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435 HIGHLAND AVE - BUILDING INSPECTION (2) NOV-21-2008 FRI 10:43 AM FORTNEY WEYGANDT FAX NO. 440 71 7i —As', now an FORTNEY & WEYGANDT,INC. 31269 BRADLEY ROAD NORTH OLMSTED, OHIO 44070-3889 TELEPHONE NUMBER: (440) 716-4000 . MAIN FAX NUMBER: (440) 716-4010 ESTIMATING FAX NUMBER: (440) 716-4015 _---------------—-----------—---—FAX TRANSMITTAL-------------- --- �� To: 9" /'ry"`" " Fax No. Attn: From: Date: Comments: 0'� -44 b✓�+'� Total Number of Sheets Including Transmittal: NOV-21-2008 FRI 10:43 AM FORTNEY WEYGANDT FAX NO. 440 716 4010 P. 02/03 Cllent#:22701 FORTNEY DATE " ACORD. CERTIFICATE OF LIABILITY INSURANCE 11/14/08DIT PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Althans Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 543 East Washington St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW P.O.Box 570 Chagrin Falls,ON 44022 . INSURERS AFFORDING COVERAGE NAIG# INSURED INSURER A; Valley Forge(CNA) 20508 Fortney d Weygandt Inc. INSURERS: Continental Ins.(CNA) 35289 INSURERC: Continental Casualty(CNA) 20443 31269 Bradley Road INSURERD: Natl.Fire Co of Hfd.(CNA) 20478 North Olmsted,OH 44070 INSURCR 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 W11ICH THIS CERTIFICATE MAY Be ISSUED OR MAY PERTAIN. RTS.AREG AGGREGATE LIMITS TS MAY HAVE BEEN REDUCED IGG AFFORDED DESCRIBED PAID CLAIMS.N IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICUSIRpO YEFFECTIVE UCY EXPIRATION LIMITS LTR TYPE OF INSURANCE POLICYNUMBER A • Y A GENERAL LIABILITY TPE1077515083 07/01108 07/01109 mcH OCCURRENCE $1 000 000 X WMMERCIALGCNERALLIARILITY GETOR EMEG SIOOODO OLAIMS MADE QX OCCUR MED GXP(My aim apron) $10000 PERSONAL a ADV INJURY $1000000 GENERALAGGREGATE $2 000 A.000 GEN-LAGOREGATE LIMITAPPI.IES PER: PRODUCTS-COMPIOP AM $2000000 POLICY I X I JCC IX I LOC B AUTOMOBILE LIABILITY BUA2083195271 07/01/08 07/01/09 COMBINED SINGLE LIMB $1,000,000 X AM AUTO (�Actldwll) ALL OWNED AUTOS BODILY INJURY $ (Par P�) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Pwsce nD NON,OWNED AUTOS PROPERTY OAMAGE $ (PermudenU GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ MYAUTO oYHERTHAN EA ACC S AUTO ONLY: ADO $ Ci EXCESSNMBRELLA LIABILITY CUP2079618024 07101/08 07101/09 EACH OCCURRENCE $10000000 X OCCUR CLAIMS MADE AGGREGATE $10000000 $ DEDUCTIBLE S RETENTION $ $ D WORNiRS COMPENSATION AND WC2083999839 07/01108 07/01/09 X 001 LIM1 DTH- EMPLOYERS'LARanY WC297393473(CA) 09/16108 07/07109 E.L.EACHAcaOEM $1,000 000 ANY PROPRIETOMPARTN ERIEXECUTNE OFFICERIMEMBER EXCLUDED? EA..DISEASE-E4 EMPLOYEE $1 OOO,OOO w.&.rW.under E.L DISEASE-POLICY LIMIT 151,000,000 CIAL MOVISICNB IMIM A OTHOL Building& TPE1077515083 07101108 07101109 $5,570,240 Limit Personal Property DESCRR4IOM OF OPERATIONS I LOCATIONS I VPHICLM I EXCLUHON$ADDED OY ENOORSEMENY I SPECIAL PROVISIONS Project Name: Uncle Bob's#168 project 435 Highland Avenue Salem,MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED PCUGES BE CANCELLED BEFORE THE EXPIRATION City of Salem DATE THBREOP.THE ISSUINOINSVRBR WILL EMOBAVORTOMAIL _'In DAYS WRITTEN Building Department NOTICE TO THE CERTIPMATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SMALL 120 Washington Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Salem,MA 01970 REPRESMTAnVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 Of 2 #S216718/M215236 RML 0 ACORD CORPORATION 1980 NOV-21-2008 FRI 10:43 AM FORTNEY WEYGANDT FAX NO. 440 716 4010 P. 03/03 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/die Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leplbly Name (Ausinesa/Organizatiordladividual): Fortney & Weygandt, Inc. Address: 31269 Bradley Road City/State/Zip: north Olmsted, 0I3 44070 Phone#: 440-716-4000 Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction '2.❑ I aim a sole proprietor or partner- listed on the attached sheet, t 7. ❑ Remodeling ship and have no employees These sub-contractors have S. (]Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. © We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12,[] Roof repairs insurance required,] t employees. [No workers' 13 ® Other. r1 or renovati comp. insurance required.] *Any applieont that checks box 01 must also fill out the section beloW showing their workers'compensation policy information. t ttomeownees who submit this afdavit indicating they arc doing all work and thin hue outside contractors must submit a new affidavit indicating ouch ;Contractors that check this box most attached an additional sheet showing the name of the sub-contraotara and their workers'comp.policy information lam an employer that is providing workers'contpensudon insurance for Rey employees. Below is die policy and job site information. Ohio employee covered by Insurance Company Name: Stage of Ohio — Bureau of Workers Compensation Policy#or Self-ins.Lic.#: 733228 2-28-09 Expiration Date- Job Site Address: 435 Highland Avenue City/State/Zip: Salem, MP. 01970 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 rats lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one- ar imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fins of up to$250.00 a day again tr list violator. Be advised that a copy of this statement may be forwarded to-the Office of Investigations of the DIA for ' uraace coverage verification. `1 f do hereby certify under t c ins nd penalties ofpequry iliac the information provided above is true and carreca Signature: r Grect Fxeeh Date: 11-18-08 -� Secretary ensurer t Phone : 440-716-4000 Official use only. Do not write In this'area, to be completed by city or town officiuL S City or Town: PermlULicenso# 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#: ;j