Loading...
HomeMy WebLinkAboutBuilding Permit #750-15 - 1160 GREAT POND ROAD 4/2/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / 'J Date Received Date Issued:W41rUPn14TANT- A plicant must complete all items on this page LOCATION' ✓ L (D. � __ �� = x_�. _ ��� - ' PROPERTY 01NNER 9�-5 . -�,�D�- -- LL �'� Prnt100�Year®I'd.Stru�cture:� yesn'�6 MAP,N®: ++PARCEL: _rZ©NING+DISTRICT �Histonc Distn;ct yesheShop,Village eyes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial El Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg U. hers:' t� ❑ Demolition ❑ Other D Septic q'Well - ° [] Floodplain N"Wetlands �.tWaterslied�Distnct _ - O Water/Sewer_ DESCRIPTION OF WORK TO BE PERFORMED: lwe- Identification Please Type or Print Clearly) �7�^ ��S—�3o OWNER: Name: f &&2 '':5 l Phone: Address: d 41, ST/� /'fir CONTRACTOR' Name: �Y r f _ s �/ enl�i� � $3 sPhone•CD3 8 F Adtlress: AI� CSO G G- - �-7 y Supervisor-s:Construction'License s_ P -� _ Wome ITmprovement License; .._ -- — _ _- _ T ARCHIT -EPd�EER ,/v//�iael foul Phone: �o 3 Z31,74 " Address: ✓l�o`! ��" 411,(kxl)l jegme? Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. If- Total Project Cost: $ DSU FEE: $ V - Check No.: Receipt No.:w NOTE: Persons contracting with unregistered contractors do not have access to the g unrnn ty funci Signature}of Agent/Owner _ Signafure.of contractor _. I r.� - _ n i-�'--_o n /�....L:r:...J mi-4. ni x.-. I—I C+nmmr%A Dinne 1 Building Department The fohnwing is-'a-list of the required.forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And 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 o Workers Comp Affidavit o 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn•-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Plans Submitted ❑ PlansWaived-❑ Certified Plot Plan ❑ Stamped Plans ❑ .TYPE OF-%SEWERAGEDISPOSAL- Public Sewer ❑ Tanning/MassageBodyArt ❑. . .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_q S Si nature COMMENTS : V'\� r iHEAHEALTHR viewed ` G Signature COMMENTS y ' 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 Tawe Engineer: Signature: Located 384 Osgood Street FIREDEPARTME"iii` Terhp Dumpster on site yes no– Located-at 124 Mair Street -Fire ®epartrnent sk— tureldat" COMMENTS -Dim-ension 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 B Notified for pickup - Date F E Doc.Building Permit Revised 2010 ocation "d A� -� _ 1' 10, "� 7oZ.. Date L 753 -15- TOWN 53 -l5" TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ��'l Foundation Permit Fee $ Other Permit Fee $ TOTAL $ , Check# 8 6 03 wilding Inspector F NORTH . ver G - h ver, Mass, ` A- cocNicA..CM 7,45 RATE0 fkv U BOARD OF HEALTH Food/Kitchen PER IT T, D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ........... • • y............. ....................... ....... .......... Foundation has permission to erect buildings on �. .& CA Rough tobe occupiedas' a. .�........... 4 .42. Za.... .�1................................ Chimney J provided that the person accepting this permit shall in every respect conform 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 44) PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S TS Rough Service ................. .........................:.............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. r "�`?r t' �r'�• yyr �+t;?i•-~'� �'�qy,�'. wfat ?i.�J�j I r .!. �' N �� �`�. :.�`.c a�nJ� k 1, �` 3 ��� � •�:$r+af,(���.. k _ CL nt a x s' ✓� Fy-'°C .,r'.r 1 s '�} cr 3 t t k St t � rx, .• ,:s F �\ #,y + U. t —f y� r��- ✓fY 4�.fit 7 ✓ i .jfi i t a* A36�' uj +t '� r .r;��' y i kdF rJr � �, ��`CCr„ ' r a� •(yet,' 3 { t �' r �t 4 :� OY Max, 5 �ix, � §� ,a^ '4�4 x +A I ,�.r. ��Y rf MV tl'r 3 "f ] S f•J�. a^ N��� l�`'',Ss��� J ,. '4 S � F ti�9 ( �t+` � ���. � t t4 �� � X �4z, .a."✓n +• •k _ N m.a�`,� , a s •,,. Asa wwo,1p LL ;� >•� y"{+t „��k �kt� aux r4 F1�'.A�.���rk Y+r�� �� �',� a r�t �'. ,E.r- �,L� '`�4 � �'' M"'Irryz 1 CCC s, iy � - ' n'x'��r�r °J ay. �}� ,� ix, ,T"'3 '` t• a +1 r�,nr�r � i „� ,� ..+ �I{'�l7-� .._ '� 4 �,. irr Yx�.r+* %v �iY• t� s �.� 2' rv�aJ ' ''� cI 5iss5y'yrsq�'P A�:: .. F S } ,��' h°}P •�'• G a „ s.3 1 F* t i �,, ,�4 Y§ v�q"f t Y a+ t '} C �' t 5 i- t � 'd• 31�. h h axe �ac}"S xr Y'.ra iV �IS. �u��'� `r f t s � qd • -t _� �,�( . . � +'"A.� S' _. �,',d..t��'Y•�r �"r`E..y'`�*r �-F_ r t3 •r S z-•� 4 t5 a r Y N N� U O U ppN O r ORDER CONFIRMATION 24934-8 Pg: 1 EVENT DESC: ALUMNI WEEKEND EVENT DAY: SATURDAY D ATE: 05/16/2015&�8ii8Ah �k�TVi&& EVENT TIME: 18 Clinton Drive,Hollis,NH 03049 DELIVERY: THU 05/14/2015 OR EARLIER 603-882-1234 or 603-881-8833 fax PICKUP: SUN 05/17/2015 NOON 1-888-RENTENT SALES PERSON:MG PO#: www.intents.com email: sales@intents.com ORDER DATE: 10/31/2014 TERMS: NET 10 DAYS HEATHER FERRARA (978)725-6300 x3214 BILL ST.CYR (978)2654485 B BROOKS SCHOOL S LOWER FIELD I 1160 GREAT POND ROAD H 1160 GREAT POND ROAD L ACCOUNTS PAYABLE I NORTH ANDOVER MA 01845 L NORTH ANDOVER MA 01845 P TEL: (978)725-6300 TEL2: FAX:(978)725-6215 QTY ITEM DESCRIPTION PRICE TOTAL 1 20'X 20'WHITE FRAME TENT(HPT) 275.00 275.00 1 60'X 100'WHITE CENTURY TWIN POLE TENT 3,600.00 3,600.00 1 9'X 10'WHITE MARQUEE WALKWAY TO CONNECT TENTS 150.00 150.00 100 FEET OF SOLID SIDEWALLS-20'X20'&9'X 10' 1.05 105.00 320 FEET OF CATHEDRAL WINDOW SIDEWALLS-60'X 100' 1.15 368.00 20 FEET OF RAIN GUTTER(2- 10 FOOTERS)TO CONNECT 9X10 TO TENT 2.00 40.00 360 FEET OF WHITE MARKET LIGHTS(7 WATT ROUND BULBS) 1.10 396.00 ABOVE LIGHTS ARE INSTALLED ON PERIMETER OF 60X100&9X10 6 HALOGEN RING LIGHT W/6-75 WATT BULBS-6"-60 WIDE-CTR POLES 200.00 1,200.00 2 50 FT WHITE STRING OF 60 WATT BULBS-20'X 20'CATERER TENT 45.00 90.00 BROOKS SCHOOL IS RESPONSIBLE FOR POWER DISTRIBUTION TO LIG 1 16'X 21'DANCE FLOOR 616.00 616.00 9 8'LONG X 14"HIGH BLACK STAGE SKIRT-FRONT&SIDES OF STAGE 8.00 72.00 2 STEPS FOR STAGE[15"HIGH] 30.00 60.00 TO INCREASE TO A 16'X 28'ADD$152 CARPETED STAGE DECK ARE AVAILABLE FOR ADDITIONAL FEE 1 16'X281 STAGE"PAIMTED WOOD TOP" [15"HIGH] 1,064.00 1,064.00 SPECIAL INSTRUCTIONS: SUB TOTAL: 10,089.60 ADDITIONAL CONTACT:ERICA CALLAHAN 978-376-9304 CELL FINAL SCHEDULE TO BE DETERMINED IN SPRING! SALES TAX: 0.00 PAID NON REFUNDABLE DEPOSIT$2000 NOV 20 M.C. DELIVERY: 115.00 0.00 TOTAL: 10,204.60 DEPOSIT PAID: 2000.00 BALANCE DUE: 8204.60 Customer Acceptance Signature oilr� t t.6: r3. ;rye;yt;r 1..f Yqu IV qjq, Mt j, i F} t' tlr I I t•{, '( #<"• j r i;t_ ..