13 MALL ST - BUILDING INSPECTION (2) • r
1p / Fhe Common vvealth of Massachusetts -- — — ---
U I` Board of Huilding Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.1 for_1111
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dvelling
This Section For Official Use Onl
Building Permit Number: Date Ap^d: _dam/
Building Official(Print Name) —W" i m Lure D' ate
SECTION 1:SITE INFORNIN4N
I �ropgr�„ddresJs+ ( A� M 1,2 Assessors Map& Parcel Numbers
Apt
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of$ecord:,
1S\aTr rO2m CA SL�k._rrl Pn>< - O,`11p
Name(Print) City,State,ZIP }
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied [3Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriptio Proposed Work':
il
G/ C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
licm Estimated Costs:
(Labor and %laterials) Official Use Only
I. Building $ (960 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 70,00 2. Other Fees: $ AMU
4-Mechanical t1IVAC) S IL{ (�qo List:
5, ;\lachamiccml I Fire $ --
Su mssion) Total All Fees: $
6 Check No. Check Amount: Cash
G. Total Project Cosh. S fq ❑ Paid in Full ❑Outstanding Balance Due:
°Ca �,� dj (��n ,-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction
tru�Lct iono{SCup'fer(v�isor5 License(CS—L) ---- ` � �_
I.icensc Ilp` i
Number Expiration Date
Nan,c of CSI. I lulder
cC ��+� � List CSL'I)-pa(.we below)
_\ i C
No. and Street _ -- Type Description
l'J �. O O LI IlnrestricleJ Buildings ti to 35,000 cu. 11.)
-- R Restricted l&2 Family Dwelling
City fotw, State.ZIP M Masonr
RC Rooling Covering
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
I'cic hone Email address D Demolition
5.2 Registered Home(IImpro ment Contractor(HIC) is I D s 1 r" f
Secksj 191 0, \7\A'\ Gn-� T�L ` I IIC Registration Number Expiration Date
1-11 o nl Nai a or I IICIA-4(CVgeios.t r1utn�to N�ame
-- - -
N mid S ,f;1_!in�OOty
EmailaJJrcss`�7h( � / R
Cit off/" wn,State,ZIP 'b Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING nnPERMIT
I,as Owner of the subject grope y authorize )� �n\ A �c,r\\\ L:II�
DAL-
in I mat rs r e to work authorized bg this building permit application.
a► i4o
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 Ottner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his,her own work, or an owner who hires an unregistered contractor
plot 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
ypw.m;p..g„y { a Information on the Construction Supervisor License can be found at nA\N g>.mase.go).'jIli,
'_. When substantial work is planned, provide the information below:
Total floor area(sq. R.) _(including garage, finished basentent'attics,decks or porch)
Gross living area(sq. 11.) _ _ Habitable room count
Number of fireplaces Vmnberofbedrooms
Numberofbathroonis Number ofhalfbaths -------- ------
---------------- ------------------
F\pe of heating System -------_—_--- —.— Number of decks, porches--
- - ---- ---------
r)peot,coolingsystcnr unclosed Open
"f ut;d Project Square Footage-may be substituted for"focal Project Cost"
l)ffice of Consumer Affairs&B smess Regnlatto$4s
HOME IMPROVEMENT CONTRACT OR Type ff 5
Registration: A51859 - private Corppi;
V- -
i Expiration 1/13/2012 r
SEO OIA BUILDERS INC
GLENN PETERSON j
9 TRINITY AVE ,,��-
t LYNN, MA 01902 Undersecretary. "
_Dcp utment of Public�tfcr. 4
Bo ird.'of Bmldi 14� Rc��ulatiunv tnd S trd
timd e`
Construction Supervisor- License
License: CS 95367.,E
Restricted to: 00
DEREK PETERSON .;
R TRINITYAVENUE.
k `LYNN, MA 01902
Expiration: 4/16t2ol2_ )
C'i�imnispioner Trp: 20399 /,
r
A- _
r(
RESIDENTIAL REMODELING CONTRACT
This form complies with professional standards in effect January I-December 31,2011
Sequoia Builders Inc. THIS CONTRACT IS
ENTEREDINTO
Sequoia MA. License #CS 95367 THIS DATE:
9 Trinity Ave. 7/25, 20,11
Bu
ilders
Lynn , MA. 01902
t � PHONE 781 595-9005 FAX 781 595-9015
NAME
Matt& Sue Formica
BUYER/ RESIDENCE ADDRESS CITY STATE/ZIP PHONE
OWNER 13 Mall ST. Salem MA. 01970 1-978-869-
PLACE OF BUSINESS(IFANY) CITY STATE/ZIP PHONE
CONSTRUCTION LENDER: Name and address of construction fund holder is:
Home owner Responsible for all Payments
(Name and Branch Address of Bank,Saving and Loan Assn., Escrow Agent,Joint Control or Other)
DESCRIPTION OF THE PROJECT: Finish guttung all ares of kitchen that are needed. Gut out fist floor bath& build out to match
furthest part of house to add Sink. Level out Kitchen floor. Install insullation in floor and walls in kitchen . install new hard wood
floor in kitchen.plaster all walls. Plaster new ceilings in designated rooms& front hall. Install new back door &Anderson 6 slider
out of Kitchen. Plumbing, Electrical , HVAC. Sand&refinish hardwood floors. remove&reinstall in front living room .
Work performed at 13 Mall St. Salem, Ma.01970
(Street Address And Legal Description If Known)
TIME FOR COMPLETION: The work to be performed by Contractor pursuant to this Agreement shall be commenced within
( )days from this date or approximately on (Date): 7/25/2011 and shall be substantially completed within ( )days or
approximately on(Date): Commencement of work shall be defined as(Bristly Describe Type of Work Representing Commencement):
OccupanyCertificate from Town of Marblehead /Yiz°/- (S.�•�y r G.- e-�� Ss� —"L
PAYMENT: Owner agrees to pay Contractor a total cash price of$55.00 per R%mark up of total cost of J614Home owner
will pay for all Materials. Home owner will be responsible for paying all subcontractors directly . Down payment(if any)
$10,000.00,
Payment schedule as follows:
There will be A weekly meeting to go over progress of job& to discuss weekly payment
Upon satisfactory payment being made for any portion of the work performed, the Contractor shall, prior to any further payment being
made furnish to the person contracting for this improvement,a full and unconditional release from anyclaim or Mechanic's Lien,for that
portion of the work for which payment has been made.
ALLOWANCES: ne following items or specific prices as indicated are included in the contract price as allowances. The contract price
shall be adjusted upward/downward based upon actual amounts rather than estiptated amounts herein
This Job Is strickly a Time&Material with an 8% mark up of toatal cost ofjob iru;a g subcontractors
TERMS AND CONDITIONS: The Terms and Conditions attached are expressly incorporated into this Agreement.
You,the buyer,may cancel this transaction at anytime prior to midnight of the third business day after the date of this transaction. Seethe
attached Notice of Cancellation form for an explanation of this right.Cancellation by the buyer after the right to rescind has passed shall be
deemed a material breach of d ' cement and entitles Contractor to damages.
OWNER/BUYER SIGNATURE DATE
CONTR, TOR/SELLER SIGNATURE OWNER/BUYER SIGNATURE DA-
X y1
'0 ABCAFornra.
TERMS AND CONDITIONS
1. CHANGES IN THE WORK. Should the Owner, construction is an agency coupled with an interest. In the event the Owner occupies the
lender,or any public body or inspector direct any modification or addition projector any part thereof before the Contractor has received all payment
to the work covered by this contract,the contract price shall be adjusted due under this contract, such occupancy shall constitute full and
accordingly. Extra Work and Change Orders become part of the contract unqualified acceptance of all the Contractor's work by the Owner and the
once the order is prepared in writing and signed by the parties prior to the Owner agrees that such occupancy shall be a waiverof any and all claims
commencement of any work covered by the new change order. Theorder against the Contractor.
must describe the scope of the extra work or change,the cost to be added
or subtracted from the contract,and the effect the order will have on the S, INSURANCE AND DEPOSITS. Owner will procure at Owner's
schedule of progress payments. Failure to have written authorization shall expense and before the commencement of any work hereunder, fire
not be deemed fatal to the collection of the extra work. insurance with course of construction,vandalism and malicious mischief
clauses attached,such insurance to be a sum at least equal to the contract
2. RESPONSIBILITIES OF THE PARTIES. Contractor shall price with loss,if any, payable to any beneficiary under any deed of trust
promptly notify the Owner of(a)subsurface or latent physical conditions covering the project, such insurance shall also name the Contractor and
at the site differing materially from those indicated in this contract,or(b) any subcontractors as additional insured,and to include sufficient funds to
unknown physical conditions differing materially from those ordinarily protect Owner,Contractor,subcontractors and construction lender as their
encountered and generally recognized as inherent in work of the character interestsmayappcar. Should Owner fail to do so,Contractor may procure
provided for in this contract. Owner as added work shall pay for any such insurance as agent for and at the expenses of Owner, but is not
expense incurred due to such conditions, required to do so.
