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21 MANNING ST - BUILDING INSPECTION I'he C'onunon weal th of MaSSaehnSC(IS - - - Board of Building Regulations and Standards CI'I'1 OF JJJJ r r;, Massachusetts State Building Code. 780 C NIR SALEM 'L,'•' XeriseJ.l6rr'ill l Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tnu-Finnilt Du cllins+ This Section For Official Use Dill Building Permit Number: Date A lied: J19dVL.r2 Building OlLcial(Print Name) Sigr atur 1 SECTION I: SITE INFOJIMATION 1.1 Property Add�s��/A//�� n� 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yes no Map Number Parcel Nunther 1.3 Zoning Information: 1.4 Property Dimensions: Tuning District Proposed lJse Lot Area(sq It) Frontage(1) 1.5 Building Setbacks(D) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.JU.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check iY es❑ Municipal❑ On site disposal system ❑ ' SECTION2: PROPERTYOWN RSHIPt 2.1 O or R (_o Muni:lPn Cit•.5tatc.ZIP ���,yq �� �i Nu.un Street Telephonehone hmuil AJdrcss SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Sp•cit'y: BriefD crition Proposed Work-: _ �Np o _ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Offlclal Use Only 1. Building S I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard City7own Application Fee 7, Plumbing S ❑Total Project Cost(Item 6)x multiplier _ _ x -- _. Other Fees: $ 4. Mechanical (II\'A(•) S List:_ 5. \Icchanieal (Fire S ---- - Su+�ressiont Totul :\II Fees: S_ o. Total Project Cnst: S Check No, _--('heck amount: _ _-__-- Cash:Amount: 0 Paid in Full 13 Ou(st:mding BaLmce Due: � r SECTION 5: CONSTRUCrION SERVICES 5.1 Construction Supervisor License(C'S1J rz 1 � I.icen,e Number Ic raw D;ue Na me of Csl. Inlder Li,t C'SI.1')pe(see below) n �i//r�� Sl_ _ 7')pe Description No. and Street U Unrcstrieted I Uuildin•s u' to i5,11110 eu. 11 ) R Resiricted IK?family Dwcllin• Citriroan.Slue.L IP —__---_ NI klasonry RC Rooting C'overin -. W'S Window and Siding sF Solid Fuel[]timing Appliances I Insulation 'I'elc hone Email address D Demolition 5.2/1/�rgistered Hoo�gye IIm/provv"lent�Contractor(HIC) Z �'/ y''/!/l /y�N //(9/(�/ • IIIC Registration Numher P. pirali n Uule MCC n P ) a lie o C t islr5 � I II lgl Na jp� Nu } S e•t Email address Cityfrown.State,ZIP rde hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Issua a of the building permit. Signed Affidavit Attached? Yes .......... No........... O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1•as Owner of the subject property,hereby authorize 114 A4 L. L ot/. ZOn/I. to act on my behalf,in all matters relative to work authdrized by this building permit application. Print Owner's Nwne(Electronic Signature) QKate SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information cont a' th' appI'cation is true a r to to the best of my knowledge and understanding. Z A I'ri a O\\ner's AuthoriieJ,\genl's N; o. -1'a•• Ic Signature) Da NOTES: I. 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 Hume Improvement Contractor(HIC) Program),will no have access to the arbitration program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at \\\\\\ m.r.. ,gip ,,, i Information on the Construction Supervisor License can be found at %%%% .nrts< ;o JD. '_. \Then substantial work is planned, pro\ide the information below; Total fluor area(sq. ft.)