12 LIGHTNING LN - BUILDING INSPECTION T Nam'•/�A-h?�—� n)
` The Commonwealth ofMassachusetts
' y Board of Building Regulations and Standards RECEIVED FOR
�j Massachusetts State BuildingCode;,780 ONECT1011AL SE F ` C&,=
USE
Building Permit Application To Construct,Repair,Renovate Or �p Wh� t�e�.�dMar2011
One-or Two Family Dwelling' �Ri L
This Section For Official Use Only
Building PekmitNumber. Date Applied:
Budding Of (Print Name) Sigoahne
Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Panel Numbers
1.lals this an Accepted strdoyes no Map Number ParoclNumiber
13 Zoning Information: 1.4 Property Dimensions:
ZouiagDisuict Proposed Use 1ot—&ea(sg8) Frontap0*
1.5 Building Setbacks(tl)
Front Yard Side Yards -
Rear Yard
Required - -Provided Requ'ued . Provided Required Provided
1.6 Water Supply:(MG.L e.4Q§54) 1.7 Igood Zoos Inforlmatlop: 1:8 Sewage Disposal System.
Public O Private 0 ions Outside Flood Zone?Cheokifyesrl "cipal 0 Onsitedispaw System 13SECTION2: PROPERTYOWNERSE"a
21 Ownert of Record: vt,
�idYnOS Snfner � �o �t�/✓1 � ,;
Name(Priot) uly,Stat%ZIP
No.and ShW Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupisd 13 1 Repairs(s) ❑ ration(s) ❑ 1 Addition O
Demolition • _. 0 'Accessory Bldg.O 1 NumberofUnits _ Other Specify
BriefDescription ofProposed Work:
�3�lfbn«+�—Sc c 11
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated frosts:
abor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:3 Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing' $ 2. OtherFees: $
4.Mechanical (HVAC) $ List:_
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount: Cash Amount
��� ❑Paid in Full 13 Outstanding Balance Due
16a-tL� Tb �ROt�rJir.15L112trp
t�
i
1 , C cep �, ! 7/5
A
SECTION 5s CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL), 1 7 ry 3
Lice=Number Expiration Date
Name ofMHolder LCM Type"(see below)
�e
Eric W.Palm
Na and Street - ' -. .. � :T3'Pe Description
3 Hilton Street u Uarestricted0huldinpupio
Salem M9A 61990( x Restricted 1&2Famil Dwelling
(Sty/fown,State,Z@ M MaSonry
RC Rodin Covedo
WS Window and Siding
SF
Sold Fue
odFue Burning Appliances
Tel come .. .Bmm7addmss' D Demolition _.
5.2 Registered Home Improvement Contractor(HIC) ' l a 0 3
Atlantic w'CitlllECltall�i:,L..,.. ,BICRegistrahon umber ExpbationDate
MccompanyNameorHi Venue
No.and Street Finailaddmss
Cityfrown.Stat0P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFMAVIT(M.G&e.In§25C(6))
Workers Compensation Insurance affidavit mustbe completed and submitted with this application. Failmetoprovide
this affidavit win result in the denial-ofthelssuance ebuildingpeimit
Signed AffrdwitAtleched? Yes.... ....:13,-
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR MM DING PERMIT
f�
1 I as Omer ofthesubj proPY.hereby mttho`rize
to act on my behalf,in all matters relativetoworkauthorized by this building permit applitFti(n.
Printowmes amepechnnicsigoalure) Dtte,
SECTION 7bs OWNW OR AUTHOMED AGENT DECLARATION
By entering my name below.I hereby attest under the pains and penalties ofpedury that all ofthe information
contained in " applica' is accurate to the best ofmy Imowledge and understanding. ,
i _
Print Owner's orAnthorirrd Agent s Name(Rlearonic SigoaNre) Date
NOTES:
1. An Owner who obtains abuilding permit to do his/her own work,or an ownerwho,bites an unregistered contrador
(not registered in the Home Improvement Contractor(HIC)Prog(am),will not have access to time atbitrafion
program or guaranty fund under M.G.L.r.1'42A.Other important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found atwww.massZo—v/dos
2. When substantial work is planned;provide the information below:
Total floor area(sq.&.) i (including garage,finished basementfattirs,decks or porch).