} t , ' . rr1 t(Ir7_.• '. .!`!I . r/" . I t. 1' !•7 Ir' "1.'ll r :I i it i Mi to 4•J.. ,. + 1 -)fr ya tll(}`iv! i i' �I i i /t lr� ir. r •.?i rr Al ii it ; +{ i!'.+r� ,!'jli`i4:, i✓' i, � It tJi i 'i ';w ,Ir, r'"!r7 i r+ + r '`! '% 11 I r !i l i ,..'i + - it ,l { ! 1 Aj i, Ilr+ ..i?(ir /: . , ' '7r .: ;• fif+;";• !�, r , t' ti;, i , i r l •, �i .' .`ir''� , ls , I`, , • ; KYw ri ( will ! • , 7 c ; b ) '4 001 i') 'ri) i ," 'rr. i` , 1 ii" ' ;+ l.. .. i ,.II„+' r r+e"1 y 1 Il BE" +s., 4 e`: i i)i + l 01 to 4 11 ii i •iii,. •' i'7i Ion )"UiiAif 1 7 ,1 } _J:. 11 'A, ., i '({ i +• � 'I i r,l iO rri7 ' .1 7•I r r i 10i (1 i( 77'i u I . 1'i r`. :k �•; _`% i •' 7.it i3 'r.iJ�9lwti r' r<. , r 7✓Si '' itf .`' rr ii{ {. + r}tl { !i` +f ' ri, I/ i l'• ii•. + ,. I r i1 i; /i . IMPORTANT DOCUMENT Certificate of Flame Wssistance ISSUED BY Date of Shipment 2/24/2014 CRegistration Number CHORINDUSTRIES INC. Sales Order# F-140.01 t.�.> SO-601120 EVANSVILLE, INDIANA 47726 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: 269800 CHRISTIAN DELIVERY CHAIR SERVICE INC DBA CHRISTIAN PARTY RENTAL 18 CLINTON DR HOLLIS NH 03049 USA G%STEL CA(/,c��G N 9 ET h4 Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109. Serial# 8151030 1) Description of item certified: CENTURY MIDDLE 60WX20 SNYDER WHITE VINYL WITHOUT WEB GUYS Flame Retardant Process Used Will Not Be Removed By O Washing And Is Effective For The Life Of The Fabric N SNYDER MANUFACTURING INC, PHILADELPHIA PA Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC P trate age: 3(1Certitofiffame Re5t',5talice Date Manufactured AZTEC TENTS Invoice Number: 0202537-IN 2665 COLUMBIA ST Customer P.O.: 1/8/2014 TORRANCE CA 90503 800 228-3687 Customer Number: CHR 030 This is to certify that the materials described below have been flame rgtardant vemlor Tmae Name treated(or are inherently flame retardant). eN'" Mandl Gras Mesh F-222.04 \ - California Comb. Lam-Tex 12,14,16,180z F-419.01 { Coated FabricsClear Vinyl 169a/20ga F-570.02 Christian Party Rentals k ° OAF Clear Vinyl 16ga/20ga F-593.01 a� �.rm DAF OAF --75-93 18 Clinton Drive Exclusively Expo PolySateenUner F-434.01 Hollis, NH 03049 , Ferns^ Precontraint 502 F-444.01 \j •�•a r .;,:.: Ferrad Preterit t 702 F-444,08 Phillips Textiles Phil-Tex Liner F-500.01 PVC Tech. Deco Cloth/Velon F-504.01 Snyder Weatherspan F-140.01 Tri Vantage Flresist Sunbrella F-368.05 Certification is hereby made that the articles described below hereof are made Tri Vantage Patio 500 F-121.02 from a flame-retardant fabric or material registered and approved by the Th Vantage Big Top F-121.10 California State Fire Marshal for such use.The fabric has been tested and Tn Vantage Vanguard Weblon F-069.01 TO Vantage