The Owner is responsible to supply water, gas, sewer and electrical If the project is destroyed or damaged by accident,disasterorcalamity,
utilities unless otherwise agreed to in writing. Electricity and water to the such as fire,storm,earthquake, flood,landslide,or by theft or vandal ism,
site is necessary. any work done by the Contractor in rebuilding or restoring the project shal I
Owneragrecs mallow and provide Contractorand his equipmentac:ess be paid by the owner as extra work.
to the property and provide toilet facilities. Owner shall obtain and pay for insurance against injury to Owner's own
The Owner is responsible for having sufficient funds to comply with employees and persons under Owner's direction and persons on the job
this agreement. This is a cash transaction unless otherwise specified. site at Owner's invitation.
The Owner is responsible to remove or protect any personal property
and Contractor is not responsible for it or for any driveways, lawns, 9. RIGHT TO STOP WORK: Contractor shall have the right to stop
shrubs,etc. - work ifanypayment shall not be made,when due,to Contractor underthis
The Owner will point out and warrant the property lines to contractor. agreement. Contractor may keep the job idle until all payments due are
received. This remedy is in addition to any other right or remedy that the
3. DELAYS. Contractor agrees to start and diligently pursue work Contractor may have. Such failure to make payment when due, is a
through to completion, but shall not be responsible for delays for any of material breach of this agreement. Owner acknowledges that the
the following reasons: failure of the issuance of all necessary building additional costs for the delay in stopping and starting the project shall be
permits within a reasonable length oftime,fundingof loans,disbursement treated as an extra and allow Contractor additional costs in accordance
of funds into funding control or escrow, acts of neglect or omission of with paragraph one hereof.
Owner or Owner's employees or Owner's agent,acts of God,stormy or
inclement weather, strikes, lockouts, boycotts, or other labor union 10. CLEAN-UP. Contractorwill remove from Owner's propenydebris
activities, Extra Work ordered by Owner,acts of public enemy, riots or and surplus material created by this operation and leave it in a neat and
civil commotion, inability to secure material through regular recognized broom clean condition.
channels, imposition of government priority or allocation of materials,
failure of Owner to make payments when due, or delays caused by If. LIMITATIONS. No action of any character arising from or related
inspection or changes ordered by the inspectors of authorized to this contract,or the performance thereof shall be commenced by either
governmental bodies,or for acts of independent contractors,or holidays,or party against the other more than two years after completion of the project
other causes beyond Contractor's reasonable control. or cessation of work under this contract.
4. PLANS & SPECIFICATIONS. If plans and specifications are 13. ATTORNEY FEES. In the event there is any litigation or
prepared for this job, they shall be attached to and become apart of the arbitration arising out of this agreement, the prevailing party shall be
agreement. entitled to its reasonable attorney fees and costs.
5. SUBCONTRACTS. The Contractor may subcontract portions of 14. PAYMENT. Upon satisfactory paytnent being made fbranyportion
this work to properly licensed and qualified subcontractors of the work performed,the Contractor shall,prior to any further payment
being made,famish tothe persons contracting for the improvement,a full
6. FEES,TAXES AND ASSESMENTS. Owner will pay for taxes and and unconditional release from any claim or Mechanic's Lien, for that
assessments of all descriptions. Contractor will obtain and pay for all portion of the work for which payment has been made.
required building permits, but Owner will pay assessments and charges
required by public bodies and utilities for financingor repaying the cost of 15. ASBESTOS AND HAZARDOUS WASTE. Unless the contract
sewers,storm drains, water service, schools and school facilities, other specifically calls forthe removal disturbance,ortransportation ofasbesms
utilities,hook-up charges and the like. or other hazardous .substances, the parties acknowledge that such work
requires special procedure,precautions,and/or licenses. Therefore,unless
7. COMPLETION AND OCCUPANCY. Owner agrees to sign and the contract specifically calls for same, if Contractor encounters such
record it Notice of Completion within five (5) days after the project is substances,Contractor shall immediately stop work and allow the Owner
complete and ready fir occupancy. If the project passes final inspection to obtain duly qualified asbestos and/or hazardous material contractor to
by the public body but Owner fails to record Notice of Completion,then perforu the work or the Contractor may perform the work at contractor's
Owner hereby appoints Contractor as Owner's agent to sign and record a option. S '❑ r r t n e a undertheccmtrlet.
Not ice of Completion on bchal fofOwner. This agency is irrevocable and
o
CITY OF SALEM
' ' Yk PUBLIC PROPRERTY
* 1*4
DEPARTMENT
\lu.w
12C\VA1rlL\tiiu.\iigIL•1• is $dll•N, Md♦\.u.11l V' I IN1AWZ^
I'IA. ))i•;IS•vi'd e f ox 011.74C•'/1146
Yorkers' Compensation Insurunce %intiovit: guilders/Cuntrscturs/Electrlc►anyMlumbers
% t lllcant In nrinutio
/, •, 1:111yam Pant Le •bl
ViIITiC illue,yvri OraaniraiinrvindivuluulC SF�lf101.R �U\1 ��� Tar
1Jdre..r: C1 I (� \n1 \Ti ,/�JktPr
City,Alre,Zip- —ttkKt Jt� 01901 I'hunri/
IIre ru mt vinployer7 Check Iha:tpproprlute bolt:
1 U 1 ,un J cmpluyur with 4. I)po off project(ruyulred):
.r ❑ I am a ycnersl cuuaxlor and 1
�•0eulPluyces(cull Jn /ur paralinie).• hive hind the.luh•cuniracturs 0• ❑New curtstrucuun
1.Int a sale proprietor or partner• listed on the aniched sheet % 7• ❑ Remodehng
whip and have no empluyees These subcontrsetors have
working tier me in any capacity, ,wrken'comp, msluonca. �' ❑Domolirian
I Kn workers'cwnp. insuranw J. ❑ We�rs n ern 9• ❑ Duckling additiim
nyuireJ.) porstinn and its
atttccrs have exereircd their Io•0 Eleerrical repairs ar additions
7.0 1 and J honwuwnur ding A wark "llf"of exemption put hIQ6 11.0 Plumbing repairs far
additions
myself.IKo trorlicrs'cunip, c. 152,§I(4),and we htivd no
insutance required.) r cmpluyuex.Ilv'o workers' 12.0 Ruul'repaid
comp insuraIse rcyuirLvl.j I7.0 other
s y•,phcuv ihd Chucks km nl mom:Jw fill vo the wenun t,,6 .awwine iACir wwkoi Cuntyenveiup IvaiCy iufiuuyu un
'I lumwiwngn uhu vainlil best ulti4vh inaiutine i +re Janie dl wurk and Thor him monde Covington m"I wtwiir a new amderir iiwliaeine wok.
'( .n'rJ.hvC ihd ingCk Ohio ksx miw Jtgchwl•in aaJithr.d.hgur.huwine the tam"of nle iiitv.en rxt,M and their wwkerk'cony.prlwy inikrmmom
/our mr rutylayrr that Lr proriJ/ng IvvrArrl'cufnprnrnNon Inmrnfrcr/lir fay rmp/uprr.4 Br/uov/i tM pv/&y and/ul.oif�
Insurance C'umpaty Valner�___ .
I'ulicy 4,x Suif•ins. Lie.M; -
EApirusiun Dale:
1JbSite \tldnss: k1s MaA c-,.1,- Is nl \. AN. 0117c l .
Attach it orgy a(llw worked'eumpenxatlun policy duclarallun pago(showing she policy number and expiration date).
"huge 10 xcura coseruye as required uudcr Section 2JA u1'JIGL c, 152 can lead to rho imposition of criminal penalties of a
fine up to SLinQiM Jndlut uue•year imprismimunt, Jx well Js civil penullius in the 1'unn of STOP WORK ORDER and a fine
of up ro i250.rM it Jay.Igainal Iris v60u1111'. 110 advtacd that a copy of this.dutemum may be 1'urwJrdeJ to the Onsets ul
In Y,]II1'Jimits at :he DIA ;i7r nl.uau'ce cnvcrJ�e\Ci ilicatun.
/Ju hercAy i iris/ x.l•r Ibr p,rinr,fad pre r f to/perjury thvr the iu urinal/ow prvvi✓e�Jjub/a N isS I me I d"d correct
ii,t�uwe '�/ o�0,/
LI)a and wrifr in dilr urea, ru he cunrpleled ey city ur roivrr a/Jodi[.\uthnrily (cirvie,inc): . "11- fun"C lerk J. L••Icclrical lutpccrur i.r
i
information and Instructions
Pinion In she service of another owlet.Illy conlrlct of hire,
�g,ls;ac hu;etrs l;cneral LJWa chapter 1 i2 lrywres all employee o provide workers cmnpensauun lift their cnlp ogees.
I'ursu.ttlt to gins salute, an t,"#4 rfe iv doineJ as.. every Pen
:.press or unpl,cd, oral of wruten." , or an two or snore
,cd ,n a iwm emerpnsa, and including the Icgal rcpresenutives of 3 deceased ccs- yor,:V the
�n erepfuper i+Joined as' an Individual,purtnership.asboc/atloe,corporation ut other
1^al cJ cm Howavcr the
�f the I; ,cguing eng,ay Ialioe or other legal entity,emp Y gcrop occupant of the
g
cceever or trustee u1'.m indivlJual, prrmenhtp,aasOe re air work gin;w h dwelling house
of a Jwclling house having{not more than three apartments and who reside,fhefcin, or the n'uch
owner a eons to do Inaintenance, f such mpg or p
.hvellmg boobs of another who employ. {K
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer•'
�tGL chapter 132, y35C(ly) also states that ,every slate at local licensing{al shall withhold the Ihfoece or
required.'
renewMal
al of a Ilecase or permit to operate a busiasa or to eoa,truet buildings In the ce cove,wealth re or any
renetcnnt ,vlro has not produced acceptable evidence of cumlith 04e with the Insurance revenge req
AJJilionally, �I as notp prod
l 52. a23C(1)brutes"Neither the commonwealth not any of iV polilicat subdivisions shall
anwr into any contract for the performance ul'public work until seeeptablc cvidence ofcolupliartce with the insuronca
reyuinments of this chapter have been Presented to the contracting authority."
►VVllcsttu P I to our situation and,if
tlsation atlldavit completely,by checkingthe boxeW11hathep urt(Bcute(s)of
plea.,l a rill.set the workers' comps es and hone nunlber(s)along) with no employees other than the
necessary.supply.rub eontractor(s)nume(s),address( )' P
insurance. Limited Liability Companies(LLCworken'Limited
ean+pensaonaitnurance,(If ao)LLC or LLP doss have
netnbers or parinen, gin not required w carrybolingill to the
employees,a policy i, required 8e advised that t6 Also be isure to 111111121141 ate Ae ul'nJavndustrial
�l4nt The l 1RJav i should
application for the permit or license is being requested•not the DrlPadtnent of
�ccidenu for confirmation of insurance ea coicatiorequired to obtain a workers'
he rullImed to the city or town u"Aveuny questions regarding the law ur if you ace
Industrilil Accidents. Should Y try q e s st the number listed below. Stir-inured compaoia should enter their
compensation Policy.please call the Dap
sclr•insurance license number on the appropriate line.
City or Town Omelets
The Department has provided q spacers the bucaollm
the app
Plcnse he vure that the affidavit is complete and In legibly.Investigation
applicant
ut the affidavit fur you to fill out in the avcnt the 011iea of Investigations has to contact you regarding
1'l:rse be sure to till in the permitilicmlse number which will be used its a reference number. In addition,an+PD
hurt must submit multiple pennit,'license applications in any given year, need only submit one
aRidsvit indicating current
�J or marked by the city or town may be provided w the
Policy.. t bola utitrn Uf nccesaary) and under"lob Site Address'the applicant should write"all inayb n in (coy or
town)." %copy of the unldavit Ihat ha,bean ofncially sump'
to any business 4)
applicant as proof chat a valid afRduvit is on file rot tutus permits or licenses. A new uiiidavit must commercial Riled ve sae
not
� f rlugrea hem r owrefs tr citizen is burn leaves vte)aid pers ining a nris NOTgrequired ocomplete th s affl v t venture
�)I Vice tit h,.CifigittUns 1Wuld like 1J thultk you Ill advallCe for Your
eGUpera11U11 711J should you halo.illy 4uebuans.
i ha
please do nut hesitate to give us a call.
fhc Ucpunncnt's address, tolcphuna aThe Cnd fix ommonwealth of Mossaehusetts
Department of Industrial Accidents
Offle*of[nvtadgadona
600 Washington Street
Boston, MA 02111
'fag. # 617-727.4900 ext 406 or 1.977-MASSAFE
Fax M 611-727-7749
www.maw.gov/die
CITY OF SM..&M, NLASSACHUSETTS
13UMDLNG DEPARTMENT
' 130 WmmNGTON STREET, 3w FLOOR
TEE. (978) 745-9595
PAx(978) 740.9&M
KINMERLEY DRISCOLL
MAYOR THci usBT.Plzim
DiltwrOR OP PLBLic PROPERTY/BCILDNG COWMISSIONER
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 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:
(name of hauler)
The debris will be disposed of in
((name of facility)
(address of facilit
signature of permit applicant
7a 0
date
07/21/2011 TR 14:36 FAX 2001/001
-740 -arnc�
CERTIFICATE OF LIABILITY INSURANCE 7
1
7/21 11
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.
IM POR7ANi: If the certificate holder is an ADDITIONAL INSURED,the policy(im)must be endorsed. If SUBROGATION 13 WANED,subject to
the terms and condfions,of the policy,eertaln portmes may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in IieU Of such eMorsemenga).
CONTACT
PRODUCER
NAME'
Benevento Insurance Agency Inc EdiFEN LIE
. (781) 599-3411 RRX ry ; (781) 561-7200
497 Hlrmphrey Street ADDRESS:
Swampscott, MA 01907 PRODUCER 4233
�_....
INSURERS)AFFORDING COVERAGE NAICa
INSURE INWRERA:Patrona Mutual -.
Sequoia Builders, Inc. iNSURERa:.Granite State _-
9 Trinity Ave. ---
Lynn, MA 01902
COVERAGES CERTIFICATE NUMBER: 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 OFSUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CI-AIMS.
AWL SUER EFP POLIO IXP "' .._.._.. ..
LTR TYPR OFINSURANCE POIIGY NUL93LJ2 MIDDIYYYY MMID UMT3
GENERALUAMUTY EACH OCCURRENCE S 1,000,000
TXCOM
ERCIALGENGRALUADLITY CTR0008946 2/5/11 2/5/12 oANaGES(511QreEmonP)._ $ 50 000
ACIAIAISwADE OCCUR MED EXP(Aw..P..] SPERSounLacnVINURY S 1 000 000
GENERALAGGREGATE $ 2,000,000
GENL AGGREGATE LIMIT APPUE3 PER PRODUCTS-COWJOP AGG S.2,090,._O,A D..._
POLICY PRO. LOC S
AUTDMO91Le UABILIN COMBINED SINGLE LIMIT S
(Ca cc A)
ANYAUID BODILY INJURY(Por porso„) $
PLLOWNED AUTOS 90DILY INIUHYIPRT xckenQ S
$CHEOULED AUTOS '-
PROPERTYOPIMGE $
HIREDAUTO$ (PererclaenC
NON-OWNED AUTOS $
UMBRELLA LIPS OCCUR EACH OCCURRENCE S
IXCE33LWB ^CLAIM&.. AGGREGATE S
DEDUCTIBLE
RETENTION $ $
WORKERS COMPENSATION YVC STATU- OTH-
ANOERPLOYERS'UABIUTY X..TORYJ.M
$ ANYPROPRI=PIPARTNER,EXECUTNE N/A WC009852828 9/14/10 9/14/11 F.L.EACNACOCENT $ 100,000
OPFICERAIENGM FXCLUDED7
wannawN In NH) E.L.DISEASE-FA ew LOYf S 100,000
DESCRIPTION POP OPERATIONSbWow E.L.DISEASE•PQLICYLMIT S 500,000
OE3CRIPnON OF DPIJIATIDNSI LOGITON3I VEIBo cR (ANaeN ACOR0101,AYLSAAM Renf,lw SPMAub,ilnwro ep,e.ieroqurea)
Job: 13 Mall St, Salem, MA 01970 Client: Formica
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W
City of Salem ACCORDANCE WITH THE POLICY PROV1310N$.
Salem Building Dept
Salem, MA 01970 AUMORQED REPRESENTArnE
t3rvan Benevento
®1988-2009 1601Mt TION. All rights re tl.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD