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7 HERBERT ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7"edition ReOv S Jan ary Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner nspector of Buildings Date SECTION 1: SITE INFORMATION 1.1n 1 1.2 Assessors Map&Parcel Numbers I.Ia Is this an accepted street?ye no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: 'Lone: Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Rec rd: 1 CXOtt(lLA (ZCZV-OtJ�-)Ca T Name(P 'n t) Address for Service: Sign Lure Telephone SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) %_ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Workz: t-'AeA-0 tG;n)6-- '°S�V_ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ �S L Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee - 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ , :70 Check No. Check Amount: Cash Amount: 6.Total Project Cost: $T "`� ❑paid in Full ❑Outstanding Balance Due: C - �,CL , � ova � -e_ ��':�7 - SECTION 5: CONSTRUCTION SERVICES L Licensed Construction Supervisor(CSL) wog ga "� 1 11 - Q_)D, KC , License Number Exp m[on Date Name of CSL-Holder ^ ,,^ List CSL Type(see below) VtJ7t l �`V�} Description Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling 'gnature M Masonry Only RC Residential Roofing Covering eleplai a WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home I,m�iur v`e ne`nt entractor C) HIC Company Name or HIC eg t t �,�/� Regi4stration Numbcr Expiration Date ignanne \ etc one SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152. § 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...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, C 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. 0 S' ature of Own Dat SEC_\TION 7 • OWNER'OR AUTHORIZED AGENT DECLARATION 1, (� ,as Owner or Authorized Agent hereby declare that theotatements and information the foregoing application are true and accurate,to the best of my knowledge and bch� I - t �t Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: 1. 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(I-IIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the H1C Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" a CITY OF SALEM �a '4 DEPARTMENT OF PLANNING AND q ' E COMMUNITY DEVELOPMENT 120 WASHINGTON STREET ♦ SALEM, MASSACHUSETTS 01970 TEL: 978-745-9595 ♦ FAX: 978-740-0404 KIMBERLY DRISCOLL, MAYOR LYNN GOONIN DUNCAN, AICP DIRECTOR HOUSING REHABILITATION LOAN PROGRAM WORK WRITE-UP PROPERTY INFORMATION: September 16, 2010 Homeowner (s): Raczkowski Residence Date: REV: October 15, 2010 Address: 7 Herbert Phone #: Prepared by: Cliff Ageloff Case #: 1. LICENSE: The contractor must meet all local and State licensing requirements and personally have in their possession currently valid licensing in order to bid on the work herein. 2. INSURANCE: Contractor must show proof of adequate liability insurance and workmen's compensation coverage be provided. 3. PERMITS: The contractor must obtain all required building permits prior to starting work. Copies of the required permits must be submitted to the Housing Program. 4. CODE REQUIREMENTS: All workmanship must conform to the Program's guidelines, all applicable Massachusetts Building Code and local codes and must be of acceptable quality, as determined by the Housing Programs Inspector. Contractors are responsible for verification of field conditions, measurements and quantities. Submission of a bid is presumptive evidence that contractor has evaluated all site conditions which pertain to the work herein. Permits and Permit Fees to be included in all bids. WORK SPECIFICATIONS for REPAIRS THIS IS FULL COMPLIANCE PROJECT FOR LEAD PAINT STABILIZATION —SEE ATTACHED REPORT— HUD and MA GUIDELINES APPLY 1. NEW ASPHALT SHINGLED ROOF • Shingle 1800 SF Approximately— Contractor to verify all dimensions in the field prior to bidding • Repair as needed all exterior trim to make ready for new coil stock coverage • Use 30 Year Tab-style shingles only, Tamko, Iko or GAF. Owner to select color 1. Demolition: Strip all asphalt and roofs to expose sheathing. Remove deteriorated sheathing and roof boards. Remove all non-essential roof attachments. Remove and dispose all flashings and drip edge. 2. Disposal: Legally dispose of all material. Debris may not be stored on site for more than 24 hours unless in a covered dumpster. Thoroughly clean all roofing debris and nails from building perimeter. 