Weblon/Coastline F-069.01 passes NFPA 701 Large Scale.See chart to right for trade name of Verseidag Duraskln B1673,B3515 I F-530.01 flame-resistant fabric or material used and additionally referenced on the label of the fabric panel. THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING a` David Bradley General Manager- Manufacturing Name of Applicator or Production Superintendent Tide of Applicator or Production Superintendent ITEM CODE ITEM DESCRIPTION UNIT ORDERED PRODUCED Z22130CM2002 30x20 Mid Jumbotrac Top EACH 2 2 UW Blockout White-w/2Ratchet Tensioners Z22140CE4002 40x40 2pc Jumbotrac Top EACH 1 1 UW Blockout White-w/8Ratchet Tensioners Z22140CM2002 40x20 Mid Jumbotrac Top EACH 2 2 UW Blockout White-w/2Ratchet Tensioners 2520FC2002 #20x20 ipc Festival Top EACH 2 2 UW w/Ratchet Tensioners& Flag Blockout White #with Double Valanc Z22520FC4002 #20x40 1 pc Festival Top EACH 2 2 UW w/Ratchet Tensioners& Flag Blockout White #with Double Valance Z211203002 #20x30 1 pc Top Only UW EACH 2 2 Blockout White #with Double Valanace /ZFRT Daylight Freight Prepay&Add / oGREMg33romimiEmNi1i1 mini DOCUMENT O C U M E N T�'�'�'�'�'�'�'�'�'�'�'�'�'Lr�PrJr3 a SCoextif icaW of F lResistapee S S REGISTRATION ISSUED BY S APPLICATION Date of Shipment 5 a 3/2/2006 NUMBER INDUSTRIE INC.® EVANSVILLE, INDIANA 47725 Tent Identification 5 5 F121.4 �' MANUFACTURERS OF THE FINISHED 04238076 5 5TENT PRODUCTS DESCRIBED HEREIN S This is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: 5 S5 269800 5 CHRISTIAN DELIVERY & CHAIR SER 5 5 1CLINTON DRD8 BA CHRISTIAN PARTY RENTAL S - HOLLIS NH 30496576 5 5 � 5 5 5 5 5 5 5 Certification is hereby made that: 5 The articles described on this Certificate have been treated with a flame-retardant approved S 5 chemical and that the application of said chemical was done in conformance with California 5 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 SS SS Serial # 8067300(l) 5 Description of item certified: 5 FIESTA MARQUEE MIDDLE 9WX10 5 5 Flame Retardant Process Used Will Not Be Removed By 5 SWashing And Is Effective For The Life Of The Fabric 5 5 FJQJM RC)VT F CTATF4Vti.1 F NC Signed: Q-'&/'2' � Cj v ` SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. r.Pff�J7JJrC3Plr�PrP�J@�LPrPr� rJ� � O�rJ1r �7rJ� Jr �J��J� ����7�c The Commonwealth of Massachusetts Department of IndusoialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AiWicaut information riease Print Leeibly Name(Business/Organization/Individual):Christian Delivery&Chair Service, Inc. DBA Christian Party Rental Address:18 Clinton Drive City/State/Zip:Hollis, New Hampshire 030419Phone#:603-883-5326 Are you an employer?Check the appropriate boa: Type of project(required): 1.❑✓ I am a employer with 40 employees(full and/or part-time).* 7. C]New construction 2. i am a sole proprietor or partnership and have no employees working for me in U 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure Lhui aii cwnimuiurs either Tuve workers'uumpunsdUon insurance or are suic i l.0 Electrical repairs yr auuiuvilla proprietors with no employees. 