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HomeMy WebLinkAboutBuilding Permit #943 - 107 COLGATE DRIVE 6/29/2012 BUILDING PERMIT of "un rry q O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ l( 4. ' Permit NO: �l Date Received �,yA°R�rEo * � f, ^ SSACHUS� Date Issued: C�� IMPORTANT:Applicant must complete all items on this page 1E y 't -1 - 1 Jr�•�• fk Y 4:j. .(y ' it '.T fir r Tx. i'y t T 3 { rYj L OCATIOI 7i f ti rT }�R�i t �P ✓ Y L t, 3 r { < OS. z -.�4i r i } � ?t, �K �t a q : r 1 r•}- > ,� _��' '- ��' ++1� z �- d ) --, .r � r AA z a M 9..� t { +tr L3�r• _. 11.ar }PROPERT�I 1�UNERb >� - 5 x� M,50 5+3.`)t �& x.✓ +r. +r yZ �rt f i- 1 { MAP7N0 3F 4, r`P,�4F�CEL�P �°; ZONING bISTRIG� � z�� t Historic DistFxct �t t' � ,3 �yes�.�r o ' �.r. .1s �. .� t 4 r + s 9 4 5�.t h ♦ � i r c $ c e- r �� 3 su �,:i; z x fti x' TYPE OF IMPROVEMENT PROPOSED USE Reside - I Non- Residential ❑ New Building Rr6ne family ❑Addition ❑Two or more family . ❑ Industrial ❑AI ation No. of units: Q Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ©Septic` C�Well t T x " C�Floo�iplam ti�Wet{ands alllatershed`Distict 2 v„-;r ��1„c �,.f. w �F.�•`l.�r+ s 'f -� .t?� 1 -. t' S �r � x tt � � � r � .: N ESCRIPTION OF WORK TO BE PREFORMED: 'f 0d t--- /'<� /\')0 Y/9-1-- /N-S-7—/ALL. )}t?C- O e R,14161 --f 6 d -S h,,V CA.-L-e- Identification Please T e or Print Clearly G i OWNER: Name: �' �//�D�V10 L LJ/4 Phone: Address: CONTRACTOR Name wk Phone ; 5-4 ,Address' •! i i } .r� !1 S i } f 3 I e '`2. x' ,�r F 3 Y � Ca�� t - �Supervisor'sYConstrnGtioni,icenser + r r h ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PER T.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. a e) / Total Project Cost: $ V�C�d FEE: $ (!�� Check No.:-- Receipt No.: ,� b—/ NOTE: Pers ns contracting with unregistered contractors do not have access to the guaranty fund ma inaturef`Aent/ wner : Si .nature of contractor r Location/6'0)— �S Ls N 04., No. Date • • TOWN OF NORTH ANDOVER ® SO Irl)r ye' e 0 Certificate of Occupancy $ . Building/Frame Permit Fee $ � 1 Foundation Permit Fee $ �J R Y Other Permit Fee $ TOTAL $ Check# , 25469 Building Inspector 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE,DEPARTMENT Temp Durnpster on site ,des 71s Located at 124 Main 5tree# Fire Department si natureldate 9 COMMENTS ti 4 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 2007 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 2.2007 7-1 an' z ✓ - , Office.of Consumer Affairs&'BGsiness Regulation THOME IMPROVEMENT CONTRACTOR ' Registration: ,101;03358 Type: Expiration: Private Corporati . ASH&Sg #t Arthur Walsh Jr. 55 Pleasant St N Andover, MA 01845'x. Undersecretary y* i Massachusetts- Department of Public SafetN Board of Building;Re-ulations and Standards '�ff Construction Supervisor License +, License: GS 22680 9 � 4 ARTHUR J WALSH JR 159A WAVERLY RD N ANDOVER, MA 01845 t Expiration: 6/9/201 Commissioner Tr#: 29327 � y NORTFI Town of S E ., Andover o - to No. - h ver, Mass, ' �� • 1 A coc"Ic"t—C. 11 7,9 poRATED �P�,`,`5 S U BOARD OF HEALTH PERM !X T LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erectCFoundation........ buildings on ... Rough tobe occupied as ...........f� . ... .... ....................... .� . ... ... .......�........................... Chimney provided that the person accepting th permit shall in every respect confo to the terms of the application Final on file in 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 CONSTRUCT ST TS Rough Service ............... ....... ................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building 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. Smoke Det. SEE REVERSE SIDE MASSACHUSETTS ROME IMPROVEMENT CONTRACT This form.satisfies-all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but doei not include standard language to protecthomeowners. Seek legal advice If necessary. Any peis m1planuing home�tnprovemonts should first obtain a copy of"a Massachusetwoonsumer guide to home improvement"before ag-mg.to any work on yourriesidence.You may obtain-a free copy by'calling the ' Office of Consumer;Affairs and.Business•Regulation's Consumer Information Hotline at617-971d8787 or 1..888:283-3757: Homeowner Information 'Contractor Information ame .. pang Name XS . Street Address(do not use.a Post-Officeea address) trector/Salesperson/Owner Name /07 vG C,47?�- AfK Cityrrown State Zip Code usiness Address(must include a so address) . NO z1vew 1-7q 0" ��- DaytimePhone Evening Phone itylIown State Zip Code Mailing Address pt different from above) 3usinew Phone liederal Employa ID or S.S.Number IavmWialutn" "im 1 Acme It.o"aatlarat�?I®6v -Hzpani� b •- The Contractor agrees to do the following work for the Ham meer nt sp=uyMLQCLy 40 F f G-e-iw rare�. •��/�a Required"Permits-The-following building permits are required Proposed Start and Completion Schedule-The fdllowii g sebedule will and will besecured.by the contractor as the'homeowner's agent; be adhered to`nriless circumstances beyond the contractors control arise (Owners who;secure their own permits will be excluded.from the Guaranty Fund provisions of to when contractor will begin contracted work MGL chapter 142A:) ate when contracted .work will be substantially completed Total Contract Price and Payment Schedule a o The Contractor.agrees to perform the work,furnish-the material and labor specified above for the total sum of. Payments will be made according to the following schedule: SQupon.signing contract(not:tb exceed 1/3 of the total.-contract price.gr the costof special order items,whichever is-greater) or upon completion of or upon completion of S23000 upon completion of the contract (Law forbids demanding fall payment until.contract is completed to both party'.s.satisfacpon) The following matetial/equipmentmust be special S paid for ordered before the contracted work begins mi order S b be paid for to meet the..completion schedule.(**) 'NOTES:('h Including all finance charges(••)Law requires that any deposit or down-payment required by the contractor before work begins may not creed the greater of(a)one-third of the total contract price or(b)the actual run of sny special equipment or tatstom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Isav emress.warraatvbeivrurovidedbythe••..tractor+ No Yes -( t e s+� yrrantvmv"tbe �..r.a othe•ovhaetl Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any tliiid party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aereement Contract Acceptance-Upon signing,this document becomes a bindingcontract underlaw. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest)ras been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract Take time to read and fully understand it Ask'questions ifsoatething is unclear. • Make sure the contractor has a valid Home Imrvovement ontra' r R-Astration The WW requires most home improvement contractors and. subcontractors to be registered with the Director ofHome Improvement Contmctdn Registration. You may inquire about.connactor, registration by writing to the Director atone Ashburton Place,Room 1301,.Boston,MA 02108 or by calling 617-727-3200 ru 1-800-223-0933. Or • Does the contractor have instuance7 Check to see that your contractor is properly iasmed. • Know your rights and responsibilities. Read the Important Information on the ieveneside of"foim'and get a copy of the Consumer Guide to the Home hhprovemcot Contractor Law: You may cancel this agreement if it has been signed at a place other than the,contractoris normal lace of business, rovided contractor in writing at his/her main office or branch office ordina mail p p You notify the third business da followin the si ry poste b3 telegram sent or by delivery,not later than midnight of the. Y g gning of this agreement.See thaatrached notice of cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two idmtiut copies of the eemraa tuut be co*taed and,laced.One copysbmdd go to the The other copy should be kept by the Homeowner' Signature Contractor's Signature a Dau ,Date Contractor Arbitraition The Home Improvement Contractor Law provides;homeowners with thenghty—initiate an arbitration action(as an alternative to court action)if they,have a- spite with a contractor. The same.iightis poi automatically'afforded to a. contractor,however.!The:Contractor.would han tp resolve any,dispute heJshe.ltas with a homeowner in court unless ... both parties agree to.the optional:clause provided below:.This clause would give the.contractor the same right to arbitration as is afforded to the-homeowner:by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has:been.approved by the secietary of the Executive Office of Consumer Affairs-and Business Regulation and the consumer shall be ir'ed /"bait to such arbitration as prOvid assachetts General Laws,cha 142A,� HomeownPis Signdture Contractor's Signa NOTICE:`The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.i The:homeowner.may initiate alternative dispute resolution even where this section:is not s stately signed-byy-the pardese Homeowner's Rights A homeowner's rights under the.Iiome'Improvement Contractor Law(MGL chapter I42A)and other consumer protection laws(Le.MGL chaptc`r`93A)may not be waived in any way,even by agreement: However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible-for completing the work as described,in a timely andworkmanlike manner.* Homeowners.may be entitled to.other specific legal rights if the contractor guarantees, or provides.an.express warranty for workmanship or materials. In addition to.guarantee's or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability:and frtness_for a particular purpose. An enumeration of other matters on whichthe homeowner and contractorlawfully agme.may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in dplicate and should not be signed until a copy of all exhibits and referenced documents have been attached Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by,the contractor. Any modification.to the griginal coniract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired Accelerated Payments A contractor may not demand payments inadvance.of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a.contractor deems him/herself to be financially insecure,the contractor may require that the.balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or.need additional information about the Home ImprovementContractorLaw or other consumer rights, or if you wish=to..obtain a fi eecgpy of"A Consumer Guide to the Home Improvement Contractor Law,"contact: . Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor'Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal nrea iattonof disputes or to register formal complaints against a business,call: • Cofisirmer`'Complaint'$ecti0n " Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 The Commonwealth of Massachusetts u' Deparhnent ofllidustrial Accidents Pz Office of Investigations 4 •� 600 Washington Street Boston,MA 02111 Wwwanass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El lectricians/Plumbers Applicant Information U/#" ,// Please Print Legibly NaMe(Business/Orgaaization/individual): ��vv #"� Address: ,_� n e o s ,q1 r -s--T City/State/Zip: AIJ Atfl d( )<i1q J4A- Phone#: c?Zi Are you employer? Check the/appropriate box: Type of project(required): 1.®' am a employer with 1 4. ❑ I am a general contractor and I employees (full and/orpart-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' insurance-t g- ❑Building addition [No workers' comp.insurance comp. required.] 5. ❑ We axe a corporation and its 10.❑Electrical repairs or additions 3.❑ I tun a homeowner doingall work officers have exercised their 1 I.❑Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12. insurance required.] t C. 152, §1(4), and we have no ❑Roof repairs employees.[No workers' 13.❑ Other comp.insurance required.] 'Any applicant that checks box#I 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. tcontractors 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. Irthe sub-contractors have employees,they mustprovide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for ncy employees. Relow is thepolicy and job site information. v)a— Insurance Company Name: / �� G' Policy#or Self-ins.Lie.#: 7:2 L16 GI6'',O�112'eo �, - Expiration Date: �d Co f 7 Job Site Address: 7 y �/7� a� City/State/Zip: �l&)AAi �L'� 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 ofMGL 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 WORD 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 hereby ce under thepains and penalties ofperjrrry that the infornradon provided above is true and correct. Sit*nature: Date: Phone M )de--- A��� !tel 7 Official use only. Do not it.wite in this area,to be completed by city or toren offzciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person- __ Phnnp#- propool Page# of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH .North Andover, MA 01845 Proposal Submitted To: / ''// Job Name• Job# Address / 7'. J Job Location Date , Date of Plans Phone# 47 7 k `Fax# Architect We hereby submit specifications and estimates for: _?l) � ✓ 1!a�i� Q L J tJ Cr �1 1? f.CtnOr,�L , ` �l�c`u-t.�l� ?.1,�/�,� �,.� G-� - i ��Ls-✓-tai, all, We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: / n UUD ' � ��:t �;i,�, r'�jriL „ �,/ u r.. fyyd $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order,and will become an extra charge over and Submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our cohtrol. Note—this proposal may be withdrawn by us if not accepted within days. 1 21cceptance of proposal The above prices,specifications and conditions are satisfactory and are 4-aigature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance— 3 C, Signature CERTIFICATE OF LIABILITY INSURANCE DATE122/12/201 i� 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. 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 endorsement(s). PRODUCER CONTACT Durso & Jankowski Insurance NAME: PHONE FAX Agency Inc (A/C. No. Ext): (A/C. No): E-HAIL 198 Mass Ave Suite 10113 ADDRESS: PRODUCER North Andover, MA 01845 CUSTOMER ID#. INSURED INSUREDS) AFFORDING COVERAGE NAIC I Arthur Walsh INSURER A: A.I.M. Mutual Insurance Co 33758 dba A J Walsh & Sons INSURER B: INSVAER C: 55 Pleasant Street INSURER D: North Andover, MA 01845 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. LcrrPOLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (Hx/aD/rrrr) (_/../r y) LIMITS GENERAL LIABILITY EACH OCCURANCE $ ❑CONP1£RCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ❑CLAIMS MADE ❑OCCUR PREMISES(Ea.occurrence) ❑ MED EXP (Any one person) $ ❑ PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES ER: GENERAL AGGREGATE $ ❑POLICY []PROSECT ❑LOC PRODUCTS-COMP/OP AGO $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT FIANY AUTO (ea accident) $ ❑ALL OWNED AUTOS BODILY INJURY (per Person) $ ❑SCHEDULED AUTOS BODILY INJURY(p¢r accident) $ ❑HIRED AUTOS PROPERTY DAMAGE (par accident) $ ONON-O(iNED AUTOS $ $ �U:IBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ ❑£..CESS LIAB ❑ CLAIMS MADE AGGREGATE $ ❑DEDUCTIBLE ❑RETENTION S - 9 WORKERS COMPENSATION xc aTATU- 70TH- AND EMPLOYEES LIABILITY ® roar L_TEA THE PROPRIETOR/PARTNERS/ EACH ACCIDENT A EXECUTIVE OFFICERS ARE E.L. $ 100,000 ❑ incl ® eXCl. 7014648012011 11/14/2011 11/14/2012 E.L. DISEASE-POLICY LIMIT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 COMMENTS /DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 1600 OSGOOD STREET POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHOAI2ED REPRESENTATIVE .