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Building Permit #140-14 - 128 AUTRAN AVENUE 8/13/2013
t pORT/1 BUILDING PERMIT TOWN OF NORTH ANDOVER ^+I F S _ APPLICATION FOR PLAN EXAMINATION Permit NO: J Date Received Date Issued: / ��ssgcKus IMPORTANT:Applicant must complete all items on this page i LOCATION r* �-- b���� PROPERTY OWNER �emhi Print MAP NO: PARCEL��ZONING DISTRICT: Historic District yesno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential U New Building u One family U Addition U Two or more family U Industrial U Alteration No. of units: U Commercial U Repair, replacement u Assessory Bldg U Others: U Demolition U Other U Septic U Well U Floodplain U Wetlands U Watershed District U Water/Sewer Tt I. I I/l 3 w( r/!iI M r I/t C d — a a w -y-- S,e e sd Identification Please Type or Print Clearly) OWNER: Name: VI,OCA 44 k1w /O'C Phone: 7k 6F-3- 5T (3 Address: o� _ct 14 All e_ CONTRACTOR Name: / Ulu IPhone: s Address: 10 7 L_o vt It Sa y Supervisor's Construction License: Exp. Date: Cs - 094og�- t� -�-� - Ao1-3 Home Improvement License: ,�- Exp. Date: t -7� � � �'- 3 ARCHITECT/ENGINEER Phone: _ Address. Reg. No. FEE SCHEDULE:BOLDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ '� UV FEE: $ �J J-- Check No.: l p4s-1 Receipt No.: 7_ Plg3 NOTE: Persons contracting with unregistered contractors do not have access"esu fu Signature of Agent/Owner Signature of contractor TOINN OF, NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print- PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: PARCEL: ._ ______ ZONING DISTRICT: Historic District 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 p Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date.:- ARCH ITECT/ENGI NEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature.of Agent/Owner Signature of contractor Plans Submitted 171 Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ Location U � � AZ— N o. Alo—j v Date . - TOWN OF NORTH ANDOVER D' • ti Certificate of Occupancy $ 5 ov a ' Building/Frame Permit Fee °$ -3 *� Y ;7 , ' Foundation Permit FeeIT $ .m reiwa?.e" Other Permit Fee $ r TOTAL $ c s. 4 F e Check# !� k G f l; 3 Building Inspector I Plans Submitted P3 Plans Waived ❑ Certified PlotPi"an ❑ 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 CONSERVATION Reviewed on 1 Signature COMMENTS LUC w /- I CSD 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 Towii Engineer: Signature: I, Located 384 Osgood Street FIRE DEPARTMENT` -Temp Dumpster on site yes no Located at 124 Mair, 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 I I NOTES and DATA— (For department use i i El Notified for pickup - Date 3 Doc.Building Permit Revised 2010 r Building Department The foli',ovving isa list of the required forms to be filled out for the appropriate permit to be obtained. Roofh,g, 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 ❑ 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 ❑ Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ 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) ❑ 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) a Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ 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 cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-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.Buil\iing Permit Revised 2012 r �,• _ � - ' � .. � .. i .r I I4 . ' - .� i I � _ i 1 e _ � a I '� J � �� }' _ _ I a. � I NORTH Town of ? E ndover No. 13 ; h ver, Mass,, ' 101 ' o .a...■ COCMICMl WICK y1. s u BOARD OF HEALTH T LD Food/Kitchen PERM Septic System • THIS CERTIFIES THAT ......... .....Qh,,fh.!ir. yw1,fk„ ., BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .JaLalw......... .... AY.+r&.ONAd......... .. ....RIS Rough LAII to be occupied as ......... ..:.�.1 ......?sperm*its ..... ... .................... ..A....... Chimney provided that the person accepting thall in every spect 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 CIO VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 61 PERMIT EXPIRES IN 6 kjGVFHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIQfAI16RT Rough Service .................. ........ ........... ....... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required 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 Page No. of Pages �LyER9 I l TELEPHONE: 107 Lowell Street r� K HUTTON'§[� 685-2627 Methuen, Massachusetts 01844 PR SAL SUBMITTED TO r PHONE DATE STREET P /(�1� � JOB NAME _:�;,)fte CITY. STATEAN ZIP CODE JOB LOCATION C/" ale ARCHITECT I DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: In e. C sg2dS4 4 booed `—' OCA !yl fit, S 19P praVOOP hereby to furnish m erialand labor — compl to in.accordance with above specifications, for the sum of: V' �tffnll rs($ /`7`�d • UU ). (Payment to be made s follo s: ` 6;>_ U eo /-e All material is guaranteed to be as specified. All work fo be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifica- Authorized tions involving extra costs will be executed only upon written orders.and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents Note:This proposal may be or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. P P Y Our workers are fully covered by Workmen's Compensation Insurance. Withdrawn by us if not accepted within days. Arreptana, of Fraposal—The above prices, specifications and conditions are Satisfactory and are hereby accepted. You are authorized Signature to do the work as specified.Payment will be made as outlined above. 4� Date of Acceptance: Signature , The Commonwealth of Massachusetts Department of Industrlgl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibl Name(Business/Organization/Individual): Address: 107 Z_a"-e- City/Stat -e- City/State/Zip: /��7`//(�P� q �l 4h�yone#: Are you an employer?Check the appropriate box: Type of project(required): 1.rfI am a employer,with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. I #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers,comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. }te a V 2 lei S _)__V ter/.1/'c Policy#or Self-ins.Lic.#: a 6 0�gs / Expiration Date: Job Site Address: u A, �,ra/✓ City/State/Zip: AlfI- � /4jo Ver ' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 "undere pa' s peenaal i s f per• ry that the information provided above is true and correct. Si ature:� `� Date: ^( � 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." 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 not more than three apartments and who resides 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"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a 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(7)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 may be 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 Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding 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 permittlicense applications in any given year,need only submit one affidavit indicating current policy information(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 marked by the city or town may be provided to the applicant as proof 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 bum 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,telephone and fax number: The Commonwealth of Massa chtzsetts Department of Industrial,Accidents Office of Investigations 600 Washington Street Boston,MAS 02111 Tel,#617-727_4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 www mass.govfdia A CERTIFICATE OF LIABILITY INSURANCE O7T-03-2013 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 polity(les)must be endorsed. tt 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). PROOUCER CONTACT NAME HU B INTERNATIONAL N EW PHONE FAX 299 BALLAROVALE STREET IA/G No Ext: C", AIC No: E-MAIL WILMINGTON,MA 01SB7 annimss PISURER(SI AFFORDING COVERAGE NAIC 9 INSURER A:THE TRAVELERS INDEMNITY COMPANY CFAMERKAi INSURED INSURER 8: HUTTONS GENERAL CONSTRUCTION INSURER C: INC 107 LOWELL STREET INSURER D: M ETH UEN,MA 0184.4. INSURER E: INSURER F- COVERAGES RIEVISION 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. ADD SUB POLICY EFF POLICYEXP LIMITS 1LIRR TYPE OF INSURANCE NSR WvD POLJCYNUMBER (MWDD/YYYY) fIwMiDDNYyy1 GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS--MAGE � OCCUR PREMISES(AnyoEa ne person)MED EXP(Any one peson) $ PERSONAL&ADV INJURY g j GENERAL AGGREGATE 5 GEN'L P.GGREGATE LIMIT APPLIES PER: PRODUCTS-COMPtOPAGG S POLICY JEC7 17 LOC S ALITOMOBILELIAGIUTY I OMBFNJEJ SINGLE L[M171T g a a^talc of ANY AUTO I BODILY INJURY(Pcrponwn) S ALLOWNED SC.MOULEO S AUTOS AUTOS BODILY INJURY(PcraoriAent) HIRED AUTOS NON-0V'6Y ED ,7OPERooTTY MAGE S AUTOS er anl I S UMBRELLA LIAR I OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S Dm I RETENTION S S WORKERS COMPENSATION X TORY L M TI S TH AND EMPLOYERS'LIABILITY Y MER ANY PROPRIEI-ORlPARTNERIE CLI'l��p—•; NIA E.L.EACH ACCIDENT $900,000 OF?ICEWIVEMBER EXCLUDED? I._. ;6HUB 06-21-2013 06-29-2014 (Mandatory in NH..) E-LDISEASE.-EA EMPLOYEE $100,000 ryos.describe under '68048519 DESCRIPTION OF OPERATIONS Win. E.LL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS J VEHICLES(AUach ACORD 101,Addltlonel Remark3 SchedUe,If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE TOWN HALL CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORTH ANDOVER,MA01945 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRES`NTATIVE (P1488-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks u1ACORD Z-d LZ9Z-989-8L6 uoi1ona1suo:D u90 s,uo))nH d6£:£0 0L 0L 6nV Client#:3727 HUTTO NSGE N ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMADIYYYYJos/13rzo13 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(les)must be endorsed.If SUBROGATION IS WANED,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 NAME CT HUB International New England PHONE 978 657-5100 AX 866-475-7959 AIC,No.Ext): APC No: 299 Ballardvale St E-MAIL ADDRESS. NEE.CERTIFICATE HUBINTERNATIONALCOM Wilmington,MA 01887 INSURER(S)AFFORDENG COVERAGE NAIC O 978 657-5100 INSURERA:Peerless Insurance Co 24198 INSURED INSURER 6:TRAVELERS IND.CO. Hutton's General Construction Inc, 1 NSURER C:Commerce Insurance Co 34754 107 Lowell Street INSURER D: Methuen,MA 01844 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEEN ISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERMD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. INSR AIDIDL SUERPOUCY.E F POLICY EXP LTR TYPE OF INSURANCE INSR VWD POLICY NUMBER MM/D KWDD LIMITS A GENERAL LIABILITY CBP8157203 D511912013 0511912014 EACi OCCURRENCE S11,000,000 DA AG TO REKTED kPD MERCIAL GENERAL LIABILITY PREMISES Eaoc urrence $100,000 CLAIMS-MADE n OCCUR MED EXP(Any one person) $5,000 X Ded:500 PERSONAL BADV INJURY S1,000,000 GENERAL AGGREGATE 52,400,000 GE NIL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 1,000,000 X POLICY PEa LOC $ - C' AUTOMOBILE LIABILITY 13MMBDHMZY 511 912 01 3 Ors1191201 COMB iderd)SINGLE LIMIT IEa aBINED) S ANY AUTO BODILY INJURY(Perporson) $5500,000 ALL OA'NEDX SCHEDULED BODILY INJURY(Per amiderd) $500,000 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $100,000 Ix HIRED AUT05 X AUTOS lPcraccideM $ UMBRELLAUTAB HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION SS ER D WORKERS COMPENSATION VX STATU- OTH- ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOMPARTNE%EXECUTIVEEL EACH ACCIDENT S OFFICEEMBER EXCLUDED? ❑ MIA A R/M (Mandatory in NH) I EL.DISEASE-EA EMPLOYEE S If yyees,describe under DESCRIPTION OF OPERATIONS La I E.L DISEASE-POLICY LIMIT S A BUILDING CBP8157203 5/1912013 051191201 $390,265 WIDED$1,000 SCH.EQUIP $278,087-ACV RENTED EQUIP. $25,000 WM000 DED. DESCRIPTION OF OPERATIONS I LOCATIONS1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more spars is required) HOLDER IS LISTED AS ADD'L INSURED FOR LIABILITY IF REQUIRED BY WRITTEN CONTRACT.WC COVERAGE BOUND CERT TO FOLLOW DIRECTLY FROM TRAVELERS, CERTIFICATE HOLDER CANCELLATION Town of Norfh Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE MNTH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks OACORD PS942851IM942827 DV001 L'd LZ9Z-989-8L6 uoi)oni1suoC)Uae s,UOJ1nH d6C:C0 0L EL 6