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HomeMy WebLinkAboutBuilding Permit #107-11 - 1 HIGH STREET 8/4/2010 BUILDING PERMIT Of NORTH q Std tD 06 ti TOWN OF NORTH ANDOVER F . `-4' APPLICATION FOR PLAN EXAMINATION Permit NO/Z)`4 Date Received �gSSACHArgo U`-+��� Date Issue IMPORTANT:Applicant must complete all items on this page gk LOCATION - W . _ Print n "PROPERTY F RTY OWNER_ Print . IM !� MAP NO: PARCEL: ZONING D]STRICT. Historic Distract- yes n Machine Shop'Village yes o a� i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition - Two or more family /, 11 dustrial Alteration No. of units: ommercial Repair, replacement Assessory Bldg Others: Demolition Other 4 Septic Well Floodplain ;w_; Wetlands Waterst►ed District ' Water/Seaver _ _ - I O � DESCRIPTION OF WORK�TO BE PREFORMED: 6-C ic. YO X100 o, a� � �h Ori /10 a Identification Please Type or Print Clearly) OWNER: Name: v # Phone:9-7F- �3' 3679 Address: z W11A 5� �cAVdV7Xj i eta r ha. µ . CONTRACTOR Narne:Pe �'� F z j iI ,fi(h a -� � _Phene.� � _ vf mj ;tom - . Address: Gtn lr►'1 .. _ h )� d 41 _ a t Supervisor's Construction License: �C�o�t 1 ' _, ='Exp. Date: k e _ Home Improvement Licenser Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F. Total Project Cost: $ y5- FEE: $ �! Check No.: I Receipt No.: NOTE: Persons contracting h unregistere contractors do not have access to the guarantyfund 1 � Signature of Agent/O.wnei ' ; igna-ture of contractor �� a Plans Submitted Plans Waived, Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS ` -HEALTH - Reviewed on Signature COMMENTS Zoning Board of-Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer:"Signature: - Located x384 Osgood Street FIRE DEPARTMENTTemp Dumpster;ostt yes`m o Located at 124ManS#rhe#. r Fire Departnennatufeldate.:: w ` .� . _ • _4 RK . �w w h e COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I i ❑ Notified for pickup - Date i j Doc.Building Permit Revised 2008 i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products j i NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I jl New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers .Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application l i Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. /-,,) Date Date col NORTM TOWN OF NORTH ANDOVER ►. 9 • I ; : Certificate of Occupancy $ • j-� �'�S'••• Etn Building/Frame Permit Fee $ scMus Foundation Permit Fee $ Other Permit Fee $ ` TOTAL $ Check # / 2 3 2 j 5 Building Inspector ORTH Tovm Of Andover O •� l '`�K` ' to A K E O d®ver, Mass., COCMICMEWICK V ADRATE D PP���� Is, BOARD BOARD OF HEALTH Food/Kitchen .Pr. RM IT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT..... ?. 1�°Z. — '. ..................................................................................................................... Foundation has permission to erect........................................ buildings on ...j........ . .. ' '1.....sj��. .............................................. Rough t 1:e.. � ....... /.. ...........���.. .1. ..................F-I/—/e) ..... '1�4 J Chimney to be occupied as................ ........... .. ..... ........... provided that the person acceptin this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSI MTI STARTSRough ............................................ ,..,.....:.......................... Service BUILDING Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lath.ing or Dry Wall To Be Done FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. e7 rJ�rPrJ�rPr�rJ�cPcPPrJ�c�.Pr.PrJ�i=Pr.Pr Pr1 V _-�.- T °��° DOCUMENT. 7 � PLPff Eli C 7 ] , �1 - t -1 5 , 5 ! ISSUED BY Date of Shipment 5 °' REGISTRATION 4/30/2007 5 ` 5 NUMBER y NDE=SIRIE INC 5 EVANSVILLE, INDIANA 47725 Tent Identification C5 C ti S1:140.1 �r E ° MANUFACTURERS OF THE FINISHED 04464877 STENT PRODUCTS DESCRIBED HEREIN >- SThis is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: 5 657150 5 5 PETERSON PARTY CENTER IN� 5 I 139 SWANTON STLJ 5 5I 5 �I 5 WINCHESTER MA 1890 5 4 5 S 5 5 5 5 5 5 01 Certification is hereby Bade that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 Schemical and that the application of said chemical was done in conformance with California 5 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. S SSerial# 5 5 8047000(2) 5 5 SDescription of item certified: 5 S NAVITRAC END 40WX20 SNYDER 5 WHITE VINYL 5 5 Flare Retardant Process used Will Not Be Removed By 5 Washing5 5 �rld Is Effective The Lite �f The fabric 5 5 SN}"DER MFG NEW PI IILADELPHIA;OI{ Signed: -x_-- � 61L . Pj Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. tj CO 1�cPrJ�rJ�rPr�r�rPrPr�r�rPrJ�iJ�cPrJ�rsrJ�clPr�rJ�u'�r�un��l��nr��mr�rJ�rJ�c1�P�LPrPrJ�r�rJ�rs1�1�PrJ�rPrs?�Pclfl�u'�r��rJ�rPr1rJ�rJ�rJ�r�cPr�cfrJ�rJ�rJ�r�cPcPrJ-r�rJ�r1� ryf,. ..:.. ... ._.»c,:.:.�.:....�. -.. 1.�. a.':r:),. - .i_"� ,.s.i.:u. {•+4 �:_: a.�,-rr ---------------------------- l zt - s:-•>v:. �'tr _..gc4��.s__�— .. - z�. } xq�1'�, • l LJ rJ�rJ�rJ��Pr�cJ��Pc.�r�rJ�r_P�rJ�rJ�r�rJ�i 1 �c�� ® ti t� �'t�c�rs I ®���r������������(�� ❑o ' ri'•yr S� 3 j . 5 ii Y� I 5� Certificate of la d Res ee 5 5 REGISTRATION ISSUED BY 5 S APPLICATION Date of Shipment 5 �e 8/28/2006 5 a 5 NUMBER _jINDUSTRIEINC. 5 z. 5i a 5 i EVANSVILLE INDIANA 47725 Tent Identification 5 17140.1 MANUFACTURERS OF THE FINISHED 04337696 TENT PRODUCTS DESCRIBED HER 5 This is to certify that the materials described have been flame-retardant treated S t: 5 (or are Inherently noninflammable) and were supplied to:657150 5 SPETERSON PARTY CENTER INC 5 139 SWANTON ST 5 5 5 WINCHESTER MA 1890 5 5 5 5 5 5 5 � 5 5 5 j Certification is hereby made that: 5 S The articles described on this Certificate have been treated with a flame-retardant approved 5 jchemical and that the application of said chemical was done in conformance with California 5 SFire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 5 Serial # 8047200(1) 5 5 Description of item certified: 5 NAVITRAC MIDDLE 401AIX15 SNYDER 5 WHITE VINYL 5 5 5 Flame Retardant Process Used Will Not Be Removed By 5 Washing And Is Effective For The Life Of The Fabric 5 5NF9 - --- 'W 61 5 cNvnl;;lzbnt:r, u,nr-rrr aro=r ���-ria nr_r Signed: 5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 .p ��P�Pr.PrJ�rJ�rJ�cPr�"?.J�rJ�cPr.Pn.J��.�f N T SI to of 5 �� S REGISTRATION ISSUED BY Date of Shipment C APPLICATION @ ' OM8/28/20065 NUMBER NDUSTRIE INC. ., Cj 5 EVANSVILLE, INDIANA 47725 Tent Identification 5 5 1=140.1 © MANUFACTURERS OF THE FINISHED 04337696 5 TENT PRODUCTS DESCRIBED HEREIN [� S This is to certify that the materials described have been flame-retardant treated 5 ; r, 5 (or are inherently noninflammable) and were supplied to:657150 S SPETERSON PARTY CENTER INC 5 139 SWANTON ST CWINCHESTER MA 1890 S i S 5 5 _ 5 5 5 5I 5 S� Certification is hereby made that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California 5 S Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. S 5 Serial # 5 5 81047200(1) 5 5 5 Description of item certified: S5 NAVITRAC MIDDLE 40WX15 SNYDER 5 WHITE VINYL 5S 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric S 5 '�nivnra NMY,NFW 13HII anrLLA O[ Signed: 5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 CjPc(�rPrPf���r�Pr�rJ�rJ�rJ�r�cPrJ�r�r P�Pr�r�rJ�rJ�rJ�rJ�rJ�rJ�rJ�rJ�rJ�rJ��PrJ�iJ��Pr�r�cP�Pr��Pr PrJ�rJ�cPrJ�rJ�cJ�rJ�rJ�r�rJ�rJ�r�rJ�rJ�cPrPr�rJ�r�rJ��Pcl�PcP�P�P�P�PrJ��PcP�P O af` - ., _....' ,-..,:.:.._":...�..���:..:ks. ::...a..,i�•.>_.�•,..�_... .:.,,..3..,-. -rc�:.=4X✓'+:s^.5..,'e`.�1•;�: 4.--:�}w'YA.r.r�. ..��i`Pd':`W`Lv�s ]f�`� =nea�.aa�,.-=.�..,^..r�ws-` _.a+.s°:"i..' - �''�.r�,`ls,�•�s CICPC�CPCPCPCICICILPLI�L C1�r�ClCPCl G - ` ' `�` `:t Y �PCPOPEEPCPCPLI�CPLI�CPLI�CPCJECIP�PCP ❑° c ' �: Certificate to of Fly esis ee 5 � S S S REGISTRATION BY S APPLICATION a Date of Shipment 5 5 NUMBER INDus?RIEINC. 8/28/2006 5 EVANSVILLE, INDIANA 47725 Tent Identification IS 5 1=I40 1 ®p MANUFACTURERS OF THE FINISHED 04337696 5 5 5 TENT PRODUCTS DESCRIBED HEREIN 5 y 5 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to:657150 5 5 PETERSON PARTY CENTER INC 5 S139 SWANTON ST 1 WINCHESTER MA 1890 5 5 5 5 5 cCertification is hereby made that: S SThe articles described on this Certificate have been treated with a flame-retardant approved 5 Schemical and that the application of said chemical was done in conformance with California S 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. S Serial # 8047200(l) S CCS Description of item certified: S 5 C, NAVITRAC M[DDLE 40Wa1�SNYDER c 5 WI-LITE VINYL 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 CNYIIER MEG NJEW PHIL ADD PI-41A AH Signed: -�-- � � � Pj I'j Name of Applicator of Flarne Resistant Finish ANCHOR INDUSTRIES INC. U t�cPCPCPr��PCPEPCPEPEPEPCPCPCPr�CPCPCPClrJ�rJ�CPCPCPr�CPrPr�EPCPCPE I��r�Et�cPEPC PEPCPCPEPEI��PCPCPCPEPCPEPCPcPrJ�EPrJ�CPEPEPCPCPCPr�EPCPEPCPCPEPEPEPCPCP 0 O./ • r ,...a.:..-.'. - ,. .. � t.,.a.2x.issx'i3�XJ;!/ei'7dJ eu _ - — _ _ __ �}y� IHSS p'T EEO` �#"u-e �PLnCJr1CP�lC�PCPCPCPL(L(CPCI�LI� t fJ t;b'>� � �� .a.��� w±iS L, zrv. SCortif of an-N Resistapee c5 ISSUED BY S F' REGISTRATION Date of Shipment S SAPPLICATION ' S NUMBER us H ei8/28/2006 5 C� EVANSVILLE, INDIANA 47725 Tent Identification S 4 I=140.1 MANUFACTURERS OF THE FINISHED 04337696 5 r` ,7 TENT PRODUCTS DESCRIBED HEREIN 5 E' ; This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to:657150 5 5 PETERSON PARTY CENTER INC 5 139 SWANTON ST i 5 5 WINCHESTER MA 1890 5 5 _ 5 5 5 5 5 5 Certification is hereby made that: 