117 HIGHLAND AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR
MUNICIPALITYMassachusetts State Building Code,780 CMR USE . .
Building Permit Application To Construct,Repair,Renovate Or Demolish a JRer*edMarXll
n One-or Two-Family Dwelling
•,( This Section For Official Use only
BuildingPekmitNumber - DateAp
/l Building Official(PtintName) signature VDate
U ) SECTION 1:SITE INFORMATION
1.1 Property Address: / j 1.2 Assessors Map&Parcel Numbers
1/ 7 a/ O
1.lals this anacce�streeC?yea_ no Map Number Parcel Number.
13 Zoning Information: 1.4 Property Dimensions
4
Zoning Disttict Proposed Use Lot Area(sq R) Frontage(ft) Z
1.5 Building Setbacks(ft) o
Front Yard Side Yams L. Rear Yard
Requited - Provided Required Provided Required Provides
1.6 Water Supply:(KG.L c.4o,§54) 1.7 Flood Zoae Informatlou; 1.8 Sewage Disposal System: Nrnn
Public❑ Private Zones_ Outside Flood Zone? D 1*
Check ifyes❑ Municipal❑ On site disposal system ❑ L
SECTION 2.- PROPERTYOWNERSEUI c
2.1 Rwnert of Recor�r^ C� n
Name(Print) / Gty,state,Zw
117 �� �n
No.and Street a Telephone Email Address
SECTION 3:DESCMMON OF PROPOSED WORKS(check all that apply)
New Constriction q Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits- Other Specify:
BriefDescription ofProposed Work:
i
SECTION 4:EST MATED CONSTRUCTION COSTS
Item .,s,. . _ Estimated Costs:
abor and Matarials official use Only
1.Building _ $ a 1. Building PennitFee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Applicat on Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $' 2. OdterFees: $
4.Mechanical (HVAC) . .$ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost $ Check No.L &S7 Check Amotmt: Cash Amount
❑Paid in FuB-.. t� ❑Outstanding Balance Du=
Sew tN SfaS� iP �3o
SECTION 5: CONSTRUCTION SERVICES t
&I Construction Supervisor License(CM) IG 7 917—� 3 �
8
IaceaseNumber ExpitationDate
Name of M Holder -
I List.CSL Type(am below)_ tf�
Eric W.Palm
xn.aadStreet - 3f ilton Street j ` D .
? - U Unrestricted
Description icted to 3 000 cu.1t.
Salem MA0f970 ' R Restricted M2 Family DweUrn
City/rown,State,ZIP i M Masonny
RC Rooting Covering
WS Wmdowand Siding
SF . Solid FuelBunuagAppliances'
I insulation
Televiume Bmailaddress D I Demolition
5.2 Registered Home Improvement Contractor QHQ Pao kct3 )Z
Atlantic WeatllcriaatiVly'La.
- ffiCRegistratron ®ber - ExphationDate
HIC Company Name orHI venue
Salem MA 01970
No.and Street - F nail address
/f State;ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L r-152.§25C(6))
Workers Compensation Insurance affidavit mustbe completed and submitted with this application. Failure to provide
this affidavit will result in the denial ofthe Issuance a building permit
SigaedAff1davitAffwhed? Yes.......... ! No........_.O
SECTION 7a:OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
II,as Owner ofthe subject property,hereby authorize t- C It"
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print oxmer's Name(Electronic-Signatme) Date .
SECTION 7W OWNEW OR AUTHORIZED AGENT DECLARATION
i
By enteringmy name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained in appE�Ibp/n�is(h�y�7 accurate to the best ofmy knowledge and understanding.
