7 LIONS LN - BUILDING INSPECTION Nqs 13q g
fIECEIVED
{� The Commonwealth of Massachuse s
1 Department Public Safety
[v Massachusetts State Budding Code(780CMR) 1015 MAR 33 A 4' 52
Building Permit Application for any Building other than a One-or Two-Family Dwelling
/1 (This.Section For Official Use Only)
U ' Building Permit Number: Date,Applied: BuildngOfficial:
` )SECTLIOJ
N aN1:LOCATION(Please indicate Block k and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK.
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ 1 Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1'Other ❑ Specify: iQe v+s o .0
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No tam
Is an Independent Structural Engineering Peer Review required? Yes ❑ No C;,'
Brief Description of Proposed Work:
L.
n
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY -.
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA - -
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ - H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) _
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ [fill ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal.❑ A trench will not be Licensed Disposal Site❑
.Private❑ or indenti(y Zone: or on site system❑ required❑or trench or specify:permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :N1.,A i tlstmic _onamssum it vjc,v Prnkc_g
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑. Yes❑ No ❑ -
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
p 1 C-K v p u�q
SECTION 9:-PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner`` -
fIek,�
Name(Print) No.and Street City/Town Zip
Property Owner Contact linfbnuation:
7F1- F.25'- 1/7y
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
/ �j
n p?r - ks. ys (/c✓'Mr�c9`6- /`F NULL &Oc/S
Nine Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.—
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2). -
f budding is less than 35,000cu.ft.of enclosed-space and/or not under Construction Control then check here O and skip Section 10.1
1�0.,�1//Registered Professional Responsible�- �foor Co�n`st`ruucttion Control
C7L-1G-S 9 P-7!yt4Y �t.✓i4 44
C!• GSn.�.rZe
Name(Re�gistrant� Telephone No. a-mad address '� Registration Number
.�J« /xs- 0ad S
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
M « �c✓.
Company Name
��j " /'_ W24 [� S— f`1 �—
Nmne of Person Responsible for Con!Talc
License No. and Type if Applicable
treet Address City/Town State Zip
/�r�e e�rt .c _dc, /"<,4, co
Telephone No. business Telephone No. cell a-mail address -
SECTION 11:6VOItKP.RS'CObIPf:NSAI'ION INSUKANCSi AFFIDAVIT' M.G.L.c.152 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the budding permit.
Is a signed Affidavit submitted with this application? - Yes❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE - . .
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S. Mechanical Other $ Enclose check payable to
6.Total Cost $ q Q d (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip Q
Municipal Inspector to fill out this section upon application approval: `
Name Date
p� �ze tponunio�uuealtt/a��aasaclusaelti
.Office or Caosumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration 173510 Type:
xpiration 10110I2016 Individual
l
KEVIN MARLEY ,�
3- KEVIN MARLEY
f
49 VAUTRINOT AVENUE
HULL,MA 02045
Undersecretary
Massachusetts _
Board of 8 Safts Department of Public S
g Regulations afety
Construction and Standards
License: SuPen-jwr
080242
aci
KEVINpMARLS ttt n, '
49 Vk OtAve,� w .
IiuO hIq 02045 i®
1
Cotntnissiorier Expiration�
07/102013�•
rM
' CITY OF SALEM, MASSAC HUSEM
i BUILDING DEPARTMENT
��' ._ 120WASHINGTON STREET,3'�FLOOR
TEL(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR THomAs ST PIERRE
DIRECTOR OF PUBIJUROPERTY/BUIIAING 00MOSsIOMR
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 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
c/
—z-T Date
i
MARLEY a .
e
r
49 Vautrinot Avenue 0 0
Hull, MA 02045
617-935-3469
License#C8-080242 D
THIS AGREEMENT shall be made on the 1 st day of April, 2015 between Kevin Marley, hereinafter called
the Contractor and Laura and John Holian, hereinafter called the Owners.
Article 1 .
1.1 Job Description
Remodeling of single family townhouse.
1.2 Scope of Work
The Contractor shall complete all of the work stated in this contract to be performed on property at 7 Lions
Lane, Salem, MA,
This work pertains to downstairs living space i
1. To remove popcorn ceiling and first floor living space only to smooth plaster finish.
2. To remove existing wall into a half wall.
3. To re-cut existing island granite and remove old wall cut out.
n 4. To install 3 /: crown molding in living room and foyer y on first floor only.
