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HomeMy WebLinkAboutBuilding Permit #423 - 15 PETERSON ROAD 12/1/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: TMP—AR—TATNTT:'Apphcant must com Tete all itemson this page LOCATION Pri (/ PROPERTY OWNER /`L�/�'U I Y��XJ/✓ n Print MAP NO: d`J PARCEL:/(Ag ZONING DISTRICT: Historic District yes (2�o Machine Shop Village yes 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 tl� Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED:` ")009 C E- /S Ltj •✓yGui-S' I,J(g C �Artt E S Identification Please Type or Print Clearly) OWNER: Name: ��wi D rh Phone: &/-2- L/70- 3,3// Address: CONTRACTOR Name: SIJ ,I �,�n,�" t` �� Phone: Address: ��o C�'r� .S7-' G°n j tt/Uva C �.Sl ✓tom}q- a Supervisor's Construction License: / S-76Exp. Date: 71th G Home Improvement License:_ 1 l �( G� Exp.. Date: 4 V/Cj 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. OU Total Project Cost: $ FEE: $ ��� Check No.: �` O S� Receipt No.: � �� NOTE: Persons contracting with unregistered contractor o not have access to the guaranty fund ignature of Agent/Owner2ZS1k«F> �-- Signature of contractor 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 f 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) ❑ BuildingfPermit 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 i .. In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeal's 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 I� Doc: Doc.Building Permit Revised 2008 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 �.�s. DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS 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 Town.Engineer:Signature: Located 384 Osgood Street :FIRE DEPARTMENT -Temp'Dumpster on site yes no Located at 124'Main:'Street Fire.Department signatureldate .COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions: Total land area, sq. ft:: i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 1.66 Section 21A—F-and G min.$100-$1000 fine_ I NOTES and DATA- For department use i i Notified fori k cu p P Date ! Doc:.Building Permit Revised 2008 1 F' Location SGh f. No, a Date F: NaRTM TOWN OF NORTH ANDOVER 3: .• , •. oAL •� k x s r • i ; , Certificate of Occupancy $ : •�s';^�'Et�'a Building/Frame Permit Fee $ 2-1< s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # SE, 22669 c,, Building Inspector r. �ORTH Town of Ando. ver 0 .......... No. L3 o t dover, M ass.., o COC HICMEWICK 7�ADRATED `s BOARD OF,HEALTH RM '1 P Food/Kitchen Septic System T T `� BUILDING INSPECTOR THIS CERTIFIES THAT........Ll ��� ......................... Foundation has permission to erect........................................ buildings on . . .. ,l.�n...... Rough C ....... •... ....... )j�to be occupied as /.n�� d.....,. _ ...................................:........................... 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 Final p� PERMIT EXPIRES IN 6 MONTHS UNLESS CONS U STARTS 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. 01/02/2006 23:51 9782785010 JOHN BEAVER PAGE 10/10 Renewal RENEWAL BY ANDERSEN MA H16 Llcvnse Fedorall Tax 1D#r83-40420 bvArldersen.ro wrxnoiv nennr.¢Menr ..An&r;aC„M,, Or GREATER MASSACHUSETTS AND.Nrw HAw.sTi r, 104 Otis.Street•Northborough,MA 0 332 Phone. 508.919.0900•rax 508.91.9:0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyerlel Name Date of Agmemenr AZ 10 Bu erlrl$lreet Addroa,CI oto,and Zip Cedn 6`r� r q Wail Addlass Home�V,,h­ �um6or Work Telo hono Numbar bOYI � C ygrl'7J111 � -7– 1 76 .13/ Buycr(s)hr,.rebyjnin.fly and severally:iqt ccs to purrl?wcr the pmt'lucL%and lor services of J i&L Windows,h]e.dba Renewal by And.rrscn of G rcatcr MaSsachasctts and.Ncw Hampshire("Contrictor"),in acc:nrda)cc with rhe terms and conditions described on the from and the rew>rscof this agreement. a.ntl on the aunch.ed specification 5hcct(s)(collccti"wly,this Am greeent").Buyca.%)hereby agrees to sign a cornplution ecrtiflC,tl:c aftcr Contractor has corn I work under this Agrecmcnt d Method of Pymnt: Cash ❑Check ❑Mastercard ❑VISA 1Tot J A unt:�Pv Estimated Srorting.Dale; f ❑Discover 4'a Financed,App#: Deposit Received(33%):___..O Name on Credit Card: Balance at 51art of Job(33%): ... .......... F9imoted Com lotion Date: Credit Card#: Balance on Substantial /S .1_�, Completion of J °°); _- CC Exp.Date: CC Security Code: By initia.ling herr.,you a,cknowl cdgc that Ihc..Balance at Start of Job and the Balance on Substantial Completion Buyer Initi s- nw „f Jub.cannpL bu made by credit card and nitist be made by personal check,bank chr..rk,or cash,. Buyer(s)agrees a understands that this Agreement constitutes the entire understanding between the Parties,and that there are no.verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written Consent of both Buyer(s) and Contractor.Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a, completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT I F THERE ARE ANY BLANK SPACES. Renewal And s o Greater MA anal NH Buyer(s) Buyer(s) 13y: L..ff7/F r Si,gnatu of Pr uct t anager Signatu..M Signal.ilro. Pr'in I Na??tc of Profit a Managac Print iNamc Print Namc YOU, THE BUYER(S), MAX CANCEL.THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF T fE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. CK— — — — — — — — — — — — — — -- - — — — — — — — — — — — — — ec— — — — — — — -- — — � NOTICE OF CANCELLATION NOTICE OF CANCELLATION Date of Transaction L _j- 0 -0 You,may cancel I Date of Transaction 0 "d .You may cancel this transaction without any penalty isr obligation,within this transaction without any penalty at obligation,within three business�ays from the above date.if you cancel,any three business goys from the above date.If you cancel,any t Eroperty traded in,any payments made by you under the roperty traded in,any payments made by you under the olntira4t of Sale,and any negotiable instrument executed ontract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security I by the Seller of your cancellation notice,and any security interest arising out of the transaction will be canceled. interestarising out of the transaction will be canceled. If you cancel,.you must make available to the Seller.at . If you cancel,you must make available to the Seller at your residence, Lin substantially,as good condition"as I your residence, in substantially as good .condition as when received, any goods delivered to you under:this when received, any goods delivered to you under this Contract or Sale-or you may,if You wish,comply with the I Contract or Sale•or you may,if you wish,comply with the instructions of i4e Seller Tegardmg,the.retum shipment of instructions of tW Seller regarding the:reihiM shiphidi t of the good at=fhe_Seller s a*pe'nstl and risk.If youdo make I the goods'at the-S`elletrs expense and r1- Ifyou da make'" the goods available to the Seller and the Seller does not the goods available to the Seller and the LZIr does not, pick therm up within 20 days of the date of your Notice 1 pick them up withi»_2®.days.of•ttte.dWe ofyo�Ir Notice' of Cancellation,you mor retain or dispose of,the roods i of Canadll'ahon;�may retain;or.dispuiv io the goods without any further.ob i on. if you fait to makke the I without airy further.obligation. If you fail to make the goods available to the Seller,or if you agree to return the I goods available to the Seller,or if you agree to return the goods to the Seller and fail to do So,then.you remain liable 1 goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract. for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and I To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written 1 dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen l notice, or send a telegram to Renewal by'.Ander'sen of Greater Massachusetts" and 'New Hampshire; 104 1 of Greater.Massachusetts and New Him— hare, 10:4 Otis Street,No rf�tbFroy ugd 0113,,�NOT LATER THAN Otis DNIGHT OF r/hborough A 01(5532,NOT LATER THAN MIDNIGHT OF !! 13 I HEREBY CANCEL T1415 TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. i Consumers signature Date Consumers Signowre Data RAA l'nn.._ Whit.. o:.-r- 01/02/2006 23:51 9782785010 JOHN BEAVER PAGE 09/10 Mn erre RENEWAL 13Y ANDERSEN MAMCticense#149601(expires 1/24/10) �vAndersen. '' WINDOW pEPLAnEMEHT .„n„d.�.„c„„a�Y OF GREATER A4ASSACHUSS AND NEW Fcdexnl Tax 1Dfk 83-0404Z01 EI't' 104 Otis Street•Northborough,Massachusetts 532 Phone 508.919.0900•Fax 508.919.0903 Bayer(s)NAIrc SPECIFICATION SMELT V1 Date of Agreement qdQ The Buycr(s)listed above hcrebyjointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT of which this S acifieation Sheet is a art. WINDOW DETAILS 1. C trac for will Install a total of _ windows in.Owner's home,using the following individual Double Hung(DB) uai sash quantities: ❑ Cotta g.c sash(1/3 top,2/3 bottom) ❑ Oric),sash(2/3 top,1/$bottom) 141 Casement(CW) ❑ Hinge right ❑ Hingc left(as vicwcd from exterior): ❑Standard handle ❑Metro handle Double Casement(CDW) ❑ Standard handle ❑Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or[] 1:2:1 ❑ Standard handle 2 Lite Gliding Window(GW) F-1 Metro handle r Glidct/Picture/Glider(GFW) ❑ 1:I:1 or ❑ 121 I5 Awning Window(AW) Piciurc Window(PW) Tray or 130w Window alio Doors(see separate boor Specification Sheet) / 2. es ❑/No Qty of Windows to be Custom Fit Replacement: 3. L7 yes 9 Qty of Sills to be replaced by Contractor: 4. ❑ Yes o Qty of Windows to be New Construction.Full frame(includes new interior&exterior casings) Exlerior casings: ❑ Fine []Maintenance-free material ❑ Factory applied 908 Fibrcx brickmold S. Glacinq to be: 5�HP),o E0 SmartSun-r (7kx 0r d tL&�ryle) ❑ Other If other,please specify: 6. Exterior color to be: [ 'te ❑ Sand ❑ Canvas ❑Tc1Tat0ne ❑ Cocoa Bean 7. interior color to b,-: White ❑ Sand ❑ Canvas ❑Terratone ❑ fine ❑Maple ❑ Oak Note: into for color can.Only be white,wood or same color as exterior. Wood interiors need to fi.nishcd by Owner. 8. Hardware: [ Wh;te ❑ Stone ❑ Canvas ❑ Brass .Double Hung; 9• C1 Yes o Install Liftswitlt ouble I-lung Windows � 10. Screens: windows to have: alf or ❑ Full screens Screens to be: 1 nberglass ❑ Aluminum ❑TruSccne zle GRII,LE DEFAILS 11.Windowsmliy: : Yes ❑ NO If yes: Grillc Between Class(GnG)❑ RemGvable Interior Wood am\v)[:] rull Divided light(roc) Qty Qty: Qty: Qty: Qty: Qfy: 1.74 E-1 on oW cm,"hrte Glidnr CPW or GRA Draw grille pattern's above Use additional sheet if needed Owner approved(ixuitials):CQP't ADDITIONAL WORK DETAILS 12.❑ Ycs Contractor will remove metal frames of windows. Qty of Uni ts:_ 13.❑ Yes No Contractor will install new paint-ready or stain-ready casings. �ftterior casing qty of openings: Exterior casings qty of openings: [] Pine d Maintettanec-free material 14. Yes [] No Contractor will install paint-ready or stain-ready inside or outside stops lty of openings: Interior stops qty of openings: 1 Exterior stops qty of openings: [v]cr'ne Maintenance-free material 15. Owner is a e that CotttracMr does t do arty paintitag• C_ 1 Owner Initials )p -�t 16-El Yens VNo Contractor will wrap exterior casings with aluminum coil stock of color. � ^te; Wrapping may be required with storm window removal,removal of storm windows will leave screw holes in casing. 17.LIQ es ❑ No Contractor will insulate,caulk and scat windows with 3-point system to prevent water and air infiltration. 18.b7 ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19.I�'res ❑ No 0uil0 din a —Contractor will secure any and all necessary permits. The fee for the per.mit(s)is not included in the Cont�t Pn c a . a separate heck is required th tim f sale for this f �/f 20. Addikional'ob detail D l 5 S Z 7,V d WJ � ! e• 21. [\- es ❑ No Owner agrees to be present on the final day of installation for final.inspection and to deliver final payment. No fiatal payment,911411 be dewlnnded until the coniraci ins completcd to thr,satisfaction of all parties: It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding betwcetl the parties,and thea are no verbal understandings changing or modifylt><q ally of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such cltu�ges are in Writing and signed by both the Buyer(s)and Contractor. Duyar(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal at a Grcator MA and NH Buyer(s� Buyers) (� �� due Manager SiSignature A) PrintName of Product Manager Print Name Print Name ' The Conranonwealth of Massachusetts Departineat of Industrial Accidents Office of Investigations 600 Washingtoit Street Boston,MA 02111 www.mass gov/dia Workers'.,Compensation Insurance Affidavit: Builders/Contractors/Electriciains/Plumbers Applicant Information Please Print I�e�ibly Name(Business/Organizadon/Individual): i)ene J C it � 11 r erS e Y) Address: 104 City/State/Zip:. /Vof1� bo r'T �1.�.3�_ Phone 4: 00 Are you an employer?Check the appropriate box: Type of project (require ft 1.'E�'I am a employer with 0 0 4. ❑ I am a general contractor and 1 6. ❑New construction employees:(full and/or part-time).* have hired the sub-contractors odeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. x em ship and have no employees These sub-contractors have 8. Demolition working for mei any capacity. workers' comp.insurance. 9• ❑Building addition [No workers'comp.insurance 5. ❑ We ate 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 worker's' 13.❑Other comp.insurance required.] °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. $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. Insurarice Company Name: �,' 114 r Ke,n-e— l f1 s�t 1,-G n C L' Policy#or.Self-ins.Lic..#: �J ln��L � i�`f Expiration Date: ,I Job Site Address: 7 ��Ti.c City/State/Zip: DC(/fi/�- " 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 X500,00 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 eer' uaader the pains andpenalties.ofperjury that the information provided above is true and correct: ) b Signature: % Date: G Phone# Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# a Issuing kathority(circle one): 1.Board of health 2.Building.Department 3.City/Town Clem 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M 4 ' •.:y^ - �tua;+,yep � �/ � /,/ // r I y c Qtn yo€rd oiEuiIdin;Reg1lstonsand�,�zdnr ds U0nSt,ICtICl1•SupwiscrLicerse.,;:,, . i •=--���w- _ Licenss;;CS •S57G7 . • .-•�-�-��• &_�P/5'1198_ f � 7r'- 95707 °=�Iisti�ni7pl , ' �• ,,• -- :7-- Bp1AN DZ-NNISON: as CRESTCIP.CLE`= ^ --�,r� - fir' 4 WOPIC 57=,�ti IJiA OiBCi Commissign.r; F , NEWAL BY RSON BRIAN-DENNISON E. 10 OT:ES S I SEE i NOP!HBOPOUGH, MA-0.1532 . ' 7?5-CA7 va sOfW7/G7-?CH4?0 .. .... -+.. _. _.. .... . _ • Board ofDuilainQRaanlaiionszrdStandards L� HOME inrR;aoVE1E7 C07i5ACTOR z p,;=Bois_=:r?412010rt d 'r:!t linpI=ment Card BRIAN QEIaNISbt — 1 ., 104 OTIS NOP,7HBOi,CIA CJ1532' ` Administrator �� ,�x`�,4_, �����F�m�„Y�^�� ,saa�' � Rp 7�'t..^ �-a �>,�- a`�y�,4n'3� + i oc?'..-a!'aGl:':^J`.'! �• '+,bd'u�13�a � ��u�u�'�"� �1 � a��� "��•�,a�9�ma�1 u, �d�� .b .1�"'§'��Yc3'.m �+; ION CAT 2 ACX 333 '? .l 0 . �VEFUSm n, FDED Ell ;tam Baa 3C3�E >=�?OW. ml 48106-033-3. I oFTiJ e�t'ew.`'im H�i�� r 1 E _ 'vi OtvC CO ER.Em � _r , �.IC x Rs:IsMal by Qndersorn 11r.suPE�x t-?� �r�Ins�r��ca CG Da�ti a aL Wndowra, 1 riC• I INSUREa f?'p�5cr�i3li'i3L'? I 104 L7i:S vi INSUFE?C: WOti�t"IOOrcuo,,WIA 0-152 I INSUPyR?, COVEPAGES THE POLICIES OF.INSUF-t Ncsc USED a=-Low-�SVc S=-'M ISSUED 70'e HE INSUPED NAMED MED ASOVE FOR,THE POLICY FZRIOC'INDICAT_0;.NOTtNITr'STfi�1DIfiIG ANY.REQUfRE:�Ei!T,—1--RIA CR COtdD?IGN OF ANY CL N—' -ACT OR OTHE:c DOCUMENT WIT'r, RESPECT TO WHICH THIS.C=m 11rICATE IAY BE ISSUED PERTAIN.THE INSUPkNC:'AFF'JR.D=:) RY,HE POLICIES D=SCRI3-' F=R=!N S,—,Ej=T TO k L Tr.:T'c F'a',�CLL'SIDIdS AND CDFdD1T10F S OF^L1CO� ' a- ^t IS'1 t^ r rJL1CIa. Ar --LIMITS SHOWN fi�Y H;KVE E3=cw'REDUCED 3Y PAID CLAIh'S. L-4 lus_a�� -�7e ry:ikg arxC= I ?CLf^ Y11Ma�4 I POL'C�=—v r r I. ;IGYa IF3v^�'aIOM '. cJaePAl::asiu; 'esCr 507 404 09!07,20C)g eq1'idl7C'90 _=ACHDr.^upr_=ac:- : I 1 �JOn 000 l commzn'-ALGENERALLVS!L,'^: I S la=r��es rE4 � I 1 00.000 CLAIm.s.MADE n OCCUR ,. MED. -P(Anp one oer.�,n) 13 PEPSONAL&ADV INJURY I s• 1.000.000 r ft�cMIT _ . IG'cNE2ALAE=aE�r_ I5 �.D0D.D00 n R_Cn.r-_IRc:..PPI.r_�P=R.. PRccucrS.aDI�;P/O. AGa I s '),000.000 ' I POLICY n J�T 7 LG^ A �5 MCC,f.D 5330 110/01!2003 1 /011 109 � COMBINED sI NGr=LIMIT AN,-AUTO + � ° (Es e�cenq ALL OWNEOALI CS g =_-^DILY It:JURY SCHEDULED AU'rC5 {?: pe>•��) 5 HIFED AU CS { NOBODILY INJURY s F;-0'u1M.-_'*DAL7C5 I(?:(a PROP-::!f DA VIGE I . {Per em-:�tlenq GA'AGa LJ lU3Y I ALri C ONLY,EA A=DENr I S At Y;U 0 EA A= S rF1AlU I AUTO CNLY. AGO Is El EACHOCCLIP"VUC6`4. CLAUS MADE � AeR=_A7e. s 1 A E !;yq(�99 . A 4 9 C aTH.I s t FhOer v�a�t COMPENSATION rl«k A.alD vv WEC r1- I-4 0� 1//2009 0121!11//20 10 I I RY LIftT- I I eR Afy?ftC�S?^r�rCP?F'A�'l E Ufi-e W I EL=JCHAC-I--IT I S ^DO DDD DirICE°PdE�{EEq? C:'JCeD9. ttYee,tle_'1n tri( (EL.DISeASa-EA.EMPLOY =-e .DDD SPECIAL PROv!StCNS b¢tae EL D!---ASF.POLICY L Imrr I s 500.DDD �BE«iiPitJ�uP.^.EAgaW9lLwi:;T.®kdl't�:,,::LZSl: s' EIC?a.ti^. .BYSPsC1.—' PF^OMa"idP:m t CE77 FICA HOLD " a• rr -D 4DL.'°iEs BE=:Er--n BO=ORE r�'a-r,Pr":P'iCX a0py o:.E�CF,:am lem•_'LUG u-'sUr`lf9'�' C:dC.}.`Jd�v 00_r,� v...er.•s} ;Er - :'C::4e._=? gd-:.,^ a IjIJ Il&:^^dSE f rk sJx.TieN dk,�m"IL� OF API KVIDi L.^rN ''n In-tuRei,ITS ..S __;. GR .. / � q, . � + j�{0.I1i�`J P.'_'s�.D>deE.1Px'.:-ri b'e 1��fyj.,;• j " "