Loading...
HomeMy WebLinkAboutBuilding Permit #420 - 1749 SALEM STREET 12/1/2009 Location/ 7 1 � "'rr No. v Date /� -/ c / ,.ORT1y TOWN OF NORTH ANDOVER 3?O�,t`•D I•,�10 N w e a Certificate of Occupancy $ �ss�cMus Et Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22666 Building Inspector 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 - _ ( yA Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o 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 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: J�)E-GOSt/3 Phone: Address: CONTRACTOR Name: 3 1 , t, .• Phoney S �7-5 0 A __ - -c ddress: Supervisor's Construction License: � Exp. Date:-, I �G 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.: M3, Receipt No.: (f NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund ignature of Agent/Ovvner,_ Sk Signature of contracto 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: 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I 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 I Located at 124 Main Street Fire Department signature/date COMMENTS i 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 i ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 F NORTH ToVVn of gAndover No. w - z- A K E dover, Mass., � COC MIC ME 7�AORATE0 S E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ►,c.t. .. Q ..::• �.......... ............................................................................. Foundation tl^ �. has permission to erect........................................ buildings on ... '.T.'I......... A. ..I'G��lr..... Rough to be occupied as...... 'T . .a --...............:...............:............................................................... 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 PERT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS 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. 10/17/09 01:18 FAX 6037787994 LAFENINA 904 MA HIC license#149601 (ezpres 1/24/101 Federal Tax 1D8 93-0404201 Renewal RENEWAL BY ACNDERSEN byAndersen, WINDOW REPLACEMENT OF GREATER�L-vsSACHUSETTS kNi) NEw H,-\.NipSHIRE 104 Otis Strool-Nordiborough.-\Lk 01532 PholW508-919-0900-Paz:508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT B,.Iy,.,:,I Nome D.to of Aq,eernerl BLYe'(0 Street Add'— C"St-le ':F,'ndl f9 F Ma:!Add—, Home Telephone Nub., Work Telephone Number ) fluxt-1. lion.1.,% j''illik and (.I purdla.,, the p1t)(ILICUN.uid/oi sen ices ofj&1, ncluws.Inc.d1ja Rc.i IvN\aIb%All(ILl"llol Glralcv Mit-„Ik htlst,[(>atid Nett Hatllp<hirr "CollInIt t,I­: 0 RA *and 11)1' I-1 1' 1'thIS .ill cILC0I(h1I1((1%%ilh the tcrnisand condition.,deSCI-il)Cd 011 Ill”Ii011t ;tgIc.-III"IIl .nil t it Ithe atI'll h'.-d tzIxt ilic.l[it'll skirt this"AgIven)ent").Buc et(si I iot cbv aN m,Io sli-pi a t,orll I)It'll'Ill(Cl li Ill A[C',:111 IT Method oFPymnt:,jCosh jCheck � o:ilercard -)VISA Estimated Slartirg Date Total Job Amovnf. 5C 1� , . / — k; I ❑U Discover :1 Financed,App#: F -1 10 1 '1 h ............ Deposit Received(33`01:., - , ..1 W Name on Credit Card: < Balance at Start of Job(330.): J i Estimated Completion Date: Credit Cord -L#: Balance on Substantial Completion of job(3 3'6): CC Exp.Date: ecurity Code: B%illilialill't LII;Ll the Balmict:at Stat l o1job and illu 13alanc,'Ili subsull)(iill Collipl"lioll BuyerInitiaW-(yld ,I�JI-I)Glilll(lt lit I�Mdl--Ill-CrffhtGIrd ilIld MLISIL be ljjadc by I)Crsonal 6)cck,bank die(k.t)r cash. Buyer(s) agrees and 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 q from this Agreement will he 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 ,I written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Renewal by Andersen of'Greater MA and Nfl Buyer(s) Buyer(s) v plillt Pi-irit Nanic Prilli.Nallit. YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN ENTLANATION OF THIS RIGHT. - — — — — — — --- — — — -- — — - NOTICE OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction You may cancel I Date of Transaction You may cancel this transaction,without"onj perial or obligation,within this transaction,without any penal or obligation,within three business days from the tovedate.