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HomeMy WebLinkAboutBuilding Permit #286-11 - 14 WEYLAND CIRCLE 10/7/2010 i BUILDING PERMIT NORTH O�ttUeo 16stip TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Z � OQ . 10 Permit NO: Date Received A°Rwr.o �SSAC HU`��� 01 Date Issued: IMPORTANT: Applicant must complete all items on this page CAO(� r x h ' awl I�rtClt WR, E['CTY § WN1- 3- /y " � RM 42 � s ANS '. ARC � 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 X Other !-CP;,)P. ` l upt We1jo � ,F acalplai. 1 des Waters- d strict 0flF ,.,�. DESCRIPTION OF WORK TO BE PREFORMED: alb 6F,6,ec - o,.- lyxI4 q- /,,2x/.-L ulLaw l i�� r4e) / & r X-emafIYG� O� /O Identific tion Please ype or Print Clearly) OWNER: Name: °'"0Y i ��U� s Phone:2R/- 71(1- O F'PP AddressA/ l�� �a�� 0 l--ev 1 U ';'-"';&'e"'-"1'�i"Mr < 40 -S r r ` aMIM p+✓rvr�ifs C� stractlon v r Tame rrp �tr� r�elit Ice y H, 'Exp � ��, 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: $ FLS FEE: $ 3 Check No.: / J-41� Receipt No.: 93 " NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i 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 ❑ L 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 i DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS i it 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 rM ART� T DisFIREDPnc� Located at 124 Mali1 S#reet y W ire Depart ent sllgra�tul elciate 1 r i r c , 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 Permit Revised 2007 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location A No. Date NORTh TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ s�cMus Building/Frame Permit Fee $ U Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #Mi 23526 Building Inspector r f. it y�7ia w a yy. v.. 5iu e is �, of d �� S _ v �� 5 REGISTRATION ISSUED BY S APPI lGATI Q ' Date of Shipment rq ON i S JNUMBER � NDUSTfiIE INC. 5/10/2006 SEVANSVILLE, INDIANA 47725 Tent Identification Sis I-lo I MANUFACTURERS OF THE FINISHED 04263446 5 5I TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated21 5 13aI (tar are inherently noninflammable) and were supplied to: 5 5 I 657150 5 PETERSON PARTY CENTER INC S } 5 139 SWANTON ST 5 r S z S WINCHESTER MA 01890 5 r L, S S S 5 4 5 S 5 Certification is hereby made that: S SThe articles described on this Certificate have been treated with a flame-retardant approved S LIN chemical and that the application of said chemical was done in conformance with California � Fire Marshal Code. All fabric has been tested and passes NPPA 701-99, CPAI 84, ULC 109. 5�_ C5 Serial # 8020500C(2) 5 5 Description of item certified: 5 PIES"I'A TOP 12WX12 SNl'I)WFIITE 5 I VL91023970A (1PC) 5 5 Flame Retardant Process Used Will Net Be Removed By 5 5 Washing And is Effective For The Life Of The Fabric 5 S ——�N4441;� h,iia�.rrtr.,rniu,al P1=111 'SA4 ,�;�}!1 Signed: ij Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC.. S ....... ���n��n������n��n�n���n�n�n���n���n�r���� o l� Date . /1- 6-�'7! •�.,Y.�SL�Sb� b ? II TOWN OF NORTH ANDOVER PERMIT FOR WIRING b This certifies that . . . . . IC I. .I . . .Ae . . . . . . . . . . . has permission to perform . . SDS?� �. . 5, %' rj. . . . . . . . . wiring in the building of . . . . 0114. r, . . . . . . . . . . . . . . . at . ,r! . . . � L ''L�?. . .C� . . . . . North Andover, tilass. Fee .�4. 'o Lic. No. . L 2 . . . . . . e Z ELTRICAL INS PECT t7R SSot� Check 112-03 l 2012Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed " on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be.deemed_by-the-Inspectorof-Wires abandoned.and_invalid.ifhe—_. ._ or she has determined that the aufhorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or.the installing entity stated on 916'permit application. . ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effector existence"during the qualifying period beginning on August 15,200 and extending-through August 15,2012. ule 8—Permit/Date Closed: `5 **Note:Reapply for new perm ❑Permit Extension Act—Permit/Date Closed: III I m��eaacuasa o /,t� 3 oe offival qLT e only 0 Pei 1 . a' Oc upanc,, and Fee Che ked ' BOARD 4'F FIRE.PREVENTION REGULATIONS �lza.e Ula+= per: 0 ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORI All woA robe pafoumed i�accordance v iththe.?.•lassachuse=i Electrical Code OdEt t_517 ch a' 1.-1&0 O 3 (FL- � .P?J2 L1'L'4:k O TYPEAL :IXFOt-'rf TJI ") Daae.. Thursday, October 25, 2012 C' tv or Toi�-n of; North Andover To xTto Inspector arFiTa;t 3 B •this aptp canon the undersi.?ned gives notice of his or her intention to perform the electrical work described helov, I 1 Location(qtr eet c \;umbei) 14 Weyland Circle ty Owner or Tenant Jori Blumsack Telephone.No. 7817240899 C Own i's Address 14 Weyland Circle Is this permit in conjunction.with abuilding permit? Yes ❑ ?1a © (C:heck�kPPr,o riate Box Purpose of BuildingUtility Authorization No. z Elistina Service amps Volts . Overhead El Unctcacl ❑. -No.of'fieters 9IUD New service: Amps i Volts 0ve,rhead❑ Undar°d'❑ No:. of Meter �_r...w rNumber of Feeders and Ampac:itt- j Location andature of Proposed F tertr ic;rI 14'ar^:I:c (1 �� j t,�.r cit nS�sc^r\ C`oinpletion {11164tlaw in utile nwx&e,waived�r'rh'z bis ec.ar r 1o.of Recessed Luminaires No.of C:e1.-cusp.(.'addle}Fairs O.of lotil Transformers KVA KVA r 1o..of Luminaire Outlets No.of Hot Tuts Generators Ln m10.of Luminaires. ove - : o.o mergence rg rtarg Swimming Pool rad, ❑ i-nd. ❑ Batten Units 73 7 No.of Receptacle.Clutlets No.of 00 Burners. FIRE ALAR'IIS Zones 0 `ar.f6 etection tin, 9 No.of SO-itches No.of Gas Burners Initiat ne Devices -No.:of Ranges Via.of Air C onT d, aha No.of Alerting Devices ro ans ti? eat Pump I-N, uyn er Ons ?`{J. a 4lttalne No.ofWaste Dispo.str°r `I'oeals: iletertion Alertirig Devices 10.of Dishwashers S acea`Area Heatin_ Ii Local unrrrp ❑ Other, p ❑ connection No.of Dryers Heating Appliances .'ecuritv'Svstems.' 0.00 10.oflerices or E trg:ulfrrt :'o.of atero.o o.o .)ata Wit Ing: Heaters KIN' Ballasts 'SignsN7o,of Dia-ices or E uivaleut 7.00 1 e eLolrrmunicatlonSjrina: No.HvdromassageBathtubs o.of motors,: Total HF ti-o.ofDehicesor E uit�ent 0.00 2� OTHER.. attach ad,*i©na'rlatai#{.fdr:ired,OF ns requirezr-?v tira hmpec tr.!0i"7n . Value of �lMien requ�recl by municipat polic;°. 3tinumValue of Electrical W urk: Work to Start: _ Inspec dors to be requested in accordance,wi b MEC Rule 1 Vit.and,Avon courole:t Jon. ItiSI Rk-N E COVERAGE, 'Unless+,carved by:he:owner,no permit for•the performance of eiec•-nca1 vorl.m _!::Sue unl the Licensee pros desproofof habrlity.insurance including corrrpleted opezaGori' coverage or its substaiidal The - rr:_ undersi gried c er*�frr that such coverage rs in force..anc has,exhibited prof of same to the perurit r5st<Eu;'Mlt _. C HECK ONTE: LNSUTA. C'E ❑ BOND' ❑ OTHER' ❑ (Specify) 1 celArl-'under thepains acrid yw aches atfpe€ja!rr•�that the infol rrrartron vn this arppiacr don rs urine acral loin lerte. FIRM NA I—,American Alarru&.Co:auniunications.I:'nc. LIC`.NO- 12.12 C. M A Licensee. Richard L. Sampson, S r. signature LIC.N'O.: 5 02 D �(Ur._vplxaible.era€ei• "exempf`°iiF1heticor-6Tina:; Bus.Tel:No,. 7811 441-21111111 Address. 9 7 BroadA-av .?irIiaratori. M—A 02474 Alt.TA.'No.: 1471-s.. seclmty work requiresDepartment ofPdbhc Safety S"License: Lic.-NoSS C0,000090 OWNER!S.INSURANCE X AIA°ER! lam aware that the Licemsee does,not.l hive rlre.liaoilitl insurance coverapa norniall_� required by law. By my signature.below.,I hereby. irzive-his requirement- I ain the(check one) ❑owner_❑-3' ner r ami". C3tiruer�_-� eni Signatut e: Telephone-No. PERLV1T FEE: S' NORTH TO" of And 0 L A K a dover, Mass., /0 �. I� COCKICMEWICK V %S RATED P' �S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System L BUILDING INSPECTOR THISCERTIFIES THAT...............�.A..�.......... I...v. !!!�Sl�:4. t.w...................................................................... Foundation has permission to erect......................................... buildings on ....N........ !ki. .. , ► .........4;.1�:................... Rough to be occupied as.....(410...1.4...... ........l.,M ... & ......a...Y.I.I. .... Cr ...P.....T�/�1't�'... chimney 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 30 � - Final PERMIT EXPIRES IN 6 MONTHS - UNLESS CONSTRU N S 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 BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner, Street No. SEE REVERSE SIDE Smoke Det. ,,t '.7 r r-J rJ r7 ecr—s r- 1;1-1,�. "IMPORTANT PL:fj R NT�Pc�"rPcP�r�cPrPcPPrPrP�Pr�r�l� O s� Y ,p REGIST,ATiON c ISSUED 113Y5 �jl �4 , Date of Shipment 5 ' Lr1 APPLICATION �`` S Z S� ? 5 $/2$/2��6NUMBER �IEI 5 4 . C 4: EVANSVILLE, INDIANA 47725 Tent Identification 5 5 r' MANUFACTURERS OF THE FINISHED oa337696 � I 110.1 TENT PRODUCTS DESCRIBED HEREIN 5R.1 5 t This is to certify that the materials described have been flame-retardant treated c 5 + (or are inherently noninflammable) and were supplied to: S I 657150 5 PETERSON PARTY CENTER INC 139 SWANTON ST 5 S� r, = 5 ' WIN�HLSTER MA 1890 Pj � 5 �I 5tai 5 S 5 1. Chi 5 Certification is hereby made that: S Cli The articles described on this Certificate have been treated with a flame-retardant approved S E, che�rnical and that the application of said chemical was done in conformance with California S til Fire Marshal Code. All fabric has bei­n tested and passes NFPA 701-99, CPAI 84, ULC 109. S # Serial (2) 5 Description of item certified: 5 IP; rIESTA I:XI'A1 )A[3LE TOP 14Wxl4 5 I SNYDL:R 130�\'1 II'[T VL 91023970A In Flame Retardant Process Used Wiii Not Be Removed By S Washing And Is Effective For The Life Of The Fabric 5 ,c� 5 Signed: s.ur�ycu ftiar-F;-�Lau-NwE+�DI-L-P++��a-ew--- --_ —_— Y 5 L� Name of Applicator of Flame resistant Finish ANCHOR INDUSTRIES INC. t7 cPrPcP�Pr.P��Pf�_P�PrPPr�lcPrJ r�PrJ��P�P�PcPcrr?Pr��PrPrPTc�fi;Pc��PcPr�rJ�ePcPrJ�rPrJ�rPrJ�rJ�r.PcPrPrPrPrPrPcPrJ��J�rJ�r�r�rJflsc?,�.PrJ�rP�PrJ�cPrJ�rPrJ�cPcPrJ�rJ�r� O ' �I<tssacltusetts - Depat-t tint (If' Ptrl)[ic Cafet\ (j(t.trt[ tt( [3;tilclin<< Rei-tilatirtns and St;tIldai-ds . �.,�. Construction Supervisor License License: cS 63219 Restricted to: 63 MARK TRAINA 33 HANFORD RD' STONEHAM, MA 02180 C Expiration: 4/27/2011 issi4uier Tr-9: 14425 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 TVashington Sheet Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): FC— ? C C/n Cl , /c Address: z�2 sc,,jaI & St City/State/Zip: 0 dPS ,K /�714jPhone #: 2 Are you an employer?Check the appropriate box: Type of project,(required): 1.® I am a employer witho20y 4. ❑ I am a general contractor and I 6. E]New construction employees (full and/or part-tirne).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. [:] Building addition [No workers' comp.insurance comp.insurance.= required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all worn: officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]i c. 152, §1(4), and we have no 13.®,Other. employees. [No workers' 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box wrist 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. Lam ah employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /I e%,7i� �(� r�G1�7 /t y� ��J�',• (�O Policy#or Self-ins.LLiic.4:liC/C. y�3(��sw 3� Expiration Date: Job Site Address: / 7 l /�f1G[ /i1G� City/State/Zip: 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 nnposition 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. P do hereby certify'under the pains and penalties of pejury that the information provided above is true and correct. Sign re: /� L ei Date: CJ 7 Phone#: Official use only. Do not write in this area, to be completer)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 th DATE(.MIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1 10/5/2010 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(ies) must be endorsed. If 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). PRODUCER CONTACT Michael Bonacorso NAME: Bonacorso Insurance Agency, Inc. PHONE Ext);_(781)273-3200 FAX,_N_o):t781)273-0600 .) --... 83 Cambridge Street A.DoaIESS:mike@bonacorsoins.com P.O. Box 1502 PRODUCER _CUST0MERJR1E00003879 -Burlington __ - -MA ,01803_ _-_ -_ INSURER(S)AFFORDING COVE RAGE NAICd INSURED INSURER A-Republic Franklin Ins. Co. INSURER Travelers_ -Indemnity Peterson Party Center, Inc. INSURER C Hartford Insurance Co. 139 Swanton Street INSURERD: INSURER E Winchester MA 01890 INSURER F: COVERAGES CERTIFICATE NUMBER:2010 MASTER 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. 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 PAIDCLAIMS. INSR -----.-.--- -" -- -----— �iADDL SUBR --- --------' POUCY EFF POLICY EXP LTR j TYPE OF INSURANCE ININ R POLICY NUMBER MM/IX)/YYYY MMlDD/YYYY ! LIMITS - GENERAL LIABILITY I EACH OCCURRENCE _ $ 1,010-o'.0-90 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - -- - - - PREMISES(Ea occurrence) $ 500-000 A CLAIMS-MADE X 10/9/2010., OCCUR X X PP 4361629 1 _ � � 110/9/2011 I MED EXP(Any one person) $ 10,000 ,PERSONAL&ADV INJURY :$ 1,000,000 ! j GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG S 2,000,000 ! POLICY j X PRO- LOC $ AUTOMOBILE-LIABILITY j COMBINED SINGLE LIMIT i—- (Ea accident) $ 1,000,000 j ANY AUTO BODILY INJURY(Per person) $ ALL OWNED.AUTOS X X BA 92968836 10/9/2010 10/9/2011 BODILY INJURY(Per accident)- X I SCHEDULEDAUTOS PROPERTY DAMAGE - $ X HIRED AUTOS j (Per accident) X j NON-OWNED AUTOS Underinsured motorist BI split -.$ 1,000,000 Uninsured motorist BI split limit j$ 1,000,000 I X � UMBRELLA UAB i OCCUR CMS-MADE ___ $ 5,000,000 A EXCESS LIAB AGGREGATE --_--�_--- -- ...-0 _ ------- -- '$ ---5,000,000 EACH OCCURRENCE- DEDUCTIBLE ! i$- __-- ARETENTION $ X X 4361631 10/9/2010 110/9/2011 $ A WORKERS COMPENSATION I �j 1 GSC STATU- I 'OI H-j LX—LT9RY_LIMIZS;._SER__ .------ AND EMPLOYERS'LIABILITY VYIN ANYIPROPRIETOR/PARTNE R/EE.L.EACH ACCIDENT i$ OFFCER/MEMBER EXCLUN/A 10/9/2010 10/9/2011 !— _ _ 500,000 (Mandatory lnNH) 4361630 E.L.DISEASE-EA EMPLOYEE$ 500 000 Ifyes,desaibeunder -- -- -- ------ - -"-- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 C 1 Equipment Floater X 0 BE DETERMINED 10/9/2010 10/9/2011 Leased and Rented Equip: j $100,000 Umit DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach AGORD 101,Additional Remarks Schedule,If more space Is required) Evidence 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 :yichael J. Bonacorso ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD