HomeMy WebLinkAboutBuilding Permit #354-11 - 178 WATER STREET 10/27/2010 BUILDING PERMIT "O RT b
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION '" ^
ti
Permit NO: Date Received �� o oA ea�g5
SSACHU`��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
bqATIONiL4 l I .C� �1I ( 12�. S.f �A l ,
t. �y Print
PROPERTY OWNER � v
Pririt •', , J _ i `T:F�� � *,-tk
MAP 210: : PARCEL_ZONING DISTRICT= Historic Dtstnct � � :6 yes: : o
Machine.Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ Ofamily j
EJ Addition Cc iwo or more family ❑ Industrial
❑AJteration No. of units: ❑ Commercial
vf�epair, replacement ❑Assessory Bldg ❑ Others: _
❑ Demolition ❑ Other j
Septic 0.1Nell ❑ Floodplain "❑Wetlands 1�,1Nate�shed District
D.Water/Sewer, _ 'F
DESCRIPTION OF WORK TO BE PERFORMED:
U OL Q ov XA,,S tS'W S f rrvCLd
- I
Identification Please Type or Print Clearly)
OWNER: Name: 72Y Phone:
Address: 19d A/f��r. S� /v
f4 aUCv�� ems, V lti
CONTRACTOR Name:, Phone:
adaress Cg 5'1". HAL 0,ki
� t w�ri` ::Y'p'� t"r*�"vi?.?,�Nia• t ,.- .- ..� ..:• t ih.... � �:�,y ��'ZJ� �Y._� .
t.
Supervisor's Construction License: C '�7 aVb�. E*: Date:,. ( C
Home Improvement License:. 1 I Exp. Date.: 17
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON
$925.00 PER S.F.
Total Project Cost: $ -7 m 0 FEE: $
Check No.: C1 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor ` Ay_�(4 'V"
I
t
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
t Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools ❑
Well - ❑ Tobacco Sales ❑ g
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
f THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM _..
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT - ❑ -> - ❑ ~`
COMMENTS
rY
i
CONSERVATION Reviewed on Signature-
1•�
COMMENTS
J
HEALTH -
Reviewed on Signature "
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
PlanningBoard Decision: Co _
Comments
Conservation Decision: . Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW'Town Engineer: Signature:
r
Located 384 Osgood Street
FOOMMENTS.
-DEPARTMENT -Temp Dumpster on site yes no'
ed at 124 Wiri.Street , -
Department signature/date
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
® Notified for pickup - Date
Doc.Building Permit Revised 2010/October
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
❑
E
n
gin
ee
rin Affidavits for Engineered.
n
eered
products
sign offrom
Fire Department prior to Issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers
Com Affidavit
avlt
❑ Photo Copy of H.I.C. And C.S.L. Licenses _
❑- Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of
Proposed p d Work With Sprinkler. Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
(VOTE: 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
OTE: 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
irnust be submitted with the building application
Doc:Building Permit Revised 2008
it
I
LocationA S
d
r:
No. Date
,.pR,►, "TOWN OF NORTH ANDOVER
3� • . pL.
a
Certificate of Occupancy $
NUsE~� Building/Frame Permit Fee $
Foundation Permit Fee $ '
Other Permit Fee $
TOTAL $
Check # ! o f d
236'12
Building Inspector
S-
O Q ,
r:
Mike 781-254-5218
Bob 781-724-4842
I/We,the owners of the premises mentioned below hereby authorize you to furnish all necessary materials,
labor,and workmen to install,construct and place the improvements according to the following
specifications,terms,and conditions listed below.
Date-08/30/10
Proposal submitted to: Leon I_eavdts
Phone- 978-360-3623
Address: 178-180 Water St.
City:N.Andover,dila.
IContact Person:Michael Keo!han
6
I Rem,ove existirng shingles to root boards.
2.) Replace any needed roof boards.
i 4_) Install 9'Metal Drip Edge.
.5_) Install 15#Felt(Paper to pear of roof.
64 Install orcihiteclurral shingles to entire roof,choice of color to customer approval.
r 7.) Remove all debris with on site dumpster.
8.) 10 Year wcwornty on material and labor.
Payment vall be paid in furll of completion of gob.
t
N Total Dae$7,000-00
.gob completed on 10-5-10
Balance doe 900.00
Customer Signature dalMcGovern Roofing
ORTH
TONM of, r
No.
�% o dover, Mass.,/ ()
T O = LAK 1
I� COCHICHEWICK V
7,p AERATED p' '`C�l
`S BOARD OF HEALTH
PtRAnIT T , D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT........ !(t............ ........................................... .
........................... Foundation
has permission to erect........................................ buildings on ....I ...'.:1 ........1 3..r�t. .................... 1r_.-...... Rough
. �pfii t0 b8 occupied as..... ...... ...... ..............�...... .. ... . . . . . . . Chimney
provided that the person accg this permit shall in every respe 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
UNLESS CONSTRUC TARTS Rough
........................................................ .........:................:......... Service
BUILDING INSPECTOR Final
Occupancy Perrrut Required t0 Occupy Building GAS INSPECTOR
gh
Display in a Conspicuous Place on the- Premises — Do Not Remove Fnal
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.
rrorn.oarudrannAOucaraxiU.IVICLaugnin insurance PageGOfG Uate:1U/26%1U1UU3:3UPMPage:2Ot2
q�p DATE0 /26 0)
CERTIFICATE OF LIABILITY INSURANCE OP ID BS
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(les)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
NAME:
PHONE -FFAX--
McLaughlin Insurance Agency (AIC,No,Ext): (AIC,No):
828 Lynn Fells Parkway ADDRESS:
Melrose MA 02176 CUSTOMERID#: MCGOV-1
Phone:781-665-2775 Fax:781-665-0295 INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: Commerce Insurance Company 34754
Robert McGovern Roofing LLC INSURER B: A.I.M. Mutual Insurance Co.
Robert McGovern
36 Wallace St INSURER C: Western Wor1d Insurance Co.
Malden MA 02148
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THATTHE 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 RAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERAL LIABILITY NPP1266485 07/16/10 07/16/11 PREMISES(Ea occurrence) $ 50,000
CLAIMS-MADE FxI OCCUR MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO El
LOC $
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
A ANY AUTO 10MMLP6476 03/17/10 03/17/11 BODILY INJURY(Per person) $250000
ALL OWNED AUTOS BODILY INJURY(Per accident) $500000
X SCHEDULED AUTOS
PROPERTY DAMAGE $ 5000
HIRED AUTOS (Per accident)
NON-OWNED AUTOS $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB El CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION To BE ISSUED BY CARRIER 03/20/10 03/20/11
AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ /A E.L.EACH ACCIDENT $ 100,000,
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Evidence of insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
NORTH-1 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of North Andover AUTHORIZED REPRESENTATIVE
384 Osgood St
North Andover MA 01845
ON dpO
4_ 79AtORCf C I n s reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
Massachusetts Rome Impl'ovement Sample Contract
This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"a
Massachusetts consumer guide to home imprpvemene'before agreeing to any work on your residence.You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1488-283-3757.
Homeowner Information Contractor Information
Name ompanv Rame
ro
Street.Address(do not use a FFost Office Box address) Contractor/Salesperson/Owner Name
$6 1-j- M_ 5131— p�G
Ci frown ,TState Zip Code usiness Address(must include a street address)
Daytime Phone Evening Phone ityrrown State Zip Code
79✓3g6.L A'2_3 'MAW DV &
Mailing Address(It different from above) Business Phone 1jederal Employer ID or S. .Number
Law requires that mon home un- Home pmvement Connaclor net.Nmoher Expini lan date
pm=nent euuttactors have a
` sad mairh�aboo oumhc '
The Contractor agrees to do the following work for the Homeo ner: L� /q 6"Ju
e m ewOrKtO comPletea,sPeC1171119thelype,brana, e a m n s o e e on ace
Requi red.Permits-The followingbuilding permits are required Proposed Start and Completion'Schedule-The following schedule will
and till be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractot's control arise
(Owners who secure their own permits will be ,f
exelpded from the Guarant3l Fund provisions of _�0 f Ll/JU Date when contractor will begin contracted work
MGL chapter 142A.)'
Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule '
The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of M
Payrrlents will be made according to the following scheduler
I
S _ upon signing'contract(not to exceed 1/3 of the•total contract price or the cost of special order items,whichever is greater)
1
$ vt> by / / or.upon completion-of 110%
S - by _/_/_-or upon completion of ��
upon completion of the contract. (Law forbids demanding full payment unticontract is completed to both party's satisfaction)
The following material/equipment must be special $ to be paid for
ordered before the contracted wori'begins in order S to be paid for
to meet the completion schedule.(**)
NOTES:(*1 Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special orderedin advance to meet the completion schedule.
Express Warrants Is an express warrapty being Provided by the eontracto o Yes all terms of the warraoiv must be attached to the contractl
Subebutractors-Tiieeontractor agrees to be solely responsible for courpletion of the work described regardless of the actions of any third
paity%subcontractor utilized by the contractor. The contractor further tigreeg to be solely responsible for all payments to all subcontractors for
Materials and labor under this agreement
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 been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear.
• '
Make sure the contractor has a valid Home Improvement Contractor R.etaatration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Ithprovemeut 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
1=800-223-0933..
• Does the contractor have insurance? Check to see that your contractor is properly insured.
• Know your rights and responsibilities. Read the Important Inforittation 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 has been signed at a place oifier than the contractor's.normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the
third business day following.the signing of this agreement. See the attacluecl notice of cancellation fonts for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies of thc-eontract must be completed and signed. One copy should go to the horneowner.The other copy should be kept by the contractor.
omeowner's Signature "Ottire
Date Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners withthe 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 affordeq to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
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 Business Regulation and the consumer shall.be required
to submit to uch arbitration as provided In Massachusetts General Laws,chapter 142A.
Ho eowner's Signature W_— ' 7–V
C e
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 Riglits
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter]42A)and other consumer
protection laws'(i.e.MGL chapter 93A).may not be waived in any way,.even by agreement: However;homeowners
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 Guad provisions of
ranty bun
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workmanlike manner. Homeowners may be entitled'to other specific I gal rights if the contractor guarantees
or provides an express warranty for workmanship or materials. In addition to guarantees or warranties pro
vided,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 consumer rights. If you have questions about
your consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicitte 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 attachments'is to
lie given to the owner and the other kept by the contractor. Any 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/l erself
to be financially insecure, 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 worlL. Withdrawal of funds from said account-would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,orf you wish to obtain a free copy of "A Consumer Guide the Home Improvement Contractor
Law,"contact:
Consumer Information Hotline
Office of Consumer Affairs and Business'Regulation f
.10 Park Plaza,Room 5170,Boston,MA 02116
6I
( 7)973-8787 or 1-(888)2833757
If you want to verify the registration of a contractor or if you have questions or need additional
Information specif cally
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
ANIS/OR
Better Business Bureau
(508)652-4800
.(508)755-2548
(413)734-3114
' VlIIss.tchusetts- Department Of Public Sa#•eta
Beard of-Building Regulations and Standimis
Construction Supervisor License
Licenses; Cs 87607
Restricted.to:�00 e
ROBERT C MCGOVERN y j
36 VVALLACE STS = '
MALDEN, MA 02148 `
Expiration: 12/24/2011.
CommissionerTr#: 19710
. .✓fie �arr�r�co•�ciiec�l� o���aoluaelta t
' Ofrice of Consumer Affairs&$fisiness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 4M6 Type:- I
Expiration:: 4/7/2012 Individual ;
Ro ert`C.McGovern j -r,;
Robert McGovern\ t� F , J
36 Wallace Street
Malden,-MA 02148 Undersecretary__
of
1
i
R CERTIFICATE OF LIABILITY INSURANCE OP ID BS DATE(MIU/DDNYYY)
09/01/10
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(les)must be endorsed. III SUBROGATIONWAIVED,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
NAME:
PHONE
McLaughlin Insurance Agency Arc,No (A/C,No):
828 Lynn Fells Parkway ADDRESS:
Melrose MA 02176 CTOMERID
USMCGOV-1
Phone:781-665-2775 Fax:781-665-0295 INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSURER A: Commerce Insurance Company 34754
Robert McGovern Roofing LLC INSURER B: A.I.M. Mutual Insnrance Co.
Robert McGovern
36 Wallace St INSURERC: Western World insurance Co.
Malden MA 02148 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCELISTED BELOW HAVE-BEEN ISSUED TU THEINSURED NAMED ABOVEFOR THE POLICY PERIOD
INDICATED:NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
UKLNILU
A R COMMERCIAL GENERAL LIABILITY BOUND 07/16/10 07/16/11 PREMISFS(Ea occurrence) $50,000
CLAIMS-MADE Fx-]OCCUR MED EXP(Any one person) $5,000
PERSONAL 8-ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000
POLICY JCa LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
A ANY AUTO 10MMLP6476 03/17/10 03/17/11 BaaccidODILY NIURY(Per person) $250000
ALL OWNED AUTOS BODILY INJURY(Per accident) $ 500000
X SCHEDULED AUTOS
PROPERTY DAMAGE. $5000
HIRED AUTOS (Per accident)
NON-OWNED AUTOS $
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB kd CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORK ERS COMPENSATION TO HS ISSUED BY CARRIER 03/20/10 03/20/11
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTN�� TORY LIMITS ER
/A E.L EACH ACCIDENT $100,000
OFFICER/MEMBER EXCLUDED? �i
(Myaensdatory In NH) E.L.DISEASE-EA EMPLQY $10 0,0 0 0
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $S 0.0,0 00
DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,IT nwre space Is required)
Evidence Of insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MELR-01 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
- " �� •- AUTHORIZED REPRESENTATIVE
CLoa 2a dp
(.0iVETC-4009 ACORDA rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD