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2 LARCH AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 'I4j'1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For'O ral Use Only Building Permit Number: to Applied: Budding Official(Punt Name) SignatuDate ff SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers z Lw�e.✓ goy I.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning 'strict 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 ,P•e l . o .3 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Floo Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zg�'�9 Public Private El Zone: if yes Municipal W1 On site disposal system ❑ SECTION Z: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ee6Enr ,Tijf1//�n �"sr,./s7,/.sr�a�J� oJiBl� Name(Prints' �- City,State,ZIP 200 LF�9Ep/O/s� i/� T08'r,g T_DMA l.� No.and Street °� Telephone mail Address 35� SECTION 3: DESCRIPTION OF PROPOSED WOW.(check all that apply) New Construction W1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work: A, �-ae SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how�fee is determined:;': ❑ Standard City/Town Application Fee 2.Electrical $ /9000 ❑Total Project Costs Ptem 6)x multiplier: x 3.Plumbing $ / 2. Other Fees: $- 4.Mechanical (HVAC) $ 2.9 List: - 5.Mechanical (Fire $ - ` Su ression ✓�A Total All Fees:$ Check No. Check Amount: Cash Amount 6. Total Project Cost: $ fgP7 ❑paid in'Full O Outstanding Balance Due: � ���� a � g3 . �0 SE;C�I( l�'5.:CNSTUCIgSE � 5.1 Construction Supervisor License(CSL) ♦os/bZL z-�/ ��s'os-sA5 Q�o.//ELL License Number Expiration Date Name of CSL Holder List CSL Type(see below) !l No.and Street ,TY,k?e' .: r .' E U Unrestricted(Build in s up to 35,000 cu.ft. �rw/✓f/S �7.G o�Z3 R Restricted 1&2 FamilyDwelling Cityllown,State, ll M Masnnry RC Roofing Covering WS Window and Siding Ee1^�•�q a/�C ai-f.5�3q SF Solid Fuel Burning Appliances l0 7.9.4/-IZZ/ cYa✓e/oa.ne.,t. .2e - I tnsutaton Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Sri ettLC'L HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street / Email address /77.ba/fTW /J�A e �Y9 y�8.7G7-H�7B City/To Tele hone SEC ?N 6:WOt#ICRRS' CQMPENSAION INSItANCE AI EG17 AYIT;( I GL grak5y �) f ' Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan e of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE CONI-L T-f-D,WIIE°N OWNER'S AGENT;OR CONfOA-CT01t:pAPI IDS POR=BT)II 11Y AEA I,as Owner of the subject property,hereby authorize 6'X a ^- 50-0 1"p J P 2 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's on Signa re) Date �i, SECTION 7b: OWNER r OR AUTHORIZED AGENT I)ECLAR TION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date a r NOT%0 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(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at 3nnt.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) T"&oG (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) 9/oo/ Habitable room count 9 Number of fireplaces L Number of bedrooms Number of bathrooms 7 Number ofhalf/baths Type of heating system w/,/D/O LoC.✓lw/✓ Number of decks/porches / Type of cooling system —ice- /_Z7✓ Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ;�. CITY OF S.M.E1NI, .iti''1ASSACHUSETTS BUII.DII NG DEPARTMENT 120 W.1sHINGTON STREET, Yo FLOOR TEL (978) 745-9595 PAX(978) 740-9846 K1SfBERLEY DRISCOLL MAYOR THo"ST.PmRRE DIRECTOR Of PUBLIC PROPERTY/BUILDING CO`LtimioNER 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 11 L5 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: � i/7:/�.��dcYo.✓✓Ee✓i GES (name of hauler) The debris will be disposed of in : (name of facility) (address of faci ity) s�of permit lican� date dcbri.Offdm 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 joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the 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 or 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 line. City or Town Officials - Please be sure that the affidavit is complete and printed legibly. The Department has 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 must submit multiple permittlicense 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Oftfce 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 CITY OF S.U.&M. 2LNSSACHLSETIS BI:ILDLNG DEPARTMENT \ 120 W.ISHINGTON STREET, 3'a FLOOR. TEL (978)745-9595 FAx(978)740-9846 iamBERLEY DRISCOLL MAYOR TH06tAS ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLNIISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibty Name(Busimssi'Organizatiorvindividuxl): ��r.'tw /JE1/�i .�-• L t. Address: i9i Sis.i T../ i✓7e:-/ Jf4iF7-- City/State/Zip:jtlnn4dzMd/ ,� o_ i9�T Phone #: 978- 7�7=9 7B Aree u an employer?Check the appropriate box: Type of project(retpriret0: I.t rJ I am a employer with�_rr 4. [] (am n germs!contractor and 1 6. [r3 New construction employees(full and/or part-time).• have hired the sub-contractors 2.0 1 am a sole proprietor or partner. listed on the attached sheet.: 7• ❑Remodeling ship and have no employees -These sub-contractors have & 0 Demolition working for me in any capacity, workers'comp.insurance. 9. 0 Building addition (No workers'comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or addition myself.(No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' l3.❑Other comp. insurance required.] •Any opplitvhe that checks box s I muss also Fill Out the section Mow showing their worked'comtxttsuioa policy intumtsttoa }}Inmeuwnrn who submit this of 1dovh indicating they am doing all work and then hire outside contmmon must wbmh a am affidavit indicating suck ;Cw nwaa that cheek this bon must attached an additional sheet showing the name of the mb.comta aars sad-their workers'comp,policy inrmrtwuon. I am an employer that ls providing workers'compensadon Insurance for my employees. Below is the poncy and job site information. , Insurance Company Name: L.b u9z4l/e> /.r t Policy#or Self-ins.Lie.#: &/if 2-3i3-97 yAS-a, Expiration Date: 05' oT-zai 3 Job Site Address: City/Slate/Zip: . &. �7t Attack 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 ofcriminal penalties ofa fine up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the Corm of a STOP WORK OR and and a fine of up to S250.00 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 certify under Ilse pains and penaltles of perjary that the lnformadon provided above is true and cornea Siutalore• =z2eL- Dote T iir iL Phone#: 5178. 7rb 7- 19?'7,47 oJflefd use only. no not write in this area,to be completed by city or town off/cial City or Town: Permit/License# _ Issuing Authority(circle one): 1.Board of Health 2.Building Depurtment 3.City/Town Clerk 4. Electrical inspector S. Plumbing Inspector 6.Other Contact Person: _. Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty AR INFORMATION PAGE Mutumm Uberty Mutual Group Issued by LIBERTY MUTUAL FIRfi INSURANCE 16586 175 Berkeley Street Boston,MA=17 Policy Number WC2-31S-373485-012 Issuing Office 181 RENEWAL OF: WCl-31S-373485-011 Issue Date 05-14-12 Account Number 1-373485 Sub Account 0000 1. Insured and Mailing Address FEIN 264123470 ARTISAN DEVELOPMENT LLC 191 SOUTH MAIN ST STE 101 RISK ID 820276 MIDDLETON,MA 01949 Status 46 - LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 0 5-07-2 012 to 0 5-07-2 013 12:01 A.M. standard time at the insured's mailing address. 3. . Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verfication and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration ' of Remuneration Premium See Extension of Information Page Minimum Premium $ (MA) Total Estimated Annual Premium $ Premium will be billed ANNUAL Producer 0004-098265 JUDITH B PINNEY 325 MAIN ST UNIT STE 201 i NORTH READING MA 01864 Sales Representative 3000 r M Sales Office Name WESTON 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 A All Rights Reserved Ed. 07/01/2011 Insum r. n sac RO o® CERTIFICATE OF LIABILITY INSURANCE 6/26/20 12 DATE IMM ) • �� 12 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 certificate holder is an ADDITIONAL 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 CONTACT Judith Pinney Pinney-Linnane Insurance Agency PHONEPat, (978) 664-1250 ac No:(978)664-3651 280 Clain St. #101 E-MAIL ADDRESS: PRODUCER.UJ ID A 00004054 North Reading MA 01864 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A:Liberty Mutual Fire Ins. 16586 INSURER B ESSeX ARTISAN DEVELOPMENT LLC INSURERC: 191 South Main St. Suite 101 INSURER D: NSURER E: Middleton MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1132100609 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR rypE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LTR VO POLICY NUMBER MMIDDIYVYYI UAMIDD/YYYYI LIMITS B GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY 2CM6509 /12/2012 /12/2013 PREMISES Ea occurrence $ 50,000 CLAIMS-MADE aOCCUR MED EXP(Any one person) $ 1,000 PERSONAL B ADV INJURY 8 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) E ALL OWNED AUTOS BODILY INJURY(Per acatlen) E SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per ecrident) $ NON-OWNED AUTOS S 8 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOWARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? O NIA (Mandatory in NH) C131S373485010 /7/2012 /7/2013 EL.DISEASE-EA EMPLOYEd$ 500,000 If Yes,de scribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St. Salem, MA 01970 AUTHORIZED REPRESENTATIVE M Linnane/LINMS1 ACORD 25(2009109) ©1988.2009 ACORD CORPORATION. All rights reserved. INS025(20DBDs) The ACORD name and logo areregistered marks of ACORD J _62 ✓� a Office of Consumer Affairs and vusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement retractor Registration Registration: 168063 __-- Type: LLC Expiration: 1 2/1 012 0 1 2 Tr# 207066 J ARTISAN DEVELOPMENT LLC. �� V THOMAS O'CONNELL — w 191 SOUTH MAIN ST. 101 — MIDDLETON, MA 01949 b 1< N Update Address and return card.Mark reason for change. Address Renewal [] Employment Lost Card DPS-CA1 0 50M-04/04-G101215 - - Office�of coime ena Buo ines's`" aho> License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 166063 Type: Office of Consumer Affairs and Business Regulation s Expiration: 1W 012012 LLC 10 Park Plaza-Suite 5170 -= Boston,MA 02116 VA AN DEVELOPMEN-T THOMAS O'CONNEL`L z.. j-7 191 SOUTH MAIN ON MIDDLET , MA O1kJ4 ,..�. .-/ - � Undersecretary Not valid without signature �I }r of rice onsumer g s&f ess a^on a r HOME IMPROVEMENT CONTRACTOR Registration 468063 TYpe•j ' Expiaton, $'u3Lb12012 LLC THOMAS O'CONF� 191 SOUTH"MA �k z MIDDLETON,MA 01' ,9r [Jndernernemry � N I >>vf r�.a6GuNcl t, lkp' = ,n of Pttf}ta S tiet'.: . Board-of Buildin " Regulations and Stand u'ds Construction Supervisor License x License: CS 104622 x, TtiOMAS O'CONNELL t.' 2 MUSTANG CIRCLE y: DANVERS,VA 01923 Expiration: 2/4/2014 10462271, ' ,� n�ttGuacttc Dc,paa`tni,ent of public Board of Buildttt Re4-dfqfion,44.lnd Stand.ttda 4 Construction Supervisor License ti License: CS 88931 ,RALPH AMEOLA,1 ...; ,11 ATLANTIC AVE -'SAUGUS I 0 1906 :? F -„ry , erg• ;. i Expiration: 10/Sml0 3 1,z1 r-.. t'ununissiuom'.i Tr#: 2120Z AC<>RhPCERTIFICATE OF LIABILITY INSURANCE —DATE�/2012 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 certificate holder Is an ADDITIONAL 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 CONTACT Judith Pinney y Pinney-Linnane Insurance Agency PHONE . (978)664-1250 q/C No:(97 8)664-3 651 260 Main $t. N101 AD RIESS, PRODUCERCUSTOMER ID 00004054 North Reading MA 01864 INSURE S AFFORDING COVERAGE NAIC Is INSURED INSURER A:Libertl Mutual Fire Ins. 16586 INSURERB ESSeX ARTISAN DEVELOPMENT LLC INSURERC: 191 South Main St. Suite 101 INSURER D: INSURER E Middleton MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1132100609 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 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADOLTYPE OF INSURANCE INSR D POLICY NUMBER MM/DDY� MMIDDYIYYYY LIMITS LTR B GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CN6509 /12/2012 /12/2013 DAMAGE T RENTED 50,000 PREMISES Ea occurrence $ CLAIMS-MADE FXI OCCUR MED EXP(Any one erscn) S 1,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- $ E T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Peraccident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICERNEMBER EXCLUDED? NIA (Mandatory in NH) 131S373485010 /7/2012 5/7/2013 E.L.DISEASE-EA EMPLOYE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $00 000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Reardon Residence ACCORDANCE WITH THE POLICY PROVISIONS. Larch Ave Salem, MA 01970 AUTHORIZED REPRESENTATIVE M Linnane/LINMS1 ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD � �kiL) a , D633 CITY OF SALEM ROUTING SLIP - L'ew, onstruction Cerit ice of ccupancy LOCATIONS G,Cl/" 4t�e— DATE �ASSESSORS DATE Z 93 Washington St. CITY CLERK DATE 7 1 Z 93 Washington St. C/ PUBLICSERVICESDATE ►- � ( kyt�flM fti►v✓4yru�te� l 120 W hinaton St. II p��S�tru- (( �y,v ira or rrif Crj WATER DATE 120 Washington St. �4/(rq�✓/w(�0`� rwrc..A� CROSS CONNECT E r`�� tt � •ti.l-Pry 5 JdUmafi v'e 1;95x " PLANNING DATE I �► G �� tr� 120 Washington St. CONSERVATION TE 120 Washington St. ELECTRICAL f DATE 48 Lafayette FIRE PREY TIO DATE 29 Fort Avenue p ' HEALTH (� DATE � 120 Washingt St. i 3 BUILDING INSPECTOR TE 120 Washington St. 8C5 a �