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HomeMy WebLinkAboutBuilding Permit #710 - 1160 GREAT POND ROAD 4/25/2011 OORTH BUILDING PERMIT 0 cluto 16 tq�o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received ��goq / 9SSACHUs�'t Date Issued: IMPORTANT: Applicant must complete all items on this page �" Kms'^' ttmcax-- ",e "9 ,.,...f zxSbD K^ .'p¢ �➢ C Kn➢ .K c y. Ao AT E AROPERT '0UVNER `: �'; 7rM /rs"" _� K•vd a „. ' 1 it ics '6} KIK �, MAP NO N� PARCEG: 11NEQ IC> t�R[� : M 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 9 Others: ❑ Demolition ❑ Other �,Septic �, F1 hell ��loadplatri � t1a�dM i V k Tt'sla del is�ri y Water/Sever 1, o v DESCRIPTION OF WORK TO BE PREFORMED: EKcc�- 0- 5-0 X(P o Y- is x,a 'Fern 11n� a � Identification Pease Type or Print Clearly) A OWNER: Name: 9.ec;�ks -3C � Phone: 9�� -7-�- 63� . 9 Address: o /fle IAAVely, l U ZR CONTiCTOR Name ` phor e 7 — y3 w � - ., r� '3 x4 n K, a a z E✓x "" x , Ti aKt3. s: ` 'z 7. •P Addres ,, S,u ej, orr Cofttrludreri`:Lice se 19 `:' e .a f : ,i� Kc F . .ui, rte` > •z� ' xxz ARCHITECT/ENGINEER Phone: Address: Reg. No. i FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $,!::,?crT-rrD FEE: $��t� �— Check No.: 4J41—? Receipt No.: OZ �— NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund S�gnstureof`Agent/Owner . „ K Signature of ct ct�r 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 Pp Permit Application I ❑ 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 DEPARTMENTMITORM07 Revised 2.2007 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 Tam, 'I slfi? yeses °no` L15catat 124 Main Street s � ��'.- e Tai, Flre nepartmen#signatureldet ❑ C101M, MENS ✓ r 3 a d< � ,r r Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location//w No. W o —J/ Date ,.ORTq TOWN OF NORTH ANDOVER 9 i Certificate of Occupancy $r ^° Building/Frame Permit Fee $ ( vim s�CHU Foundation Permit Fee '$ Other Permit Fee $ TOTAL $ Check # " Building Inspector ORTH F ' ONM O ' 5 Andover No. 6 _ -: - L A K__ dover, Mass., 1•< A- COCMICHEWICK ADRATED 9:1 C, `S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... IMMI L L..................... ....... Foundation .................... buildings on11410 .. . ........ • Rou h has permission to erect.................:. g ... ..... ........... g to be occupied as... .�..X..� ....:...T�!�iin�;ev�ie�ry .. . ...ItL�........ ........ ......................... Chimney e provided that the person accepting this permd sharespect 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 a` PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUC T TS ELECTRICAL INSPECTOR 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. 1, - Y' r !` 0' x 60' x 9' Century Tent �res5 9' x 50' x 9' Canopy } W Grass Frick Holl �i;:L��4ia;�\\�ti�;,,._...,.,... •!'u`%_�.:Y'�?'S`n'r'TYhv_c>.,.%vi;"_c'•u�i�''•�,�! 'f "' _ IMPORTANT DOCUMENT 5 Certlf lea ��e t�aL?ve of Fla Resin ee . 5 SREGISTRATION ISSUED BY 5 55tR. Date of Shipment 5 !:APPLICATION cN®INC. 5 a S NDUSTRIES 5/10/2006 S (' S NUMBER 5 EVANS LLE VI INDIANA 47725 Tent Identification � 5 t 5 i °r FI 40.1 MANUFACTURERS OF THE FINISHED 04263446 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 5 (or are inherently noninflammable) and were supplied to: S C 5 657150PETERS5 S1SWAST WINCHESTER N PARTY CENTER INC 39 S ' 5 WINCHESTER MA 01890 5 5 5 . 