Loading...
HomeMy WebLinkAboutBuilding Permit #898 - 10 ASHLAND STREET 6/21/2011 TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Permit NO; Date Received Date issued: IMPORTANT:Applicant must complete all items on this page LOCATION Z A5bkx( � , �nc(jV ; Print PROPERTY OWNER t2 /re C a 1-r Ck - _Unit# 7 Print MAP NO: PA.RCEL:o-d ZONING DISTRICT: Historic District yes no nit Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 11 Demolition ❑ Others: ❑ Other �rrti. (-I wolf � �'j,e„ T„i�� � S17 � t it• 7 u vr uLCI/.�t;Vver DE CRIPTION OF WORK TO BE PERFORMED: St 112 Oxi , i (Identification Please Type or Print Clearly) OWNER: Name:_ b rncc(2x(-ri -L- 7.55/7 Phone k7 Z9T Address: 120 '&X -^—VQ �l�+m l�' CONTRACTOR Name: &an Phone: Address: I UYe LGr�i /I�J9 ©��jL Supervisor's Construction License: 99/y� Exp. Date: Z /Z Home Improvement License: 152-Z?3 Exp. Date: lS Za/Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.,$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: (t // �� 0'a . Check No.:_ % f/ Receipt No.: C/3/ NOTE: Persons contracting with unregistered contractors do not have access to ua � n Signature..of A ent/Owner.` ------ -- -- -. . Signature of contractor r Location No. —Jy'-�--- Date �ORTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Mus Et�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ 1 TOTAL $ Check #A 2451 ; Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art El Swimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/..c ales ❑ Private(septic tank,etc. ❑ Permanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS drr,i�.dd�saJs°rd :c,9id 'V�G`vt'1-.0 iJevl.{ lC1CUt�. I COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dempster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS I 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 ❑ Notified for pickup - Date f i Doc:.Building Permit Revised 2011 June/mi I I I - I a 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perr Addition or Decks ❑ Building Permit Application Li Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses C. Cory Of C011-0-act ��it�l�i'/del V �l�l. iOf i/ IeVdILfOf l 1--la i Gi Pro f sea V tfol'K V�!!'ii"i � i'ii�KiC1' i�ial� h\I p p �o Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o 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) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 1 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 Doc: Doc.Building Permit Revised 2008mi NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Pe at. g rmit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Filli (Location of Facility) Signature of Permit Applicant i Date � r p e D) AS /v SS t°. - cue f-Pe- �sst5cbbsattsconauA,�e�'GerruerL• seel<legalndvlcelfiueeessn -"""u 6LUrl.saw(ARMcha Office of Consumer guide to homeIUM hefine a n'• g- Pa on pla"a home' p I42A�'blit Bees not fnclude srandard A$airs and Be meas Its g�Cetngtn aa3'work on �p`a'{emen[s should first obtain a co " ��Rtztflolinlmns Consumer Yonr deengr-or 6lzs82 obtain copy by cit g the, .$ameowner�- �Uimalion Rn'Uno at 617- Y obtain a free c N /7l �� GO.0 aatorinf©rt 7s7. StedAddress(donutuseapo st O ic.;%x address) /-�rla�ddG�. � /�/�arlSaicsP�On/OcrnerName CiTYrfawn State zip Code siaessL.i 1s `S 6/�„� A (mu s[includeastnettaddre�s) D ePhaae EVMM, 9Phan R�sX.�J ✓yy//sGvs!mss/l�r myn", { g MailmgAddre5s(!i diffetnntfmM above) ffaP Code/ anslaessPhone mlosrermaemaaham6im �� loYerMOrS•S.-HImb er The Contrnetnr agrees to 6a uonx 09�tcauquar Ehe'=allowing worIt for the Homeo ae t 1, s"P�'�`d7G . em ewo 1t FM R Roquired.11ormits-The followin':b.:�Idin ' and b be seed gFetmits are ragaired prag�ascd Siart OZ, bcthecaatract6rLrDvisions, agent, beadheredto and Comp latfareschednle-Thefn { ers WhO SeCTIre their p t unless circumstances be HG*ing schedule will egCI�tded from the j ttI7tll4 - Yatid the eonlxaotnYa control wise MGL chapter 142A, ` Date when contractor will be • b`m cantmcted work, r'- --Acta when con Total Contract peace and pn r r hacted 'work will be substantially completed. T]reConhactora Ymp^ greet to perform the vowl4.tucsrish tltemat$lid!and labor specified above forth,total P A-hls will be made aba-o dieg t„the fonowing schedule: sum 6fi "� � ) CD (� an signing cont-.ct(sotto exceed 113 ofthe-totalcontract '> » Y �-,fib mple8onnf ►��{ ( ��r �eCosEofspecialnrderiteias,wfriebevcrisgreater} or Upaa Cn F r%1 t n by p.Mniplflan of S upott completion of the contract (Law forbids d emandin The f-Howba materiel/ P Ymemnntil corrhact