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28 HIGH ST - BUILDING INSPECTION t ' The Commonwealth of MUSUOItISCUS Board of Building Regulations and Standards CI"I'Y OF 11 y, Massachusetts State Building Code, 780 C'NIR SALLM '�'•�•• K,•ri.reJ.lGu•'Ull Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Funnilt Du ellh{q "rhis Section For Ofrch se Dal Building Permit Number. Date pplieJ: Building 011icial(Print Name) Signature Date SECTION is SITE INFORMATION 1.4 ro rert/Address: 1.2 Assessors Nlap& Parcel Numbers la Is this an accepted street?yes no Map Number Parcel Nmnh r 1.3 Zoning Information: 1.4 Property Dimensions: Luring District Proposed Use Lot Area(Nq It) Fromage(Il) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if vsO Municipal ❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ow t of Re ord: Name(Prim) Uty:"SWrc,LIP - / �e,—sew- 3 U. and Street " J,7 7 2Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner•Occupied ❑ Rep0lrs(s) ❑ Aiteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': F 41e �,,,a/�„ as[/ 7? ..r �/ 4 zY' f� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I Labor and Nlaterials) Official Use Only I. Building g I. Building Permit Fee: E Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee j ?, Plumbing S ❑Total Project Cost"(item 6)x multiplier x '_. Other Fees: E q. Nlechanicul 1111':\('1 S Lisl: I s. Nfcclonical (Fire Su ucssion) S 'rotal :\II Fees: E -__ ------- ---" ----- - n. Total Project Cust: S /L/ pv ('heck No. __('heck :\mount: - -------Cash :\mount: ❑P,IiJ in Full 0 Outstanding BaLutce Due: t , SECTION 5: CONS"fRUCTION SF.RVI('FS 5.1 ('onstruction Supervisor License(C'SL) I.icanse Nunlhcr I vpiratiou Data N:une of CSI. I holder Li � / St(.'St.1)PC!sec halowl � G"r// �T -------_.--- f Description No. and Strecl �� U 1�nreslricleJ I BuilJin's ti to iS,I1m0 eu. It.l r.{i�4�e rc' ,rfrt G ----_—.... R Restricted1 2Fumtil M%ellin Cil_ri loon..Slate.LlP M Masonry RC Roolin Coverin W'S W'indaw and Siding SF Solid Fuel IAuning Appliances -�p7?37 Insulation I cle hone Email address D Demolition 5.2 eg tere/Q 11 me Improvement Contractor(HIC) C' ���� I IIC Registration Nmnt cr FNpirniun Dole III Cot 1pall) wnc or IjC' Itegistrant Name . an S ee wf '/ /: p/� Email address City/Town. State,ZIP (/ eaves 'fete 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 I,as Owner of the subject property, hereby authorize tp-act on my behalf,in all mauve to work authorize by this building permit application. S Print Uwncr's Nmne(Electronic Signature) ale SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering"ny>n,9below! ereby attest under the pains and penalties of perjury that all of the information containe s ap a i is true and accurate to the best of my knowledge and understanding. rint ots s or:\tithorireJ,\gcnt's Name(Electronic Signature) Data 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 Hums Improvement Contractor(H IC) Program).will no have access to the arbitration program or guaranty fund under I.G.L.c. la_'A. Other important information on the HIC Program can be found at \~% nee.. •.,,t ,"A Information on the Construction Supervisor License can be found at os k\, III, ? \\'hen substantial work is planned, provide the information below: Total floor area(sq. ft.) _ (including garage, finished basement allies,decks or porch) Gross living area(sy. It.I _ Habitable room count \umber of fireplaces-_.. Number of bedrooms Number of bathrooms _ — — - ---_ Number of half baths 1)lie ofheatingS)Slaltl .. _... . -.. ._ Numherof decks, porches. . .