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320 LAFAYETTE ST - BUILDING INSPECTION (12) PL*NS*WT-B£fIIUEP rD APPROVED BY T*IE ,W5PXTDIR PF,IIIaR TO A PEMT B,EWG GRANTED v CITY OF SALEM lQ No. aO —& Fe.'� Date Is Property Located In Location of, the Historic District? Yes_No ✓ Building 3),0 Is Property Located in .haler— M— 9 TO the Conservation Area? Yes_No BUILDING PERMIT.APPLICATION FOR: Permit to: (Circle whichever apply) Roof, R_erooce Fth Siding, Construct Deck, Shed, Pool, Re c PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name Part: &--ers GLC. Ton cApri Address & Phone 3�n L0.f A%AAe 6A-, boAetVr r} (781 )-596 -3377 Architect's Name r/4MooV T k ti tan! (l�erioL ,�PPc rw� iNc. f4 � ,MA ,Address & Phone CNe (,en�e%&I 01W (7e1)-9Ila -©oaY Mechanics Name 6yr2 oj NCr )Tarrs Cor-rriaAj,�-aliani�,��°w�'?'��f� GJo(�bo rot NN. Address & Phone )I -60A MAIN.9. o3sg (6o3)S6 q �� n I r Whet Is the purpose of building? /o /lG/uSrtii� /1aL1-o t7PA Lj for Cinf-kr(�t/rre/PS5 Material of bullding? ✓o MA7cl 1 ESV ISbi f1 N If a dwelling,for how many families? I WIII building conforr)n two law? l S Asbestos? N11� Estimated cost f7l/ City License M N P' state Wconse # Dome Improv ent i Lie. i " Signs re of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE C; "f w,r& P a5e�7 �6 'Ir' lbw 16 [)(A. NL\,b be k,Y,A A J k\\ bu t'-1 ON Too of 71�e ex '5 'n kKjWc,,bQ, (,Ji � iN �jUi�Uiylq oN -/Iv- i il' l 4!'-foor. MAIL PERMIT TO: lower Aeaere /yi3�k2QP/'(PJL� 3O L rtcuv sr. lve5� ��k, M19 ols8 APPLICATION FOR PERMIT TO LOCATION ,32Z2 L�iFE�rr� PERMIT GRANTED APPROV D 1 P LIFCTOR OF BUIL NGS OJENV. IIIIIIIIIIIIIIillllillillllllllllllllllll 20@6013000326 Bk:3325 Pg;511 CITY OF SALEM av3®r200e 14:28:03 OTHER Pa 1/2 PLANNING BOARD 100b JAN —9 P 2: 2b January 9, 2006 Decision For The Petition of New Cingular Wireless PCS, LLC For The Property Located At 320'Lafayette Street A Public Hearing on this petition was opened on December 15, 2005. The following Planning Board members were present:Walter Power, Chuck Puleo, Gene Collins,Paul Durand,John Moustakis,Pam Lombatdini, Christine Sullivan,Tim Kavanagh, and Tim Ready. The Public Hearing was continued to January 5, 2006. Notice of this meeting was sent to abutters and notice of the heating was properly published in the Salem Evening News. The petitioner is requesting a Wireless Communication Facility Special Permit under Section 5-3, Special Permit Uses, of the City of Salem Zoning Ordinance,to allow the installation of four (4) antennas within faux screen atop the eastern penthouse and two (2) antennas within a faux screen atop the western penthouse,both located on the roof of the building located at 320 Lafayette Street, Salem, MA. The petitioner is also proposing installation of ancillary equipment within an existing room on the first floor.The faux screens are to be painted to match the existing building. The Planning Board reviewed the application and plans submitted and found that the petitioner addressed the requirements of this section for the issuance of a Special Permit. _�b6 tL On January 5, 2006, the Board closed the Public Hearing and voted by a vote of nine (9) in favor (Power,Puleo, Collins,Durand, Moustakis,Lombatdini, Sullivan,Kavanagh,"Ready),none opposed, to grant the Wireless Communication Facility Special Permit for the location stated above,in accordance with the application (dated November 22,2005) and revised site plan dated January 3, 2006, entitled"Cingular Wireless,Salem Park Towers", sheets T-1, Z-1 and Z-2,and drawn by Aerial Spectrum,Inc.., submitted and now part of the file and subject to the following condition: 1. The applicant shall submit to the Department of Planning and Community Development a written report, signed by the Salem Fire Inspector, that the room to contain the ancillary equipment for the wifeless communications antennas meets fire safety codes and the equipment, including battery backup generators, does not pose a fire safety hazard to the residents of 320 Lafayette Street.. This endorsement shall not take effect until a copy of the decision bearing certification of the City Clerk that twenty (20) days have elapsed and no appeal has been filed or that if such appeal has been filed that it has been dismissed or denied,is recorded in the Essex South Registry of Deeds and is indexed in the grantor index"under the name of the owner of record or is recorded and noted on the owner's certificate of title. The fee for recording or registering shall be paid by the owner or applicant. I hereby certify that a copy of this decision is on file with the City Clerk and that a copy of the decision and plans is on file with the Planning Board. 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 *TEL: 978.745,9595 FAx: 978.740,0404 0 WWW.SALEM.COM - v r -gg Walter B. Power, III Chairman 'i ore iJAN 3 0 2006 1 hereby certify that 20 days have expired from the date this instrument was received, and that NO APPEAL has been filed in this office. A Tr6e'66"'p ATTEST: CIT CLER{<, Salem, Mass. _.__ T?3T'A - � x � ' R Zs ,s//ie -(ramriranueall/ 'a '✓ do c�iunetld s ^r _ _ < ' BOARD OF,QUILDING REGULATIONS . . =License': CONSTRUCTION SUPERVISOR 6£ Number.,CS ,0078778 &rthdafe 07105M 967 y„ Expires. 07/05/7006Tr.no: 28151 `? b -t Restricted 00 DAVID D SYKES T' e PO BOX 1193 Qfiz WOLFEBOROFALLS NH_03896 Commissioner 00 35,000 cf enclosed space tr1G`182 Family Homes - - r f Failure to possess a current edition of the - Massachusetts State Building Code x xx � wr is cause for revocation of this license .4 DIG SAFE CALL CENTER:7�(888)344-7233 Certificate of Liability Insurance Date of Issue 01/04/2006 Producer I This Certificate is issued as a matter of information J. Cll/ton Avery Agency, Inc. only and confers no rights upon the certificate holder. This certificate does not amend,extend or alter the 27 South Maln Street 21 Box 1Mai coverage afforded by the policies below. Woffebon;NH 03894-1510 Companies Affording Coverage (603)569-2515 Company C N A A Insured GREEN MTN COMM Company C N A B Green Mountain Communications Company O PO Box 356 Company Continental Casualty Wolfeboro Falls, NH 03896-0356 D Company Commerce&Industry E Company F Coverages 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 decribed herein is subject to all the terms,exclusions and conditions of such policies,limits show may have been reduced by paid claims. Cc Type of Insurance Policy Number Policy Effective Policy Expiration Limits Ltr Date Date General Liability General Aggregate $2,000,000 A ❑ Commercial General Liability C2082342699 12/31/2005 12/31/2006 Products-Comp/Op Agg $2,000,000 ❑ Claims Mad ❑� Occurrence Personal&Adv Injury $1,000,000 ❑ Owners&Contractor's Prot Each Occurrence $1,000,000 ❑ Fire Damage(anyone fire $300,006 Med Exp(Any one person) $10,000 Automobile Liability g ❑ Any Auto C2082342704 12/31/2005 12/31/2006 Combined Single Limit $1,000,000 ❑ All owned Autos Bodily Injury ❑J Scheduled Autos (Per Person) ❑d Hired Autos Bodily Injury ❑d Non-Owned Autos (Per Accident) ❑ Property Damage C Garage Liability Auto Only-Ea Accident ❑ Any Auto Other Than Auto Only: ❑ Each Aggregate Excess Liability Each Occurrence $5,000,000 ❑J Umbrella Form D C2082342718 12/31/2005 12/31/2006 gg 9 $51 0001 000 A re ate ❑ Other Than Umbrella Form