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Building Permit #753-11 - 107 SANDRA LANE 5/9/2011
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 2' s--'?--// Date Received Date Issued: Al IMPORTANT:Applicant must complete all items on this page LOCATIONr ' --- � C Ali f- P _ PROPERTYOWNER Print MAF Na: PARCEL: ZONING DISTRICT: Distric# yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family- Industrial Alteration No. of units: Commercial Repair, replacement, --- Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Dater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I Identification Please Type or Print Clearly) OWNER: Name:-^ ,�,� aa�n(��..j�- �. Phone' Address: tO`2 c�f' Jdr r CONTRACTOR Name: Gf" kJ ziU._2\Sf4 rit r t Phone: SST /" —0T?A Address: Supervisor's Construction-License: g5"9Q7' Exp. Date: (;'�lei Home Improvement License: I i6 Q Exp. 'Date- ARCH ITECT/ENG IN EER Date;ARCHITECT/ENGINEER Phone: ' Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ (� (�, FEE: $ G Check No.: 23 �Z Receipt No.: �// 7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent/Ownignature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans i I 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 384 Osgood Street FIREDEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS j 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 ❑ Notified for pickup - Date Doc:.Building Penn it 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: Doc.Building Permit Revised 2008 pRTH TO" of over . 0 No. 5,5 , LAKE O over, Mass., �COCKICMEWICK 7�AQ RATED `SS BOARD OF HEALTH Food/Kitchen PE ,RM I T T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.............................. .. G�' ... ......ff.-:....................................................................................... Foundation �G'�cif ra �c r✓c' has permission to erect........................................ buildings on ..1.�l...�1........................................................................ Rough r to be occu ied as �.7�.Q......!l.o.� v p' U`' c . ........................... ....... ............................ .. provided that the person accepting 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 CONSTRUCTION TARTS 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. 104 Otis St.,Northborough,MA 01532 J&L Wuanows INC. D/B/A g MA Home Improvement Contractor (508)919-0900•Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012) byAndersen.mali Federal Tax ID#83-0404201 WINDOW REPLACEMENT -And—Company _ CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agr ement �A l y Buyer(s)Street Address,City,State,and Zip Code 10SAAC no A aICC E-Mail Address Home Telephone Number Work Telephone Number Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen ("Contractor"),in accordance with the terms and conditions described on thefront and the reverse of this agreement and on the attached specification sheet(s) (collectively,this"Agreement').Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. r� Method of Payment:❑Check OCredit Card ❑Cash Total Job Amount: Estimate�diStarting Date: ❑Financed Deposit Received(33%):/3o,� —" 1 , a o a- Balance at Start of Job(33%):/ oZ ' If payment is by Credit Card please fill out Estimated Com let' Date: r Balance on Substantial // ° /- J- the Credit Card Receipt of Deposit Form Completion of Job(33%):13 By By signing this agreement,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. J&L Windows,Inc.d/b/a Renewal by Andersen Buyer Buyers) By: l x /I /, �' Signatu Pro t Manager ign ture J Signature j Ca,.�'S Print Name of Product Manager Print Name PrTnt Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. — — — — — — — — — — — — — — —91<- — — — — — — — — — — — — — — -ate— — — —-- — — — — — — — — — — NOTICE OF C ' ELATION NOTICE O C NCEUATION Date of Transaction /3 / Y. may cancel Date of Transaction /� dG// , You may cancel this transaction,without ny p natty or obligation,within this transaction,with a penalty or obligation,within three business days from the above date.If you cancel,any I three business days from the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed by you will be retumed within 10 days following receipt I by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to theI be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply I Contract or Sale;or you may,if You wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the ggoods at the Seller's expense and risk. i the goods at the Seller's expense and risk.If you do make If yyou do make the-goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them u.p within 20 days of the date of your Notice oIf your Notice of Cancellation,you may retain or dispose of Cancellation,you may retain or dispose of the goods Df the goods without any further obligation.If you fail to without an further obligation. If you fail to make the make the goods available to the Seller, or ifyou agree I goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so, thengoods to the Seller and fail to do so,then you remain liable fou remain liable for performance of all obligations under for performance of all obligations under the Contract. -he Contract.To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and :igned and dated copy of this cancellation notice or any dated copy of this cancellation notice or any other written ler written notice,or send a telegram to Contractor.J I notice,or send a telegram to Contractor.J&L Windows, 3r L Windows,Inc.d/b/a Renewal by Andersen, 104 Chis Inc. d/b/a Renewal by Andersen, 104 Otis Street, itreet, Northborough, 01532, BY NOT LATER THAN Northbo gh 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF /r G/ _.(Date) OF o l ,(pate) HEREBY CANC TH TRANSACTION. i 1 HE Y CEL THIS TRANSACTION. Buyer's Signature Print Name Date I Buyer's Signature Print Name Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink Renewal RENEWAL BY ANDERSEN MA HIC License#149601 (expt'YAfldersen. 7��.�. Federal Tax lD#�83-0404201res LA 01�;REATER MASSACHUSETTS AND NEW iitiiVii Jr1IRE WINDOW REPLACEMENT -Ande—Company 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Buyer(s)Name Date of Preelent `oS Q ,c• -of/ The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services li ed bel ,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. PATIO DOOR DETAILS 1. Install total of: Permashield Gliding Patio Door(s) ❑ 5'10"x 6'8" ® Other(not VailabLe in 8068) Op.panel is EZ left ❑ right(as viewed from exterior) Interior and Exterior Color to b White Canvas ❑ Sandstone ❑Terratone (Color same inside and out on PS) Hardware: Metro: ❑ White Ston Bright Brass ❑ Other—Specify ❑ Yes ® No Gliding Patio Door to have sidelight? Size: ❑ Yes No Grilles? If yes: GBG ❑ INTW ❑ FDL(Pattern is standard as viewed in book for all doors) 2. stall total of: Narrowline Gliding,Patio Door(s) 6'0"x 6'8" ❑ Other: Op.panel is ❑ right(as viewed from exterior) erior.Color: White El Canvas San rraton (Interior is WOOD and customer must paint or stain) H dware: tro: to ❑ Can as ❑ Stone ❑ Bright Brass Other—Specify: ❑ es ❑ o Gliding Pa' r to ve sidelight? Size: ❑ s No Grilles? If yes: G ❑ 11*11W ❑ FDL (Full Divided Light) 3. Install tal of: Frenchwood Gfiding Patio Door(s) 6'0"(16-8" ❑ Other: Op.panel is❑ left E] right(as viewed from exterior) r.or lor: ❑ White ❑ Can andtone ❑ Terratone In nor Woo Pine ❑ Oak Maple In 'or Finis : finished 'te(Availab only with bite a or) ❑ Unfinished(Paint/stain done by customer) Hard are: etro: 'te Stone ❑ B ' Bras Satin Nic ❑ Ye ❑ o Gliding Pa o door to have sidelight? Size: ❑ Yes No Grilles? If yes: GBG ❑ INTW [I FDL (flrll Divided Light) 4. Install total of: Frenchwood Hinged Patio Door(s) ❑ 6'0"x 08" ❑ Other: R Yes ❑ No Active/Passive Panel?: E] Left ❑ Right(viewed from ext.which is active) Yes ❑ No Active/Stationary P e ❑ OLeft.