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HomeMy WebLinkAboutBuilding Permit #382 - 176 FRENCH FARM ROAD 11/17/2009 BUILDING PERMIT 0* "°oT"qti
bf.`. "6 0
TOWN OF NORTH ANDOVER °3 4 - -
APPLICATION FOR PLAN EXAMINATION
X04
Permit NO: Date Received 7 p *
oRATeo
�SSACHUS���
Date Issued: o
5 IMPORTANT:Applicant must complete all items on this page
LOCATION 1 `I r'�"-�t4 OW M
PROPERTY OWNER C:.t `�-` �&Zln
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic.District yes Nn
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family f
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 PREFORMED:
a 3 0�-� (�-, IAC"Mt-v LJ
Identification
Identification Please Type or Print Clearly)
OWNER: Name: 2-ac--Q rv2rJ Phone:
i
Address: [ rZ(n3c-(-
CONTRACTOR Name: T vA"A �' i%A, L� Phone:
Address: 3t> HAS-5
C l
Supervisor's Construction License: ©� 2 Q I C
p Exp. Date:If 'T�
Home Improvement License: `7 Exp. Date: t Z :z !
i
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: $ ( t C)o 0 o FEE: $ �� Z
Check No.: OOZ oc,3 S Receipt No.: 2 e
NOTE: Persons contracting with unregistered contractors do not have access to the gqayntyfund
Signature of Agent/Owner + Signature of contractor
Location X121 �Y�/ ,l—fi�rar
` No. Date )/
�6
�ORTM TOWN OF NORTH ANDOVER
�? o • OL
Certificate of Occupancy $
ssCM us•E Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # e,2
226 � 8 _
Building Inspector
Y N
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools ,f Y
Well Tobacco Sales Food PackagingAalesy
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
4 INTERDEPARTMENTAL SIGN OFF - U FORM j
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
honing 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
p
DPW Town Engineer:S gnature:
" Located 384 Osgood Street
it •
FIRE DEPAF�TMENT -~Tbmp Dumpster on site yes rid {
Located at 124 MaimStrehet`
Fire Department signature/date
COMMENTS
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
I
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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/Crossectlon/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 androof of recording
g
must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
i
I Revised 2.2008
I
C ��G�DIC DG'jD
ZZ EL CO CO EE:EEC
ChiYnne'ys Residential & Commercial Roofing All Types Of
CHIMNEYS POINTED-REBUILT-CAPPED
Siding Expert Masonry Work
Mass Toll Free *Roof Leaks Experts * Licensed & Insured
1-800-WAIT-4-US Locally Owned& Operated Since 1976 License#034200
(924-8487) IKO® 03aBB ? ozm 02'9VA-V We Work Year Round
infrg
Proposal To: Ellen Ford Date 9/14/09
Street: 176 French Farm Rd. 978-681-8713
N.Andover, MA
Replacement Window proposal
1. Remove existing(23) double hung windows as
careful as
ossible to minimize interior damage if
p g Total cost..
any at all.
2. Remove existing 1x4 exterior trim boards from(3) Harvey Classic =
Sides. Paradigm Tapestry =$ 12,200.00
3. Install (23) new white replacement double hung ©,s�s.� A'p� � "
windows from exterior and fasten. *Notes* /� °c' t Q'
4. Window Specs: Harvey Classic or Paradigm _If Paradigm windows are chosen, they must be or-
Tapestry. Low/E Argon gas filled,fully fusion dered by the end of September 09 to retain existing
welded, 1/2 screen, double locks and 6 over 6
GBG grill package. price.
5. Install insulation on all sides of new windows -may additional interior sill work is not included in
this proposal. Additional work will be discussed and
6. Install window tape for draft prevention.
confirmed with homeowner and will result in addi-
7. Install new 1x4 composite trim on(3)sides of new
windows and seal tional costs of time and material.
8. Install new custom bent white aluminum coverage -Discount: All Under One Roof will deduct $300.00
to all (23) exterior sills and seal. from the final balance if homeowner awards us both 9. Seal interior and exterior as needed with white the roof and window proposals.
sealant.