is co 1 ntdamd before the e9�PT�tc^t must be special g • mP eted to both party's satis'fnetion) to meet the eanhacted w"'f begins fa order to be paid far Fomplefion sib-edulu('`) ---- to be paid for NOTES:(+)Ia"&9 all finance ch s not exceed the �) a }Iaw requites t My d whiehmusthe� of(eJrnte-tldrdofthe tatalcontraex�coar(b psAA 't�®y 9MrnntiacterbaforoWork begins arpY special ofd�••d m�v�ee to meetthe rnmplction schedule went or castor¢ Exnr�ss WnrrsafR r an Madematedal Sube}tntractoMa-='"tybeinnm �a s - �auizacmr n[=:s to he sole— Sv rna c a actar7 No yw PariYubcontrnctaruUlixed Yrespmrsiblefnrcoinmpdetianaf�ho antrrmsofthenrarron mustboattn atelia s and IaborUnder the co rirnctar The contractor further g work described regardless of the Ld u1e cantrne CongractAace titin a mcnt !=8 to be solely*bnsible for g �0m ofany third ptattce payments rgn= to all cantrictsball not im I 6,fibs doetrmcntbeeutnes a Ilia • subcontractors fm P Y that any Tien o=other sectni contract under law. TJaless orb carefully befora signg this canimct tY interesthas been placed on fire ie' erwise noted within sldence. Iter,iew the&Uomag oam o ns athis nd eS the Donkbepressuredinto eco mom$the contract Take rim¢to road and fol , rmvcta`a,, ti Ho n, fully underst=4 it Ask $ubcautractors fio be °TM1Ca Can cmr questions If aometltfn iegfsau6on registered:•::th the Direcinr ofHo a The law g is analeB, 1800-223-01i]'writingto thoI3 r cbocatOneAslrbotinnplar�eIt t 130 MMt Contractor ton,MAy02, y YoMost u inquire about�� �a t ID and Does the cnnitactar have in n+MA 02708 or by calling 617- `�0r " sma ice2 Check to see g ?27-3200 or KnowYam'rightsand trsponsibilities. Raeti �Youromhactoris Guide to the Romo-Improyemcm Can, Raflr l� properly r sea aide �Fortant lttfUrittation an the reYerse side of this form and get"copy of the Consumer you may cancel this a �-_ contiactorin writing atg emetrt if it has bean signed ata pfaee obex third business d g s/ltet maitt ogee orbranch othce I Mn@ CO otor'a narra, ay fnAowingdhe sign, z og by ordinary mafl'posted,fry telegramplace nfbusiness,Provided DO a�eetnent See lire attrcltedaotice of cancelli a orby delidety,not Iat:ct than m You n0fify the OT'�I�?`: '$C,$CO atfanformfar �ghtof[he 4Oidmth5la°piesofthaaa"Inh;mest6e MY , �tionOfthisright. �nmrn°aend5tsn<d,t3aecaPJ'sfioitld��i eath� F� SI'AC'ESI!! PXalwaidhel¢ptbythecantraaar, Homeowner'st1 � i Signature / F oohs mre .Si na /. s m . Date • f � ANORT►y TONM of over No. - �b _ o , dover, Mass., COCMICMEWICK ADr�ATED V? .2 S ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING.INSPECTOR P THISCERTIFIES THAT......... ... ..........��.... a.. .... . ........................................................................ Foundation Z.has permission to erect........................................ buildings on ...�5w/.......�...................�. .. ... . ......... Rough to be occupied as............................S... ...... . ......... ..... Chimney provided that the person accepting this p rmit shall in every respect co rm to the terms o 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 e PERMIT EXPIRES IN6 M LTS ELECTRICAL INSPECTOR UNLESS CONSTRUC N S Rough ~ Service ...................................................................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. i The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers Applicant Information Please Print Legibly I Name(Business/Organization/individual): -Ran k CandZCb ,lCald(JQ3 li& N AV64V Address: gi City/State/Zip: L 4? Phone#: Are yox an employer?Check the appropriate box: Type of project(required): 1. I am a employer with � 4. ❑ I am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y9. ❑Building addition We are a corporation and[No workers 5.comp.insurance ❑ � tid it10.E1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1l.❑P}�2mbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12. Roof in, insurance required.]f employees.[No workers' comp,insurance required.] 13.n Other *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 a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam 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 AddressJ -/Z thla17d S City/State/Zip:/U. Attach a copy of the workers'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$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. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for ins anc, ove age verification. X do hereby cert r tke p enalties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: 9-7 —1S2 [[Offuse only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# icial ssuing Authority(circle one): I.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: h i f i I ►� .� ,.•'�i� tis s.�,• ,c ,` „cu:L.�' !" "cerise: CS SL 99141' S Restricted to: RFW FRANK CANDIDO 34 W 6TH STREET LOWELL, MA 01850 Expiration: 4/6/2012 - (',snuuiscissni,r. Tr#: 99141 Officeo�oiume�air�s�dsin4tu a HOME IMPROVEMENT CONTRACTOR' Registration: 1.52283 Type: - Expiration: .`8/1 5M12 DBA CO'S H OME IMPROSVEM_E_NT. F_. i FRANK CANDIDO 14 41 SYCAMORE ST �R - LOWELL,MA 01852 _ Undersecretary I i i 6/24/2011 10:06 AM FROM: Risman Byette Insurance Agency, Inc TO: +1 (978) 688-9592 PAGE: 002 OF 002 6/24/2011 6:50:20 AM PST (GMT-8) FROM: insurancevisions.com-TO: 19788510106 Page: 2 of 2 .acted CERTIFICATE OF LIABILITY INSURANCE '" I THIS CERTIFICATE IS ISSUED AS A MATTER OF NFORMATIOM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER.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 WSURER(S), AUTHORRED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: M the tortiiicals hold►is an ADDITIONAL INSURED,the polig(iea)wwst be srMlar9 - M SUBROGATION(S WAIVED,subject to the teras and conditions d the policy,entlin policies wrap,puke an sndormswwwt, A atatswlwM so Ibis CertN'kimle does not mrdsr rights to the osrtiflente holds in Neu of such endarseere s. PRoallc�e BYETTE INSURANCE AGENCY INC 853 MAIN STREET .HONE 7 351-0105 TEWKSBURY, MA 01876 ArfORDaIO COYERACE MAIC i FAURER A 00UREG FRANK CANDIDO r+suRElre; DBA CANDIDOS HOME IMPROVEMENT 41 SYCAMORE STREET rlsisre6lo: 7 LOWELL MA 01852 r41MERE I COVERAGES CERTIFICATE NUMBER I0487465 REVISION NUMBER: - THIS 13 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 REDUCEO.BY PAID CLAIMS. Mit IRJINII TTIE OF INSURANCE EFF EJP rNurrrot LMfTr oENERALLIANK Y EACH OCCURRENCE $ COMMFACIAL GENERAL LIABILITY PREMISES E$Dean . f f CLANSJJADE OCCUR MED OP(Any one ) S PERSONAL i AIYV INJURY S GENERAL AGGREGATE S GEHI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COhPJOP AGO S POUGY PRO. LOC S AUfOMOaL[LMeLRY S ANY AUTO BODILY WARY(Fw PSI ALL AUTOS OWNED AUT ED BODILY IN kW(Pr acdd6A) S HII�AUTOB e NU �cadar� f UNNIMILLALMaOCCUR EACH OCCURRENCE $ Tis LIAR CLANSaIADE AGGREGATEH S DED RETNITION S 1 f i i A rraeam N"Tm MCI-311-357126-010 12MC 2010 12/10/2011 ,/ &TATS' I• V ANO EMPLGVERS•LAARRJTY ANY PROPREI?1 TDPPARER*_XFCUrNE Y J M OFFILERAEMrER EXCLUDED? aY MIA E.L.EACH ACCIDENT S (Yawdabry In MMI El.01SEJASE•EA EMPLOYE S M ,daaobsPTION ands$ OPERATIC bear E.L.DISEASE-POLICY LAW 1 50000 DEtCR/TDM OF OFiRAT101$fa/LOCJ1TIntle J tlEIeCIJEe t�h AC01�tet,A,$rA7n$f Aaa�r4s Bah$iNti AaIA YCa M r�quka/l THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR FRANK CANDIDO SHOUL.O.ANY OF THE ABOVE DESMSIED POLICIES BE CANCELLED BEFORE TOWN OF ANDOVER THE EXPIRATM DATE THEREOF, N0110E WILL BE DEUVEFM IN 36 BARTLETT STREET ACCORDANCE WITH TMEP0=V�1°iONS. ANDOVER MA 01801 M AUI110R aE V&SENTATRE Jeff El&iclge O 1910-MIC ACORD CORPORATION. All fights reserved. ACORD 25(2010105) The ACORD$lams and logo ars registered nil mft d ACORO Cor NO., 1040716S CL10:T CODs: 1!77061 Dob Deroohm oat 6/24/20LI 6:46:14 AN Peg* I of 1 TEis certifiesta Cancel$ and avvercada$ ALL pro iously issued certificates. I ATE(MMIDD/YYYY) ACORQ CERTIFICATE OF LIABILITY INSURANCE D4 06/23/2011 PRODUCER 978,851.6678 FAX 978.851.0106 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Byette Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 853 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Tewksbury, MA 01876 Shawna Lamarche INSURERS AFFORDING COVERAGE NAIC# INSURED Frank Candido INSURER A: Max Specialty DBA: Candido Snowplowing INSURER B: 34 West 6th Street INSURER C: Lowell , MA 01850 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDT TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MM/DD/YYYY DATE MM/DD/YYYY GENERAL LIABILITY MAX012400005403 11/03/2010 11/03/2011 EACH OCCURRENCE $ S00,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 50,000 CLAIMS MADE FX] OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 500,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION TO FOLLOW UNDER A T TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N I ANY PROPRIETOR/PARTNER/EXECUTIVE❑ SEPARATE COVER E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR I 36 Bartlett Street REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Andover, MA 01801 Shawna Lamarche/SHAWNA ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD