S AFFORDING COVERAGE NAIC• Lynn MA 01901 INSURERA Llo s Of London INSURED INSURER B Aobicco, Inc INSURERc: 172 Whalers Lane INSURERD: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER:CL118400941 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 WOOL SUER POLICYEFF POUCYEXP LTR TYPEOF INSURANCE MinPOLICY NUMBER MMICOIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE O RENTED 100,D00 PREMISES Ea o:runerice $ A CLAIMS-MADE ❑OCCUR L114200000041 /22/2011 /22/2012 MED ERP(Any one person] $ 1,000 PERSONAL&ADV INXRY $ 1,000,000 G ENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT.IMPLIES PER. PRODUCTS-COMNOPAGG $ 2,000,000 X POLICY PRIIEO- LOC $ AUTOMOBILE LMBILf1Y COMBNED LIMJT IEaeccidart' S ANY AUTO BODILY NJLIRY(Per parson) $ ALL OWNED SCHEDULED BODILY INJUF.'Y(Per zrcitlenN $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED ALTOS A.UrOS +Para;pdan[ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION RC"SATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPFIETORIPARTNERIEXECUTIVE E ,EACH ACCIDENT $ OFRCERIMEMBER EXCLUDECR El NIA (Mandatory In NH) EL DISEASE-EA EMPLOYE $ If Yes,describe under DESCRIPTION OF OPERATIONSOeI . EL.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIDNS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Evidence of General Liability, coverage is subject to policy terns, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION (97 8)531-6864 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Stueve Contracting �anY C ACCORDANCE WITH THE POLICY PROVISIONS. 92 Aborn Street Peabody, MA 01960-5659 AUTHORIZED REPRESENTATIVE David Zeller/NINA ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(20100e).Ot The ACORD name and logo are registered marks of ACORD HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE IS HOLDER. THIS CERTIFICATE DOES NOTAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURERS AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. MPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. If SUBROGATION S WAIVED, subject to the terms and conditions of the policy,certain policies may require and endorsement A statement n this certificate does not confer rights to tl1a certificate holder in lieu of such endorsement PRODUCER W4757253188®a 2k00000b000805412825980000231381000 0000001 2011-01-07-13.56.30.OMTOD 000000000005 212 Plne, D 1901 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Roblow Inc 172 Wholem Lane Salem, MA019704000 THIS IS TO CERrIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTR T1TB OF NaMAN9B POLIW NUMBot FOLIOTEFPBOM DA1E POUIOY 111I4pATn%N DATE A = AND EMPLOYERS'LNBIIflY LIMIT$ THE PR OPRETORi PARTNERSIDMCUTIVE OFFICERS ARE: wcL❑ExcL❑ 2350361 7123/2011 7123lZD12 STATUTORY LIMITS OTHER CwwWoAppllw to MA OpeeatlmaDWI. CX ACCIDENT $ 1,GD0,00 ISEASE POLICY LIMIT $ 1,000.00 ISE48E-E4CH EMPLOYEE $ 1,000,00 DESCRIPTION OF OPERATIONSIVEHICLOW11CIAL ITWS CERTIFICATE HOLDER CANCELLATION STUEVE CONTRACTING CO SHOULD ANY OF THE ABOVE DESCRIBED POLR:IESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 92 ABORN ST WHTE THE POLICY PROVISIONS. PEABODY, MA MOW AU'rHORILED REPRESENrATIVE