10. All windows are covered by mfg. warranties. Balance due upon completion
11. Both the Classic and Tapestry windows meet the Referrals available upon request
new tax incentive programs (in your neighborhood)
1. Building permit included. Highly rated member of the BBB
2. Removal of all work related debris. Thank you!
3. Contractor workmanship warranty=10 years un-
der normal conditions.
In— House Crew, NO Sub Contractors!
cceptance of Proposal—The above prices, specifications and conditions are satisfactory and are herby ac-
epted. You are authorized to do(theworkas specified. I layment will be made as o lined above.
Date of Acceptance: '4 \ l Signature:
X
tk©RT#j
own o : 4 over .
No.3 4'Z- 0 . . .... ...-ZAA
- - dover, Mass.,//.
T LAKE 1.
COC MIC HE WICK V
7�ADRATED
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...... �. *........ •
' ' ' ' ' Foundation
has permission to erect.................... �� .............
p buildings on ....�....................... �' .............n!!... . .. .............. Rough
W k #W! Chimney
to be occupied as.....p� ........... ... ..... .............. ....................... ................................................................................. y
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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
Z .UNLESS CONSTRUCTIO S Rough
g
........................................................................... 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.
The Commonwealth of Massachusetts
Department offtidustrial Accidents
Office ofInvestigations
600 Washington Street
" Boston,PM 02.711
www.anass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El lectricians/Plumbers
Applicant Information Please Print LegibIy
Name(Business/Organization/Individual):
Address:-- ,3 -Y:, Tom"'►-n,� t �� t13Z�
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box:
I.Vl am a employer with S� 4. ElI am a general contractor and II-
8.
Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors . E]New construction
2.❑ I am a sole proprietor orpartner- listed on the attached sheet . ED Remodeling
ship and have no employees These sub-contractors have E]Demolition
working for me in any capacity. employees and have workers' `
[No workers'comp.insurance comp.insurance_t g ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 tun a homeowner doingall work officers have exercised their
1 I.❑Plumbing repairs or additions
myself. [No workers' comp• right of exemption per MGL
insurance required.]t c. 152, §I(4), and we have no 12.E]Roofre pairs
employees.[No workers' 13.❑Other
comp.insurance required,]
•Any applicant that checks box 411 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 state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providitrg workers'compensation insurance for my employees. Belaty is the policy and job site
information.
Insurance Company Name: r`i`� )•dy j
Policy#or Self-ins.Lie.#: 6 Expiration Date: t t l g Qs i C9
Job Site Address: >i 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 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 WORD 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.
Ido hereby certify under the pain andpenalties ofpei jury that the information provided above is true and correct.
Sitamture:
Date: I t I `�
Phone#: 1!21 9
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):
I.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector
b.Other
Contact Person: Phone#-
a
1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR, 7t'Edition
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or 71vo-Family Dhvelling
I
SECTION 8:ADDITIONAL APPROVALS
I
1. Ballardvale Historic District Commission: Date:
Z. Board of Health: Date:
3. Conservation Commission: Date:
4. Design Review Board: Date:
5. Electrical Permit Number: Date:
6. Fire Prevention: Date:
7. Planning Board Lot Release: Date:
if 8. Preservation Commission: Date:
9. Zoning Board of Appeals: Date:
j
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Massachusetts Home Improvement Sam .leContract
Ff
m satisfies ail basic requirements of the state's Homevlmprovement.Contras
e to protect homeowners. Seek legal advice If necessa for leu(MGL chapter 142A),but does not include standIrd
ucetrs consumer guide to home improvement"before a Ci A ing m person planning home improvements should first obtain a copy of"ence.You ma
Consumer Affairs and Business Regulation's Consumer Information Hotline at 617m973-8797any work on your or 1.8-8 obtain
3 375 free copy by calling
Homeowner Information
/111 VVI
00 Contractor
otrap Information
�e {� % n i G
1 I` C'1 n l mPany ar°e
U
I' �+ r � �.
Sttcel Address(do aot.use a Post Offim Box address) AnZA 1;*9PM
Can
actor/Salespasan/Owner Name
-.Girylfown statezip Code
usiness Address(must include a street address)
(�a 5_7(3 (, w��/r���C
Daytime Phone-.. Bveniag Phone - 1A v ��
ity/Tovvo - -
State 1 Zip Code
Mailing Address(]t different from above) - 4
usiness Phone edam immlova ID or S.S.Numb,.
Lu•req..:..<War mon nn.
t mweams k+we � Souk�NwmmtGcauaaa.lug.N®6er Expintwn Nie
V J
The Contractor agrees 1 to do the following work for the Hnmeo mer // (�,py��1
ego o l � V2_61 4'
m e ypr,, eau
3 0H R t"K-e,� Wit,noWLJ_5
Fb--
its The following building
permits are required Propused Start and Completion Schedule-The following schedule will,
red by the contracmras the hotoeowncrs agent be adhered to unless circumstances beyondthe contracmu s coatxol arise
secure•their own permits will be the Guarantor.Fund provisions of U'i� m`�r 142A:)
_Date when contractor will'oegin contracted work
i t— Dam when contracted work will be substantially completed
Total Contract Price and Payment Schedule /
The Contractor agrees to perform the work,famish the material and labor specified above for the total sum of.
t (*)
Payments will-be made according to the following schedule;
$ 0 upon signing contract(not to exceed 1/3 of the total'con
to act price or the cost of special order items,whichever is greater)
by_/_/ or upon completion of
or upon completion of
upon completion of the contract (Law forbids demanding ding full payment until contract is completed to-both party's satisfaction)
The following material/equipment must be special g
. ordered before the contracted work begins in order .g to be paid for
to meet the completion scheddle.(") .. to be paid for
NOTES:(•)including all finance chargesLaw requires that any deposit or doc.•a-pavmeut required by the contractor before wod:begins notch mus the peat,or(a)d in advance
ceShe total he cornt.prim or(b)the actual cost of any special eguipmentor custom made material
which taunt be special ordered th advance to mea the mmpletim schedule:
Exresswarrahry-.lsan enress'warranrvbeiar rmlded.b.the.coatraeror?
.. _ Subcontractors-The contractor agrees to be solely responsible for m No Yes all terms of sire warranty be attached to the contract
puny/subcdntractor utilized by the contractor. The contractor furlber amPletron of the work described regardless of the actions of any third
Materials and labor-under this agreement pr~✓s to be solely responsible for all payments to all subcontractors for f
Contract Acceptance-Upon signing this document becomes a binding contract under law. Unless otherwise noted within this document the
contract shall not imply that any lien or other security interest has ban placed on the residence. Review the following cautio
ly before signing this contract ns and notices
careful
Dont be pressured into signing the contract Take time to read and
fully understand it Ask questions if something is unclear.
Make sure the c ntrr toi as a valid pine Ito rovemont Contractor RMe 's lion The law requires most home improvement contractors and
registration
m be registered with the Director ofHpme Improvement Contractor Registration. You may inquire about contractor
registration by writing to'the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727.3200 or
1400-223=0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured,
• Know your rights and responsibilities Read the-Important Information on the reverse side of this form and get a copy of the Consumer
Guide.to the Home Improvement Contractor law.
You may cancel this agreement if it bas been signedat a place other than the contractor's normal place of business,provided you notify the
contractor in writmg at his/her main office or branch office by ordinary mail Posted,b tele
contractor
business day following the signing of this a po .y perm sent or by delivery,not later than midnight of the
ng agreement, See tilt attached notice of cancellation form for an explanation of this right
DO NOT SIGN THIS CONTRACT IF TLFIERE ARE kNY BLANK tut
7woidartiral eopi conaaa.must be mmplaed and signed.Onc �`�SPACES..,
eqPY should go m the homeown,.The er copy should be kept by rhe contrsaor.
n igna it
C n ctor's Signature
Date
Date
Contractor Arbitratiod
The Home Improvement Contractor Law provides homeowner;with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in courtunless
both parties agree to the optional clause provided below, This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor'Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and
BI1SIIIeSs Regulation and the consumer shall be required
to submit to such arbitration as provided In Massachusetts.General Laws,chapter 142A.
Homeowner's Signature Contractor's Signature
NOTICE.The.signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution
initiated by the contractor. The homeowner may initiate alternative dispute resolution even where.this section is not
separately signed by the parties.
Homeowner's Rights.
A homeowner's rights under the Home Improvement Contactor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowner;
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law,
Homeowners-who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home ImprovementContractorLaw. 'The contractor is responsible for completing the work as described,in_a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if-the contractor guarantees
or provides an.express warranty for workmanship or materials. In addition to guarantees or warranties provided by the
contractor,all.goods sold in Massachusetts carry an implied warranty of merchantability and fitness-for a particular
purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be'added to the
terms of the contract as long as they do-not restrict a homeowner's basic co
ns
umern'
ts..If you have questions
Your-onsumd/homeowner rights,contact the Consumer Y q ons about
fh Information Hotline(listed below).
Execution of Contract
The contract must be executed in duvlicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been_
filled in
or marked as void deleted or not applicable. One original.signed_copy of the contract with atxachments is to
be given to the owner and the other kept by the contractor. Amy modification to the original contract must be in writing .
and agreed to by both parties,Contracted work may not begin until both parties have received a fully executed copy of
the contract,and the three day recission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself
to be financial) insecure,tree,the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account:would require
si atures of both aerie
eq the
t� parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumeriighu,or if you wish to obtain a free co of "
Y A Cons
PY umer Guidetothe
HomeIm
Law,"contact: provement Contractor
Consumer Information Hotline.
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 51
70,Boston,MA 02116
(617)973-8787 or 1-(888)2833757
If you want to verify the registration of a contractor or if on
have
Y questions or 9 additional information specifically
'about the contractor registration component of the Home Improvement Contractor Law,contact:
Director of Home Improvement Contractor Registration
Bureau of Building Regulations and Standards
One Ashburton Place,Room 1301,Boston,MA 02108
(617)727-3200 or 1-800-223-0933
For assistance with informal mediation of disputes or to register formal complaints against a business,.call:
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508)755-2548
(413)734-3114
ISSUE DATE I 011312009
a
RODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
ems,Insurance Agency LLC CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
22 Chickering Rd,Rt 125 DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
North Andover,MA 01845
COMPANIES AFFORDING COVERAGE
INSURED
All Under One Roof
0 Temple Drive COMPANY A A.I.M.Mutual Insurance Co
Chuen,MA 01844 LETTER
A5 as
,
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 BYTHE POLICIES DESCRIBED H:�REIN IS,SUAIECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMI"I'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR DATE(MM/DD/YY) DATE(MMIDDNY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE
PRODUCTS-COMP/01'AGG.
Q COMMERCIAL GENERAL LIABILITY PERSONAL&ADV.INJURY
Q
=CLAIMS MADE Q OCCUR
EACH OCCURRENCE
Q OWNER'S&CONTRACTOR'S PROT.
FIRE DAMAGE(Anyone tire)
0 MED.EXPENSE(An)�a person)
AUTOMOBILE LIABILITY
COMBINED SINGLE i
LIMIT
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
(Per persmi)
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY
HGARAGELIABILITY (Per=iderd)
PROPERTY DAMAGE
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND STAT LIMITS STATE OTHER
EMPLOYERS LIABILITY x MA
THE PROPRIETOR/
A ARNERSIEXECU IVE EL EACH ACCIDENT 100,000
FFICIERS ARE. 7009464012009 11/09/2009 11/09/2010
INCL ®EXCL EL DISEASE-POLICY.LIMIT S 500,000
EL DISEASE--EACH (OO 000
EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
ALL UNDER ONE ROOF IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY.
Zi _.m ,. ., .. _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 WRITTEN NOTATE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
TOWN OF ANDOVER
16 BARTLET ST ek C'e_o�j�*.NDOVER,MA 01810 UTHORIZED REPRESENTATIVE
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