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HomeMy WebLinkAboutBuilding Permit #678-14 - 158 MAIN STREET 4/3/2014 r HO DT a q� BUILDING PERMIT 3� ,�::,'. "'''• °� TOWN OF NORTH ANDOVER �i APPLICATION FOR PLAN EXAMINATION Permit NO: o + Date Received �1 �9SSAC HUS��� Date Issued: d M OORRTANT: Applicant must complete ,�, ee all items on this age LOCATION 169 1 1 1 at n c�~ . ' y©(-+ � A-n&ueMot PROPERTY OWNER .5} C re,q br-4 Pr, tCM Lan A p(}�skotj, cchuP h n Print MAP NO: t, PARCEL:y� 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: 11 Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑ Water/Sewer 1p a 1a ce- Ep D m Mme-mbrah e , p it 00 Identification Please Type or Print Clearly) OWNER: Name: S} • �`L t`1 Phone: —5-11 7a4 Address: CONTRACTOR Name: rm Phone: (pQ 3 C5 Address: PC) ]�)a X S �{ 0 3a r fn 7 Supervisor's Construction License: CS + Exp. Date: a5 �� '09 J0 I(�q 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: $ LJ , . FEE: $ � Check No.: v Receipt No.: d NOTE: Person contracling with unregistered contractors do not have cess to the kuaranty fund Signature of Agent/Owner_ Y Signature of contract6l�A�tzx r I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page • LOCATION Print. PROPERTY OWNER LL Print 100 Year Old Structure_ yes no MAP NO: _ .PARCEL: ZONING DISTRICT: .- _ Historic District yes no Machine Shop Village yes no a TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential i ❑ New Building 0 One family [I Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial 4 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑-Septic ❑Well, ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: y Home Improvement License: Exp. Date: . 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�; Sigafur� e of_contractor V Plans Submitted Plans Waived ❑ Certified [ iot flan ❑ Stamped Plans ❑ - r 4 • J J Plans-Submitted ❑ Plans Waived,[] ,.-Certified PF Man ❑ Stamped Plans ❑ -. .. ,,. ,E_pF-SEWERAGE-DiSPDSAL .:.. -.. Public Sewer ❑ Tanning/MassageBodyArt ❑. . Swimming Pools ❑ Well ❑ Tobacco.Sales E.1 Food Packaging/Sales ❑ Private(septic tank,etc. _., Permanent Diimpster on Site ❑ THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i DATE REJECTED DATE:APPROVED PLANNING & DEVELOPMENT" ❑ ❑ COMMENTS ONSERVATION Reviewed on Signature COMMENTS ` HEALTH Reviewed on Signature COMMENTS k Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I J Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connectionisli_gnature& Date Driveway Permit •DPW Towo Engineer: Signature: Located 384 Osgood Street ;.FIRE D:EPARTMr NT.-:Temp Dumpster on.site yes no Loircate6l'4;024Mair`Str'eet: Dep COMMENTS artme'it sig a/date " a• _ _ .F ► natu'r" • . •:�ti < •.: ;, ;. , �,. ,� ; ,:.:.. ...,. �. COMMENTS -Dii? ensloci 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.fin.e NOTES and DATA— For department use I 4 I LI Notified for pickup - Date i i Doc.Building Permit Revised 2010 Building Department The fol��wing iva list of the required.forms to be filled out'for the.appropriate-permit to be obtained. I Roofill,g, Siding, Interior Rehabilitation Permits ol Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or G.S.L _Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products I dum ster. ermits require sign off from Fire Department prior to issuance of Bldg Permit NOTE. All p p i 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 We decision from the Board of Appeals that the apu•W period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+.ted with the building application r Doc: Doc.Bui?ding Permit Revised 2012 I Location No. i q Date • - TOWN OF NORTH ANDOVER • �� ED . • e Certificate of Occupancy $ ' Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector r �ORT1y E To w' n of 2Andover O - ..:` 0 No. IV— * ;4.., h ver, Mass, 3 t �Q cocN.CNEwICN S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ................Z.zS.............. .... ..... {.!1........................ ........ Foundation BUILDING INSPECTOR V .. has permission to erect .......................... buildings on .......�.�.� ..........4E!l,� ....... ...... ..................... . r Rough tobe occupied as .............. .� ...........4. ..Gll,l4�......................................... . .............. Chimney provided that the person accepting this ermit shall in eve 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 UNLESS CONSTRUCTI N ST RTS Rough Service ................. ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy 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. Commercial Property Record Card PARCEL ID:210/041.0-0005-0000.0 MAP:041.0 BLOCK:0005 LOT:0000.0 PARCEL ADDRESS:158 MAIN STREET FY:2014 PARCEL INFORMATION Use-Code: 906 Sale Price: 0 Book: Road Type: T Inspect Date: 04/28/2005 Owner: Tax Class: E Sale Date: 12/31/99 Page: Rd Condition: P Meas Date: 04/28/2005 ST.GREGORY ARMENIAN APOSTOLIC Tot Fin Area: 6638 Sale Type: Cert/Doc: Traffic: M Entrance: C OF THE MERRIMACK VALLEY Tot Land Area: 0.48 Sale Valid: N Water: Collect Id: RRC Address: Grantor: Sewer: Inspect Reas: C MAIN STREET Exempt-B/L% / Resid-B/L% / Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 COMMERCIAL SECTIONS/GROUPS LAND INFORMATION Section: ID: 101 Use-Code: 906 NBHD CODE: 35 NBHD CLASS: 5 ZONE: R4 Category Grnd-Fl-Area Story Height Bldg-Class Yr-Built Eff-Yr-Built Cost Bldg Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class 6 6638 1.0 D 1939 1957 645,300 1 P 907 S 20908 0.480 167,759 R Groups: DETACHED STRUCTURE INFORMATION 1 90 6638B-FL1 1 Str Unit Msr-1 Msr-2 E-YR-Blt Grade Cond%Good P/F/E/R Cost Class 1 906 6638 1 1 2 906 6274 1 1 AS S 3000 0.00 1980 A A ///78 5,700 3 S1 S 96 0.00 1995 A A ///90 700 3 VALUATION INFORMATION Current Total: 819,500 Bldg: 651,700 Land: 167,800 MktLnd: 167,800 Prior Total: 819,500 Bldg: 651,700 Land: 167,800 MktLnd: 167,800 SKETCH PHOTO 74 1SA•F 3$ 59 274 Sq.Fttie FR 1g.U0$gR 22 7 Ft 75 54 158 MAIN STREET Fie 11 61:176 Xt Parcel ID:210/041.0-0005-0000.0 as of 4/1/14 Page 1 of 1 II U tit Massachusetts-Department of Public Safety iJ Board of Building Regulations and Standards ' Construction Supervisor License: CS-059W9 DAVID J.FRA", PO BOX 63 ' North Salem NH$3 r ` r 'y Expiration k Commissioner 0410912016 4d H ;,,69 i 04FMD65091 Dos: 0410911965 �ly�: i9.Hair OLt 1 �I+ 4! Exp:04109/2019 ys sex ..,...........-..,.--- A?'l.( MAW. 8.Po sox 63 -" SAL.EI ,NH.A3473 , ;S/N/FONSTRUCTION MGMT LLC X 63 EM,NH 03073 . 3-329-6355 Fax 603-329-6356 Dec 18,2013 S/N/F Construction Mgmt is pleased to submit a bid to Mr.Mike Collins for a new membrane roof system over the church,. A9- - S/N/F Construction is a safety-orientated company. We are concerned for the safety of our employees as well as the trades working among them.All ladders will be properly set and secured. The work area will be supplied with sufficient first aid and fire extinguishers.All solvents will be accompanied with material and safety data sheets. Safety lines will be used as required. All trash containers will be roped off with warning lines. SCOPE OF WORK: remove and replace approximately 600 sq ft of EPDM on low sloped roof. • Erect safety rails and flags round work area. • Remove and dispose of membrane sheet and wet insulation. • Remove approximately 6 rows of asphalt shingles. • Supply and install new P.T.wood perimeter nailers as required. • Supply and install new%2"poly ISCO insulation over the built up roof surface,fasten with screws and plates. • Supply and install Carlisle 45 mil reinforced membrane over the new insulation mechanically attached in the seams per manufactures' specifications. • Install the EPDM membrane up the steep sloped roof and terminate beneath the asphalt shingles. • Re-install an additional row of asphalt shingles for a watertight seal. • Flash all pipes and protrusions per manufactures' specifications. • Lift A.C. condensers and install new roofing and separation sheet beneath condensers. • Fabricate and install new aluminum drip edge and flash over with cover tape. • Dispose of all generated debris and Pve roof surface swept clean and watertight. 61 City assessments,taxes,and fees excluded. Total materials and labor: $4,650.00 Sincerely, David J. Frahm The Commonwealth of Massachusetts 07 Department of Industrial Accidents d Office of Investigations ' d 1 Congress Street, Suite 100 Y 4 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �� L V �`^ �(��j-�~(�(�C-��(�[� `�C(C� -�-VLLC- ,Address: � X � 3 Address: � 1 City/State/Zip: i\`• Sw` m K CI 0_'-Y3Phone#: &Q V 3 5.5 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-tune). * have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9 F] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.&I'Ifoof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 131-1 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. TContractors that check this box must 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: E j M CCd SS k n SU('gr) L �—McLliCbe,4er , N t4 Policy#or Self-ins. Liic. #: LUC 89665Q/ Expiration Date: Job Site Address: 1 R� MQ,l 0 ST, o ,l VIAouer City/State/Zip:./ a 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 In of per' ry that the information provided above is true and correct Signature: Date: l / 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#• i AC40RO CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY) 4/1/2014 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 AME CT Linda Dacey, CIC FIAI/Cross Insurance PHONE (603)669-3218 FAIC.Nok(603)645-4331 1100 Elm Street -DIE: ldacey@crossagency.com INSURERS AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURERA:Ohio Security Ins Co 24082 INSURED INSURERB:Ohio Casualty Insurance Company 4074 SNF Construction Management LLC INSURERC:Peerless Ins Co 24198 PO Box 63 INSURER D: INSURER E: North Salem NH 03073 INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 All Lines 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 PAID CLAIMS. INSR TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP L POLICY NUMBER MM/D MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea oc rre ce $_ 300,000 A CLAIMS-MADE OCCUR 5867139 /6/2014 /6/2015 MED EXP(Any one person) $ 15,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JFCT PRO LOC $ AUTOMOBILE LIABILITY COMBINED BINEDrtSINGLE LIMIT 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BK55867139 /6/2014 /6/2015 BODILY INJURY Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident) $ X UMBRELLA UAB [Al OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,OOC US055867139 /6/2014 /6/2015 $ C WORKERS COMPENSATION WC8906501 X I WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN (3a.)NH E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) rathy and David Frahm /13/2014 /13/2015 E L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below Excluded E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN St. Gregory American Apostolic Church ACCORDANCE WITH THE POLICY PROVISIONS. 158 Main St. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Richard )Zennedy/BN5 t/ Til ACORD 25 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgmnn5i m The Annon n2ma anti Innn ern ranietararl martre of ArnRn ACOOREP® DATE(MM/DD/YYYY) INSURANCE BINDER 3/14/2014 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY BINDER# FIAI/Cross Insurance Peerless Ins Co B1431444453 1100 Elm StreetDATE EFFECTIVE TIME EXPIRATION PATE ME X 'AM X 12:01 AM Manchester NH 03101 3/13/2014 12:01 PM 5/11/2014 NOON PHONE 603)669-3218 FAX (603)645-4331 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY SAIC,No Ext): ( AIC No): CODE: 8110019 SUB CODE: PER EXPIRING POLICY#: WC8906501 AGENCY 00138857 DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY(Including Location) CUSTOMER ID: INSURED Snf Construction Management LLC Po Box 63 North Sal NH 03073 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD ❑SPEC GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES $ CLAIMS MADE FIOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/OP AGG $ VEHICLE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ WC & Employer's liability WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ 500,000 AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $ 500,000 E.L.DISEASE-POLICY LIMIT $ 500,000 SPECIAL CONDITIONS/ FEES $ OTHER TAXES $ COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE Linda Dacey, CIC/LD9 -y �'�" `� �= o'�-�• ACORD 75(2010/04) Page 1 of 2 ©1993-2010 ACORD CORPORATION. All rights reserved. INS075(201004).02 The ACORD name and logo are registered marks of ACORD A� INSURANCE BINDER °"3`X014"' / / THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY BINDER# FIAI/Cross Insurance Ohio Security Ins Co 6143543933 1100 Elm Street DATE EFFECTIVE TIME DATE EXPIRATION IE __[ X AM X 12:01 AM Manchester NH 03101 3/6/2014 12:01 PM 5/4/2014 NOON PHONE ACNo Ext: (603)669-3218 ac No:(603)645-4331 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY#: BK55867139 CUSTCY ID: 00138857 DESCRIPTION OF OPERA71ONSIVEHICLESIPROPERTY(Including Location) INSURED Loc# 00001/Bldg# 00001 SNF Construction Management LLC 85 Corinthian Drive PO Box 63 Deerfield, NH 03037 North SalefA NH 03073 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS Contents, Special 500 80 5,300 IxBASIC FIBROAD ❑SPEC ' Special GENERAL LIABILITY Each Occurrence, Flat, $250 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY D MAGE TORENTED PREMISES $ 300,000 CLAIMS MADE Fx_1 OCCUR MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMPIOP AGG $ 2,000,000 VEHICLE LIABILITY Combined single limit COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS MEDICAL PAYMENTS $ X NON-OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ WORKER'S COMPENSATION WC STATUTORY LIMITS AND E.L.EACH ACCIDENT $ EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ SPECIAL CONDITIONS/ FEES $ OTHER TAXES $ COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORrLED REPRESENTATIVE Linda Dacey, CIC/LD9 ACORD 75(2010/04) Page 1 of 2 01993-2010 ACORD CORPORATION. All rights reserved. INS075(201004).02 The ACORD name and logo are registered marks of ACORD