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California 5 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. C5 5 Serial # 5 8047200(l) C5' 5 5 Description of item certified: 5 NAVITRAC MIDDLE 40Wa15 SNYDER 5 5 WHITE VINYL 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 �AIY1�2 MM NFW 131 AnF1 13HIA 014 Signed: 5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 � rJ�crclcPr�c�rJ�LrrJ�r�rJ�rPr�cPr�rJ�r��.rr�rJ�cPrJ�rJ��rJ�r�r�r�rPr�cP�PrPcJ�r.nc.PcPrJ�rJ�rPr�r�r��.rcf�rTrf��Pr�rJ�rJ�rJ�rJ�rJ�r.rr�rJ�cncPrJ�rJ��rJ�r�rJ��P�n�.ncP�PcPrJ��P o E k3(r��rs'=J�rJ-D�rJ�rJ�r�lnFLUDiara�rl��fi. ._. �_._._.�.�:.Y......._�:.._:.—.IMPORTANT 4 DOCUMENT�P�PcPr�rlrJ�rJ�r�rJ�rJ�rJ�rPr��PrJ�cP O `` +, � ` S 5 5 . -Hic to of -'Flan-?e esi ce 7 ISSUED BY Date of Shipment 5 5 REGISTRATION 4/30/204 uc�f $o 0 5 5 NUMBER v INL`USTNES INC. 07 5 5 SlF �� EVANSVILLE, INDIANA 47725 Tent Identification 5 i 5 MANUFACTURERS OF THE FINISHED 04464877 5 h F140.1 E S TENT PRODUCTS DESCRIBED HEREIN 5 5 . S This is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: 0 5 r 657150 5 PETERSON PARTY CENTER INP 5 5 139 SWANTON ST 5 5 5 SWINCHESTER MA 1890 5 S 5 5 5 5 5 S (`ertification is hereby made that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California T 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 I5Serial # 5 j 8047000(2) S 5 Description of item certified: S 55 5 NAVITRAC END 40��a30 SNYDER t WHITE VINYL 5 Marne Retardant Process Used Will Not Be Removed By 5 5 5 Washing And Is Effective For The life Of The Fabric 5 5 SNYDER MFG NEW PHILADELPI-IIA,OIi Signed: 'W ( _" 5 IPj Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 � �c1-rS�PrJ�rJ�rJ�rJ�r�r�c�.J�rJ�cPrJ�rJ�rJ�rJ��J�r��r�rJ�r_Pr.Pr.Pr�rJ�rPrJ�r�rJ�rJ��Pr�r.J�rPr�rJ��PrJ�oPr��P�r.P!��P�PrJ�rJ�r�rJ�r�r.PrJ�rPr��PrJ�rJ�rJ��r�rJ��P�Pr�rJ�r�rJ��PrJ� t] The Commonwealth o ?lxas a f s cli iisetts r, Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ,l.fA 02111 www.111ass.00VIdia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Pi..umbers Applicant lnforrrtation Please Print Le MIy Name (Business/Oreanizatiowindividuall: paw h [1 Address:�3Sf- City/State/Zip: 6Jj� p -� M A Phone #: - 70? - yD o o Are you an employer?Check the appropriate box: . 1.❑ 1 am a employer with 90-D 4. Type of project(required): ❑ 1 am a general contractor and I 6. E]New construction employees(full and/or part-time).'` have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp. insurance. [No workers' comp. insurance S. 9• Q Building addition ❑ We are a corporation and its required.] officers have exercised.their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] * employees. [No workers' �- comp. insurance required.] 13.®Other /�br _7-P17 • fill out the section below showing their workers'compensation policy information. Any applicant that checks box q t must also t HOmCONners who submit this afridavitindicating ac Po y they are doing all work and[lien hire outside coattractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-c6mtrectors and their workers'com . li p po qy information. I ant an employer that is providing workers'compensation Insurance for my employees Below is the of information. / p Icy and fob site Insurance Company Name: 1bel&Al Policy 4 or Self-ins. Lic.#: Z -96 /7 a 9 Expiration Date: O Job Site Address: f City/State/Zip: Attach a copy of the work s'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S I,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebn cer,�ifp Hier lire sins an enalties of perfnr1,that the information provided abo►r is tr a and correct. Si nature: Date: Phone{f• 7oseD"" Do not►vrite in this area,to be contpleded by cl or town official 4 ,/f Permidi,lcense# rity(circle one): alth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plurrtbittg Insp ctor ii! Public 13(1;1(*(! of 13uildin" Re�-, ui;rti<ln: ;rn(! `t;rn(l; l-('k Construction Supervisor p or License License: CS 60219 Restricted to: 00 MARK TRAINA 33 HANFORD RD STONEHAM, MA 02180 Expiration: 4/27/2011 ( mmksiititer Tr#: 14425 s Client»: 635556 PETERPAR2 ACORD- CERT(E l(__'A C OF LIABILIT'UT NSURANCE DATE(MM/OD)Yl'1') Prooucea 416/10 THISIFICATE IS ISSUED AS A NATTER OF INFORMATION USI Iris Sery of MA, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O Pox 920444 HOLDER.THIS CERTIFICATE DOES NOT Ar„END,EXTEND OR Needham, MA 02492 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INsureo INSURERS AFFORDING COVERAGE NAIC# -- Peterson Party Center Inc INSURER A: Hanover Insurance Company 22292 139 Swanton St I>,SURERB: Liberty Mutual Insurance Company 23043 Winchester, FAA 01890 INSURERC: INSURER D: COVERAGES INSURER E: .1 I I THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW MAY PITHSTANDING J ANY RECUIREt 1ENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN LTR NSa TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DAT[ MM/DQfYY DATE MM/DDNY LIMITS A GENERAL LIABILITY ZBN6482025 10/09/09 10/09/10 EACH OCCURRENCE $1,000,000 X COMIMERCIAL GENERAL LIABILITYD.:'.1AGE TO RENTED r- 5300.000 CLAIMS MADE lil OCCUR MED EXP(Aly one person) S5,000 PERSONAL 8 ADV INJURY $1,000,000 GENTAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY X jE 0 X LOC PRODUCTS-COMP/OP AGG Q 000 000 A AUTOMOBILE LIABILITY AMN6398554 10/09/09 10/09/10 ANY AUTO - COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY 5 (Per person) X HIRED AUTOS - X NON-OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ -- (Per accident) GARAGE LIABILr Y ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ -. AUTO ONLY: AGG A - EXCESS/UMBRELLA LIABILITY UHN6482021 10/09/09 10/09/10 - EACH OCCURRENCE $5000000 X1 OCCUR ❑CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE - $ RETENTION 5 None $ f B WORKERS COMPENSATION AND WC2Z11259617029 10/09/09 10/09/10 X WC STATU- OTH- EMPLOYERS'LUIBILITY - ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1$500.0 Q OFFICER(MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $5001000 SPECIAL PROVISIONS below OTHER E-L.DISEASE-POLICY LIMIT IS500,000 nESCRIPTW)N OF OPERATIONS I i OCATIANR I VEHICLES I Fxrt USIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ,30_ DAYSWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILRY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 252001108 )1 of 2 #S4312552JM4063373 BJECG 0 ACORD CORPORATION 1988