_ __—_--_(including garage, finished basement attics.decks or porch I Gross tieing area(sq. 11.) Habitable roost count Number of fireplaces .- Number of bedrooms Numher of bathrooms \umber of half hmhs Number of decks, porehcs. I\Ile 01 e001111g s%ste111 _ _ - Fllclosed I 1, "tonal Project Square Footage'nuq he sub;6tutcd for"Total Project Cost" S ACTION, INC t 47 Washington Street Gloucester, MA 01930 Tax Fxpmnt it 042.3RA.3,19 Agency: NSCAP NGRID Application# PROGRAM: AARAWAP 0':. JOB NUMBER: 0 DOE Work Order# 0 E.S.C.performed? No Work Order Date: 11/23/I Primary Contractor: A&M General Contracting .Other Contractor: Manchester Electric #Bulbs installed 0 CostofBulbs $0.00 Client: John Dunn- Inspt$175.00 Max $0,00 ' Street: 21 Manning Street Other In Kind $0.00 City;State;Zip: Salem,Ma 01970 Electrical Work $0:00 Telephone: 978-744-3760/Cell: 508-395-6588 $Amount KeySpm $0,00 _ $Amount National Grid $0.00 Blower Door Test: Yes Other Utility S0.00 Inspect Knob&Tube: No Date Job Completed: Estimated Repair Total $1,020.00 Actual Repair Total $0.00 Weatherization Estimated Actual Cost Est Cost Act Cost Door kit - 5 $43.00 $215.00 - Regulm•doorsweep 2 $15.00- $30.00 Automatic door sweep - 3 $22.00 $66.00 An sealing 2-part foam(per hour) 2 $75.00 $150.00 wain air sealing 2-part fuem(per hour) 2 $75.00 $150.00 Weatherstripwindow(per side) . $5.00 Seal ducts-mastic $62.00 Seal ducts returns-mastic $62.00 W/S.&insulate attic hatch 1230 1 $30.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 Weatherization Total j $641.00 $0.00 Insulation Estimated Actual Cost Est Cost Act Cost :1 st 11.Sub-attic R38 open 65 $1.40 $91.00 - Attic flat R30 open 330 -$1.30 $429.00 Atticslo es R30 restricted 70 $1.41 $98.70 Thermclome $175.00 Attic kneewal R13 FG $1.25 Altic:Uge WA R15 Nlow W...brane $1.65 Attic kdeewall floor R30 restricted $1.41 Insulate attic stairs&walls $130.00 - Sidewalls-Wood shingle R15 720 $1.70 $1,224.00 Interior.wall-. faster R15 DP $1.81 I"rigid foam:board $1.85 Duct insulation R5&seal.seams- $2.95 1-Iydronlc Pi r Pe insul to I"R5 $3.25 Stearn pipe insulto 1.25"R5 $5.25 - DHW pipeinsuationR5 6 $2.50 $15.00 Insulate door-1"rigid board R7 1 $44.00 $44.00 Sill2,parr foam w/FG bait RI9 50 $2.00 $100.00 Insulation Total: $2,001.70 $0.00 DOE Other Measures Estimated Acutal Cost -Est Cost Act Cost Root vent-small $76.00 Gable vent-.rectangular $88.00 Recessed can cover $30.00 Cut/finish attic/kneewall access $100.00 Test drill sidewalls-4-sides $60.00 Blower door:test I $45.00 $45.00 Vinyl replacement wiindow- 101ni. 8 $350.00 $2,800.00 Faucet ae rater: . $15,00 - Low flow showerhead $25.00 $0.00 $0.00 $0.00 $0.00 .. $0.00. Other Total: $2,845.00 Energy Conservation - Est Cost Act Cost Total:(Max$10,000.00) $5,48T70 $0.00 Repairs Estimated Actual Cost Est Cost Act Cost Remove&dispose fallen FG 2 $60.00 $120.00 Adjust door striker plate $20.00 Door entry lockset $70.00 Repair door hinge $25.00 Slide bolt $20.00 Sash lock $9,25 Steel pre-hung door w/lite $610.00 Solid core door w/hardware 1 $350.00 $350.00 Glass replacement-to 64 ui $42.00 Site-built interior bulkhead door wlambs $415.00 Clean gutters(per hour) 2 $60.00 $120.00 Building permit Fee 1 $100.00 $100.00 Health & Safety Vent clothes dryer toexterior 1 $85,00 $85.00 Vent bath exhaust tan to exterior 1 $85.00 $85.00 Replacement window laad,afe prances $ $20,00 $160.00 Repair/H&S Total:(Max$2500.00) $1,020.00 Work Order Sub Totall 1 $6,507.70 $0.00 Measures. Estimated Actual Cost - Est Cost Act Cost Other $0.00 Othcr - $0.00 ++HeatingSystem.Repair $0.00 $0.00 ++Action approval only Estimated Job Total: $6,507.70 Job cannot exceed$10,000.00 Job minimum=$500.00 Job Grand Total: $0.00 .AUDITOR: Doug Cranford _ NSCAP 98 Main Street Peabody, MA 01960 Tax Exempt#: 042-385-280 _ - Agency: NSCAP PROGRAM: National Grid/2011 JobNumber 0 NGKiD Application#: 0: We" Ordet# 0 - Work OrderDale: 11/23/11 Job Limit: Primary Contractors A&M General.Contracti Per Unit $4500 00 _ Other Contractor: Manchester Electric --------���Client: John Dunn K+T Yes=1 No Street: 21 Manning Street. K&T: 0 City; State,Zip: Salem,Ma Telephone: 978-744-3760/Cell: 508- - Stand Alone: No Pee Code: 0 - - Blower Door Test: Yes Stand Alone Yes=1 Now Inspect Knob&'Tube: No Elec.Contractor: Attic Insulation Estimated Actual .Cost Est Cost Attic flat R49 o en - Act Cost Attic flat R38o en $1.53 $1.40 Attic Fla[R30 o on $l 30 Attictlat R20 o n Attic flat R10 open $1.23 Attic FluU $1:15slo e R30 restricted $1 41 AniEflat/slope R20 restricted $1.35 Attic flat/slo eKl0 restricted $124 Attic-kneewall RIT $1 25 Attic kneewall our R30 restricted $L41 Attic/kneewall floor transition DP Finished attic access $175.00 Temporary atticaccess� - $75.00 Crawl space R19 w/poly vapor barrier $2.53 Garage ceiling/floor R30 $2 00 Themiadome - $1$2.00 - Roof vent-large Roof venF—sm $95.00all $76A0 Turbine vent $160.00 12"stack vent $145.00 Pro a vent - $375 Gable vent-.all sizes $$3..75 Softil vent - - 00 Ridge vent(per lin.ft.) $26.00 $22.00 Attic air selling 2-pad foam(2 hwrs man) $75.FlFl Vent er/bath exhaust fan $85.00 Page 2 National Grld201 1 Est. Wall Insulation - — Act Cost_ Est Cost Act Cost Single nailed asbestos asphalt R15 DP Doubles led asbestos/nlumino,a al Dp Brick/stucco R15 DP $2.20 Interior wall Iblow-plaster RI DP $2.75 Clapboard/wood shingle vinyl RI DP $1'.81 - Test'drill.4 sides 600 $1.70 $1,020.00 $60.00, Air Sealin Limit: Single Famiry w/Blower Door Von All Others=$200 Door kit - Regular door swee - $43.00 Automatic door swe $15.00 - Air seating2- - $22.00 part foam(3 hours max) Sash lu ck $75.00 Glass to lacement $9.25 Blower Door Seto -$42.00 Perimeter wrap R5 $45.00 $1.82 'Total Air Sealin Cost: Heaton S stem Measures Duct insulation&seal seams Is It) Hydronic pi a insulation to 1"R5 - $2.95 Hydronic ti einsulation 1.25"+RS $3.25 - Steam pi a insulation to 1,25"R5 A $3.50 Steam pi einsulation 1.5"-2"RS 60 `'r' $5.25 $210.00 Boiler/furnace replacement ,.Na $6.05 $363.00 Program re air $0.00 $0.00 Actual Total does not include$175.00 K&T charge. 