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract 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 1 by the Seller of your cancellation notice,and any security by the Seller of your cancellation notice,and any security interest arising out of the transaction will be canceled interest arising out of the transaction will be canceled. If you cancel, you must make available to the Wier at if you cancel, you must make available to the Seller at your residence, in substantially as good condition as your residence, in substantially as good condition as when received, any goods delivered to you under this i 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 the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of the goods at the Seller's expense and risk.If you do make X the goods at the Seller's expense and risk.If you do make thegoods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not pick them up within 20 days of the date of your Notice pick them up within 20 days of the date of T our Notice of Cancellation, you may retain or dispose of the goods of Cancellation,you may retain or dispose a the goods obligation. without cm( further A If you fail to make the without any further obligation. If you fail to make the goods avoi oble to the beer,or if you agree to return the 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 goods to the Seller and foil to do so,then you remain liable or 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 To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen notice, or send a telegram to Renewal by •Andersen of Greater Massachusetts and New Hampshire, 104 1 of Greater Massachusetts and New Hampshire,` 104 Otis Street, NortjsbQr�Ugh MA 01532 N v- * NOT LATER THAN Otis Street, Northborough, MIA 01532, NOT LATER THAN C )I .(Date) MIDNIGHT OF MIDNIGHT (Date) I HEREBY CANCEL THIS TRANSACTION, h I HEREBY CANCEL THIS TRANSACTION. Ccirs—",Signet— Date I Consumer's Signature Date RbA Copv - \Vliitc k:llstollicr Copy-Yellow CLI6t0IIICr C011y - Fink 10/17/09 01:18 FAX 6037787994 LAFE14INA U 05 Renewal RENEWAL By ANDERSEN XIA rue iccitsc e ta9col(c# 81/24/10) EderalTaxlDtt s:;_oaoazot byAnder5en. wiNoow RCRLACCMCNT Or GREATER A/IASSACHUSEITS AND NEW HAMPSHIRE 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Btiver(s)Name Datcol'Agreeutenl o e O J -F.\ 1611 L /0 n The Btlycr(s)listed nbove hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and lelnts described on the S}xcification Shect and the front and the reverse of the accompanving CUSTOM WINDOW AND DOOR REAIODELING AGREEM•NT.:ti which tlik Specification Sltect is a part. �J(iri\ Nt\r` L t (�' WINDOW DETAILS 1. Cordniclor will htst:all a total of wiztci , in Owner's home,using the following individual e}uantifies: Double Hung W13) ❑ tAlual sash ❑ Cottage sash(I/3 lop,2/3 bottom) ❑ Oriel sash(2/3 top. 1/3 bottom) Casement(CW) ❑ Hinge righl ❑ Hinge left(as viewed rronl exterior): ❑ Standard handle ❑ Imeho handle Double Casement(CD\b') ❑ Standard ttnnille ❑ Metro ltarldle Cnseanent/Pichu'e/C:wentent(CfAV) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GP\V) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(A\1') Picture Window(MV) Bay or Pow Window PatioDoors(see separatepool,SpecificationSite et) b t?rr-�r'J��((?