3. Roof Board Repairs: Re-sheath roof with 1/2 " CDX Ply 4. Flashing: REMOVE ALL OLD FLASHINGS FROM ALL AREAS. PROVIDE THE FOLLOWING: A. New Flashing at the Chimney: Lead and counter-flash, install EPDM at roof deck to seal B. Penetrations: Replace all flashing with new to accommodate the existing conditions in the most workman-like manner. 5. Vent Stack: Provide and install new neoprene and metallic flashing unit for each penetration. Seal as needed to existing vent stack; use ring clamp to seal. Provide PVC vent extension for each stack as needed and install as repair in conjunction with roofing. 6. Drip Edge: Install mill finish aluminum drip edge at all perimeters, including gable-ends and eaves 7. Venting: Meet code requirements where achievable within the existing configurations of the roof. Use common venting methods of ridge and soffit or gable end vents where other venting is not practical. Gable-end vents are acceptable where other venting schemes are not workable. 8. Gutter, Fascia and Soffit: Remove and dispose existing gutters. Replace ALL gutters and downspouts using a seamless gutter system. Repair all deteriorated fascia to match existing including cladding and finishes. Provide splash blocks and divert water away from foundation. 9. Ice and Water Protection: Install adhesive EPDM or comparable membrane-type or equal ice and water shield at all valleys, roof/sidewail intersections at dormers, rakes and eaves. Adhere directly to roof deck. Install membrane to cover T from edge of eave and 3'from edge of rake or as required by code to clear plane of interior wall. 10. Low-Pitched Applications of Shingle: Ice and water shield for FULL COVERAGE all shed or dormer roofs with less than a 2/12 pitch and shingle over to match new shingles. 11. Chimney Repair: Repoint as needed to accommodate new lead coated copper flashing 12. 151b. Felt Underlayment— required for all roofing. Lap 4" and staple to deck for full coverage except where ice and water shield shall be applied. Apply horizontally, rake to rake, ridge to eaves, leaving no roof deck exposed whatsoever. Lap 4" over all ice and water shield applications at all rake and eave locations. RANDOM TEST CUTS WILL BE MADE. ROOFS NOT FULLY PAPERED WILL BE REJECTED. 13. Shingle: Standard Three-tab 30 year shingle; color by owner. NO ARCHITECTURAL SHINGLES. 2. Sidewalk Repairs/ Driveway Repairs • Replace brick and restore all walkways 1. Remove and dispose all deteriorated walkway and driveway surfaces—Approximately 500 SF finished walkway and driveway surfaced 2. Remove subsurface obstructions 3. Grade to slope per existing site conditions; accommodate rise at dwelling entry 4. Slope away from house and maintain grade to street 5. Provide stone dust, crushed stone and other suitable fill as needed to make uniform all sub-surfaces. 6. Compact as needed to stabilize all sub-surfaces 7. Provide and install brickwork to match existing configuration at parking and access-ways. 8. Replace all remaining walkways and replace in-kind; remove all material and provide new walkway 9. Seal all edging sweep in fines to complete all work. 3. Smoke and CO Detection: 1. Provide and install new smoke and CO detection for MA compliance: Single-family residence. Provide replacement.batteries for all units. Units shall be Kidde or First Alert battery-operated, 9v. 4. EXTERIOR PAINTING and LEAD PAINT REMEDIATION & FULL-COMPLIANCE LEAD HAZARD ABATEMENT USING COST EFFECTIVE METHODS PART 1: GENERAL - 1.01: FULL COMPLIANCE SCOPE A. See Lead Hazard Abatement Report for full-compliance scope. 1.02: DEFINITION OF WORK INCLUDED A. The lead paint remediation required under the Specifications, Plans, and Contract Documents shall include all labor, materials, tools, equipment, insurance, and related services as needed to perform the specified lead paint abatement work. B. Lead Paint Abatement shall include, but not be limited to: 1. Paint removal; 2. Paint stabilization; 3. Component removal; 4. Installation of enclosure systems; 5. Supply and installation of replacement components; 6. Refinishing, complete priming and repainting to match all impacted and adjacent component surfaces; and 7. Legal disposal of all lead-based paint waste and contaminated materials. 1.03: FEDERAL & STATE REQUIREMEMENTS A. Federal and state regulations mandate that all housing properties being rehabilitated using public funds must be inspected for lead paint and that, if found, all said lead paint shall be either removed and/or stabilized. B. The Owner shall assume that the Contractor's bid incorporated only the highest levels of lead- based paint abatement compliance set forth by the U.S. Department of Housing & Urban Development ("HUD")and the Massachusetts Departments of Public Health ("DPH") and Housing & Community Development ("DHCD") unless otherwise specified herein. C. All abatement work shall comply with the standards set by all applicable federal, state, and local laws, ordinances, regulations, and guidelines in place at the time the work is implemented. The Project is subject to compliance with, but may not be limited to, the following standards: 1. MGL c.111, §§55.190-199A; 2. 105 CMR 460.000; 3. 454 CMR 22.00; 4. 310 CMR 30.00; 5. 29 CFR Part 1926; and 6. 29 CFR 1910.1025. D. It is incumbent upon the Contractor to modify, as needed, all practices, means and methods as amended, modified or changed in any and all applicable regulations. E. Only Massachusetts-licensed lead abatement contractors are authorized and shall be permitted to perform any or all of the lead paint abatement work. 1. If the Contractor is a Massachusetts-licensed lead abatement contractor, the Contractor may perform the work in accordance with the Plans, Specifications, and Contract Documents. 2. If the Contractor is not a Massachusetts-licensed lead abatement contractor or chooses not to perform the work, the Contractor shall hire only Massachusetts-licensed lead abatement sub- contractors to perform the work and shall be no less responsible for those sub-contractors full compliance with the Plans, Specifications, and Contract Documents. 3. The Contractor shall ensure that the lead abatement contractor, whether a sub-contractor or the Contractor itself, meets the statutory standards for full-compliance abatement. 1.04: INTERIM CONTROLS A. All lead-based paint abatement measures shall conform to Full-Compliance Standards. Do not proceed with any methods for Interim Controls unless these were specifically addressed by the inclusion of a 'Risk Assessment' as part of the Lead Paint Report and required by the Owner as part of the Contractor's bid. 1.05: LEAD PAINT REPORT A. The property has been evaluated by licensed lead paint inspection services and both interior and exterior surfaces have been tested. The results of these inspections and tests are set forth in the lead paint inspection reports (together, the "Lead Paint Report") identified below: 1. 9/1/2010 Kevin Nestor#11359 Residential Inspection Company Reading MA B. The Contractor shall interpret all information and other data contained within the Lead Paint Report as approximations and shall conduct the lead paint abatement accordingly, including as follows: 1. The Contractor shall verify all measurements and quantities in the field; 2. all work shall be completed in every detail even when not specifically called out in the Lead Inspection Report or elsewhere in the Plans, Specifications, or Contract Documents; and 3. Where there may be a question of methods, abatement materials, and/or compliance objectives, the Contractor shall implement, employ, or achieve the more stringent. C. The intent of the Lead Paint Report is for the subject property is to achieve Lead Abatement Compliance according to 105 CMR 460.000. The Contractor shall be required to perform all tasks necessary to make the premises acceptable for the receipt of"Letter of Abatement Compliance"for the housing units and locations defined in the Lead Paint Report. 1.06: EXTENT OF LEAD PAINT ABATEMENT A. Unless stated otherwise in these Specifications or in the Plans, no additional lead-based paint removal will be required beyond the removal from those areas identified in the Lead Paint Report referenced herein except for the following: NO ADDITIONS FOR THIS PROJECT—SEE LEAD PAINT REPORT ONLY PART 2: PRODUCTS NOT USED PART 3: EXECUTION 3.01 Resident RE-LOCATION A. Residents occupying units to be de-leaded must be temporarily relocated during the course of the de-leading work. 3.02: GENERAL FULL-COMPLIANCE ABATEMENT GUIDELINES A. The Contractor shall apply the following full-compliance guidelines and methods where applicable: LEAD-BASED PAINT COMPONENTS PER GENERAL METHODS FOR LEAD PAINT REPORT OR FULL-COMPLIANCE SPECIFICATIONS LEAD PAINT ABATEMENT WHERE APPLICABLE) 1 Interior Door and Window Casings, Scrape and feather existing surfaces for Jambs, and Trim: Compliance with minimum requirements. 2. Interior Stairs—Treads and Risers: Scrape and feather existing surfaces for 3. IStair Parts, Mop Boards, Misc. Trim: Compliance with minimum requirements. Exterior Iron Railings: Install new cast iron to match the existing type 4. and configuration Window Sashes—All Wood Units and All Install Harvey Energy Star Vinyl Replacement 5 Window Components only when identffied window to match the existing window Lead Hazards, Including All Basement configuration. Window Sashes Make compliant by using the most cost- effective6. Cabinets and Components: Means and methods unless otherwise specified. 7. Closet Components— Interior: Replace all components for full compliance. Exterior Window Trim and 'Hot' Trim Wrap with standard gauge and color coil stock 6. (above 6'), All Sills and Exterior at all windows as needed with materials to Casings: match existing 9. Porch Ceilings: Install vinyl coverings or replace as needed with materials to match existing 10. Exterior Columns and Newel Posts: Re lace and repaint to match existing. Repair and repaint, wrap with aluminum, or 11. Lower Trim: treat as needed for full compliance. Make compliant by using the most cost- effective12. Exterior Door Casings and Jambs: Means and methods unless otherwise specified. Stabilize, repair, and repaint with two (2) coats 13. Interior Walls: or repair as needed with materials to match existing. Replace with similar materials and paint with 14. Interior Railings: two (2) coats according to the Plans and Specifications. Remove and replace to match existing; use 15. Exterior Lattice: vinyl or pressure-treated wood as needed with materials to match existing Stabilize all surfaces per the Lead Paint Report. Prime the entire house body with tinted 16. House Body: Primer using Alkyd primer as need; paint house body two coats of latex exterior paint, California 2010 orequal Provide and install Therma-Tru panel door with 17. Standard Exterior Doors locking handset and deadbolt, pre-hung unit with half/lite thermal glass, match opening size and prime all new trim. Other Interior components—closet Cover with sheetrock, mud and sand, prime 18 interiors, trim, misc. one coat, replace all components to match existing configuration and function. 19. Exterior Surfaces/ Masonry/Other See specifications above / remove as needed for repairs and encapsulate at indicated Meet compliance standards by most-cost effective means while retaining door. Unit may Historic Doors & Jambs (Interior Panel- be dipped off-site or hand-stripped in place. p, Treat jambs for compliance. type): Prime and paint all work for complete coating of subject surfaces and remaining components. 3.03: WASTE DISPOSAL A. All lead-laden materials removed as part of the abatement shall be disposed off-site in accordance with local, state, and federal regulations or ordinances. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leelbly Name (Business/organization/Individual): �Cr1 QJQ­\5NX\,) \QQ AfK, Address: q Ci /State/Zip: . 1.l Phone #: Are you an employer? Check appropriate,box: Type of project(required): I. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction 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. ❑ Remodeling ship and have no employees These sub-contractors have S• ❑ Demolition workingfor me in an capacity. employees and have workers' Y p tY• t 9. ❑ Building addition (No workers'comp. insurance comp, insurance. required•] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing airs or additions 3.❑ I am a homeowner doing all work ❑ g repairs myself. [No workers' comp. _ right , exemption per MGL 1(4), and we have no 12.❑ Roof repairs insurance required.] t c. 152 employees. [No workers' 13.❑ Other 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 allwork and then hire outside contractors must submit a new affidavit indicating such. tContractorsthat check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contactors have employees,they most provide their workers'comp.policy number. I am an employer that is providing nwrkers'compensation insurance foamy employees. Below is the policy and Job site information. \ n Insurance Company Name: Policy#or Self-ins. Lic. \#: II.�a�+� �� Expiration Da ilo Job Site Address: i��' �+ City/State/Zip: 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 hereb certifyxralerthe pains and penafties of perjury that the information provided above is�true rue and correct Si a (� A}• Date: � V rPhone - `ficial use only. Do not write in this area, to be completed by city or town official ty 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 #: CITY OF S�U.&\I, lr'LksSACHUSETI'S • BuELDIING DEPARTNffANT 130 WA HINGTON STREET, 3t0 FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KI�LBERLEY DRISCOLL MAYOR THomAs ST.P[ERRE DIRECTOR OF PLBLIC PROPERTY/BUILDING CONMUSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # 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 MGL c 111, S 150A. The debris will be transported by: v�lc�� CY���C�c�l1t1Y1C (name of hauler) The debris will be disposed of in : I S �,L 3 1 (name of facility) )�4 (address of facility) signature of permit applicant date dcbri.fKdw Office of Consumer Affairs and gusiness Regulation 10 Park Plaza - Suite 5170 ' Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 106603 - Type: Private Corporation Expiration: 7/24/2012 Tr# 297944 AJ WOOD CONSTRUCTION, INC. Richard Smith PO BOX 1769 SALEM, NH 03079 -- Update Address and return card.INIark reason for change. - - Address � Renewal D. Employment I,J' Lost Card DPS-CA1 Ca 50S!-04104.6101216 Oiner'Af7:s �I in Reg I hones License or registration valid for individul use only Ottice o�Co n Tim HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: - 106603 Type- Office of Consumer Affairs and Business Regulation Expiration. 7/24/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 AT ODD CONSTRUCTION,INC.-- Richard Smith 4 RUSTIC LANE DERRY,NH 03038 Undersecretary Not valid without signature Department of Public ti:tfM) Commonwealth of Massachusetts may, ]ius.achelseti.- Division of Occupational Safety 7i!�i)5 Biru-tlofBuildiW upervisor and Still! Hea9wERowe,AcfmgCommissioner W sth Construction Supervisor License Deleader-Contractor License: CS 70882 RICHARD S. SMITH Restricted to: 00 ,^ Eff.Date 06/23/10 RICHARD J SMITH Exp. Date 07/10/11 f i D ! - PO BOX 1769 C00172.1 LLLIII 9`,t SALEM, NH.03079 _ nremeer�c.oru.es.T. so Expiration: 712812011 IIIIIIII�I hill IIIII1111111111IIIIIIOIIIIIIIIIII1 ��E� Tr-: 19314 -- ACORD. CERTIFICATE OF LIABILITY INSURANCE Doaiioriolo PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION. .- Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 182 Parker St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lawrence, MA 01843 978-681-1112 INSURERS AFFORDING COVERAGE NAIC# A.J.Wood Construction,Inc. INSURER A- Liberty mutual Ins. P-O.Box "'uR Salem,NH 03079 INSURERC PLSWtER 0: INSURER E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - INSB�, POUCYHUMBER 1 POLICY EFFECTIVE. POUCYEXFIRATLON LIMITS; GENERAI.UABO.ITY EACH OCCURRENCE Is M-=-1PiGP 0 COMMERCIALGENERALUABRDY Esi 1 CLAIMS MADE-OCCUR 1 cne pgaon M INJURY REGATE GENL AGGREGATE LIMIT APPLIES PER ( -1PATP AG POLK PRO- LOC AUTOMOBILE IIAOILRY COMBINED SINGLE UMIT ANY AUTO (Eaac m) 3 ALLOWNEDAUTOS - BODILY INJURY _ SCHEDULED AUTOS (Perpe -m HIREOAUTOS BODILY INJURY S - NON-OYIL�AUTOS lPatacaEem) PROPc4TYDAAL',GE S (Peracadent) I GARAGEUABIUTY I I AUTOOINLY-EAACCIOENT S ANYAUTO OTH-SaTW+N EAACC S i AUTO ONY-- AGG S 7 GESSIUMBRELLAU&OIUTY I EACH OCCURRENCE S OCCUR ❑C-LAIMS MADE AGGREGATE LE' S S I RDEDUCTIB S RETENTION S 3 WORKERS COMPENSATION AND WC231S353819029 OW 312010 02/13/2011 we sraTu. Q EMKQYPRS LIABILITY EL EACNACGCENi 3 $��OOO ANY PROPRIETORMARTNEIMOc rN. OFFICER/MEMBER MLUDEOT EL DISEASE-EA UJPLOYEEI s 500000 OasOID Ind"UEIALROVISION S OP .SP h EL DISEASE-POULYLIMIT s 500000 OTHER DESCRIPTION OF OPERATONS I LOCATIONS)VEHICLES I EXC WSIDNS ADOED BY ENOORSENIENT I SPECWL PRC=SIDHS CERTIFICATE HOG9ER __ CANCELLATION SNOULO ANY OF THE ABOVE DESGWBED POUGES BE CANCELLED BEFORE THE EXPURATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO NAIL__DAYS WRITTEN _ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 SO SHALL _ IMPOSE ND OBLIGATION OR UADIUTY OF ANY IOND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES AurxoRLzm -.. — ACORD 25(2001108) - - O ACORD CORPORATION 1988 T -d - d2S=60 OT LI .JeW .d10/IHU 01 :08 PM Financial Insurance PAX No. 6034323852 P. 001/001 ® CERTIFICATE OF LIABILITY INSURANCE 9/9/2010 .DucER (603)432-6414 FAX: (603)432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION :-inancial Insurance Services Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 950 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A Peerless Insurance CO A J Wood Construction Inc INSURER B: PO Box 1769 wauRER c NSURER D. Salem NH 03079 INSURER E: COVERAGES 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 TH E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. INSt D POLICY DUMBER PAOUCY EFFECnVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea dCCM M $ 100 000 A X I CLAIMS MADE ❑X OCCUR CBP8706685 8/16/2010 8/16/2011 MEDEXP(Anyone Person) $ 15,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO A X ALL OVANED AUTOS BA8693505 7/8/2010 7/8/2011 BODILY WJJRY X SCHEDULED AUTOS (Per person) $ X HIREDADTOS BODILY INJURY 5 X NON-04"MEDAllTOS (Perecdden0 PROPERTY DAMAGE $ (Perecdde ) GARAGE LIABILITY ALTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EAACC $ p AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CU SMAOE AGGREGATE 5 $ DEDUCTIBLE $ RETENTION 8 S WORKERS COMPENSATION I 4QRYSTATU- OTH- ANDEMPLOYERS-LIA91LITY Y i N E.L.EACH ACCIDENT $ ANY PROPRIETOR/ RIEXECUTIVE❑OFF OFFICERMEAIOER E%CLU EXCLU DEd! E.L.DISEASE-FAEMPLOYE $ (Mantletory in NH) t1W,deecd6a Vnder EL.DISEASE-POLICYLNIT $ SPECIAL PROVISIONS"MV OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULDANYOFTHEAROVEDESCRIBED POUCIESWCANCM I ED BEFORETHEEXPIRAT10N �— DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,RU'"FARURE TO DO SO SHALL ,�—�1♦/) IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR • 1 �� REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ Sam Fragala/PAT ::•.,xwt.:.�� :>':-r.;.%�.:-.`le.= ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 aoI1B01) The ACORD name and logo are registered marks of ACORD