51,593.00 Est Total AUDITOR: Doug Cranford - - I 50.00 I jAct Total CITY OF SMY-AI, UxsSACHUSETTS • BUILDLNG DEPARTMENT 130 W ASHINGTON STREET,3•0 FLOOR TEL (978)745-9595 FAX(978) 740-9846 l I.NiBE MY DRISCOLL MAYOR THOUAs ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BURDNG CON IISSIONER 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 1 l 1.5 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 betransported by: (name of hauler) The debris will be disposed of in '04/4 �0 ,0�M'e�l Qu�c �c/'k 7r (name of facility) (address of facility) //Asisnatur—e�o rrr t applicant Z 2 date dcbna:if d,x CITY OF SALEM '16 ,�' PUBLIC PROPRERTY DEPARTMENT \nt.nil Y:,n IN,•II \I N,Yl 1 iC\yn,rn.\,:Iu.\jI8Cb1'•j,111'N, M.,U.\UII V 11vJl'11� Workers' Cumpeneadon Insurunce \fOdorit: U Ill lders/Cuntracturs/E lei:trlelifwilPlumbers \ 1 11(cunt Infilrmutlon PI 4.� Int Le 'hl NiI In Il It' n'u.ai gr;lanvalinrvinJ,r'duull: �C�n/o P6T�� � /.Q7 n Clly'st:ltl./I(1®I/r16 /n Phone if: I .\ru nit 4a uuplloyer:'Check the appropriato boa: I I am a umpluyur with 2 4. 0 1 ;un a 9ener2l contractor and I I yM°rpro)uet(rvyulreJ): 2•❑ cnlpluy"s(full andjur pall•linle).' huvc hircJ the rah-cuntrataors /a' ❑New construction I All)4 tole prnpricta or partner• lisled on the anachcJ sheet ship and have no umpluyuvw There iub•contracton have 7, RelnoJeling wurking fin Inv in any capacity workers'comp, rnsurnnce. g' ❑n@molition )NO wurkurs'cutup. insuranc@ J. ❑ We are a c1hporolion and its 9' ❑ OuiWind addition 3' nyuirud.) 0MCCra 114ve uiutcisC•d their I0•❑Electrical repairs or additions I aln a hmtluuwnur Juinig all work right(Ko ,.nrkurs'c ONWInplion pur hICL I L❑PlumbinY repairs of additions myself. omp• C. 152,11(4).anj we hnvd no insurancu required.l r cmploycus. (No\vorkea' 12'�WI'npuip .nlnp iltwr4ncurtyuind•J 13•yLluther 7{jj •'-i gplw'ux a"a checks pas air muN alw till uW the,ecoml In:low dww ow Ihmr wwkni nuns suxtup 'I lurnw,wrwn why uu,n,il this atTasvi,i,yllu,in ' N IWiI n,liun,WlWt� MiY+u doing+11 work and Ihp hip uwside eaxrarta'e'nw1 wlvna a nw+IRasvil inaiue:n w •C,.n'cwnn'hM,MnY'his box in, aomhod in addeiu,yI%hql Joiwina IN name of the rak+axr scl,Irs and IMx wwken' //am un vniployer that fr pruvldlnX rvorAeri'rutnpnlrntlon Gttarnnee/or my ern o, `O1Ap'I1OIIvy,ntbrrnanua ainorot p/1 eeti Se/ulv/s thepuNty uxd job aile InaurancuCompaity Vmne: Policy 4 ur Suiting. Lie.H: �91 J / 6•J / Eapira Ion Dale: D �y Jul) Situ-liddra3x;_a(, / �+/�.�A/A/l e�/a ii \track a cuyy,of the ,vorken'eumpenaatloe policy duclarallon pull@(showing(hslpolicy'...bur and e.eplrotlua data)/0 Natluru lu augur@ CutCNge as required uitdur Suctlen 251\ul\IGL C. 132 Can lead to the iln tine up ro i 0.04 tM and/or une•ynr 6npris,mmcnr, as wu11 ar Civil pCnuillus in Ihu loan off STOP WORK ORDER and a fine ,)fill)ro i210.tM;1 Jay.quinat Ih@ vialahlr. Ilc advi.+cJ that a copy of lhia atuhmcnt may be IutwarJed w the UIIiCe wl bn-,sny4unb ol';hc I)1,\ t9nnvur:u'Ce a,vcrage ,crilicanun. /du loer,•hy t:rli/' n r •point and penal ter ujper/liry Ishat tin iu/brtirulloe provided above is ue r nd torrerR 57 uae ordy, po nnr rvrite in 1/tir un•u, to Ae rurnpG•teJ dy Ciry ur anon'IM41uL I -- Penniul.levn,e a 1,wing .l ulhurity (Circl@ nnu); I. Ih",rrJ of Ileahh 1. Ihuldul, Ilyl.lrlulcnt 6. I. 1.i11.' onn f ('lerk J. L•'Icciric.il Irll{lccror S. Phaalpiny In,yrdar I 1)Ulnr i 1'huxu J• i I Information and Instructions v s,rsan in the service of another ureter any contract of hire, \l,Ui.l:llUietti lr:nefal Laws ;I 1 J2 rcquues Ale