- ._. I)pe of co'olin4 i)Stem I�nclosad _. _ ..Open _ }, "total Project Square Footage"nt:n he SubSlitrncd tor'1'olal project Cost- CITY OF SALEM PUBLIC PR UPRERTY ° DEPARTMENT iw:.N:1 Y:TNIN 191 \I%1'W IY. \Vn,/uAr:H/•\if.v Cl•1' • iall•.4, M.1\\.µ.in 4 I INIAW,^ I'f•.1. 7741di•/inS • I'1.r rNe•'M•'ISM �� trs' Cumpenaatlon Insurance �ffldnvit: Uullders/Contras'tun/Eleefrielans/Plumbtn � 1 illcantant In unnatlon of 01 ale Print Le •bl V;IITC IlluulTc,LlhgytvalioNlnJwnlualC�_�� �., o¢ / /�/ r/' Cily,.5rlrc.%ip ��LP,i� �p L_ I'hunei/t / 9 7Q 9 �7 `1 ✓J'9 I \n)nu an vny/loyerl Check the appropriate buy. I ❑ 1 :un a cmpluycr with 4. 0 1 :un a gcoeral colaraetor and I 1 yl"°/pr°Joel(reyulrrd): ntpluyucs(lull JntUur part-time).• buvu hint the suh•euntracture /'' Kew cunxtructiun _'• if:un a solo prnpricntr or pJnner• listed on the anaehcJ sheet : y elnaleling ship and have no cmpluycvs These subcontractors have L g tar me in any capacity, uvrkere'tamp, Tnsumnca. g' 0 Dtmolirion rkers'sump. iosurunte 1. ❑ We are a em 9• ❑ oulwing additiun pontinn and iqolttcen have crereiseJ their 10.0Electrical repairs or addition omeowner Juind all work right of esentption par MCiL 1 LO plumbing rcpuirsur additions IN'o worlten'comp• c. 132, ,1I4),and we haw nil e required.) r clnpluyeer. (No workers' 12.0 Ruul'npuirs comp, insurance nquirnd.) 11.0 Uglier •4ne.,;gdw'ild ThW cAcYe Orle rl mTyl:Jw fill uw Tho ohms 4duw Ihowwo rAViruwYlei cunlrenWhm INrlicy rnliumWiun 'I lunun,wryn wIW ild/nul Ihie elllderid indiurine They ale June ill Burs and then hire uweide euwrmron mrel iuhni,a net aln14ri1 u 4,MIGNInf\the rhreh Ihie hoe mw m Ailing •m ad irulleW ins pa, diliumid+how Aiming The t13"m orlhe lubic" anan and Ihfu MYlaeq'ror110,prlrey mrbnnnw /airs an en/pleyrl/Aaf/r prvYJ1//px IV4r�r/J'raln�tr/ltq/IOn IILf4NIMCefn//My r/n/r/pyrrr. Bdun!s rAr pu//ty and/u1 xi4 in�rrurul4/q In,urunce C'untpany Nlnne: /I in� P S w• Policy isor 3vlr ins. Lie.es:RA C k2—o-6 l/ _ -- - -_ Expiration Daro: lob iite ,\ddress: C1ty,SIJtr/ZIp: attach n cagy of Ilw workers'cumpensatlue policy Juelarallun page(showing the policy nunibur and utplratlua date). Palluru tu,ccure cu,eruget as required under Secliun?JA of\IGL c. 132 cia lead to rite ilrtposition of criminal penalties of a tine,Tte ri $1.50 if d y lets nne•year 6nprisunmunt. J.e wall Js civil pcnull,"in Iho Iunn ora STOP WORK ORDER and a tint of up m i'JQ.MI a Jay Tguina the vLalamr. Ile advi.rcd that J copy urthis slilvinwit may be IurwarJcJ w the ORDER a Irl1'�,�IlgJlu nb JI 111V UTA Tor m,nru'ce crncrJge lc/iticahon. /rla/IPri'hy a rrri/y lurJav IGr ptlinr un✓ilow"New u/perjury Awl the hi urinu/IWe pruYlded abaYr%!bNr nrll/Cerll•[R II r)//tl'fu//1.1r dilly. /)J nor write in Nfir urvu, Ili be rulny/rred ily city of,town o//h imi I T I t'rn Ltel U.pIr oilsTlI Pc'nni/L(tvnre Y1„uiny \ulhurily (circtonpe)t I IUtt I ,,rJ n(IIvJ . IhlTiiinJ6tilhrr. Clerk J. Elcvtr ic.d Inylecfur i, I1 (Ihunbiny Impccror nun: -__ information and Instructions cion in he service of another any :onirnet of hire. �Lusachu.ems t;Cneral Laws chapter I i2 leywrcs all eny)lo)en to provide wgrkers Compenxauon tar heir atop hires. Pur,u.uu to tius +latuld, in empluIvee is JCIineJ as"...every pe %press or unplicd, oral Jr written." �n ernpfuyvr is defined as"an individual. partnership,assoetauon.dorpo etch or other legal eased or any two or snore a,menhl assaetatioa or other legal entity,employing employees. However he ,a he Grce,omg engugcJ m