5. To install new 51/2 inch speed base in first floor.
6. To install new engineered wood flooring in kitchen, dining & living room area .
7. To install 3 new high hat lighting in living room.
8. To install new light fixtures in downstairs area as needed.
9. To install new tile or hardwood in bay seat area.
10.To re-install refrigerator and dishwasher after new floor is installed.
Construction on second floor living space.
11. To install new cast iron tub in master bath.
12. To install new vanity and toilet in master bath.
13. To blue board and plaster master bath.
14. To install cement wonder board in all areas in contact with tile.
15. To install new tile in tub area. (walls and ceiling)
16. To install new tile on bath floor
17. To install new trim on inside bath door only.
18. To install new shower stall in common area bath.
19. To install new toilet and vanity in common area bath.
20. To blue board and plaster common area bath.
21. To install cement wonder board in all areas in contact with tile.(common area bath)
22. To install new clear oak hardwood flooring in guest bedroom and hallway (1 coat of
sealer and 2 coats of finish to match existing master bedroom floor)
23. To remove and reinstall all pre-existing doors to fit new flooring.
24. Contractor is responsible for rough plumbing and installation of all new bath fixtures.
(including toilets vanities, sinks, faucets and including material for rough plumbing
materials only)
25.Contractor is responsible for installation of all tile work listed in the above areas.
(Labor only)
26.Contractor is responsible for installation of hardwood listed above. (includes labor and
materials)
27.Contractor is responsible for all plastering. (includes labor and materials)
28.Contractor is responsible for all carpentry. (includes labor and materials)
29.Contractor is responsible for electrician. (labor only)
30.Contractor is responsible for the cost all permitting and inspections.
1.3 General Provisions
1. All work shall be completed in a workmanlike manner and in compliance with all
building codes and other applicable laws.
2. To the extent required by law, all work shall be performed by individuals duly licensed
and authorized by law to perform said work.
3. The Contractor is responsible for keeping sight in broom-clean condition daily.
4. Any unforeseen problems (ie. unknown structural damage, etc) on the property that is
work inhibiting will be addressed with the Owner. Time and material for unforeseen
problems will be negotiated with the Owner.
5. The Contractor is responsible for all material and labor for all work listed above.
6. Some construction will be determined after the demolition process.
1.4 Responsibilities of The Owner
0 i oiwdim 2
1. The Owner is responsible for the purchasing of all lighting fixtures.
2. The Owner is responsible for the purchasing of all plumbing fixtures. (such as glass
shower doors, tub, vanities, counter tops, faucets, sinks, medicine cabinets and toilets)
3. The Owner is responsible for all demolition except where mentioned.
4. The Owner is responsible for painting.
5. The Owner is responsible for the cost of all debris removal.
6. The Owner and the Contractor will jointly work with the Subcontractors.
Article 2.
2.1 Time of Completion
The work to be performed under this contract shall be commenced on the week of April 6, 2015 (providing
all permits are in order), and should be substantially completed in a timely manner on or about the week
of May 16, 2015.
Article 3.
3.1 Contract Price
The Owner shall pay the Contractor for the material and labor to be performed under the Contract to the
sum of forty four thousand eight hundred dollars ($44,800.00) subject to additions and deductions
pursuant to authorized change orders.
3.2 Progress payments
Deposit: to be paid on the signing of contract $13,000.00
Second payment: On completion of rough plumbing, rough frame and plaster. 13 000.00
Third Payment: On completion of hardwood floors and tile work. $13.000.00
Final Payment: On total completion of job. 5 800.00
Total: 44 800.00
Disclaimer.Any deviations from contred shall be addressed with the contractor and the Owner(s)and shall be charged accordingly within reason.
e o- ooapalbm 3
Marcia Kirkpatrick
From: Thomas St. Pierre
Sent: Tuesday, April 07, 2015 1:39 PM
To: Marcia Kirkpatrick
Subject: FW: Unit#2104, 7 Lions Lane, Salem MA
fyi
___._ .__..____ _____—._ .____._..m__._.......... ......_.__.._....... _
From: Cyndy Anselmo [mailto:cvndy@ecpllc.net]
Sent: Thursday, April 02, 2015 10:24 AM
To: Thomas St. Pierre
Subject: Unit #2104, 7 Lions Lane, Salem MA
Hi Tom
Please be advised that John and Laura Holian,the new owners of 7 Lions Lane, Salem, have retained Kevin Holian
Contracting of Hull, Mass. to replace three bathrooms in the condominium and install hardwood flooring. I will be
receiving a certificate of insurance naming the Highland Condominium at Salem Trust as a certificate holder prior to
work commences on the unit.
Please let me know if you will need anything further.
Thank you.
Cyndy Anselmo
East Coast Properties,LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem, MA 01970
P: 978-741-2003
F: 978-745-9684
cyndy�'ecpllc.net
1
Signed this 1st day of April, 2015
Signed in the presence of:
Name of Owner(s
Name of Contractor
•• 4
The Commonwealth of Massachusetts
p Department oflndustrialAccidents
_+ 1 Congress Street, Suite 100
Boston,MA 02114-2017
- l( www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Or ganization/Individual): - (nq On-r..,`L.e
Address: Cl S (I U/G �k W-r- Juy�_
City/State/Zip: kXe t L Phone#: l 7'-9 S 5 - Y,6
Are yo 1.u an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* '7. ❑New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.] _
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition ,
- 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
intent that all contractors either have workers'compensation insurance or are sale 1 i.❑Electrical repairs or additions
-proprietors with no employees.
- 12.❑Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees.and have workers'comp.insurance3
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14:❑Other
152,§1(4),and we have no employees.[No workers'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 anew affidavit indicating such.
tContractors 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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 the pains and penalties ofperjury that the information provided above is true and correct.
Signature 21'�� Date
e t
Phone#:- -/ 7 �e G g !!
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
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#:
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 ajoint 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 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-contractor(s)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 permit/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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
04/02/2015 09:22 6173293877 BOYDTURNER PAGE 01/03
CL 2651485
-- Renews Mount Vernon Fire Insurance Company
6SI h`—
POLICY DECLARATIONS 1190 Devon Park Drive, Wayne, Pennsylvania 19087 Direct Bill Policy
No. CL 2651465A, A Member Company of United States Liability Insurance Group
NAMED INSURED AND ADDRESS:
KEVIN MARLEY
DBA: MARLEY DEVELOPERS
49 VAUTRINOT AVENUE
HULL, MA 02046-1119
POLICY PERIOD:(Mo. DAY YR.) From: 11/13/2014 To: 11/13/2015
12:01 A.M.STANDARD TIME AT YOUR
FORM OF BUSINESS: Individual MAILING ADDRESS SHOWN ABOVE
BUSINESS DESCRIPTION: Contractor
THIS POLICY CONSISTS OF Tt1E FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
Commercial Liability Coverage Part PREMIUM
$1,462.00
TOTAL: $1,462.00
kCoverage (s)and Endorsement(s)made a part of this policy at lime of issue
See Endorsement EOD (1195)
Agent: BOYD&TURNER,LLC.(4040)
207 Hagman Road Issued: 1 0/091201 4 8:61 AM
Winthrop,MA 02152
By; Authorised Represe ati e
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE PART DECLARATIONS,UPD 08-07 COVERAGE PART COVERAGE FORMS)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,
( ) COMPLETE THE ABOVE NUMBERED POLICY.
04/02/2015 09:22 6173293877 BOYDTURNER PAGE 02/03
EXTENSION OF DECLARATIONS
Policy No. CL 2651465A
Effective Date: 11/13/2014
FORMS AND ENDORSEMENTS 12:01 AM STANDARD TIME
The following forms apply to the Commercial Liability coverage part
Endt# Revised Description of Endorsements
CG0001 12/07 Commercial General Liability Coverage Form
CGO068 05/09 Recording And Distribution Of Material Or Information In Violation Of
Law Exclusion
CG0203 03/08 Massachusetts Changes-Cancellation And Nonrenewal
CG2136 03/05 Exclusion-New Entities
CG2139 10193 Contractual Liability Limitation
OG2147 12107 Employment-Related Practices Exclusion
CG2173 01/08 Exclusion Of Certified Acts Of Terrorism
CG2294 10/01 Excl-Damage To Work Performed By Subcontractors On Your Behalf
IL0017 11/98 Common Policy Conditions
IL0021 09108 Nuclear Energy Liability Exclusion Endorsement
L-224 10/10 Punitive Or Exemplary Damages Exclusion
L-232s 09/05 Classification Limitation Endorsement
L-278 11/07 Independent Contractors/Subcontractors Exclusion
L-418 12/05 Absolute Earth Movement Exclusion
L-419 08105 Pre-Existing Or Progressive Damage Exclusion
L-500 02/11 Bodily Injury Exclusion-All Employees,Volunteer Workers, Temporary
Workers, Casual Laborers, Contractors, And Subcontractors
L-640 11/09 Exclusion-Exterior Work Over 50 Feet
L-549 12107 Absolute Professional Liability Exclusion
L-571 02/11 Exclusion-Exterior Finish Systems
L-599 10/12 Absolute Exclusion for Pollution, Organic Pathogen,Silica,Asbestos and
Lead with a Hostile Fire Exception
L-610 11/04 Expanded Definition Of Bodily Injury
L-618B 01/09 Amendment Of Premium Audit Conditions
L-687 05f06 Auto And Mobile Equipment Redefined
L-691 02/11 Limited Exclusion-Work Begun Or Completed
L-695 04/07 Exclusion-Operations Covered By A Consolidated
Program (Wrap-Up)Insurance
L-783 10/12 Amendment of Liquor Liability Exclusion
LLQ100 07/06 Amendatory Endorsement
LLQ368 08/10 Separation Of Insureds Clarification Endorsement
NTE 01108 Notice Of Terrorism Exclusion
NTP MA 01/10 Massachusetts Notice To Policyholders
Jacket 09/10 Commercial Insurance Policy Jacket
Pll other terms and cpndifions remain unchanged.
page 1 of 1
EOD(01/95)
04/02/2015 09:22 6173293877 BOYDTURNER PAGE 03/03
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
Policy No. CL,2651465A
Effective Date: 11/13/2014
12:01 AM STANDARD TIME
R LEach Occurrence AEI IN11 +iu H irr, l.di.`a:iiii:, ,ii t iirt J u '4;4(11,Iwt1.i'1, h F. a1
J
Limit .i111 It„i';`''� I'!is.l1',�.t,pol�m' ii'pl;,t..i..in^ i�r,l', '•I'id' �'P 'i1' at, '�';
Personal&Advertising Injury Limit(Any One Person/Organization) $1,000,000
Medical Expense Limit(Any One Person) $1,000,000
Damages To Premises Rented To You(Any One Premises) $5,000
Products/Completed Operations Aggregate Limit $100,000
General Aggregate Limit $2,000,000
uj 'A811�1�Yp 4YUfi'TI,B[t '{ rf.v,;'Irr„r It i ,• ., 2,000,000
CJ $ PAd i, �`BtWgWl'l3VG', REN1;10'RPfgF;,rrf3PY^Iv,r re
kilvl,. .a
Location dress
1 49 Vautrinot Avenue, Hull, MA 02045 Territory
017
ii;P ''EM( "t�OMP;'?F�1';,CGY ti^�i�iiii:�i'iii itci iiriay„„ 11j1 liw�!'�rrr�°;ut(�h111t`t?Ik4 in ��
I
Loc C/assificat/on Rate Advance Premium
Code No. Premium Basis Pr/Co All Other Prloo
All Oiher
1 Carpontry.Interior 91341 14,300 Per 1,000 10.552
Peyroll 37.966 $151 $543
i Carpentry 91342 14,300 Per 1,000 16.903 36,751 $242
Payroll $526
MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART:
$650
TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART:
(This Premium may be subject tO adjustment.) MP-minimum premium $1,462
Coverage Form(s)/Part(s)and Endorsements)made a part of this policy at time of issue:
See Farm EOD(01/95)
a
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERI00.
Includes copyrighted material of ISO Commercial Risk Services,Inc.,wfth Its permission.
CL150(10103) Copyright,ISO Commercial Risk Services,Inc.,1983.1984.1988 Page 1 Of 1