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HomeMy WebLinkAboutBuilding Permit #917-13 - 13 WALKER ROAD 6/26/2013 c TOWN OF NORTH ANDOVER ii APPLICATION FOR PLAN EXAMINATION Permit NO: 1 _ Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page +.. LOCATIONS . , t ` r r }X t5u �wm k at N o, s tt r - «r Z g G g xPnnt f i spy ' t r ♦ t 7 .1 W37 Y+(G �r1 7,::� JJ L 1 ��J' } 'G. .t4' Y 4A J .. 4 PR®RERTY�®WNER M w a ; t , x�, r19F'f �, t >+i�. b<a r•a. .n:.` '� .+p .�i 1 £1'* fi S 3',v Y. 'Y'� btk h yy . .t" k 4�:_• x . �` r � Yr±��xln v+l•1r�.R�xs�. ,lt :! ,•c 'tin t �a�i� �'a/,�..x'"s �1`"N•r fy't,r t4;. "MAP NO �� � PARCEL�Z��"�® ING;DISTRICT . �.:.�� �HistoncsDistnct� : �tyes > ono ' �' `� �� Machine�Shop=Village kyes'�� kno' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family 0 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic a Well �; F ❑;Floodplain ❑Vlletlands ❑ ed District,. rW. ❑W`a'ter/Sewer:. .;�_ }� .t s,...„. - , . DESCRIPTION OF WORK TO BE PERFORMED: dentifi tion` Vlease Ty or Pri t Clearly) OWNER: Name: c V }} Phone: Address: CONTIRACTOR Name a t y � ��C 4� a v 1 PhoheY _ Address �rr '' f 1 c `��' (�}rC •'t•. °3«� �L€ Rr S P wT :z.�, Y .r 3 ri�h'' ti t-� a'tn,4 +`+�Myot+ i1rt� aR. ..,PAF R x rg 3...3• � �e � a• r' ,�'k m :. � �t.��+.�C�`s` r�A S.upervisor's ConstructionLieense � - Exp Date a/ , t Jr r< r: z h "i�” t .. , y _..r� 3 Y la�a t 7.:-f v �,.t3 3 :rl �i f� _: t ► Home;l^mprovement License P—Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. Total Project Cost: $ FEE: Check No.: ' Receipt No.: N G NOTE: Persons contracting with unregistered contractorlo not have access to the guaranty fund Signature of Agent/Owner Signature of contracto TOWN OF NORTH ANDOVER M 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 ❑Wetlands ❑ Watershed District D 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: 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: $ Check No.: Receipt No.: NOTE: .Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Ovvner _ Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF.SEWERAGE DISPOSAL Swimming Pools ❑ Public Sewer ❑ g Tanning/Massage/Body Art ❑ 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 ❑ ❑ i COMMENTS CONSERVATION Reviewed on Signature i I COMMENTS I i HEALTH Reviewed on Signature COMMENTS it Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Toiv;? Engineer: Signature: Located 384 Osgood Street FIRE DE PA'RTM,L-*NT -Temp Dumpster on site yes no Located at 124 Mair Street Fire Departiner`itsignature/date .;.� i 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, roast 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 i [ Doc.Building Permit Revised 2010 I Building Department The folbowing 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 app,-al 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 2012 G Lodatior 4 1 16113 WCCLr- 1>~_d. No. Date it ciZ 1 "`f� TOWN OF NORTH ANDOVER ._. ' 5����8 j696•_ 1 Certificate of Occupancy $ a Building/Frame Permit Fee $ a Foundation Permit Fee $ ' N q,a G�a ` Other Permit Fee $ TOTAL $ f Check# 26566 Building Inspector' NORTfy Town of ._ ,( .-4 ndover No. 10L2 o�h , ver, Mass, (a ` coc..Ic..ewrca �1' �d p�R�{TED S V BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT M046MIJ. �/.1.d.�......�Ad ..�.. ....... BUILDING INSPECTOR .................. .... ................. Foundation has permission to erect ....................