5 S 5 5 5 Certification is hereby made that: S 5 The articles described on this Certificate have been treated with a flame-retardant approved S Schemical 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 5 5 5 Serial # 8020500C(2, 5 5 C5 5 Description of item certified: 5 5 5 FIESTA TOP 12WX12 SNYD WHITE 5 VL#1023970A (IPC) S Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 "134DVA Mr NP-111PWII 4PE6PFi1•t1,QW Signed: 5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. Cj O cl�rJ�cPrJ�r�rJ�rJ�rJ�r�rJ�rPrJ�rJ�r�r�r�rJ�cPrJ�cPrJ�rJ�rJ�r�r�rJ�r�rJ�rJ�rJ�r PcP�Pr�r�clrJ�rJ�rJ�rJ�rJ�r�rJ�rJ�rJ�rJ�rJ�cPrlrJ�rJ�rJ�rJ�rJ�rJ�rJ�rJ�r�rJ�r�r�rJ�rJ�rJ�rJ�rJ�rJ�cPcPcnr�rJ�rJ� O 4*`�rf y rr4s1 }I � r�J��uu��r� � }i :IMPORTANT DOCUMENT U M E N T ;. 1.r .r r . t 5 rrJ�u�rc nrJ�rJ�cPrJ�u�rJ� s;: , ;, .s: 5 Certificate of planTe Resintapexe 5 5 REGISTRATION ISSUED BY 5 ' 5 APPLICATION Date of Shipment 5 W ej ® 5/12/2005r 5 NUMBER L IND INC 5 5 � EVANSVILLE, INDIANA 47725 Tent Identification k F 140.1 ° MANUFACTURERS OF THE FINISHED 04048525 5 �. 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 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 5 657150 5 PETERSON PARTY CENTER INC ' 5 139 SWANTON ST ?: e 5 WINCHESTER MA 1890 5 4 5 5 5 5 5 5 5 5 � 5 5 Certification is hereby made that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 5 5 chemical and that the application of said chemical was done in conformance with California 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. S 5 Serial # 8108975(2) S 5 5 5 Description of item certified: 5 5 CENTURY MATE EXPANDABLE MIDDLE 5 40WX20 SNYDER WHITE VINYL S S Flame Retardant Process Used Will Not Be Removed By S 5 Washing And Is Effective For The Life Of The Fabric 5 5S 5— SNYDER MFC'NEW PHILADELPHIA OH Signed: �j O ` SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. rj rJ�rJ�cJ��PrJ�cPrJcP�PrJ�rJ�rJ�rJ�rJcJ�cPrJ�cP�.fr.PcP�PrJ�cPr.J��cPcPcPr1'cfrJ�rJrJ�c.PrJ�rJcP�.J�rJ�rJ��P�rJr.PcPcPrJ�rJ�rJ�c.P�.P��Pr1'�.l�rJ�r�cPcPcPcP�.TU�rJ�cPrJ�rJrJ�cJ�t1�r� � IMPORTANT DOCUMENT 5 Cerflf ieatc, of 'Ar Ia_ Resistapee 5 5 REGIST � ISSUED BY 5 5 RATION Date of Manufacture S 5 APPLICATION " io MCNOR® 05/27/03 5 NUMBER > INDUSTRIES INC. 5 5 , Order Number EVANSVILLE5 F '�h , INDIANA 47725 368377 5 S F140.1 b E v MANUFACTURERS OF THE FINISHED 5 �j TENT PRODUCTS DESCRIBED HEREIN S 5 This is to certify that the materials described have been flame-retardant treated S S (or are inherently noninflammable) and were supplied to: 5 5 657150 5 5 PETERSON PARTY CENTER INC 5 5 139 SWANSON ST ° 5 5 WINCHESTER MA 01890 5 S 5 5 5 5 5 5 5 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 Schemical 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 SThe method of the FR chemical application is: 5 5 Serial # S 5 8108985(2) 5 SDescription of item certified: 5 55 CENT MATE EXP END 40W X 20 SNY 5 Flame Retardant Process Used Will Not Be Removed By 5 5 5 Washing And Is Effective For The Life Of Th-e Fabric 5 S5 SNYDFR MFC.NEW PHILADELPHIA,OH Signed: a —2) TENT DEPARTMENT-ANCHOR INDUSTRIES INC. Cj D rJ�u�rJ�rJ�rJ�r�rJ�r�rJ�r�rJ�rJ��u�rJ�cPrJ�rJ��Pr�u�u�rPr�rJ�c.r�rJ�rJ��P�u�cPr�cPu��nr�rJ�rJ�rJ��,r�P rJ�rJ�rJ�rJ��PrJ�rJ�r�c.Pu�rJ�r.Pr�rJ�r��P�P�Pu�u�r�r�u�r.PrJ�r�u�r�rJ� a i' IMPORTANT DOCUMENT o 5 5 s Cert iflent e, of Fla.n?e Resista?ee 5 5 REGISTRATION ISSUED BY 5 Date of Manufacture 5 APPLICATION a 'F is CNR R. 05/27/03 5 5 NUMBER s INDUSTRIE INC. 5 Order Number 'a5 EVANSVILLE, INDIANA 47725 368377 5 5 F140.1 M cM v MANUFACTURERS OF THE FINISHED 5 STENT PRODUCTS DESCRIBED HEREIN 5 SThis is to certify that the materials described have been flame-retardant treated S 5 (or are inherently noninflammable) and were supplied to: 5 657150 5 PETERSON PARTY CENTER INC 39 SWANSON ST5 5 5 � 5 WINCHESTER MA 01890 S 5 5 5 5 5 5 5 5 5 Certification is hereby made that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 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. S 5 The method of the FR chemical application is: 5 5 Serial # 5 5 8108985(2) S Description of item certified: 5 5 CENT MATE EXP END 40W X 20 SNY 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of Th-e Fabric 5 5 SNYDER MFG NEW PHILADELPHIA,OH Signed: a 5 5 TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5 D r�rJ�u�rJ�rJ�cP�.ru�u�r�u�u�rJ�cPrJ�rJ�r�cPr.J�r�cl�r�rP�Pcfr.rrJ�rJ�rJ�rJ�rJ�rJ�rJ��r�rJ�r.Pr�r.J�rJ�u�rJ� rJ�rJ�r�r�rJ�rJ�rJ�rJ��PrJ�rJ��.r�.r�r��nr�r�rJ�r..nr�rJ�rJ�cPcPu�cPu�u� 0 OThe COli j"ii'Ofii4.%ealth of_Dass chtisef1`3 DePaf---1ntew o f In dris!fial Acci%eil ';; Q ;Fce of Investig mons a _r 608 1T'�rslti: g ori ut`t ee% 021 U ���`'� 11'11%11'.IiiCcE>s.g01'�iiLr Workevs, Colxii e:l> _ :�z� _lt: tir` artre Affidavit: I�t>lltiet /Cer�f:F:=rtor°.�/ ee`t i< 't«ti 9 '�trrrll ~ A JI1 t�liit: T.Z (.?tlll l?tnl? pfc.,1se �"t`itif Le,t:lii.' _Y_ Name (Busin ess!Organizationfindividaal): Address: City/State/Zip: o PS K 4 Phone r: 2 2'/-_ Are you an employer?Check the appropriate box: Type of project,(required): L® I am a employer witl?O�CTC) 4. ❑ I am a general contractor and I ei:;hloyces (full 1_:�e fared t .s b c< ;+?acl:ors 6. ❑New constr1ction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.' � 9. Building addition 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 x•11.ElPlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]; c. 152, §1(4), and we have no employees. [No workers' 13.©,Otherfe. ?y�__ comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. J 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 showins 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. fon?nt'? ei??ployer iltat is providii?g workers'eotnpei?satior? iiisrrrance for•my er?ployees. Below is the policy ai?d job site information. Insurance Company Name: / (�/�U r1o)a/'7 t �./7�;• �Q t Policy#or Self-ins.Lie.#: /Q C_ (P/6, 30 e Expiration Date: /U A9 / Job Site Address: ���vf� «f /a�la� /�K City/State/Zip:–/,4/. �(/!/1'/t Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofper jury that the information provided above is true and correct. Sitrnature: Date: Z2 Phone#?: 7 7d 9—cl�trz, Official use only. Do not write in this area,to be completed by city or town official Cit.r o;-Town: Perna i'1,:. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing t:_:;fector 6.Other Contact Person: Phone#: * Massachusetts - Department of Puhlic I-,afet% Board of Buildin, Re.,-mlatiuns and Standards Construction Supervisor License 1 ' License: CS 60219 MARK TRAINA 33 HANFORD RD STONEHAM, MA 02180 Expiration: 4/27/2013 ( nuni��incr Tr#: 13389 A� CERTIFICATE , OF LIABILITY INSURANCE CA;E(MM,DO,�YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPCN THE CE CERTIFICATE DOES NOT AFFIRMATIVELY 10/5/2010 BELOW. THIS CERTIFICATE OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE CERTIFICATE HOLDER. THIS OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSUFcER S , REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. �"` AFFORDED•BY THE POLICIES IMPORTANT: If the certificate holder is an ADDITIOP�AL INSURED, the policy(ies} must be endorsed. If SUB ( ) AUTHORISED the terms and conditions of the policy,certain policies may require an endorsement. A staterttent on this certificate does no certificate holder in lieu of such endorsement(s). ROGATION IS WAIVED subject to PRODUCER t confer rights t0 the Bonacorso Insurance Agency, A-MECONT: Bonacorso NAME:_ Inc.IHCPHONE 83 Cambridge Street AIc,.NgExt):_(781)273-3200 Fax P.O. BOX, 1502 e-MAIL Hike@bonacors: (AX,No):(78:)',33-c., Aoc DDRESS: Ails S.com urlin ton f'R000CER -g- --PMA— 01803 CUSTOI4ERiDp00003879 NSURED - _---- - __ _ INSURERS)AFFORDING COVERAGE 3333- �_. .. Pet INSURER A.Republic Franklin Ins, CO NAIL# erson Part - - Party Center, Inc, I_N_suRER__B__:_T_rav_e_ lers Indemnity 139 Swanton Street iNsuRER c;Hartford Insurance Co. _INSURER D: Winchester MA 01890 INSURER. E: OVtRAGi_.' INSURER F:ERT iF10, Tt f UI,jEER:=0?0 Nr.S r THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAIu1ED ABOVE FOR T INDICATED. NOTWITHSTANDING ANY RE R 'V `'ICN tiUf S.` : CERTIFICATE MAYO ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO EXCLUSIONS AND CONDITIONS OF SUCH POLI CIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HE POLICY PERIOD __._--------------3333-- _ C TO ALL THE WHICH TERMSS LTR TYPEOFINSURgNCE AODLSUBR! -------------3333-- _ IN R WVC POLICYEFFpOLICYIXf - GENERAL LIABIDTY POUCY NUMBER MfA1DD/YYYYA;M/DD - .. . /YYYY X COMMERCIAL GENERALIMITS - - L LIABILITY _ A EACH OCCURRENCE S EACH -X OCCUR DAMAGE 7o RENTED 1,000,000 X X �PP 436162910/9/2010 10/9/2011 PREMISES,(EaoccurenceJ S 500,000 ---- MED EXP(Any one person) $ - - -- PERSONAL 8 ADV INJURY $ 1,OOO,COO - - -- E_N'L AGGREGATE LIMIT APPLIES PER. - - - - GENERALAGGREGAic S 2,000,^OQ POLICY X . E Q i LOC -- PROCUCiS_CO^r.a/CP C, $ 2,00o,000 AUTOMOBILE LIABILITY ---—---- ANYAUTO ! S COMBINED ent) LE LIMIT $ B ;ALL OWNED AUTOS ) 1,000,000 }( �{ �A 9296R836 _X SCHEDULEDAUTOS xO/9/2010 110/9/2011 jBODILYINURY(Perperson) $-- - -------- HIP.ED AUTOS � � BODILYINJURY(Peraccdent);S - ._.. -------- PROPERTY DAMAGE -•-_- - _X� NONdWt�EDAUTOS I _(Per accident) $ - j Underinsured nsured X UMBRELLA LIA6 nnotonst BI SER $ !OCCUR 1,000,000 I - . Uninsuretl moto s; _ EXCESS LIAR—'= j BI sc:I;l tit S 1,000,r Q�CLAIMS-MADE! EACH OCCURRENCE -- _I DEDUCTIBLE - -- ---- 5,000,000 AGGREGATE A I RETENTION $ ---_._-_$-- -_. 5,000,000 XX - - 4361631 -- " A V.'ORKL?:S COfaPEN5ATi0N 0/9/2010 1110/9/2011 --------3333-- $ An'0EMPLOYER°'LIASwTY ------ •---..; .ANY PP.OPRIETOFUPAFTNEF•E•-CUTIVY 1 N .OFFICE✓UEMBEP.EXCLUDED? E .'Y "W STATU- DTH-, N .N/AI �10/9/20i0 TORYLIh11TS_.._ __Er, -.-_-- _ (Mandatory In NH) i E.L.EACH ACCIDENT If yes,describe under I C 4361630 $ 0 000 DESCRIPTION OF OPERATIONS below 10/9/2011 - - --- _._"..----_.---- EL DISE 5_00`0 L___- EA EMPLOYEE OO C Equipment Floater X E.L.DISEASE-POLICY LIMIT $ O BE DETERMINED j10/9/2010 10 9/2011 500 000 1 / Leased andRentedui : DESCRWTiC"J OF OPERATIONS/ p LOCATIONS fVEWCLES (Arirch ACORD 101,Add@lonal Remarks SchedWr,if more space is required) $100 000 Limit of Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Peterson Party Center, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 139 Swanton Street Winchester, MA 01890 AUTHORIZED REPRESENTATIVE ACORD 25(20G. Michael J. Bonacorso INS025(200909) The ACORD name and logo are registeredm rks of ACO;;D D CORPORATION. All rights ll ad.