Prim owner's orAatboriudAgent's Name(Mechanic Sigadme) Dan:
NOTES:
1. An Owner who obtains abuilding permit to do hislher own work or an owner who hires an unregistered contractor
(not registered in the Home improvement Contractor(HIC)Progmm),will not have access to the arbitration
program or guaranty fiord under MG.L.o.142A.Other important information on the HIC Program can be found at
www.mass.eov/oca hformation on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ff.) (including garage,finished basementfattics,decks or porch)
Gross living area(sq.fl.) Habitable room count
Number of fireplaces Number of bedrooms
-Number-of-bathrooms— Number-of-balf/baHu
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for"Total Total Project Cosf'
,t �Y n o�
77dsPmmsaffi6aall : g'®��'.���e 0.1�`�{ffi L�.tl..®�ax dN
1 leneae"tnptotat bmiete9aa?mea>s ofdms".atesH
aume
'J O& gceoC�o-C+mda HoumeoP6� A°Yp�Plmmm�(MCd.ch�pclq?A�
�mgto >mptovrsoeo�)tmtdoesaat�ttadastandmd
�o$��B6��ReymlatimgC eFax mYnaikm 8aome sh°'ddfiata6>�a
�t'�mafioD °�®����0u �@��orl-88& a6taioakeeWPYb➢callmgtha
Botlineat617-97
Name - dfi-3757aron am
CoOFgtd@g0p�t0ffifg00 ���
5rmerAd CoIDt+toYName p �t�
d+�(do aot Pa 00iee73as va) Atl�he q
nVPa Caaa-�mdsvep�,, eaathefiuip„i;, LLC:
Stae Code' va.�tgt Avenue
De3aime Fbeae 'G _ HoaoesAddt�(�ahmlMse t
Erem V Pbooe
Mylinggdd-ffi Ci
@di0venl0 m ) ' ty?owe.. Stain
ahma Zip Cade
Bm^'aPbWe '
• .. i.Ta�4.trvtacmd EmFial"arIDmSB Nmabm
The COnt.�].etar �r�.cvp,� p� 't
(Ds�he indepit tlw.pra camplxte S �omWronrr - l�a as3/�•Z///_
forPlte7; 5�
0.Wda8deoF
'n - -_ amsiak tobet��dirimN�s�m.
✓WYV f )
aaduired
mH bin�tG-7befollow;agbnddia .
semtiM tiyWecomngrastb 6meemmin�td01� Aa(Owners who Seeere ">' i;aat heaP1 11 1(armd CompletloaSdt
Minded fre.Y44 are their owD Fe+�iE9'C�srt•Q� tO'�ffioimm�aces6_�-�tefotioa3v8scbedaiaw,y
IvdGb e§ID�IIesZ92.Fy)n eE8F0ttd F.'asRsio¢s of _ (o Soo the rmbamoes Watmtadte. -
Dateabet Wabaaeorwdi bUfia matmctedanrlc
�ontracPeimmd Rt3'mmt SCted I}ate Rnen aoobaetad uadr inL 6e P
bnpor agmes top�m,ye sin -'bstentie0yeoWm Ieted.
Paymeats wO� frQ°i%h&emztedal cad labor
ua716e msdeacWrdmgto The foli'mo spYi6edahovefartbemlE7smo oi:
gscbedale:
5—��upoa sigmSampatt�aai�m aaceed i9 afthet � (D)
by/—!_arupm eompletlm of WabzetMae or the con of- ka
S
S by 1 =arupoa c -�— cheimrrsgreeta)
S omplepon of
uPaa Wmpledm aftheeoetiaat, (f- lorbidsdemao� C�a �" "
/1)
,�0m+hdrl/
WrdFmeatoaat be iPaial g�Paymeof m nttmxis eam
thecamp/��m mu�7„ mmd7 ���+o 'dP Pldcd to both PatY'ss'-tigfactian)
1nchdm8a0Pmanee �— be
rmmaed theggtye�mt"')Iswrciima ara
widdrmurt ac=pziJ mdlemdmm°fm iotrl eooa3:pjgm@me�mmtmttdicd h!'lMeaotr..einrbeP
mrcm i!_ngn _ on rhemmFledon Raedate hffi ofuoy sp¢yd egaipmeetm*Vx,.,y Sabrantraga ` � 'mviacd
Pa•Ty/subeontn �b a��,tbe�ro he sole! memnt rm,x [J xo f�ye9
te' s 'nor° Yrespaaaole fo:Wm I reran:°Ftea n:mntvm
d lobo C0°b'°aor. Tbewnoaamry�6 nn
tmde t isa mr Potion ofdienadrdesp,y�m mtF.e min emntmen
CoaEscCA.scePtaace-Upm sigaing•this aStaes�basot� SBrdt�s afdre coatraet sha0 notim YiedP°a9bleforall �o°a afaoyt6i,d
Ybafore si ply dtatanYliea o:odtm°went becomesabindingombaa FeYmWts toag�h.., ae+ms tar
gaingthis cantraaL sW°°9r��ibaa bseapb,Wdm Waodalarr. Unless oWeiv+isaaoted mi
` iKz7<estreRa-med oltosigniagtheW resideo% An'ie>ithefogpcviog�o�and Mthe
`�-�sat'dAomi ��LO"`�WdfWlYua P'"' affartmst 6 'emare�.a— .txmentCm darsmnd it Asg
n nl'vntmgt the No U"Ma -�� arRee,sbnuan. Toe ��oasifsomc)m
° noes toe Dnactaratl0 fft0mafmpioyrm®tom" lawrrgairesmosthome-gu��.
Watreror)taveof�zaW7 Aktha C,.U.Mar_UT5170, foe., atorRa�saadon. You mp18°�eatWotmgonaud
a wode totheHmabapaa Cm'�heportantmr' a�C[HapaayIDf�na oo 02116 or by ry,���0Ca�gM 5.
VaMM or ae,to
You
may
r ,W�isagzo9nentifithos amsatorizw ea themve 'IdeoPt lb as andga.Wpya@.Coasmer
coat�mthird busmtss dayfo ouugf5esig®��gof�is�g m�Wh �'O s)'Lodi p°`T�by
sooaaalp)�e°fy�0�sptarbydCH
SIM rovided
ednodae ofctaceeii�'v`rat7oa�fmm Sr aPlmaat ��tof0ea
ntny oftbi;nghG
'°wR'�niatsyY 4amFS:-',6igam �]sal�j jl� PP
mei.asr�.nbeae
Homeot:aer's Sigaatmn - `' � (
Data
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration actin(as an
alternative to court action)ifthey have a dispute with a contractor. The same right is-aQA automatically afforded to a �\
contractor,however. The contractor would have to resolve my dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would gave the contractor the sane right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby,mutua0y agree in advance that in the event the contractor has a dispute
concerning this cunt ctbe cpnnaetornia5i submit the dispute to a private arbitration firm which has been approved by
Ore Secretory of the)xecutive�O#ffice�pff Fonsumer AS'eirs and Business Regulation and the consumer shall be required
to submit to such arbitrihbnpt„dvrdrd In Massachusetts General Lavrs,ch ter 142A. -
,:
Home s Signature Contractor's Signahve
NOTICE:T he signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiaed by the contractor. The homeowneer may tiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Horne Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in my way,even by ageemeuL However,homeowners
may be excluded from certain rights if the contractor they choose is not property registered as prescribed 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 mumeration of other matters on which the homeowner and contractor Imvfiilly agree may be
added to the terns of the contract as long as they do not restrict a homeowner's basic conimner 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,ornot applicable. One original signed copy of the contract with attachments is to
he given to the owner and the otherkept by the contactor. 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 bas expired;
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the paymentsehedude in cases where the
homeowner deems him/trerself to be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of fiords not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work wthdmwal of finds from said account would require the
signatures ofboth parties.
Additional Information
If you have general questions or need additional information about the Home improvement Contractor Law or other
consumer rights,or ifyou wish to obtain a See copy of"A Massachusetts Consumer Gaide to Home bnprovement"
contact:
Consumer Information Hotline
Office of Consumer Affair.and Business Regulation _
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCA13Rttebsite at hen-//wnnv.mass.eov/ocabr/
If you want to verify the registration of a contractor or ifyou have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law.contact
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Rum 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at htm:/1www.mass.aov/0cabr/
Go online to view the status of a Home Improvement Contractor's Registration
bag//db statemaus/homeimnrovement/licenseelistaso
For assistance with informal mediation of disputes or to register formal complaints against a business,tall:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-6524800,508-755-548 or 413-734-3114 via 11-11ry2010
The.Commonwealth of Massachusetts
i' 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 1 '_ Please Print Legibly
Name(Business/Organization/Individual): �Q rI/-/G I le.9 ,,z hh ,
Address: (p/ 5erfelr5icr� A¢ c
City/State/Zip: 56-W" fM O l o/-7(> Phone#: Ct kjG/3
Are you anemployer?Check t e appropriate box: Type of project(required):
1.Lof am a employer with A, 4. Q I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. Q 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
workingfor me in an capacity, employees and have workers'
Y P tY• 9. Q Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. Q We are a corporation and its ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions
myself. o workers' com right of exemption per MGL
Y Ct`I P• 12.Q Roof repairs
insurance required.]t cA52, §1(4),and we have no
employees. [No workers' 13. ther; Sl6/OA yh
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 name 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: ` Z144 rf CA
Policy#or Self-ins.Lic.#: IIJ 62-70 /9 / Expiration Date:
Job Site Address: 7 r q h /Cf rt //1 City/State/Zip: Sq/6 ,
Attach a copy of the workers'. compensation y 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 certif^pnder the __��nalties.ofperjury that the information provided above is true and correct.
Signature ,pd Date: C. 12,4
Phone#: 7 3
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Licerise#
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#:
CERTIFICATE OF LIABILITY INSURANCE
DATE T TE DO E IS ISSUED AS A MATTEfl OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI S
y� CERTIFICATE DOES NOT AFFlgMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER TXE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIYUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
O nil ER E E TIFICA E OLDER-
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the olic ies
terms and conditions of the policy,certaM policies may requ-ve and endorsement A statement on this certificate does not confer rights to the
P y( )must be endorsed. X SUBROGATION IS WAIVED,subject to the
certificate bolder in Ileu of such endorsemen s.
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME.
233 W CENTRAL STREET PHONE FAX -
(A/C,No,Ext):
NATICK,MA 01760 E-MNL
22MLW ADDRESS:
INSURED INSURERS)AFFORDING COVERAGE
INSURER A: AMERICAN 2URICHINSURANCE COMPANY NAICS
ATLANTIC WEATHERLZATION LLC
INSURER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES INSURER F.
CERTIFICATE NUMBER:
T p ERi¢Y THAT HE POLILYESOF INSURAN 111
LISTED BELOW HAVE BEENISSUEp TO THE INSUR®NAMED 460VE FOR THE POLICY PERIOD INREVISION DMBER-
ICATED.NOTWITHSTANDING
ANY REOVIREMENT,TRIM OP CONORpN OF ANYCOMRACr OR OTHER DOCUMENT WRH
AFFORDED BYTHE POLICIES pESCflIBED HEREIN BSUBJEC7 TDALL THE TERMS,IXCLUSIONSPgENp CONDITIONS OFF PCATEM MAYBE
MAY PERTAAVE BEEN REDUCED BY
PAD CLAIMS. PERTAIL THE INSURANCE
MSR
LTR TYPE OF INSURANCE ADD SUB POLICY EFF DATE POLICY E1tD GENERAL LIABIUTy L R FOLICYNUMBER (NPMO YVYY) IMM�pDtYV PATE
Lattrs
COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE
CLAIMSMADE ❑OCCUR. $
AMAGE TO RENTED $
REMISES(Es occurrence)
GEN'L AGGREGATE LIMB APPLIES PER: ED EXP(Anyone peraen) S
POLICY ERSONAL 8 ADV INJURY $
PROTECT❑LOC ENERAL AGGREGATE $
AUTOMOBILE OABILITY RODUCTS-COMP/OPAGG $
ANY AUTO
ALL OWNED AUTOS COMBINEDSINGLE $
LIMIT(Ea accident)
SCHEDULEAUTOS BODILY INJURY
HIRED AUTOS (Per Parson) $
NON-OWNED AUTOS BODILYWJURY S
(Per acciden0
PROPERTYDAMAGE $
UMBRELLA LIAR OCCUR (Per accident)
EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE
DEDUCTIBLE AGGREGATE $
RETENTION $ $
A
WORKER'SEMPLOYERS AIR
ANO
EMPLOYERR'S LIAB $ILITY
ANY PROPER HOIiIPARTNER/eXECUTIVE YM US-5 8 270 1 21-15 WC STAMOAY—O OTHER
(OPF1Man RRIEMBER EXCLUDED? WA 03202015 03@0/2016 X LIMITS
(MandmoryE NH) �L E.L EACH ACCIDENT
Il yes,dttolbe wiper $ 500,000
DESCRIPTION OF OPERATIONS Wow E.L.DISEASE-EA EMPLOYEE $ S00,000
DESCRIPTION OF OpERATONS/LOCgTONS/VEHICLES/RESTRI E.L.DISEASE-POLICY LIMIT
TMS REPLACES ANY PRIOR CFR CTIONS/SPECIAL ITEMS $ 500,000
TMCATE ISSUED TO 774E CE2TMCATEHOLDEt AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION
93 WASHINGTONST SHOULD ANY OF THEABOVEDESCRISED POOCIE9 BE
BEFORE THE EXPIRATION DATE THEREOF,NOTIQE BE CA DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM.MA 01970 AUTHORIZED REPR
acogD zs zotao a vE
The ACORD name and logo are registered marks or ACORD 198E-2p1 O ACORD CORPOR
ATION. All rlghly resemed-
AIICI
CERTIFICATE OF LIABILITY INSURANCE WE(MMIDDA'YYY)
THIS CERTIFICATE IS ISSUED AS A IVELY O OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER_ THIS
3/3/2015
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: c the certificate holder is an ADD1710NAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Eastern Insurance Group LLC CI-. Construction
233 West Central St PHONE (800)333-7234 FAX
E-MAIL AIC Na:
ADDRESS•
Natick NA 01760 INSU S AFFORDING COVERAGE
INSURED INSURER A Arbella Brotection Ins- Co- NAIC4
Atlantic Weatherization
INSUREReNautilus Insurance Co -1360
61 Rear Jefferson Avenue INSURERC:
INSURER D:
.Salem M 01970 INSURER E-
COVERAGES CERTIFICATE NUMBER�DLSTER 201INSURER F-
THIS IS TO CERTIFY THAT THE POLICIES UI INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE-III I :REVISIONN11 GNU(11 1 TME POLICY PERIOD
INDICATED. NO7W17H57ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITHrR CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT EC ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RESPECT ALL
WHICH THIS
INSR
LTR TYPE OFINSURANCE AB B
GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICYEXp
MM/OD LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE AMA N
$ OCCUR 8500042816 PREMISES Eaoroamnrar s .50,000
/20/2015 /20/2016
MED p(p(peY ane Person) $ 5,000
PERSONAL B ADV INJURY S 1,000,000
GEML AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000
POLICY X PRO M
IOC
PRODUCTS-COMPIOP AGO S 2,000,000
AUTOMOBILE LIABILITY
S
A ANY AUTO COMBINED SINGLE LIMIT
ALL EO
e acooam S 1 000 000
ALTOS X; SCHEDULED BODILY INJURY Per AUTOS 02001SO71 /20/2015 ( Person)) S
HIRED AUTO$ A AUTOSWNED /20/2016 BODILY INJURY(PI a,,Imoi $
PROPERTY DAMAGE
X
Per accident S UMBRELLA DAB X OCCUR PIPAastP $
A EXCESS AS CLAIMSfJIAOE EACH OCCURRENCE
S 1,000,000
DED RETENTIONS 600058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'LIABILITY $
ANY PROPRIETORPARiNERIEXECUTIVE YIN WC STATU- OTH-
OFFICERIMEMBER EXCLUOEOT ❑ NIA
If 05.dea I.NH) EL EACH ACCIDENT S
❑yas,Eeedbe under
DESCRIPTION OF OPERATIONS below EL DISEASE-EA EMpLO 5
3 POLLUTION LIABILITY EL DISEASE-PODGY LIMIT S
L200378613 0/1/2014 D/1/2015 GENERAL AGGREGATE
$1,000,000
iSCRIPnONOFOPERATIONS/LOCATION$/VEHICLES ARacbA EA POLLUTION CONDmON $1,000,000
( CORD TOT,AdWUI Remarks Schedule,Hmom space is requim4)
iRTiFICATE HOLDER �I
CAPJCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER
93 DMSBINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS. ED IN
SAJZMr MA 01970 _ AUTHORfZEDREPRESBJTanvE
)RD 26(2010/0B) John Koegel/pMq �
125 onlnnsl DI O 1988-2010-ACORD CORPORATION. All rights reS
Thn aCARn name nnri Innn aro roerved•nie:tAroA merlr¢of ar:rlRr1