12.�Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.[Plumoof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.nOther TENTS 6.,r-l',,,ald it GUtpUlilLlUll ai111 il$Ullt(:CI$ll'AYG dxolclstd LllCll llWIL U1 CXC1dpL1U1117C1 IVVIIrL e. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] I I I 111 *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. 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. insurance Com---y u .New Hampshire Motor Transit Association Policy#or Self-ins.Lic.#: P000749NHMTA22015 Expiration Date:01-01-2016 Job Site Address: / lQT rO -d KG City/State/Zip: Attach a copy of the workers'compensation policy declaration page(snowing the policy number and expiration date). 7 Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under a pai n enaXes of perjury that the information provided above is ere and correct Signature: Date: Phone#:603-883'53e6 Oficial use only. Do not write in this area,to be completed by city or town official %iiy of i own: Pertuiui,ictibe 4 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other (I Contact Person: Phone#: II NH/��1A NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION 50 ATION P.O.Box 3898 Concord,NH 03302-3898 (603)224-7337 CERTIFICATE OF INSURANCE 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. This is to certify that: Christian Delivery&Chair Service Inc. DBA Certificate#: 1 Christian Party Rental 18 Clinton Drive Hollis, IVH 03049 Is,at the issue date of this certificate,insured by the Company,under the policy(ies)listed below. The insurance afforded by the listed policy(les)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition or other document with respect to which this certificate may be issued. /.OVERAGE AFFORDED LANDER VVI.LAVH OF THE FOLLVVONG STATE. NH TYPE OF POLICY EXP DATE POLICY NUMBER LIMIT OF LIABILITY Continuous' Extended Policy Term Workers'Compensation 09/01/2015-01/01/2016 P000749NHMTA2015 Bodily Injury By Accident $1,000,000 Bodily Injury by Disease Policy Limit $1,000,000 Bodily Injury by Disease Each Person $1,000,000 ADDITIONAL COMMENTS: 'If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. NOTICE OF CANCELLATION: (Not annlicable unless a numher of days is entered below_) Before the stated expiration date,the cmm�anv will not cancel or reduce the insurance afforded under the above policies until at least 30 days. Notice of such cancellation has been mailed to: r--- —� NH MOTOR TRANSPORT ASSOCIATION SELF-INSURANCE GROUP TRUST I,, I VIII111jUQII LJriIlVcly U V%.A14311 Jct Vnll'V IIIV. I - dba Christian Party Rental 18 Clinton Street Hollis, NH 03049 Authorized Representative Concord,NH 603-224-7337 02/06/2015 Office Phone Number Date Issued Sep•25 14 06.16p Mike LeBlanc 978 534 7983 P. Massachusetts -Department of Pub:;c Safety Board of Building Regulations and Standcrc;s C;, c .cii,r.. pure, , License: CS-067484 MICHAEL P LEIkIMC 611 PIERCE ST LEOMINSTER NIA 01453- Commissioner 1458., .rSrC ommissione r 06/22/2016