❑ Right Door S ❑ Inswir ❑ uts ' E6rior to: ❑ White ❑ as ❑ S dtone ❑ Te atone Interior d ❑ Pine ❑ Oak Maple ht or 'h: Prefinished to ❑ U hed t done customer H ware Metro ❑ White Stone ❑ Brigh ras ❑ SaNn Nickel `NO vas ed screen ame N/A—must ch white 060me if exterior is canvas' ❑ Y No Hing Patio or to have sidelight? Size: ❑ Yes No Grilles? yes: GBG ❑ IN1'W ❑ FDL (Pull Divided Light) STORM DOOR DETAILS 5.',,Install total of: Storm Door(s) 6. flrll Vie Mid View 7. lor to b ❑ Whit Canvas andtone nze ❑ Forest Green 8. Sit to ❑ 32" ❑ 34 only) ❑ 36" ❑ Custom 0 wee Plead time) Size: 9. Har ware to be: ❑ Bright Brass ❑ Nickel ,,10. Additional job details: ) ll P�,� A d 11. Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. WO final payment shall be demanded until the contract is completed to the satisfaction of all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal by Andersen of Greater MA and NH Buy�r(s) Buyers) By: Signa a of uct Manager V! S• �__ ✓ > re ! Signature meq, /TJr (1 1P ���Cf�/� L�/,���/c" ✓c�'"^ 4,� Print Name ofProductManager Print Name Print Name The Coir marw=Lth of hiassnclzuseft€ ' D =tmehf v fImdmstid Acc�deats D o �7lpestzgations f 60C FaskbigOn Sued Boston,A(A 62111 _. .. t�,ncassgoYl�a •, ,Warkerf' Cnuipenssfian 1ns¢rsnce A.fh6s�Ste.acts/Caatr'ac�arsl�I�cfrsciaaslP��uabers _ �saf FIIforms�an Please.�'ri�t Lea A ' �Bm.e(�nsinesa<organixationtfnaivianatj. J]enPJ��' �✓y An�X yrs e n _— - Ci tSi�te�Lig; I V f. c/a Are paII ea etaployecq Cbech fire eppreprigte bay Type of project (regtared); L�-I am a rmplvpar D 4. Q•I am i genual c°atzwc and I =a+ra� ' im hired ibe sal}-r.=t ct= rmployeea(futt'ez, �PIZi , 7 Z,Q I sin a sole proprietor°rpettner- listed oa the attached sheet$ Deimolifiaa ship mad have no ees mployo 1'nese sulr s-coatsactors have - • �arliag forme.iasay�capacity, ' G°mg rns¢mnce, g, ❑$uldiag arldifioa ° cep;rn��n�e S. ❑ Weare a corPDr 6=and its. 1n.[]$itahlcal rep is w additions eve==Isbd thzit I1.0 F.hmhmg repairs or addidoas I am a homeowr d°iag Rn work, �of==iP an pw M(M mysalt[Now=l=l comp a ISZ,11(4),and we bane no 12.0 P•Dofmpmi=s iasarsaec mqui milt `'�°wrorl�e 13..Q Diner Doing`insoxaace requhad-] .fly tAMF t Mb=-z hoz 91=nt Z10 a art f=r=*M bCSorW�� •��r����p�-t f 5R'➢C.O<vrkm=b$1tt=errant imfig J=d=r d .,k ead&m�im p1uftsiudC CQ�I3C�ZDa�Fahm LIICW 8 8[711LQ1C36�64C� oatmama cheat fbu hoz moat attached as eddi$omnl sbe.dwimF the"Ent o$ ®d�s worms'amap poli�7 moa I am arc cr fhat eapraf►i�rrtg warkmis'coaspensafiaa itssararcce fol'cry emPtv}'ees 'BeIatv.is the poF.icy orad jab szte crnPlal' iR,forzaatian. r ) . Inmmwc c�mpaay Damn, �1 Ln- Pof cy#or Scf ins.Lie # irafiom Data�,, Sob Rho Addrme' /0 C D'A f���PJZ Attarli a espy cf the 4rnrl�rs' camiseasafi°n policy declarLfinn ga;e(shavg the ply atunber and etpirainn date. DfIL Failzzte to seotuc cova>:agc as required tinder Section2SA ofMC`Lr c. I:S2 oars Iced to the impnsitioa of r�m.inal penalties , IL STEP WORK QRI ane up'to$1,500.00 sndfar one-year imprisonment,as well as dual ponalbm m fire from°f MD°f and a fsnc -Of tzp tD M50-OD a&T a�inst$ie vinlatDr. Fe advised fimt a copy of ibis statcmeut map he{nrwardcd tD fbe Dficc Iu�rsdgefrona.of the DIA f=insn>:aaco covrsage vmifmfion. I d a hereby ee flu paiaa and P� M*Ua that the fAf=am jaa prbTidad ab is trut Qnd carred • 5i_rnelnrc, / , Doti Phone a,�j2cial use arrlp. Do notwrite in thin area,tD be completed iT acij'or tm m q{iaial Cty or Tofu; permitlLicense# Issrb.g AUffinrfty(drde ane): L Barra of Health Z DMITM9 Dapartmeat 3,C /Toegn Clerk 4,IIecfrloel Lnspectar `1 Pltnabiita;faspectnr fi,after Contact Person; Phan Ylassachusetts Department of Public Safeti- •Boar-d of Bdildin` Regulations and Standards 'Construction Supervisor License License: CS 35707 BRIAN DENNISON . _ , � 86 CREST CIRCLE '' ,� WORCESTER, MA 61603, Expiration: 9I8 O12 ('pmrnirelUABT Tr#: 2522 omme of Cnnm=ar off •t&$ItainM$e tiaa y DUE IMPRO Ei1T CONTRACTOR • Regisfrafi�t��s�9 (71 ht Card RENEWAL BY BPIV N DEWS Z4 OTZS SIRE --7 '�— NQmBOROUGH; tinderseettt3ty , DATE(MMroorcYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE 02/09/2011 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 poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED,sub)ect 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 - Joseph McKeone NAME.NE FAX JP McKeone insurance Agency, Inc. E-MAIL : 734-662-8100 Arc Nn: ADDRESS' P.O. SOX 333 INSURERS AFFORDING COVERAGE NAIC S Ann Arbor, MI 48106-0333 INSURER A:Hartford Insurance Company INSURED J&L Windows, Inc. Renewal by Andersen INSURER B:Nautilus 104 Otis St. INSURER C: Northborough,MA 01532 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. NOTWrrHSTANDING ANY REQUIREMENT,TERM OR CONDMON 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. INSRTYPE OF INSURANCE R ADDL SUBR POLICY EFF POLICY EXP TLIMITS POLICY NUMBER MM/DDIYYYY MM/DD/YYY B GENERAL LIABILITY EACH OCCURRENCE S 1.000 000 DAMAGE TO RE COMMERCIAL GENERAL LIABILITY NC95B461 10/01/2010 10/01/2011 PREMISES Ee occurrence $ 100,000 CLAIMS-MADE 7XI OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000.000 GENERAL AGGREGATE $ 2,000,000 GEN'_AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- .JECTLOC $ A AUTOMOBILE LIABILITY 35MCCXD6390 _ 10/01/2010 10/01/2011EO BINEDDtSINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) X AUTOS AUTOS $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accldent I S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE S DED RETENTION$ S WORKERS COMPENSATION 35 WECPP1444 02/17/2011 02/17/2012 WC STA; oTH- A AND EMPLOYERS'LIABILnY Y/NLIhfTSER Tr)RyANY PROPRIETOR/PARTNER/EXECUTIVE E.L. ACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? ❑ N/A L (Mandatory in Nit E.L DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500 000. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION INSURED COPY SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / ©1988=2D10 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD _ I 1 see a e• I�r�,�l�,tra�'�' •- - Gi - - L,�tjEf� - Df'-�- �'�__�-�`�� =*'- ..`:Y:1�-,.:t.-'r'+?�'-. - .'c'�=�,i_ �-5�•�., .A`�_ -,,�,fi. �G'it"Z• . ."�"�sa, T�'r'„"'�1'wc,' :.�`=� --__�_'.�i..,�'�`•.T�-�,w�:e �-�;:rr='�....—''...,.s;tva,-._. - V 3�_��'���:� ��..t: , tit$; -?a- �=.T��.rS ar'�'�.':y:.y ..-r,rT"_.• - 7�x=,•�-� .-,'�""'�' J�--.''�,.rJ��-•s--'w-'_.Trs�L3u'. - -r= r:,�'-_-'-''•-��^--,,w,-'.7ir�,�..-„•.,•, `rr tyu.�_..+i.:;e-. .4.� `>r.';°+, mss,-_� irzrr'•.-, .`` � �•r>. _ ���'c SUE �" , —94 -r_`' - C 1 9�. T .i2 ••1',+.� H 'A� You �Ci��LI --Sl� +( -� � ^��� h, �Y1 12 nf _,-.,� - T*, - -�i� ,.�- .c-Y--, . icy, o'•�y' ���• s-�(1 8,,_�.,, • �' r � oar`,' �- L L \��vY=5:4T S 'A•r� - �-_ L� y.. 3` n "M i Jew. s• '�jS ,�-y. •�:,-r�-.}-^-r.,'• � s'°7n-' � ''� MEN s.l” Sol' " „� HH r S E i,- ''ln �-��r,. ti"'�.r �•''j, t_u , � --�"T.. ij.h-^5"-'c-�``,,� '" �z _ nl'�'.- y l.i I��yy�i. �t'•�'J`��P.; .�.,�o-RyF—tet.�^ ,-\ �CT„•��iG�L� YIi F�1 h. !_,a: � ....'., ��� � - � _ ~ 3,�_ cam-.� .�• y �` ei ,- RT - c _ J 1�w.i- • �!v1= ���= _ ae.�"'�� iy .E+ l�'� o �1? '. 9 twil "�� ,�,- � � 3`�€�� �' _"",��.,may`�i�.,^-•"`�e1t-����.���r .agar-• ��•-,`�' �� ..,fit, -L .�� ��c�� f �t�s` 9� ,:�"o ��' °4•-Y-'�'_ �w � a .-•-.v�:l L� _ '�_ - , � -i'=- Imo, 'R- «� ==�• s'-�-'�"'�.- • '' - it �'-A n i' •.�.�. � - IR :f1 Mir M �' • � x moi.,, •'>:� • - Location No. S_f' U// Date „oR,,, TOWN OF NORTH ANDOVER 9 a y • > ; . Certificate of Occupancy $ Nu9 Buildin /Frame Permit Fee $ —® s�cst Foundation Permit Fee $ Other Permit Fee $ TOTAL $ G Check # 2 J 4- 24 1 �7 /Building Inspector