a Iwm enarpnse,vnd including{the legal reprcseutauvds of]deceased employer.Or the eceaver or uustee Of ea ioesvldual, p fthe rshan to Jo maintenance,Cunsrruction or repuir work on such dwelling;hums owner, a dwelling house having not more than liras apanmenu and who resides herein.or the occupant o ons Iwelhng liquid of another who employ. Pc Jr on the rounds or building appurtenant thereto shall not because of such employment be deemeJ to be an employer. �IGL draper 152. §25C(6) also states that "every state or local Ilcenslsg ag+ley shsU withhold the Islfoace or ny ce Uaaee with the Insurance coverage required.' renewal of a license or permit to uperaN•Auilnsss or is construct buildings In the o omoce subdivoians shall :tppllcunt ebs has not produced 15C+7) ,;ties esle Y Neither he ommonwcalth not any of its p WJitignully, %IGL dtupter t S_, 5- 1 r yuira onter ito in utthis achaptert care perforrilinCd of p esempucd b the consort gt alwhortityvidance ul cumpli:utce w ih the insurance If ave .Appliesnls ing the boxes that apply to your Aiwation a)4 if Plmtwr rill out the worked' Comb ettsation affidavit 40s)comp nd phorge nuokber(s)Along with their Coniftcute(s)of necessary,supply rub-contructor(s)nurtte(a), addrl Limited Liability P with no employl-Vil insurance. Limited Liability Companies(LLCworkdga, com pensadon irourance.(If an)LLC or LLP does have er than e members or partners, are not required to carry be submitted to the Depanmant of Industrial employees,a policy is required. 9e advised that this Also be tray davit should of Accidents far confirmation of Insurance coverage Also be sure to sign and Juts the u stAld. n thejil Upon it shoal he cidents to the city or town that the application for the permit or liednls is being requeaed, not the lh:p you have any yuestiooa regarding the law Jr if you are required 1Oonies obtain should enter their Industrial ACeiddnts. Should Y At the number listed below. Self-insured comp cOlnpensatiun policy,pica"call the Department self-insuronce license number on the a ro rgute line. r'Iry or Tows officials please he Sure that the ULL f II it is cu'nn the let*eve ;Lnd Pr the O Z ce imcd legibly, Investigations onshe as to contact tment you regarding the appprovided a spiwa at the licat- of file applicant- Affidavit for y I'I:use be sure to fill in the p<;rmit/licensa uwnlatr which will be used as a reference only submit ondf- In addition,is applicantcurrent ur that must iubmit multiple pennit"licstttsd appinder ications AJdress in jiffy ''heen re ar,tCa niceet sttnulJ write uull1locations in roviJCJ to c y nt policy iul'o7mution(if necesaary)and pP tuwnl.",\copy of the u171davit that has been officially stamped or malice by lid city or town tnaY c p dnnit not related to any business Or commercial venture applicant as proof that 1 valid affidavit is on file for future permits ur licenses. A new atllduvit must be Illled nut Jac y d:lr. \tr'hdre a home Owner or citizen is obtaines 41C. .j i license or p I i.e. a dug licmtu or permit to burn Idavaa eteJ sail person is NOT required to wmpldtc this affidavit.couperatian anJ should you have.InY 4uesuons. I ha )dice tit luve.rigatiuns would like w d)unk you in aJvance "of your pleuse du nor hdsitaro to give us a ball. rhC U.paninent's address. telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents O(flee of lavesdgadons 600 WasWillon Street Boston, MA 02111 'rel. q 617-727.4900 ext 406 or 1.877-MASSAFE Fax M 617.727-7749 www.mam.gov/dig Office osumer" ins k u"Sioes`""s"'K',go Tauon License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Registration 149839 Type: Office of Consumer Affairs and Business Regulation Expiration 2/13/2012 DBA 10 Park Plaza-Suite 5170 ' Boston,MA 02116 li O CONSTRUCTION' {K i„ MICHAEL MERCURIO 1270AK STREET WAKEFIELD,MA 01880 Undersecretary Not valid without signature i I i uutmcn[ of Public G:dlic • ,�.... l„ l�yachu5�lh- DcI ul tliun5 and�t tndnrtl> 1 Board nl'onsgtuation Suu Budt p.�rvtsor License Con License: GS 91942 MICHAEL L MERCURIO ' 127 OAK ST MA 01880 VVAKEFIELD, ExPiration: 1,412013 9263 si„ucr i Cummi.. . 4 To:+1-9787409846 Page i of 2 2011-09-08 16:42:16(GMT) 19783365533 From:Larry Lauranzano ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/201Y) 07/08/2011 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A.Penn America Insurance Co Rodrigo Guimaraes wsUREP B. Guimaraes Construction INSURER C 21 Balcomb Street INSURER D� Salem MA 01970- 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPEOFINSURANCE POLICYNUMBER DATE (MMIOONY ) DATE(MMIDDM/) LIMITS A X GENERALLIABILITY PAC6905437 03/09/2011 03/09/2012 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL PREMISES Fe oMERCIAL GENERAL LIABILITY DAMAGE TO RENTED en.. $ 100,000 c corr CLAIMS MADE ®OCCUR MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PROJECT F7 LOC B X AUTOMOBILE LIABILITY 07/08/2011 07/08/2012 COMBINED SINGLE LIMIT X ANY AUTO (E.s,Pdeln) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY N09OWNED AUTOS (Pereccidert) $ PROPERTY DAMAGE IPereccid.rr $ GARAGE LIABILITY AUTO ONLY EAACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F1 CLAIMS MADE AGGREGATE Y $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE EL.EACH ACCIDENT 8 GFFICERIMEMBER EXCLUDED? E DISEASE-EA EMPLOYEE$ If yes.describe under L. SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMB Is OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (978) 745-9595 5641 (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL .ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City OP Salem FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Public Properties Department INSURER ITS AGENTS OR REPRESENTATIVES. 120 Washington Street AUTHORIZED REPRESENTATIVE __- Salem MA 01970- _ G_':::,........>..-.- A(AC, ORD 25 (2001/08) c ACORD CORPORATION 1988 INS025(0106)05 ELECTRONIC LASER FORMS,INC.-(800)321-0545 Page 1 of 2 To:+1-9787409846 Page 2 of 2 2011-09-08 16:42:16(GMT) 19783365533 From:Larry Lauranzano IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) �_ INS025Ioioelo5 Page 2 of v4�C,`NIiIT f Salem Historical Commission 120 WASH INGTON STREET, SALEM,M ASS ACHUSETTS 01970 (978)619-s685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Moving ❑ Construction ❑ Alteration Reconstruction ❑ Painting ❑ Demolition ❑ Other Work ❑ Signage as described below does not involve an exterior architectural feature or involves a feature covered by the c District's Act (M.G.L. Ch. 40C) and the Salem Historic exemptions or limitations set forth in the Histori Districts Ordinance. District: hd Address of Property: Name of Record Owner: Description of Work Proposed: Repair/replace rolled trim to replicate existing. No changes in color, material, design, location or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: August 1 2011 SALEM HISTORICAL MISSION By: The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. RightFax C1-1 9/9/2011 5:42 : 28 AM PAGE 2/002 ' Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 0 9/0 912 01 1 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 cartificaae holder is an ADDITIONAL INSURED,the policy(es)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not corder rights to the certificate holder in lieu of such erdorsemmd(s). PRODUCER CONTACT NAME: PHONE FAX LAURANZANO INS AGENCY (A/C,No,Ed): _ FAX (A/C,No): 107 DODGE STREET EMAIL ADDRESS: PRODUCER BEVERLY,MA 01915 CUSTOMER ID M. 7242D INSURER(S)AFFORDING COVERAGE NAIC IF INSURED INSURER A: TRAVELERS DIRECT ASSIGNMENT INSURER B: GUIMARAES RODRIGO DBA GUIMARAES INSURER C: CONSTRUCTION NSURER D: 21 BALCOMB STREET INSURER E: SALEM,MA 01970 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POU CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF DATE POUCY EXP DATE TYPEOFINSURANCE POLICY NUMBER (MM,DDIYYYY) (MMMDD\YYYY) UMRB LTR INSR W VD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP Any one person) $ PERSONAL&&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY IS (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ - $ WORKER'S COMPENSATION AND WC STATUTORY LIMITS OTHER EMPLOYER'S LIABILITY YIN UB-4549P245-11 02126/2011 02/262012 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITOR/PARTNER/EXECUTIVE Y E.L.DISEASE-EA EMPLOYEE $ 100,000 OFFICER/MEMSER EXCLUDED? (Mandatory in NH). E.L.DISEASE-POLICY LIMIT $ 500.000 If yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIRESTRICTIONS/SPECIAL ITEMS TIES REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKER'S'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR GUM ARAES RODRIGO. THE POLICY DESIGNATED ABOVE IS CANCELED EFFECTIVE 09/10/11 CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 120 WASHINGTON STREET WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE SALEM,MA 01970 Charles J Clark ACORD 25(2009/09) - 1988-2009 ACORD CORPORATION. All rights reserved. RightFax C2-1 9/9/2011 4 : 35 : 47 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 09/09/2011 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:U the certificate holder is an ADDITIONAL INSURED,the policy(ies)most be endorsed. R SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX LAURANZANO INS AGENCY (A/C,No,Ert): FAX (A/C,No): 107 DODGE STREET E-MAIL ADDRESS: PRODUCER BEVERLY,MA 01915 - CUSTOMER IDP 7242D INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS DIRECT ASSIGNMENT INSURER B: GUIMARAES RODRIGO DBA GUIMARAES INSURER C: CONSTRUCTION INSURER D: 21 BALCOMB STREET INSURER E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEOTOTHE INSURED NAMED ABOVE FORTHE 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUSR POUCYEFFDATE POUCYEXPOATE TYPEOFINSURANCE POUCYNUMBER (MWDD\YYYY) (MMDD\YYYy) DMITS LTR tNSR WVD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL M ADV INI URY $ GEN%AGGREGATE LIMIT APPLI ES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILYINJURY $ (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND WC STATUTORY LIMITS OTHER EMPLOYER'S LIABILITY YIN UB-4549P245-11 0MG/2011 OPJ26/2012 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITOR/PARTNERIEXECUTIVE Y E.L.DISEASE EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-POLICY LIMIT $ 500,000 It yes,tlescnbe under OESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIRESTRIC-nONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR GUINLARAES RODRIGO. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 120 NVASHINGTON STREET WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE SALEM,MA 01970 Charles J Clark ACORD 25(2009/09) 1988.2009 ACORD CORPORATION. All rights reserved.