tclr'I as to Provide workers compensation tiff their employees. I'ursuaat to nos)uasld, in rerPlurra is JetineJ as". %Press or Implied, oral or wniten." ar an two or more partnership associauoa,corporation or other legal entity, y`r or the �n,,npluycr is defined as"an rnJrviJu 1, P' to in vm loyeea. However the �l the to,tgusng engaged m a Joint enterprise,and ittcluding the legal gal co ly.d es of a deceased emp uY' eemver ur ouster ut•.rn iudivrdual, pasmershtp,assactrlioa of other legal entity,emp e g ' P to do maintenance,cunstruclion or repair work on such in employer." owner of a dwelling house having not mare main three apamnents and who resides therein. deem occupant o i rho who employs Deemployment ,Iwrlhng house of unothar D r on the.,rounds or building appurtenant thereto shall not because of such \IGL chapter 152. t)15C(6)also states that"Ivory stets or local licensing agency shag withhold to lbfIssuo ance y faDlo avldlnce of cumPpanco with the Insurance coverage required.' renewal of a Ilecnso or porruit to aygan a Auslnlu or to construct buildings la the cO us subdivisions shall ;tpplicant wild has not produced recap of its Political \dJitionally, MGL clluptar 151, 415C(7)states'•Neither the commonwealth not any anur into any contract for the performance u.pJbo rho rkuntilt acceptable authorryviJance ul cunryliwtce with the insurance requirements of this chaplor have been p' \yyllc°nrs g D to our situation and,if es)and hone numbor(s)slang with their caniflcute(s)of Please lilt out the workers' compensation affidavit completely,by checking the boxes that apply y Y naccssary,supply sub-contrrctor(s) rates L, address! P workers' compensation ituurenee. if as LLC or LLP does have insw-ancc, Limited liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employt.•cs other than e members or Purifiers,its not required to Carry employindustrial ees,a policy is required Bo advised that this affidavit may Also be sure to be su sad dote The u111Jn Id to the v1611tThe affidavit should uastee,not the Ds;partment of \ccil emu fancontlrntation of insurance th eo coverage.. the the low ur if you are required to obtain a workers' be relit ,ad to the city or town that the upplie regarding t or license f being requested. Industrial Aceidents. Should you have pa questions eornpensution policy,yletw call the Dcprrencnl it the number listed below. Self-insured companies should enter them self-insurance license number on the a ro riute lino. iiiiiiiiiiii City or Town Officials ture oar to till out in the event the Otlice of Investigations has to contact You regarding the applicana Plea+e be#urc that the affidavit is complete ;tnd printed legibly. The Department has pryvideegu spree at the t Of nta affidavit fury I'I:ase be sure to fill in the ps nniNicense nwnber which will be used as a reference number. In addition,an applicant or it multi la Pi applications in any given year, rise only submit rite one l'locations in indicating current ubrn pthe must) ' Address" DP to this dwt • •necessary)and under"Job Si5no provided policy inf copy 11 Jut has been officially stamped tic malice by eta city or town may bar p town!