Gross living area(sq.ft) Habitable room count
Number of fireplaces Number of bedrooms
-Number-of bathrooms Number-of-half7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Opea _
P. wrotal Project Square Footage"maybe substituted for`rotal Project Cosr,
lriassac,9ausetts Home I�1
.Ilria form roveanetlt y
Inoguoge t�(sBIUI basicc�eats offfi"wes Home Improvement ContraaarLaw Sajl] Ye OIItraCt
P teUhom
Massa<hnserm CansmtierGuide toA eels @gal advim IFneees m. Ao _ (b'IGL rhapter 142A Office of Affairs and BtrsinessaRmle�mt"beforeagteeio Ylon nyrkoo gIt bnpmvememssh'oDutdo�o�chudesmndnrd
Constma
llomeoNner Info Cmnonerinf'ormatiw Hotlinear6170�denne.YOU mayo"aGee Copy of"A
17r19tion 97 or I.ggg_'91-3737 le �h)2tglhe
�a"`� Contractorinfolnnati nn°D ° h9te
Jon
U� Campem-�mne
Sheet Addr¢s(do nor urea CDd Lr
Putt O(htt8oxzddtrs)
Li �• Lanlmeod Salespetrmtt Dtmer Rmne ! -' a L7(A 4'Roun -
.I'q SUM zip Cade (9
-r✓!f7 BuriaessAddess(mutt itrclvdeastmenddma)
Daltime Phony - - 1 �—
�✓ Enmmg Phnne
7�+[� CiyRmm
SWiling Addresn It( ifI Star`
d Zip Code`r'°+fmmt above)
BmioessphMe
p`dP� loYWlDvrS.S.V
uv„smmummtmar. ��'"'®O°ervmmra¢x®ee mnher
'oPmsmo,tmvmw�em �'amnaze
TheContromoragrearoUo thetNlowingst'arh(arWeHameowner.
(Drunhe in derail theawrkm cot°Plced. 3 /
spttifying therypo.hmnd,and Bade of ma �O ta�tials�to be�m�ML+Id�d/lfimml
Required Permhs_'[hefa)lotyngbNldiog
andtvillbesecmedb)'the wntra Peonits meregW�
(On'rtersw cmras thehomwwnet's Pr1pPased Smr1Dnd Completion SrhIM lye
hosecuretheirown agate beadlt roanless ' foOolvingsWled„letsgl.
escludedfromthe Pernrltswl a q mrwmsaaresbeyondtheaen Guaranty Fund proVISIOnsof z / oaaotswntrpladse
4iGL chapter 142A.)
Date"hen wntiaaormll begin wnhacted nod:
Total ContractPrice Dad sePrfaoyrmmntghedul �Date`,hwcontmctdwoU;mllTyeCouClora 6emhsmntiNl w mpleted.oP
the wad;,Famish UtemaredN and labor ^�
Payments hill be made accotding to the sPadfied aboveforthe roml sum of- /�
FollosvingsehedWe:
upon Signing
connect(not to etceed 113 S ofUm rotal mnta
i te_by / / epnce or the mR ofspmdal otderilem
��r{�/"t/� ` p Or on cmnPletim of verisgtema.) _
S by f? / /�� of upon r
wmplaivn of O4CL
W uPon wmpleHm ofthe contratt. (Lmv forbids demao C 'O�
Thefollmting materiavequipmrnrmun 6eyPecial �g l tape]rgnaamis wID
tomeen thethewntmet und:be-ns in ortler S ep¢y for Completed to both pady'a atisfazlion)
plelm schedule(°°)
NOTLS, S mbe
'(')Ineuding all finance change; Paid for
nOtestted lhegrate (°r)Iswrequiresdpt aev
uht4i mute hespeciyo(a)onclhttdarmetocU it mdonn-paymem taquirM bY. co+manor
rderad in ad GeCOMprittm(6)theacmy wst aFa�ry sper;y befomnnrk bmim ma)•
sDoceromee am can letim aWTmentm
- P schedtk whom mademaledal
s ress lVtr rvgs ane
Suhcontramors-7ya wn Kn n b'n by the rnn ar°
Parry4subconuaaorufil' nav°ragreestobesolely ��0� 'g avtcrms nhe
nt al rzed by the wntramor. The e0�p0G ble Fm completion oFthe work deswyed wa nry mu beattac t t n e
nbor rider th' fmtheragrees to besolU regarNeu oFtheacdous ofan•
Contrect ACMphmm-U t Yrespanar7de for all Jthird
contract shall not im I Pon signing this dowmtmt bewmes a bindm �yOL°ts to eg snbeoobacrors for
cmeFull)'before si lny dear anylien mathersewrityint ew°rise under lmv UN
gn g this connect ere;t has been placed an the 43D1henvise noted within this document•the
+estdmw. Revimv the PoOossing cmrdons mdnotices
° Don't bepmssstrad into simin
° Make sure the glhewntract Take time .
o!co ttv roread and full d--audit
_asa valid Ho me hnD vemem Contra rRem 9uesdo°s ifsomelhing is tmclear.
rgnstered mth
rePstrdbon bJ mtrn m �eDreaorofHame Lv on. The law tequira most homei eocs Ulewn g th`D1CatmmlOPruk Provemwt ConttamorReginmUon. You wMiwt on"Mamors and
haaorhavekgttaacea Asl•tbeC Plaza,Room 5170,Boston,MA 07116 or uaymgnlreabotawntraanr
sceacopy ofa'broofofiosmaoce' onbnctorkrhisinsmanca bYCalling 617-973-8787 ar 8gg.3° Koon•yourrildIsaod docnmrnt cem Ym idomtation so g3-3757. .
Cuide to the Name lm�onsibilipa. Read the lmpottaot Info y°p am coafirmwvemge,oraskto
Provement ContraamLaty. rmation oo thereverse ddeofthis form and You may cancel ihisa gay wpy of the Canmlmer
wnmaaorin n,idn F"men[ifithasbeensynted IDuplaceodierthanthe
U1odbusincsd gat his/her main office er branch office b• woeactotsnetmN
DOnNOTSlPongofthisagreerawt. see hematac m'1 oh9bytelegtems el.bydeli ryZMnMv"i,ddI
otifythe
n,awmar,,rnr�C*N THIS CONTRACTIFT oFwecellation form foran 1addoightofthetI d. F'RAREA FY `� dgk
\ msno°mwromnlmma„aQ_rbea NKSPACES!!!
Homwn
t I`Date ConbaaoeD Simanaa Cam'
lJ ,J.
Contractor Arbitration t
The Home Improvement Contractor La+v provides homecowenc with the right to initiate an automatically
action tic;to
alternative to court action).if they have a disputri with a contractor. the same right is not automatically afforded le a
contractor.however. The contractor would have to resolve any dispute he/she has tile
C a homeowner in court unless
both parties agree to the optional clause provided below. fits clause would give the contractor the same right to
ent Contractor La+v.
arbitration as is afforded to the homeowner by the Home Improvem
econtrac
or
ispute
The contractor and the¢,o t
reb anbmh c ute to a can ate arbitration firm w Itich6 hasd napproved by
WncerNh4n aUon and the consumershall be required
� �cgeu¢�GO�ceofConsumerABairsandBusinessRegrd (��j i;
to snb�emisu�ch�arbitration as provided.)n Massachusetts General Laws,chap�l4 � I ��1`1k
Homernvness Signatuure
Contiactor's Signature
NOTICE:The signatures of the part es above apply only[o the agreement of the parties to al[emative d sputa
this
resolution initiated by the contractor. The homco+vnerrnay initiate alternattve dispute resolutioneven where
section is not separately signed by the parties' '
Homeowner's Rightsand
A homen++'ners rights under the Home Improvement Contractor Law(MGL chapter 14 ofHowever. ommo+mars
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreem as prescribed by law.