�...... buildings on ..........1.?) �" ........... ...... .............................. ...... Rough tobe occupied as ........... . ... .................. f................................................................. Chimney 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR d UNLESS CONSTRUCTION !R Rough Service ....................... ................................................. Final BUILDING INSPECTOR 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. SEE REVERSE SIDE Smoke Det. h 24 13 02:23p MGS Construction LLC 6034323282 p,1 PROPOSAL,/ClONTIRACT Meadowview Condominiums 5 wafter Road N. Andover, AVIA Roof In sto-JIation FROM: MGS Construction LLC 2 Lake Avenue PAGE NO. 1 OF 2 PAGES Derry,New Hampshire 03038 DATE: !tune 13.2013 Office: (603)216-2633 I Cell:(617)293-7287 Fax: (603)432-3282 PROPOSAL SUBMITTED TO: Shawmut Management ADDRESS: Meadow View Condominiums 27 Charles Street 5 Walker Road North Andover,MA 01845 (*4,5,6;8, 10, 11, 12,and ]'Building Contract) ATTN:Matthew Dykeman CITYISTATE: North Andover,MA JOB NAM]-: Roof Replacement Project i I We hereby submit specifications and this proposal/contract for the:follo�lring: I BREAKDOWN: MGS Construction will remove 2 existing layers of roofing and flashing materials from roof field including the chimney lead MGS Construction will supple and install 6'of ice and eater shield at roof eaves and valleys, 18"to either side of hip, 3'at all pipe boots/roof penetrations - MGS Construction will overlap the ice and water shield 1"over fascia/rake:boards to help protect against from ice dam damage MGS Construction will supply and install 301b felt paper to(he remaining.roof field MGS Construction will install all new drip edge and flashings i MGS Construction will re-lead 1 chimney per building j MGS Construction will supply and install manufactured leading edge to complete the roof perimeter as the manufacturers suggest MGS Construction will supply and install limited lifetime architectural shingles. Color to match new roof(completed by others)on building 1 MGS Construction will hurricane nail 6 nails per shingle to protect against blow offs Meadov,x4ew Condominiums 1 2013 Roofing project Jun 24 13 02:23p MGS Construction LLC 6034323282 p.2 In the event,that unforeseen rot is found A plywood replacement charge in the amount of$45.00 per sheet(labor and mato ial)will be billed additionally to the contract amount. Any items not stated above are to be considered as an extra charge and will be invoiced separately from this billing..All other agreements to be made in writing between the customer and MGS Construction. SINGLE BUILDING PRICING: Each building will be re-roofed according to the above specii:ications Labor and material:$17,000.00 per building SERNISINOTICES:RESIDENTIAL MGS Construction is not responsible for any shrub,landscaping,lawn or loose personal property damage while work is in progress.It is the home owner's responsibility to ensure that prior tv the start of the project all arais of concern are prepared for start of project Any shrubs,plantings,should be pulled away from the house to ensure drat ne damage will be endured by work in progress.All planters,grills, patio famishings,and other precious objects should also be moved prior to the start of any roofing or vinyl siding project Ali vehicles should be parked at least 20 feet away from the home during all work in progress thus is due to debris that could fall and:or hit the vehicle. MGS Construction is not responsible for any damages to this propeiity as this should be considered as a formal notice.All interior wall hangings,including shelving,pictures,and other precious objects should also be removed due to heavy hammering until theJ ro'ect has been completed. P MGS Construction takes extreme care in the setting up of the equipment,scaffolding and tarps used on each project in artier to protect all property and landscapes.-Any exterior damages to property incurred by NIGS Consb:uction will be remedied repaired/resolved by MOS Construction.However,we cannot be held liable for damages to plant and or flower beds,shrubbery,etc located within 15'of the perimeter of the work area. MGS Construction will not be held liable for cracked or damaged diywalI or for any interior objects that may vibrate,sbake,or fall due to heavy hammering or normal construction work. MGS Construction estimates that this project will be started and coraplewd within 14 business days weather permitting WARRANTY: MGS Construction will warranty their craftsmanship for 5 years from the date of completion_This does not include acts of nature and or damages incurred by others. Manufacturer's warranty:The manufacturers all carry limited waminties on all products used(usually pro rated after 5 years) PAYMENT TERMS: We hereby propose to fiuttish labor and materials to complete in acimrdwce with the above specifications,for the sum of One Hundred Fifty Three Thousand Dollars($753,0011.00 )per building with payments to.be made as follows: A deposit in the amount of$76,500-00 is due upon completion of four buildings The remaining balance in the amount of 576,500.00 is due within 7 days.from the completion of final building NOTE:A ten'perceitt(10°lo)of the i ejfiaiiiing balance"mn y be held:lois rel.ainage in fhe event of unusrial circ-u nsignces such as rumor . property damage incurred by MGS Construction or in the event ofliackardered materials. Please note it is unlikely that a retainage would need to behold in most cases. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standardpractices- Any alteration or deviation from above specifications involving extra nests will be ex.-cuted onlywon written orders_ and will become an i - extra charge over and above the estimate.All agreements conhngimt up on s, accident or delays beyond our control.This proposal subject to acceptance within 30 days and itis void thetion of ft undersigned. Authorized Signature r Meadowview Condominium 2 2013 Roofing project i Z. Bo.u'd rrt'Buildinsy.<c='irncrrt Rtr« Ul)11C' S<1tCt�' Construction g .ulatior, and License: UPerviso nse�rndit (IS Lice �s 57 r Lice MARK E MORDWI 18 NEWELL DR ^; N ATTLEBORO MA 02760 i f ornn,i„funi �� Expiration: 9/18/2013 q._ Tr#: 10303 r 1 Office of Consumer Affairs and Efusiness Regulation 10 Park Plaza - Suite 5170 `' Boston, Massachusetts 02116 .:> I Home Improvement Contractor Registration Registration: 171254 Type: LLC Exp:rat:on: 3;112014 T# 221733 M GENDRON & SON CONSTRUCTION LLC MANUEL GENDRON P:O.-BOX 1024- 1 DERRY, NH 03038 _ Update Address and return card.Mark reason for change. Address E] Renewal ❑ .Emplovment E Lost Card )PS-CAI 0 SOM•04/04•0101216 ' ``. Office o/ nsume*ia ea f�Lonsumcr airs mess cnu a lou License or registration valid for individul use only n L,HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: iI 1 Registration: 171254 Type: Office of Consumer Affairs and Business Regulation. 14?t�(I(3/ .' Expiration: :3/1/2014 LLC 10 Park Plaza-Suite 5170 Boston.,MA 02116 MGlNDRON&SON CONSTRUCTfON LLC. MANUEL GENDRON. 6 ENGLISH RANGE DERRY. NH 03038 —L Undersecretary Not vptid wi 1ou `' ignature I CERTIFICATE OF LIIAWLITY INSURANCE a Mm(mMwDDrffffm KATE IS ISSUED AS A MATTER OF INFORMI�TION ONLI►AND CONFERS ftp RIGHTS U E C"I MA TE How ERTIFICATE DOES NOT AFFIRMATIVELY OA NEGATNEi YAIIfEM0,UTEND OR ALTER THE COVERAGE AFFORDED BY TME POLICIES BELOW. THIS CERTIFICATE OF WSURANCE DOES NOTCOMSTrrt1TEA CONTIIIACT HEiWEEN THE ISSUING pISURMS) AUTHORQED MPORTk/!T:Hfheentdicatel7otdscec an ADD MOM I113UR �11011C 1146)mus?IN amlDrsed. 11 SUBROGATION 15 WANED,sutyed to the terata and condltioRs of the vQi1Cy,cQrW"pokic s may rcqulre and endoRemnL A stRtament on this caukate does not confer rights to he wrtNlcMw holder in lieu of such rarMaramo PRODUCER �'� CONTACT j MAW; PLA WI]Y 3T INS&FINANCIA FAX PHONE Z4 MAIN ST STS 3A (4 UC,Nq ERU: (A1C.Nok SALEK NH 03079-3t92 EatAIL ADDRES& 76BIO DWRIMM AMORDW COVERAGE NAICM INSURED —_~ IPWRQtA: AAP.TFORDErtIMBRWRrrMIdStMMCSCO&OANY M GENDRON&SON CONSTRUC CN LLC DBA MGS 711SURM O. CONSTRUCTION Wt8uRBt t" POBOX ID24 NLRHtEtD. DERRY,NH 03038 DISURE§tE tU L9URBR F: CO%13k4GI CIRIFiGA?>rttUl R: ���� R1 VISiQtJANIIIBt3t; MOTfYrrIIiTA1D11G ATn OWN=OR u1 MjX o TI*JMIORDORdTLOMCFARYIINITRAGtORUI1I�CCIf1l•B[rN7tNRF%PMTTOWNCNTIWCERTF"7ElMVGC0 ED OR WAY PERTAN.VNEN5VRMMAFFORMRVTNEPOIY=DI=mc0MtMISStNW,,10AUI.AIETONLS t=Lk*01t AWtO=TI0NSOFSUM pOLCIM Li/r591OM MY PAVE stmt RIE WJM Ry FAD CLAM wm -T PMC Y WF DATE POLICY CLP MATE lTR1 TYKOFRtSURAR04 L R MXCVwAm t �IMMLnfT1ry t?�a+Y1Y71 LMiiS GEMEMLIA IL17Y iACKOWURRENCE S COMMERCIAL GENERAL LIABILITY CLAIMS MADE [::]00CLR. )^MACE TO RENTED S EMISES(Es c=ure" PODUL GENT AGGREGATE LIMIT APPLIES PER- NAL9 ADV IUJURY s POLICY �PROJECT LOC AL AGGREGATE S fS-C1 WX)P AGG S AUrDl1061LE LLaLL1TY ' ANY AUTO Tlsiuswcx� s IM (Ea amideri) ALLOW WO AUTOS ILY INJURY S SCHEDUIJ:AUTOS Per peaonl MIRED ALJr0S DILY INAIfi'Y S FgNUYrNED AUTOS PF acetdetrl PERTYDAMAGE S I%r accideril UMBRELLA LIAR OCCUR NCH OCCURRENCE S E?CCESSLIAB CLAIMS-MADE AGGREGATE s �� Vt!=71gf S RETI?JTICAI 3 S A MAKEWSCOWEN43AMONAMDvtosr.Tvraev OTKR ee�Lore"31LAWL►TY Ynt t�a�ztysea Ia oanarzo-la oar3ozma X u4tas ANYRROPERITOFWARTNEP&X:c lrNE a FWX4b IEIaeER EXCLL eD? Q 71.EACH ACCIDENT 3 100.000 o'""Pty m e" E mEASE-EA EMPLOYEE S 100000 N rem do—am mdu DEBORIPI 04OF OPetAr W below E.L.DISEASE-POLICY LIMIT S 50opm OFSCR"ONOFOPERILTLONSt "7101*WYBOCI>ESrItmmlCi>am-%wlwiLnnis TIRSRULACSSANY PPJO8Cfl8TINCATrmUED TC)THE CMTIR(.AIEHOfDeR.kMCTAIOWoUa SCOMPCOVFRAGH. CERTIRCATEHOLDER �" d AItCEl1J1TIDN SHOULD ANY OF TW ABOVE OESCRIBED POLKMM BE CAIICELLED 111 6EF OR ET HE E EVRAMON DA'.T T.Ig 3 ="_M V�m_.L M r.L..jcg IIN ACCGRDAItr.'EVM THE 33CUCY PR" JIAJTHORZED RE }1TATNE ACO 29(2010fOS) 1119ACCIRDINIAMOARd Pogo are r*Wzftjvd mar isaMORD ImmicACOK13 C rasemed. III £'d Z8ZEZ£.�C09 011 U01jonJIsuo7 R,-)VU dp.n:7.n P.I. a7, unr CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD„-YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR.VIATION OI'ILY N,ND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E:{TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NCT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR i'RODLICER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,N RED the o'c i p II Y(�)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require airy endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C<,NTACT N1iN Patricia Blais Financial 2nsurance Services Inc Moritz (603)932-6414 ac No-(603)432-3852 PO Box 950 IF blais@fisins.com AI DRESS.P INSURERS AFFORDING COVERAGE NAIL A Derry NS 03038 INIURER A:Pee=less Fnsurance Co INSURED INl:URER 13 (MISS Construction, LLC INIiURERa PO Box 1024 INf:URER 0: INSURER E: Perry NE 03038 IIISURERF: COVERAGES CERTIFICATE NUMBER"3-14 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS:-ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 01=ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO CERTIFICATE MAY BE ISSUED M WHICH THIS OR MAY PERTAIN, THE INSURANCE AFFC}RDE[) BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR LTR TYPE OF INSURANCEIN. POLICYNUMBEfi 711M)O�FPP MMIOD EXD UNITS GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 X COP61MERCIAL GENERAL LIABILITY DAMAGE TO NT PREMISES Eaaccunence s 100,000 A CLAIMS4AADE Q OCCUR P10350 59 /3/2013 /3/2014 MID EXP rAny one person) S 5,DOD 1 PERSONALS ADV INJURY S 1,000,000 GENERALAWREGATE S 2,000,090 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP,C)P AG-G- $ 2,000,000 X POLICY PRO-ECT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE UMr i t ANY AUTO BODILY INJURY(Pei person) $ ALL ONC WNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS AUTOSNON-O�EO PROPERTY DAMAGE Peraccident $ 3 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'UABIL(TY WCSTATU- OTH- ANY PROPRIETOILPARTNER/QCECUTIVE YIN OFFICERMIEMBER E)(CLUDEO9 ❑ NIA E.L.EACH ACCIDEW $ (Mandatory In es,desttibe wider E.L.DISEASE-EA EMPLOYE S If yy DESCRIPTION OF OPERATIONS be"y _- E.L.DISEASE-POLICY U111iT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more spore is required) CERTIFICATE HOLDER t:ANCELLAT I ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- JI ITHORIZED REPRESENTATIVE Ryan Fragala/PAT ACORD 25(201Q/05) ©1980-2010 ACORD CORPORATION. All rights reserved. 1111S025mm�ns��+ Tha fir_nP11 nanny and 16.nr.era raniclararlrn.=rlrc nr Ar'nOn d Z8ZEZf,`bE09 01� uoi}owlsuoo SE)W dt0:Z0 f;l q7 ung