Workers Compensation and WC3420918 12/31/2005 12/31/2006 © WC Statu- ❑ Other E Employers'Liability tory Limits EL Each Accident 1 000 000 Executive Officers ❑ Incl EL Disease-Policy Limit 1 000 000 ❑J Excl EL Disease-Ea Employee 1 000 000 Other Description of Operations/Locations/Vehicles/Special Items Coverage as per terms and conditions of policy. Cancellation Certificate Holder Should any of the above described policies be cancelled before the expiration thereof,the issuing company will endeavor to mail 30 Green Mountain Communications days written notice to the certificate holder named to the left,but P O Box 356 failure to mail such notice shall impose no obligation or liability of any kind upon the company,its agents or representatives. Authorized Representative Wolfebono Falls, NH 03896 Thomas A O'Dowd k ie- X rIn'g('onm[�c[veFltJt OfasseChvt'£L;s - At it, a�flrAtt�trtatyixr�s -� - �-, IR MT _ w p[ "Compeoewr7a: ceA9drft[c .�„�., -- �pPLiCANTTNFQRMATTDN,+ *" _-. t'^ £ _ 9 P[ease PIiA'T I.e�[bry kI.a[�oa. - 6 7 sm nliammwaa ppeeammtng au WO& ytn2 ,p..... '` <,c ` �Stv to ,Ofl mm-aaamployapravdmg Wt3fku't,;.,ygqarfaranY unPlovpfilag aal��ob ..-a„ ny T7emc. Green Moon£aaneGo'mmuncakionsf�Incc^-�—= e 16 '�,8hne8k._ s ,�,. t=' Wol iboto,J i I�utenee;Cntnp 'AIG= .._ Paltry#:�WC3287462! e - �* ❑Iam(r&ble on�ssolep�,opneffi,genaai e�iioT o%hemcowna dud liars)axed tLe'wfi3_e.^ron h9ttd brlowwh4 agvcthEaoU.ow+a8� _ v} Tclnphonc" s Iamsaace.f'.om�tav}^ CompsaXNmtta r M. AD AY�smanw .° ttAy •�^ �� Poliny%S� At[a?SFnddi6aa�al al[eeflSAeragarX r __ N-- ���- Pafittigaciaerovetage-msrupureduuda StsP�'w oi'MOIyISB�JF lean io §moownoxfofmmipel pe*=tn,:ofae5aeatlptp 51,50400 . an.A!pTtaoa yatitsS unPrt§amnrtt;,as welj"es plvil P„-aalnes in;[Le`;am ofe STQPFIORKORDE&end'a ¢.p2[gq a,daX ageio6rme ttnde[amAd theta of [tttny tit'tarnatdedrafhe 0fria oflaviyi[gayoas m[acDLiforkrmangc ver�cauoar - �.� I db ". ry x a ours enulhes ojpegruy the�ajormaiLsn Abma.kttuex?Ad mrrvt' � � a�,�.... V s _* r - - 'XtatNtanc`f�_ (603} 5'b9``6601 f OIn8a1 Lie ONLY D na mbrlte[o tWs areaNO AM= m�� '.;"'� -_ � aBWiEuip,{ee➢artlnsuls . �"ChY or Ftgyn � ,P 'W6vatn nse�::'-�, •x^f'---:-.-. . .� '�"�a llue`n"efnB:eaeNs ., - ' - � � u �,� t s _ axP�$. s-� •�' A4eaIM DnpdRmaN= J...J � a Che�'i10inittad�eta r4aparee b required xt - '}� - m A O[M�, a r Dcvartmeri t i,:? L g tuye ae t 29 Fo- c V �yl 0 1 107t ;9 5 vl Fire '41 r"990 Fa.V 978-745-4646 9,-S.74 -77'7 FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT IN ACCORDANCE, WITH THE PROVISIONS OF THE MA.SSACHUSETTS STATE BUILDING CODE SALEM FIRE CpDt, APPLICATION AND T[iE Is HEREBY MADE FOR THE APPROVAL OF PLANS AND THE ISSUANCE OF I& CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT BY THE SALL'i FORE I)EPARTMW, C Ref. Section 113.3 of the Mass. Bldg. Code) JOB LOCATION: Lc1Lrc-kw Ark ELECTRICAL CONTRACTOR: OrK,/Q mot""Jqiro 0c)ti m LmLo—, FIRE SUPPRESSION' CONTRACTOR: 6-ree1,3,. S i�NIA IR, 01, PHONE it: q1Z-3-5 ----------7 Do's --v tA Q AFPROVALr DATE u10 71 ;15 "W'4 Certificate z approval gr4ntp y b4re b 6 or !submittal of � o project-details, by the SALIEM FIRE DEPARTMENT. All plans are approved solely -1 f - I for ldefiiificat` f type and Iodation of fire Protection de4Ace-s and equipment A,j plans�are subject to approval of other authority-an Jurisdiction. hstailer(s) shall request an e applicant dt i insp ctloix and/or ..a L OQUIREMENTS, ehi�fiie tection 41�vices- : .e"i- (ADDTTTIONA . Pment NEW CONSTRUCTION. c. PROPERTY LOCATION HAS 140 COW' LLANCE WITH rK66E PROVISIONS OF GMAT I VR '148, SECTION 26' G/E,' M.G.L. , RELATIVE TO rqE INSTALA- TION 0'F APPROVED FIRE ALARM DEVICES, tRE.rj�'NER OF rd 2RO- TS PERTY IS REQUIPID TO G-3r.A[N CO.%j?LIA-NCE AS A (XtMDITION OF OBTAINING A K"fLIDING PERMIT. ION T� 11 Col ILC."'t- t'E T?E V I IS p F P P F, .-,:(TY Di C.AT - t43, SFCTDI'ta 26 ", E, Vf o, Do-' $50.00 CItY OF SALEM 2006011100442 Bk;25278 Pg;134 " 01/11/2006 13:34:00 OTHER Pg 112 PLANNING BOARD a December 2, 2005 rt rn Decision For The Petition of Omnipoint Holdings, Inc. , a Wholly Owned Subsidiary bf T- Mobile For The Property Located At 320 Lafayette Street 6 ' A Public Hearing on this petition was opened on September 29, 2005. The following Planning Board members were present: Walter Power, Gene Collins,Paul Durand,John Moustakis,Tim Ready and Christine Sullivan. The Public Hearing was continued to October 20, 2005, November 3, 2005, November 17, 2005, and December 1, 2005. The Public Hearing was closed on December 1, 2005. Notice of this meeting was sent to abutters and notice of the hearing was properly published in the Salem Evening News. The petitioner is requesting a Wireless Communication Facility Special Permit under Section 5-3, Special Permit Uses, of the City of Salem Zoning Ordinance, to allow the installation of three panel antennas within a 13' faux chimney on the roof of the building located at 320 Lafayette Street, Salem, MA. The project will also include the installation of a 10' 8"x 8' equipment shelter in a penthouse space,located within the building. Additionally, one 19" GSM antennae and one 3 7/8" GPS antennae will be located on the rooftop to allow for FCC mandated E911 capabilities. The Planning Board reviewed the application and plans submitted and found that the petitioner addressed the requirements of this section for the issuance of a Special Permit. On December 1, 2005, the Board closed the Public Heating and voted by a vote of six (6) in favor (Power, Collins, Durand,Moustakis, Ready and Sullivan), none opposed, to grant the Wireless Communication Facility Special Permit for the location stated above,in accordance with the application (dated September 1, 2005) and site plan dated August 10, 2005, entitled "Park Towers, 320 Lafayette Street, Salem, MA 01970, 4BS-0200-B, Rooftop" sheets T-1 and Z-1 through Z-4, and drawn by Aerial Spectrum, Inc.., submitted and now part of the file, subject to the following condition: 1. T-Mobile agrees to cooperate with an gr p y future carriers intending to locate facilities on the subject building at 320 Lafayette St.,provided that such future carrier's installation does not interfere with T-Mobile's antennas. This endorsement shall not take effect until a copy of the decision bearing certification of the City Clerk that twenty (20) days have elapsed and no appeal has been filed or that if such appeal has been filed that it has been dismissed or denied,is recorded in the Essex South Registry of Deeds and is indexed in the grantor index under the name of the owner of record or is recorded and noted on the owner's certificate of title. The fee for recording or registering shall be paid by the owner or applicant. I hereby certify that a copy of this decision is on file with the City Clerk and that a copy of the decision and plans is on file with the Planning Board. 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 • TEL: 978.745.9595 FAx: 978.740.0404 ♦WWW.SALEM.COM I Walter B. Power, III Chairman Date 'JAN 11 2006 I hereby certify that 20 days have expired from the date this instrument was received, and that NO APPEAL has been filed in this office. Fit i'EST_.__._.Ci rr//;LEPK, Salem, Mass. The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Busims!Organizatlon/Individual). Address: 65 __A! City/State/Zip Phone#.0 yl Are you an employer?Check t e appropriate boz " Type of project(required): I.�I am a employer with 4. ❑ I am s general contractor and I 6. ❑New`construction ' employees(full an(/or part-time).' have hued thacub=contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working-for me in any capacity., workers' comp. insurance 9. ❑ Building addition 5. ❑ We are a corporation and its " [No workers' comp,insurance . 10.❑ Electrical repairs or,additions required.].t ,. officers have exercised their' 3.❑ I am a homeowner doing all work right of exemption per MGL' 11.❑ Plumbing7epairs Or additions myself. [No workers' comp. c. 152,§1(4),and we have no ,12.❑ of r insurance required:]t. employees [Nq workers' , 13. Other CX/ comp. insurance required.]" *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomation: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCont"rs that check this boz roost attached en additional sheet showing the name of the si&contreotors and the¢workers'comp:policy information I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. qq �® Insurance Company Name:C. Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip:aim Attach a copy of the workers' m nsation policy.declaratton 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 c er the a d pe s perjury that the information provide bove is true d correct Si atria: Date: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Liceuse# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other hone#: Contact Person: P 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 a j6int enterprise;•and including the legal representatives of a deceased employer,or the partnership,association or other legal entity,employing employ employees. However the indivi ga . ,of dual, hqm, . receiver or trustee o P,_ owner of a dwelling house having not more than-three apartments and who resides therein,or the occupant of th6— 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." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall 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)name(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 be 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 lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departr 8rhas 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant ' that roust submit multiple pemmit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped 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 Deparuneirfs address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Cllenti 54411 MACLEBR01 ACORDn CERTIFICATE OF LIABILITY INSURANCE DAI": DD YYYY) PRODUCER 08117/2005 USI Ins.Services of MA,Inc. ONIS CERTIFICATE IS ISSUED AS A MATTER OF LY AND CONFERS NO RIGHTS UPON THE CERTIFICATEINFORMATION 12 Gill Street Suite 5500 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 4043 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn,MA 01888 INSURERS AFFORDING COVERAGE INSURED NAIC# MacLeod Brothers,Inc. INSURERA: Firemen's Ins.Co. of Washington,D 21784 63 Reservoir Park Drive WSURER B: Acadia Insurance Company 31325 Rockland,MA 02370 INSURERC: INSURER D: W3URER 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. Im LTR US TYPE OF INSURANCE POLICY NUMBER OA REFOli Fli I TON LIMTI9 A cENERALLWBILRY BINDERCPAGO8105713 06/01/05 06/01106 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $SOO OOO CLAIMS MADE OCCUR MED EXP(Any mN Pill $10 000 PERSONAL S AOV INJURY $1 000 000 GENERAL AGGREGATE s2 000 000 GEN'LAGGREGATE LIMB APPLIES PER: PRODUCTS-COMPIOPAGG 32000000 POLICY PRG Loc A AUTOMOBILE LIABILITY BINDER475152 08/01/05 08/01/06 ANY AUTO COMBINED SINGLE LIMB(Ea amill S1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(P S er paITan) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY S (Par Milli PROPERTY DAMAGE S (PoractlEMN GARAGE LIABILITY ANYAUTO AUTO ONLY-EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY: AGG S B EXCESS/UMBRELLALUUIILTIY APPCUA008105912 08/01/OS 08/01106 EACH OCCURRENCE $10 DOD 000 OCCUR CLAIMS MADE .. AGGREGATE- 110 00O 000 . DEDUCTIBLE S X RETENTION to s A WORXERS COMPENSATION AND BINDERABCSIG 08/01/ 5 01/01/06 EUPLOYERV LIABILITY S RR ANY PROPPoETORMARTNERIEXECUTNE EL.EACH ACCIDENT 11 000 000 OFMCEPIMEMBER EXCLUDED? Myn. S P ECIAL PROW CemIW inM EL DISEASE-EA EMPLOYEE $1000000 "INS EelaW OTHER EL.DISEASE-POUCYUMTT $1000000 DESCRIPTION OF OPERATIONS I LOCATIONS/ Operations usual to a builder. VEHICLEb I EXCLUSIONS ADDED BY ENDORSEIAENi/SPECUAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOUITHE E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE ISSUING INSURER WALL ENDEAVOR TO MAIL In DAYS WRITTEN NOTICTIRCATE HOLDER NAMED TOTHELEFT,BUTFAILURETODOSOSHALLIMPOSON OR LIABILITY OF ANY IOND UPON THE INSURER,ITS AGENTS OR NEPINAUTHSENTATIVE ACORD 25 /08 200 1 I )1 Of 2 p8118124/M117602 JAGCD 0 ACORD CORPORATION 1988 A � S91963951 RUMOER DRIVER'S LICENSE DATE OF nRTR CLASS REST HEOHT SEX 09-12-1958 D s19 M ESPIRES 09-12-2007 MACLEOD tr KEITH R JR ' 1 132 ELM ST KINGSTON,MA DsiziFEe 02364-1920 _ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 029828 Birthdate: 09/12/1958 ;;, Expires: 09/12/2007 Tr. no: 5215.0 Restricted: 00 KEITH R MACLEOD JR 63 RESERVOIR PK DR G--ROCKLAND, MA 0237370 Commissioner 012- IJOPHmwPtuseaLUt a�ata�ud p� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration-, 107221 Expiration: 7/30/2006 Type: Private Corporation MACLEOD BROS.INC. Keith MacLeod JR 63 Reservoir Park Drive zz' - Rockland,MA 02370 Administrator = � -- The Commonwealth of Massachusetts Department of Industrial Accidents ' flfflce affnvesUgaff®os 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: MacLeod Bros. , Inc. location: 63 Reservoir Park Drive city Rockland, MA 02370 781-871-1003 Rhone' I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity } 1 am an employer providing workers' compensation for my employees working on this job. Inc companv name. MacLeod Bras address: 63 Reservoir Park:Drive city;.. Roeklaud, MA 023.10 Rhone#: 781-871-1003 Acadia Insurance BINDER61934 1 am a sole proprietor, general contractor,or homeowner(circle one) and have hued the contractors listed below who have the following workers' compensation polices: company name:r. - address: - cir+; ohoneW., insurance co:'-' company:name:�-: address, - -- - - city. _ hone,9 - .A. e hr4 : Failure to secure coverage as required under Sec non 25A m NIGL 152 can lead to the imposition of crianinot penalties of a One up to 5i.500.00 and/or one years'im prison men[as well as civil penalties in the form of a STOP WORKORDER and a fine of 5100.00 a day againYrmc. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i do herebv ce ' under the ins nd penalties of perjury that the information provided above is true and correct. Signature 316 Date Print nam ' Phoney omeial use only do not write in this area to be completed by city or town official city or town: i permit/ficense0 rl Building Department ] [I Licensing Board _ .C]check if immediate response is required C]Scicctmen's Office 1 ❑Health Departmen� contact person: phone': Other_ vrdsd'/9Y P1A1 ' CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. I'ne debris will be disposed of in: -TO 4 I f_ �P,0 (� R P<)S . �'� (+ •(Location of Facility) Pignatur�etf Applicant O Date —�--