HomeMy WebLinkAboutBuilding Permit #606 - 106 MEADOWOOD ROAD 4/16/2008 BUILDING PERMIT of"°oT bgti
TOWN OF NORTH ANDOVER Fes`° =� *°
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received `4..
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�SSACH�1`��t
Date Issued: d
IMPORTANT:Applicant must complete all items on this page
LOCATION 106 eacle>,-,A1�oaA
Print
PROPERTY OWNER_ "So
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14—
MAP N PARCEL: ZONiNG DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Res•dential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Vookepair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
9(f'r� ce �r�ctS�•l t\ew raoF kes
CrtJ,
Identification Please Type or Print Clearly)
OWNER: Name: RsIec-, Vtsc, Phone: q78� 6?7 621?
Address: 1 6 Meadow6a- 'Qaaj
CONTRACTOR Name- P ex4s : �; 1 Zc.&s Ph-one:-W 1 76G �a i
Address: 2923 , U3o�o%kc rk- (Y\A Q W&E-
Supervisor's Construction License: GS 0-73cf q I Exp. Dater 7 5 see ,
Home Improvement License: 2`�►ZZ Exp. Date: -711,q 01
ARCHITECT/ENGINEER I Phone: r
Address:_ N 1 Pr Reg. No. is� °A
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ /-I- 600 x Z FEE: $ JM
Check No.: 30 Receipt No.: J/0
NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund
Signature o Agen wnergnature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
=PublicSewer 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 CORM
DATE REJECTED DATE APPRO ED
PLANNING & DEVELOPMENT
COMMENTS `
P 3
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 Tows E iii peer: 4' e:
�r< Located' 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
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
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
LocationA�L�,
No. t� Date
MORTh TOWN OF NORTH ANDOVER
F D
41
s i
Certificate of Occupancy $
41
��s'•^ E<�' Building/Frame Permit Fee $ Mp
�
+cNus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 ' 0 8 5 Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
t
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: . 0 . '3oX 2423
City/State/Zip: (DobwMA 01?•rs- Phone.#: _7O l '760 2031
Are you an employer?Check the appropriate box: Type of project(required):_
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
co insurance.$ 9 E]Building addition
[No workers' comp. insurance comp.
required.] 5. ❑ We are a corporation and its 10..❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12R sof repairs
insurance required.]t c. 152, §1(4), and we have no WO
employees. [No workers' 13.❑Other
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 a new affidavit indicating such.
$Contractors 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: ?k (AC t)AIN'N .
Policy#or Self-ins.Lic.#:' 6 012 107 012-00-7 Expiration Date: -7 D 0
7 a
Job Site Address: t Z M O�.aoOd� AG OF-,_ City/State/Zip: NorY�^JAncl-Dver AIA,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 01j
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby certify under t e s and penalties of perjury that the information provided above is t ueand correct
Si atde: Date: t� 6� _
Phone#:
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." '
i
An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint 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 notmofe'ihan thre�,apartments and-whoresides 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"e cry state or local licensing agency shall withhold'the'issuance or
renewal of a license or permit to,opecate7a 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(t)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 maybe 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 D'epartiienthV provided space at the bottom
of the affidavitfor you to fill out in the event the Office of Investigatons_.has to contact you fegar¢ing 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 ap#vit_Odic&ting current
policy informs 'ori(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 mark
ed by the city or town maybe provided to the
applicant as praof 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephoiie-land fax number:
' �`
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 0.2111
Tel. #617-727-4900 ext.406 or 1-877-MASSAFE
_ Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
` L1ORTH '9
TO" of And
No. �0 to
•. ` ' POW
C" o dower, Mass., O
COC MICKEWICK V
TED
`S E BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING.INSPECTOR
THIS CERTIFIES THAT..... ......S.l.�o...........WS.0
..........................................................�t0....... Foundation
.........
has permission to erect.. buildings on AM ! V& .4"J ................... ............... Rough
to be occupied as...... .....�..:. ......O..r ...�.....................................................................................................................
Chimney
provided that the person accepting thi rmit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the odes 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 CONSTRU ARTS 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.
Nexus II Carpentry and
Construction Design
P.O.Box 2823
Woburn,MA 01888
781760 2031 or 978 688 7929
Fax 978 9751263
Contract
This is a contract dated April 4th,2007 between Hsien Hsu of 106 Meadowood Road,North
Andover MA 01845 (Hereafter referred to as the"Owner"), and Nexus H Services (hereafter
referred to as"Nexus")to carry out work as noted below.
GENERAL SCOPE OF WORK DESCRIPTION
WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: replacement roof and
leak repair
General details
♦ Furnish and install lifetime warranty architectural roof shingle—Timberline Slate
♦ Furnish and install drip edge
General
♦ Remove all associated trash materials and clean up yard of any debris
Work not included in this contract
Permit costs
—Unseen conditions
—Painting or staining
PERMITS
"Nexus"will accept responsibility to obtain the necessary building permits. "Nexus"will act as a
GC and work in accordance with fair and reasonable practices, and cooperate fully and under the
guidance of the"Owner"and authorized parties. Any costs of necessary permits will be added
to overall contract price at second payment.
Standard Exclusions:
Nexus H Services will not be responsible for the existing structure or previous work
associated with the existing structure.
SPECIALIZING IN QUALITY FINISH CARPENTRY REMODELING SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
i
Unless specifically included in the"General Scope of Work" section above,this agreement does
not include labor or materials for the following work(any Exclusions in
this paragraph which have been lined out and initialed by the parties do not apply to this
Agreement): Removal and disposal of any materials containing asbestos or any other hazardous
material as defined by the EPA. Custom milling of any wood for use in project. Moving
"Owner's"property around the site. Labor or materials required repairing or replacing any
"Owner"-supplied materials. Repair of concealed underground utilities not located on prints or
physically staked out by"Owner",which are damaged during construction. Surveying that may
be required to establish accurate property boundaries for setback purposes(fences and old stakes
may not be located on actual property lines).
Final construction cleaning("Nexus"will leave site in"broom swept" condition). Landscaping
and irrigation work of any kind. Temporary sanitation,power,or fencing. Removal of soils
under house in order to obtain 18 inches(or code-required height) of clear space between bottom
of joists and soil. Removal of filled ground or rock or any other materials not removable by
ordinary hand tools (unless heavy equipment is
specified in scope of work section above), correction of existing out-of-plumb or out-of-level
conditions in existing structure. Correction of concealed substandard framing.
Removal and replacement of existing rot or insect infestation. Construction of a continuously
level foundation around structure(if lot is sloped more than 6 inches from front to back or side to
side,"Nexus" step the foundation in accordance with the slope of
the lot). Exact matching of existing finishes. Repair of damage to roadways, sidewalks,or
driveways that could occur when construction equipment and vehicles are being used
in the normal course of construction.
The"Owner"is to enter into contracts for all of the above-mentioned services and provide direct
payment to"Nexus"for all of the services we are to provide.
"Nexus"will be responsible for removing all components and all construction materials relevant
to the "scope of work" in this contract.
Nexus will not accept or assume any responsibility or liability for the structure or for its
manufacturer's warranty.
Trailer and Dumpster notices
"Nexus"will make arrangements for removal of all site debris created as part of the above scope
of work and will coordinate with the local building department to confirm all
guidelines are followed. Throughout the duration of the scope of work"Nexus"will have park
on site their own trailer vehicle which is utilized to store materials and tools required to complete
the work noted. This trailer is the sole responsibility of"Nexus" and will be appropriately
insured under the company insurance policy of"Nexus".
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS.SITE AND
PROJECT MANAGEMENT
r
Contract Cost and Payment Schedule:
Total cost of work description and materials included in the proposal(excevt
materials/work stated) -$4.600.00—(Four thousand dollars and zero cents)
PAYMENT SCHEDULE
Final payment due upon completion of scope of work TOTAL $4,600-00
I have read and understand, and I agree to,all the terms and conditions contained in the
proposal above.
Date... ......"Nexus"Authorization.......... ....
.................................
Date... PT.. "Owner"Authorization.
Date..............................." Owner"Authorization......................................................
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING SPECIALIST ROOF SYSTEMS SITE AND
PROJECT MANAGEMENT
Guenur.avww N`t 11121107
_ 4yaRf.F,� CERTIFICATE OF LIABiLl1'1(EINSURp► EO ASA"A17ry1��CrIcNF41RAMPCION
THIS C
PRODUCER ONLY ANU GUNFEK5 KU Kt(�117'S UYLI
Conifer Insurance Agency,InC• HOLDER.THIS V RAGE AFF RDE NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES 6ELOW
10 Centennial Drive I NAIC#
Peabody ,MA 01960 INSURERS AFFORDING COVERAGE 33618
978 5325445 INSURER A. proBuilders Speciality insurance Co.
INsuRro wSURER e: Safety Indemnity insurance Co_ L(-
Nexus it ServlceS LLC INSURER c
p.0.Box 2823 INSURER D:
Woburn,MA 01888 INSURER e:
COVERAGES
E FOR THE POLICY PERIOD INDICATED.NOTWITNSTANDIN
IB D HEREIN IS SUBJECT TO ALL TME TERMS.EXCLUSIONS AND
CONOITiONS OF SUCH
T}{E POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TSE INSURED NAMED ABOVE
OR
ANY REQUIREMENT,TER
MOR CONDITION of ANY CONTRACT ORC Tt1ER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 6E 19SUED
MAY PERTAIN.THE INSURANCE AFFOROEU 8Y THE POLICIES D POLICY E OCTNE POLICY EXPIRATION UNITS
POLICIES.ADOREOA?E LIMITS SHOWN MAY HAVE 9EEN REDUCED BY PAID CLI►POLI TE MwoD S1 000 000
POLICY NUMBER 08/12/013 EACH OCGURRENCE s50 000
t N50. TYPE or via 08/12/07 DAMAGc YO RENT
A GENERAL LJAsILITY
NB5016032 MED EXP TAnr ana pusoN S5000
X COMMERCIAL GENERAL LIABILITY PERSONA 6 AOV INJURY Si 000(100
CLAIMS MADE I ^'OCCUR ATE S2 000 000
GENERAL.AGGREG
X Bpi)Ded:1 500 PRODUCTS•COMPIOP AGG $1000 000
GENL AGGREGATE LIMIT APPLIES PER
-
PRO- Lac 11/10107 1lnolos COMBINED SINGLE LIMIT S
g AVTOMOBILELIA9ILTTY
3116632 (Ea acdCanq
ANYAUTv BODILY INJURY $250,000
(Pat pascal)
ALL OWNED AUTOS BODILY
X SCHEDULED AUTOS (paras drki)INJURY 5500,000
IporACCdB�U
X HIRED AUTOS
PROPERTY DAMAGE S100,000
X NO*oWNEDAUTOS (PereecidaaU
AUTO ONLY-EAACCIOENT S
AN
GARAGELIABLITY AUTOOCFrHER ONLY;
EAACC S
AUTO ONLY; AGG S
ANY AUTO
EACH OCCURRENCE
AGGREGATE S
EXCESSRIMBRELLA LIABIUTY $
OCCUR Cl CLAIMSMAOE S
S
DEDUCTIBLE WC STATU 0TH-
RETENTION 3 5
WORDS COMIMSATION ANO E.L.EACH S - —
EMPLOYERS!LIABILITY EL DISEASE.
r-A ET IPLOYE S
A RF CEWRoPPRE p�C<JTRrE EL.015FJISE•POLICY LIMIT 5
OMBM
It Yee.Id�aaPa+bROoW 1 N
OTHER
DE ,pT,0N OF OPERATIONS I LOCATIONS I VENICLES)E7LCLUSIONS ADDED BY 6NIloP9EMENT I SPECIAL PROVISIONS
CANCELLATION
POLICIES BE CANCELLED BEFORE THE EXPIRATION
CERTIFlCATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL JL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFY,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,fig AGENTS OR
REFRESENTATIVEB.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 2 #56714 RBU +a ACORO CORPORATION 1988
E3t�N�l�l OF
License: CONSTRUCTION SUPERVI501;
Number. CS 073991
Birthdate: 04/07/1962
Expires:04/07/2008 Tr.no: 21477
Restricted: 00
GERALD WHITE
54 EMERALD DR
LYNN, MA 01904 Commissioner /
110i1t t10f lhlMiilj;licgiilhto s hili!.Standard, License or registration valid for individui use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. it found return to:
Registration: 129177 Board of Building Regulations and Standards
Expiration: 7/19/2009 Trll 133317 One Ashburton Place Rai 1301
Boston,Ma.02108
Type: Individual
Gerald White
Gerald White
54 Emerald Drivet,.,Gtcw.� _ , -
Lynn.MA 01904 Administrator Not valid without signature
RIFICATEF I �UKA1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
�DUCER CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS CERTIFICATE
C McCarthy Ins
•Trance igency DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW
I
FORDING COVERAGE
Centennial ,ive �I+ CONTANIE
S AF
eabody,MA -1960
1SURED
Lexus II Services LLC COMPANY E1 A.I.M.Mural Insurance Co
IbaNexusII Carpentry&Construction Design LETTER
1 O Box 2823 -
dJaburn,MA 01888
COVERAGES __ _ ANY CONTRACT OR OTHERDOCUMENT ETN S Si�)BJECT
NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO E FOR THE POLI
THIS IS TO CERTIFY THAT THE POLICIES OF INSURA - AFFORDEDj3y TILL POLICtLS DL'SCRiB.
PL=RIODINDICATL'•D,NOTWITII�SAAYND� HD.kF 'if ERCAIN,RTMHgNSURAhIEAF'
TQ, ]MCH THIS-CERTIFI�' CONDITIONS OF SUCH POLICIES•LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND LIMITS
TO ALL THE TERMS, POLICY EFFECTIVE P DATE(M�DD/1'1�N
POLICY NUMBER DATE(I1tM/DD/YY)
CO TYPE OF INSURANCE GENERAL AGGREGATE
LTR
PRODUCTS-CGMPlOY AGG.
GENERAL LIABILITY PERSONAL&ADV.INJURY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
OQCLAIMS MADEQOCCUR FIRE DAMAGE(Ady- tiff)
MED.EXPENSE(AnYd^cP�on)
OO\yNERS&CONTRACTORS PROT. .. ...._" -
COMBINED SINGLE
Q LIMIT
AUTOMOBILE LIABILITY
BODILY BJ1tJRV
(Pa pass+)
ANY AUTO
ALLO\VNED AUTOS BODILY INJURY
SCHEDULED AUTOS (per accidad)
HIRED AUTOS
NON-OWNED AUTOS PROPERTY DAMAGE
GARAGE LIABILITY
EACH OCCURRENCE
AGGREGATE -
EXCESS LIABILITY
UMBRELLA FORM __.: ._ .. .:'I'HER
ATUTORY LIMITS
OTHER THAN UMBRELLA FORM X
WORKERS COMPENSATION AND EL EACH ACCIDENT 500,000
EMPLOYERS LIABILITY
E PROPRIETOR/ EL DISEASE POLICY LIMIT 500,000.
A ARNERSw_xE� 6012107012007- 1]/07/2007.-. - .11/07/2008 500,000
FFICIERS ARE. .. EL DISEASE—EACH
INCL =EXCL EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR CATIONS.
_:CANCELLATION ._
CERTIFICATE HOLDER HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO THE CERTIFICATE
OL
HR DER ABILITY OF ANY KIND UPON THE�MED TO THE LEFT,BUT ILURE TO MAIL SUCH NOTICE SHALL IMPO
COMPANY,ITS AGENTS Of(R(.'PRESENTATIVLS SE NO Of3I IGATION
�1.
UTHORIZED REPRESENTATIVE
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