•" \copy of tit°affidavit thatits of applicWh is erc Proof m°tit a valer or citizen isdavit ts On Aid tiat obtaining a license orlurre rPennit not related to any a ttsinaf or comontere 1 vanled Out aturt Y t i.e. .t dug license or permit to burn larva eta.)sail parson is NOT required ro complete this affidavit. uesumts, I he t tt)ice ni Inveilillatiuns would like to think you in idrutcc fur your cooperaiiou and should you hwa.utY 4 lease du not hesitato to give us a call. p Fite U:p'•rrunent's aJJrevs, telephone and Th Commonwealth of Massachusetts Department of Industrial Accidents ogle•of IsvadQadons 600 Washington Street Boston, MA 02111 T'ei. N 617.727-4900 ext 06 O7749"•MASSAFE Fax # 617 J <.'t,.05 www.mau.gov/dis OP ID: SM ACORO" DATE(MMMDNYYY) CERTIFICATE OF LIABILITY INSURANCE 03121/11 ,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 INSURERS), 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 endorsements. PRODUCER 781-224-5700 CONTACT NAME: Mazonson LLC www.mazonson.com 781-224-5777 PHONE FAx 701 Edgewater Drive MA"o Eat: ac Ne: Suite 230 ADDRESS: Wakefield,MA 01880-6236 CUSTOMER ID#:A&MGE-1 INSURER(SJ AFFORDING COVERAGE NAIC# INSURED A&M General Contracting, Inc. INSURERA:Peerless Insurance Co Norman Dube INSURER B:ACE-USA 119R Foster Street INSURER C Peabody,MA 01960 INSURER D: INSURER E: INSURER F: 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 OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMR1D/YYYY MM/DD/YYYY LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERC'A'GENERALLIABILITY CBP8762001 03120/11 03/20/12 I Ea occurrence 8 100,00 CLAIMS MADE �OCCUR PREMISES MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 I GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 A ANY AUTO BA8762301 03/20111 03/20/12 BODILY INJURY(Per person) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Per axidenq X NON-OWNEDAUTOS $ $ J( UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,600,00 A CU8762501 03120111 03/20112 DEDUCTIBLE X RETENTION S 10 000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY OFF ICERJM MR B ANYPROPRIETORIPARTNDED? CUTIVE YIN C46275251 03120/11 03/20/12 EI.EACHACCIDENT $ 500,00 (Mandatory In H)EXCLUDE09 ❑ NIA Ifes,atoryin NH) E.L.DISEASE-EA EMPLOYEE $ 600,00 Dyes,deaerlbe under E.L.DISEASE-POLICY LIMIT $ 5o0,00 DESCRIPTION OF OPERATIONS below 00 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Attach ACORD 101,AddlUonal Remarks Schedule,It more apace Is required) CERTIFICATE HOLDER CANCELLATION SALEM-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 93 Washington St ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORIZED REPRESENTATIVE wA ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD J� �oinaiemxu�aall�i �� ��aawr./eG.fe�d i office of Consumer Affairs&Business Regulation I -' la°HOME IMPROVEMENT CONTRACTOR ff h Registration: 441124 _Expiration: 1/12t2012 rya, v Typo: Supplement Card } A+M GENERAL CONTRACTING INC. +4 MICHAEL FITZGERALD 5 SOUTH RIDGE CIRCLE LYNN,MA 01904 Undersecretary NIa„achu,cti, - Dcpartincnl nl puhlit �afct� Board of Builtlim_ Rceulaliun, and ,tand:ud, ..onstruction Suplrvlsor Specialty License License. CS SL 99933 Restricted to: RF,WS,DM,IC j MICHAEL FITZGERALD 9 WINCHEST COURT GLOUCESTER, MA 01930 oi-.G- is f Expiration; 6/+.9/2012 Tr= 99933 - fl