`J 16r 2. ❑ Yes [ff No Qty of Windows to be Custom Fit Replacement: p r p/R •/J L,- T (l 3. ❑ Yes []No Qty of Sills to be replaced by Contractor: ^,t­ 4. ❑Xes f_1 No Qty of to be New Construction Full flame(inchtdes new interior A exterior casings) Exterior casings: ❑ Fine [ Alaintcnance-free lttaterial ❑ Pactory applied 908 Fibres bricknlold 5. Glazingtobe: Z'11PLew•-Ek:Sill artS,11T^t (TdXCreditEtlgible) ❑ Otller Itother,plcascspecify: G. Exterior color to be ❑ White ❑ Sand ❑ Canvas Q/1'erratone ❑ Cocoa Bean . httcricrr color to be: ❑ %Vhire ❑ Sand ❑ Canvas [:k-rerralone ❑ Pine ❑ Maple ❑ Oak Note: Inlet ior color caul onk,be while,wood or sante color as exterior. Wood interiors need to finished by Owner. $. llardw•are: ❑ \PhilSione ❑ Cautvas F-1BlassDouble Hung: 9. [_1Yes ❑ No htstall s with Double Bung Windows 10. Screens: windows to Ila.we: ❑ I lalf Lt [Full screeds Screens to be: fiberglass ❑ Alnntinurn ❑TniSecltc GRILLE DETAILS 1 1.\Vindcr ws have grilles: ❑ 1•": " No I1 yes:❑ Grille Between Glass(atw)❑ Removable ulterior Wood ln'rt i❑ Ftdl Divided Light(rt,u Qty: Qty: Qty: Qty: Qty: Qtv: Qly: DH DH DH DH CW/Plctura Glider :CPW or GPO, Draw grille patterns above "Erse additional sheet if needed Owner approved(initials):( ) ADDITIONAL WORK DETAILS 12.❑ Yes No (_•011IIaCtot"will remote Metal H antes of windows. Qty of Units: 1 .❑ 1'es [z NO Contractor will install new paint-ready or slain-ready casings. Inferior casing qtr of openings: Exterior casings qty of openings: ❑ Pine ❑ Alaintenance-tttc material 14.❑ Y �No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior,tops qty of openings: Exterior stops clk,of openings: ❑ Pine ❑ Maintenance-free material 15. Owner is are that Contractor does not do any painting Owner Initials 1 G.❑ Yes [ o Cath actor will wrap exterior casings w th untittm coil stock of color. Note: Wrapping maty be required wish slor ill window removal;removal of storm windows will leave screw holes in casing. 17.gYes ❑ No Contractor will illslllate,caulkand seal\t#l�EFS with 3-point systemto prevent waterand air infiltration. 18. Yes ❑ No A limited warranty shall beissued to Owner upon completion of the job and payulettt in trill. 19.F71 Yes ❑ No Building Permit--Contractor will secure any and all necessary permits. The fee for illc pernut(s)is not inehided in the Contract Price and a separate check is required at the time of sale for this fee. 20. Additional lob details:Ft LU b r � � Tr) VC \,)0k. Vlr-� 21. Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and I, tent. h\,lhi.,d pan ment shell bo demander 11JI01/he conte-ICI 1'COurplated tO the sntistirction O!'.+11 pxrtres. 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 between the parties,and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renew",Anderseno .Gres r MA and NH Buyer(s) Buyer(s) Stature of.rrodu Manager JJ//r hAt Signature Signature Print Name of Product Manager Print Name Print Name 0A Copy- White Customer Copy- fellow t The Comntonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Corttractors/Electricialas/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): .Renee a l6 f/l'1 r�EYS Yl Address: 104 0/; City/State/Zip: ,' otA ba ro , �4 Phone#: (J 0 /�ll�'J 00 Are you are employer?Check the appropriate box: Type of project (required): L E-I am a employer with J0 4• ❑ I am a general contractor and 1 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._ emodeling These sub-contractors have 8. Demolition ship and have no employees working forme 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.E]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. 6.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Ariy 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. ] Insurance Company Name: �,' /j/C 1)�0 inst4 nz nC / j Policy#or.Self-ins.Lic.#: 7ej I`✓ - Expiration Date: / �7 Job Site Address:--L2 q1 �/T l�/ Sy City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratio 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 cer under the pains and penalties,of perjury that the information provided above is true/and correct: Sin-mature: 1�• Date: Phone#: J ��U %� Uz o Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# • Issuing A uthority(circle one): 1.Board of Health 2.Building Department 3.City/Tomm Clerk 4.Electrical Inspector s.Plumbi=ng Inspector 6.Other , Contact Person: Phone#: E '� � �Il J' l�'Of?YI77A'/t!6%�..,:GLro C�vr/'L:.duG±.r�(.l✓�.•Glti i . � •. Easrd of EuiIdin; :e_uIsf;ons snd�teadm. • � 'C�ns�r:ic2icnSup�r;r9r�rLi��r:��•,..,,.• ;:.L.•. ' Lican ra,C9 i .;����• =i�hc�«'-�1�/i 982 '. 1. _�=—•— 0;07 • `�= zea ,e�fric��_n;-�0 '„ ( . 3PIAI1 DEA[N150Cf —1 ;" ' VVORC=ST.r`.,IJA Oio03' Comn iesiong' t . - RILEVVr,L BY AND= BRIAWDENI1lSON I0" 0 I:ES S I REET -NOR HBoimOUGH, Mr1k.0.1532 , Board'ofBuiIdinQ oR e _,Llaiions<rd standards HOME IM RGA=SPefti?CON?TF,"CTOP, ERR iot 2-4120101 d !=n=nt Card R- _INA N 'LEY ti BF,AN EVIS nA NORTHBOROU11532' Administrntor • 4 i M -�'".� `q ^��3 ���;� ?x�.,t y ["-s� $�, .y-a C � � ,71 >a 1 ( li I i'. �1'%�S � 6 ` "ate=�" t Ll r< �: ti - I , � i,"'.'LS dam.�!3�9.e..rs:e. is is56'ED itd' n 'I�o[=°d i'z J� '�::.'r:[!'.TION�a *�r':.'.:J6t ILIC.'^� ism w a+�..F v e^ eiv^ m- ! lIP1..vi-:im I Itr'dC c013� irlaUfrr!O„,=" H0LEDSR.S 4 S:'�.eiFiC�°a O0S5 MOT r MEm, t d `C', at s� 'a- ®^.�..m x- gig. P..�. CVn 3�3 um- 7. v%a' �: 't:o rP'� J6:J e] v r`,nn["s"u0(', Ml -18 i 0C-'✓03ti. ipsURa's ASF=0F:)0NG COIL`MF.1°t:m - =.= Rai by kndersall Ham-rd Insurance 0oncanv IIkSU?SRA r nc• a V- window's, Inc. �f:A ,. I eC t L�0�„�t INsuee=c (�}o,6b0rcug7, ivy, �1 5s2 _. I ir:SUPL=.D: Cv EPAG'Ef I INsuR = iH-c POLICIES OF IN RANC2 LIST=-D, ?-'_ , SU ^ - OW:�,V===_!d I"SU_D 70 e H-e INSU'r,.J IfvfVED>;EO\J<=O?THE?' LICY'P=!'IOD r'^ =D ANY. =OLlRcd'Eid7 i-RM CPR CONDri ION Y CON-1-FACT - , I',uICnT_ .td0iJVIiFSTnfdDlfil3 iPERTAIN. OF :.M OR OT cn DDCJMeiUT 1Nf?H rsnSr=_C i i O WHICH HIS �-E Y �e F Rky HE , -O ! o C=AT1rICn! PJIA Ic-t 'D 0 G THE IhSURAfVCc AFFO%D SY POLICIES G=SCRI'_D f=�EIPd:S�U:JeCT 70 ALL TERMS,- i,. a3c' r0UC1=_ OWFd L' CL IOsev AND COfdDITi6N OF -SUCH !IIdITa SH^ i Y t V�-:- R=JUC20 3Y PAID c'QIhFa'. Suc. LTR Yu.;aol .e�t,NeIRSMC= I PvL°C"Y,UY13ea I PDLL ir.G I.viSC1'aiPlraTi7E3I ` - �'apgPq'-77"`� r.,,`,•-,:9'MI*15h!'r; L'3r�1'9 LlAv_RAL �i , -:,,^,P 507 404 00/07/200'9 09/0-7/2010 I EAcxt-„^uaa_nce I s n � gA� e:rt.,=L 1.00_.00.: n CCfdSS- CIA:GcNc?ALLI:,`FU^' 5 7 00.000 CL vIF.°S,MAD? 7x OCCUR A?ED EXP(Any ons Gerson) PP-?ZONAL mADV INJURYl. I s 1.DOO.r?00 c;rN=?AL,6ZPEE ATE I s x.000.000 v° LAC-rRe-•.�-:FidlTAaau=S Pei• PC. r?" PRODUCTS•C^A;PIdP AGO S' '9.0010.0010 ICY I�l J=.-T I Au v�!c'rE A=r >z 0 0/01/2003I 010i/03 CDM s1FAN-,,AVD G�niS3 -1N- - = + w (Esacannq S. 1,OdC{�JO X ALL OWlEDAUT CS €JDI:YhkJURY I S fiC:DULeD AU'iv5 ..per�.:aj NIRE''AUTCS { NOBODILY INJURY 3 fe�{'ibVNcDAALT I� =R0 --R TY DAMAGE rA'"Ge' I:STY I I-UTO ONLY,EAA=DENT IS ANYALro l =A:;e=I s OTM-;�Ti-m AUTOCNLY: IS „-- AuG D5�..�E_f;_I C URC:%.IP.a MADS q IS G:DUCT121.e I I S I F.ci=iFT ON. I I S ,a titi'DPJ c°.a coiin:sA'Iof,A'rD - ®'° - PP 1 0`2117/2009 0.2r1 J2010 I w�s,�Tu• I I°�"I ��''✓ .d t%J®° i��?Y�IrtTS A6'1'PR�R`nL �a - t N _ EACH AC,^,'�=3+rT OFFICc',f.�cY.=a EnC'.��l mClJTltim If yes, _" uL.jar I- .EASE-EA.ZMPLOYEE SPECtAL PROlt!SIONa bs!D« I"t 01-=kS% F^LICY!IiIIT I s 0%=_B ^On.000 eIPsaN of "Pi T ows r: . road r: -,;_ r - �S1C°:'a",n...`-_T.,(?Y S:':mOP.Se.::S4 i:9Ps�PF:^,L"51Wl5' t 4 F , tee.. `-•e�.7 iPl'.^.A l�i.e,Je:t ` [o. ®"t:l1' k - e t :F-UL2 AMY Or`Mel-j A?:dt a d_d R::`e5§eL'ei_S -e'='9 E �e } I s ° - Dr._Tile="PSP r:,c1. I IPS a ° °ter L�F✓ DA;— .C':CF,:rC aeeL11G 3:SUpZ3-,'i�9'.�a'Jse d s nes le 99 • ' fidR - M V—M-i-, TO-HE:_.E,;;'d"s.^.,PI:7,D.ri.ow st",;tet I/Y .TiC.f1:;7"t SIL- :F APw 0M ON:fie l4:vUrer.ITS A3D,7S CA 't s f .