may be excluded from certain rights if the contractor they choose is not properly registered
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++rork as described n a
timely and worlsnanHtre manner. Homeowners may be entitled to other specific legal tights if the contractor
,uaranrees or provides an express wartanty forworkrauship or materials. in addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied+vattaztty of merehantabifih•and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor rightslawfia-
agree maybe
added to the terms of the contract as tong as they do not restrict a homeo++mer's basic consumer rights. ffyou 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 documenofthe contra until
a ct oattachments is to
filled in or marked as void,deleted:or not applicable. One original signed copy
be given to the Owner and the other kept by the contractor. Anunmodificationhparrties h coriginal ed a�,y��uted writing
and agreed to by both parties.Contracted work may not begin
the contract and the three day rescission period has expired.
Accelerated Payments
of the dates specified on the payment schedule in cases where the
A contractor may not demand payments in advance
cure. However,in instances where a contractor deems him/herself
homeowner deems himtherself to be financially inse
financially insecure,the con
[0 6e tractor may require that the balance of fords not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said accountwould require the
signatures of both patties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or ifyou+vish to obtain a free copy of .A Massachusetts Consumer Guide to Home Improvement' '
i.
contact j
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170.Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR eebsite at Iau:ih+.+
if you want to verify the registration of a contractor or if you 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:Room 5170,Boston.MA 02116
::Zc:n'ra eoc,'ozabr
617-973-878
_ visittheHlC+vebsiteathun�':u s
7., .888-28337>7 or
Go online to view the status of a Home Improvement Contractor's Registration: . .
har:.I de..imie.ma nsdmmzimnrncimtm%liccn>r.^list.2sn
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
617427-8400
AND/OR
Better Business Bureau
508.6524800,508-755-2548 or413-734-3114 vemton,t_ii s�to
The Commonwealth ofMassachuselts
De
partment of Industrial Accidents [IEEE:
a �>
Office oflnvestigadons
Congress
ess Street,Suite 100
Boston, M14 02114-20-77
Workers' Compensation r
Alzllknun&rmation Insurance Affidavit: Buildes/Contractors/Electricia ns/Plumbers
Name(Business/Organization/Individual): Cdt11Ct1Lapur,, Tease Print L 'bl
1�tlilptlC W
Address: °
Ssliem MA 01970
City/State/ZiFUm
:
n employer?Check the a p Phone#: 97 7('y_�I y
a employer with 'J Ppr° hate box,:
loyees(full and/oi-`—� 4' El I am a general contractor and I TYPO of project(required):
a sole proprietor orpartne1 have
oln the attached b d the tors
6. ❑New construction
and have no employeesing forme in an rhese sub-contractors have7. Remodeling
y capacity, employees and have workers' 8' Demolition
orkers'comp, insurancered.] comp, insurance.* 9. ❑Building addition
5• [� We are a corporation and its 10.[]Electrical r homeowner doing all workofficlf. ers have exercised theirepairs oradditions
nce required]t comp. right of exemption per MGL 1 I.[�Plumbing repairs Pis or additions
c. 152, §1(4),and we have no 12.[�Ro epairs
employees. [No workers' 13.
Other
`Any applicant that checks box#I must also fill out the comp
insurance required.]
t all
Homeowners who submit this affidavit indicating Sechon hdow showing their workers'coin
tContractors that check this box must attached an ddi onal y are sh et he work
win the name
then hire outside contractors ation
pen must subm information.ew atiidavit indicating such.
employees. If the subcontractors have employees,they must- 22provide the workers come sub-contractors
I inn an erupjayer drat is providing workers compensation rnsrtrance Or rcontractors and state whether or not those entities have
p policy number.
in
farmatron
f ) erployees. Below is the pohcy and job site
Insurance Company Name:
r
Policy#or Self-ins.Lic.#:
7Ial �
Job Site Address: Expiration Date: 3 Za /
Attach a copy of the workers'compensation Policy. City/State/Zip:
Failure to secure coverage as required p Y declaration page(showing fine up to secure o and/or one 4 under Section 25A of MGL c. 152 can lead to the imp number and expiration date).
Of up to s250.00 a da year imprisonment,as well as civil penalties in imposition of criminal penalties of a
Y against the violator. Be advised that a co P the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. pY of this statement may be forwarded to the O
f
I do hereb cent ut t[ae Office of y der aiels,and�ientr[tieso
(perjury that the Ullormation provided above is true and
Signature: lI
, n
correct.
Phone#: C/ 7 7W1_ k/17 Date
Official use only. Do not write in this area,to be completed by city or tows:official.
City or Town:
Issuing Authori Permit/License#
ty(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical
. her Inspector 5.Plumbing Inspector
O
Contact Person:
Phone#:
ACORID®
CERTIFICATE OF LIABILITY INSURANCE DATE(NMIDD,YYYY,
THIS CERTIFICATE IS ISSUED AS q MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
is
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AlEND, 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. N SUBROGATION IS WAIVED,subject to
the terns and conditlons 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 policy certain
).
PRODUCER
C 1. COIIatrilCtlOA
Eastern Insurance Group LLC PHONE
233 West Central St . (SDO)333-7234 FAX
E MAIL o
Natick MA 01760 INSG AFFORDING COVERAGE NAIC6
INSURED INSURER A Arbella Protection Ins. Co. 1360
Atlantic Weatherization INsuREReNautilus Insurance Co
61 Rear Jefferson Avenue . INSURER C:
INSURER D:
Salem MA 01970 INSURER E:
COVERAGES CERTIPICATENUMBER3q+STBR 2015sURERF:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMIOD ABOVE FOR THE POLICY PERIOD
N NUMBER:
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WfIH 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
L TYPE OF INSURANCE -
PODCYN MBER MPoM/U0�EFf POLICY EXP GENERAL LIABILITY MMIDD UMW
X COMMERCIAL GENERAL LIABILITY EACH OCWRRENCE $ 1,000,000
A CLNMS4dADE ®OCCUR 50004261E /20/2015 /20/2016 PREMLSES ommsrKe $ 50,000
MED EXP Any one Person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENII AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
POLICY X PRO- LOC PRODUCTS-COMPIOP AGG $ 2,000,000
AUTOMOBILE UABIUTY $
ANY AUTO OM IN SING L UMIT
A Ea accident 1 000 000 AAUUTOOISNNED X SCHEDULED 020015871 SODILYINJURY(Perpemun) $
X NONOOWNED /20/2015 /20/2016 BODILY INJURY(Per accident) $
HIRED AUTOS X AUTOS
PROPERTY DAMAGE S
X UMBRELLA UAB X OCCUR PIP-Basic $
A EXCESS UAB CLAIMS-JIADE EACH OCCURRENCE
S 1,000,000
DED RETENTION$ 600058654 AGGREGATE $ 11000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'UASIUTY S
ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC STATl4 OTN-
OFFICER/MEMBERD(CLUDI ❑ NIA
(Mandatory In NH) E.L.EACH ACCIDENT $
If 9es,tlesrnba under
DESCRIPTION OF OPERATIONS below E.L.DISEASE.EA EMPLOYE $
B POLLUTION LIABILITY ELDISEASE-POucY LIMrT $
7.200378613 O/1/2014 0/1/2015 GENERAL AGGREGATE
$1,000,000
EA POLLUOON CONDITION $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLE(AttachACORD tOt,Additional Remarks SM e,ifedal more space is required) .
:ERTINCA I F HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE ACCORDANCE WITH THE THEREOF, NOTICE WILL BE DELIVERED IN
93 WASHINGTON STREET POLICY PROVISIONS.
SALEM, MA 01970 AUTHORIMD REPRESENTATIVE
CORD 26(2010R)b) John Xoegel/PMA —ter
IS0261omn0ro m ®1988-2010 ACORD CORPORATION. All rights reserved.
The Af%nPn Imam.anel Innn>ro ron:c4nrori rn—k¢of At%npn
-' '�• �•�a- ran 001 vct
CERTIFICATE OF LIABILITY INSURANCE DATE T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDERTHIS FYI
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),AUTHOgI2ED REPRESENTATIVE
UCE E C OL
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the Pollcy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and hood I nli of the Policy,hvtain Policies may require end entlasemem. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemen s.
PRODUCER
CONTACT
EASTERN INS GROUP ILC NAME:
233 W CENTRAL STREET PHONE FAX
(AG,No,EIq: (A/C,No): -
NATICK,MA 01760 E-MAIL
22MLW ADDRESS:
INSURED
INSURERS)AFFORDING COVERAGE NAICe
ATLANTIC WEATHERIZATION[LC INSURER A: AMBRICAN 2URiCH RiNANCECOMPANY
INSURER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
FYT AT THE PpLICESOFNBUflANCE LISTED REVISION NUMBER:
ANYflEOU1REMENT,TERN OR CDNDITXlN OF REVISION
OR 07ER DOCUMENT WITH REDINIC SSUWTO THE TO WHICH TTing hERTFICATEMAYBEeECY OR MAY PEATA NOTWAIT KTHE NSURANIN
PAK)CL AIMS. THE POLICIES DESCRIBED HEREIN 6 SUBJECT TOALL THE TEAMS,EXCLUSIONS AN TTON HITITIONS OF SUCH PCATE 4 BE LIMITS SHOWN MAY HAVE6 U� NG
PAp CLAIMS.
NSfl
LTR TYPE OF INSURANCE ADD SUB POLICY EFF DATE POLCY EXP DATE
L R POLICYNUMBER n1RDDIYYYY) IMEADDIYYYY) -
GENERAL LIABILITY LDArtS
COMMERCIAL GENERAL LIABILITY - ACH OCCURRENCE $
CLAIMS MADE OCCUR, AMAGE TO RENTED
REMISES(Ee occurrence) $
ED EXP(Any one person) $
GENL AGGREGATE LIMIT APPLIES PER: ERSONAL A ADV DJJURY $
POLICY PROJECT❑LOC ENERAL AGGREGATE $
AUTOMOBILE LIABILITY RODUCTS-COMP/OPAGG $
ANY AUTO COMBINED SINGLE
ALL OWNED AUTOS LIMIT(Ea acciden) $
SCHEDULEAUTOS BODILY INJURY $
HIRED AUTOS MaI parson)
NON-OWNED AUTOS BODILY INJURY $
(Per accident)
PROPERTYDAMAGE $
(Per accideN)
UMBRELLA LIAR OCCUR
EXCESS LIAR CLAIMS44ADE EACH OCCURRENCE $
DEDUCTIBLE AGGREGATE $
RETENTION $ $
A WORKERS COMPENSATION AND $
EMPLOYERS LIABILITY YM U868270121-15
we siATUfoNY OTHER ANY PROPERITORIPARTNERIEXECUTIVE 0312OT2015 031ffi1201g X
OFFICEWMEMBER EXCLUDED? EI WA LIMfTS
(MandatoryhNN) E.LEACH ACCIDIM $ 500,000 II yes,desnlbe eme
DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE $ 500.000
DESCRIPTION OF OPERATIONSILOCATIONSryEHICLESlRESTRICRONSISPECIAL ITEMS E.L.DISEASE-POLICY LIMIT $ 500,000
THIS REPLACES ANY PRIOR CBRTTFTCATE ISSUED TO THB CRR TRCATE HOLDER AFFECTING WORKERS COMP COVERAGB.
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION .
93 WASHINGTON ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
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BEFORE THE EXPIRATION DATE THEREOF,NO710E WILL 8E DELIVERED
IN ACC O 11 ANCE WITH THE POLICY PROVISIONS. _
SALEM,MA 01970 AUTHORI2ED
ACORD 25(2A70/05) The ACORD name and 1090 are registered marks of 4CORD 1BBB-20tD gCORpCOpppggTlON q11 lights reserved.
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1 Massachusetts-Department o`Public Safety
Board of Building Regulations and Standards
Construction Supervisor ?
License: CS-087977 yt
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31MION ST
Salem MA 01970-
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ATLANTIC WEATtiERIZATION LLC.
ERIC PALM -
SIRJEFFERSON AVE
SALEM.MA 01970 Undersecretary