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HomeMy WebLinkAboutBuilding Permit #284 - 189 RALEIGH TAVERN LANE 10/6/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received /0 Date Issued: /-b IMPORTANT:Applicant must complete all items on this page w t.00ATI{31V = i3 Print PROPERTY OWNERPrim�J ._ MAP NO; RCEL: ZONING DISTRICT:�Nistoric District S yes' no a Machioe Shop Village yes no r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family t,� Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic WellFloodplain` Wetlands VWatersbed D stndC, WaterfSewer v :r DESCRIPTION OF WORK TO BE PERFORMED: k W`k VJ-Ock Identificatio Please Type or Print Clearly) OWNER: Name: 6&am na Phone: 91S // Address: CONTRACTOR Name. SdOPhone .` 1 n Address:` _ Supervisor's Construction License. _ srl m Exp. Date. x L Holme Improvement License. F __ 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. rr ff vC> / co Total Project Cost: $ �//S 1. FEE: $ �, Check No.: l� Receipt No.: NOTE: Persons contracting with unre istered contractors do not have access to the guaranty d kgna"tur-e''of Ai'gentlOwner ,,; aM Signature of=contracto3 _ s 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE7-DEPARTMENT -TernpaT3umpsteron siteyes , no Located:at 124 MainlStreet .; 4 s >> Fire'Departrnent=��gnature/date COMMENTS 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 department use I NOTES and DATA— For de P i i E ❑ 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 1 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work L3 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 L3 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) o Building Permit Application ❑ Certified Proposed Plot Plan o 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 f Hydraulic Calculations (If Applicable) o 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 Location - c--�-,�- ` No. V L' Date NORTH TOWN OF NORTH ANDOVER f � Certificate of Occupancy $ CN�S<� Building/Frame Permit Fee $ Foundation Permit Fee $ f Other Permit Fee $ TOTAL $ s Check # /T�QCP 22509 (/ `Building Inspector NORTH ® of s 4Andover No. o x- A K E dover, Mass., COCMICME WICK y1. AERATED PPS\ �� _ S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • • BUILDING INSPECTOR THIS CERTIFIES THAT........... ............ ............. •"' oundation has permission to erect..................................... buildings on .� . • to be occupied as �.. ... Chimney p' 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 UNLESS CONSTRUCTION STARTS Rough .......... .. .. ... ......................... Service � D�ECTOR 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 BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ������� _ MA license#149601 (expires 1/24/10) R` NEWAL BY ANDERSEN Federal Tax ID#83-0404201 byAnderserl. '- — WINDOW REPLACEMENT mMdm Compmy OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE - - - 104 Otis Street•Northborough,MA 01532 Phone 508.919.0900•Fax 508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT } Buyer(s)Name Date of Agreement - Ikiv Buyers)Street Address,City,State,and Zip Code U U E-Mail Address Home Telephone Number Work Telephone Number Buyer(s)herebyjointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this`Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Method of Pymnt:❑Cash O Check a Mastercard 13 VISA Total Job Amount: /j Estimated Starting Date: O Discover ❑Financed,App#------------77 Deposit Received(33%): Name on Credit Card: Balance at Start of Job(33_/):f' n,A �E.C3. Estimated Completion Date: / Credit Card#: . Balance on Substantial d — � CC Secuity Code:Completion ofJob(33%):r' rCC Exp.Dal,:-' By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer Initials- of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parries,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO'NOT SIGN THIS CONTRACT IF ° THERE ARE ANY BLANK SPACES. Renewal by Andersen of Greater MA and NH Buyer(s) Buyer(s) By: k, I Signatdfe of oduct Manager6fA SignaL o Signature Y i Print Name of Product Manager Print Na e y Print lUme r 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 EXPLANATION OF THIS RIGHT. — — — — — — — — — — — — — —�<- — — — — — — — — — — — — — -�,<— — — — — — — — — — — — — — NOTICE OF kAkELLATI16N X NOTICE OF CANCE LATION I Date of Transaction : You may cancel Date of Transaction �J .You may cancel this transaction withou ny p natty or obligation,within this transaction withou any penalty or obligation,within three business gays from the above date.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 I property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I 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 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 I interest arising out of the transaction will be concele Of you cancel, you must make available to the Seller 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 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 the goods 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 I pick them up within 20 days of the date of your Notice of Cancellation,you may retain or dispose of the goods of Cancellation,you may retain or dispose of the goods without any further obliggation. If you fail to make the i without any further obligation. If you fail to make the goods available to the Seller,or if you agree to return the I goods available to the Seller,or if you agree to return.the goods to the Seller and fail to do so,then you remain liable goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract. for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and 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 i of Great6r Mass chusetts and New Hampshire, 104 I of Greater Massachusetts and New''Hampshire, 104 Otis Street, No o ,MA 01532, NOT LATER THAN I Otis Street, North gh,MA 01532, NOT LATER THAN MIDNIGHT OF (Date) MIDNIGHT OF (Date) I HEREBY CANCE TH 5 T NSACTIONi X I HEREBY CANCEL TJ IS TRANSACTION.. i I Consumer's Signature Date - I Consumer's Signature Date - RbA Copy- White Customer Copy-Yellow , Customer Copy-Pink Renewal �s�� RENEWAL By A,• DERS£N� MA License#149601(expires 1/24/10) - bYefi'dde9 al. 1�L t11V L Federal Tax ID# 83-0404201 WINDOW REPLACEMENT ..A�d.�Cc y OF GREATER MASSACHUSETTS ARID NEW HA1bIPSHIRE - 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Buyer(s)Name Date ofree ent I ' The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services list4d belo ,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. WINDOW DETAILS 1..Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) ❑ Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) �--. Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2.Lite Gliding Window(GW) Glider/Picture/Glider(GFW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. ❑ Yes ® No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes [R No Qty of Sills to be replaced by Contractor: 4. R'Yes ❑ No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine R Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: HP Low-E®SmartSunTM (Tax Credit Eligible) ❑ Other If other,please specify: 6. Exterior color to be: UZ White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: [y White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: LR White ❑ Stone ❑ Canvas ❑ Brass Double Hung: 9. ❑ Yes R No Install Lifts with Double Hung Windows 10. Screens: windows to have: 0 Half or ❑ Full screens Screens toe: ® Fiberglass Aluminum ❑ TruScene t GRILLE DETAILS 11.Windows have grilles: U Yes ❑ No If yes:❑ Grille Between Glass(GB Remova terior Wood n rw)❑ Full Divided Light(FDL) Qty: Qty: Qty: Qty: Qty: Qty: Qty: i ., 1 fl H OH DH DH .,f ctu Giider 1CPWr G Draw grille patterns above 'Use additional sheet if needed Owner approved(initials):( ) ADDITIONAL WORK DETAILS 12.❑ Yes 5 No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes 7No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑Maintenance-free material 14.❑ Yes E�_No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any painting. , )moi Owner Initials 16.❑ Yes EJ No Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.® Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18.Q Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19.E.Yes ❑ No Buildin. Pernit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract Price and a separate check'L' equ}'�ed at th tim of sale f r this fee 20. Additional details:details: aZ QcfLnr U�CJ�— /v(n E/�/ �ir(f /�'n �Q�,5, /1/1 l.l� Ti L bjo- LeP AA fir C 1_-116P 21. [!tel es ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terns. 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. Renewal by Andersen of Greater MA and NH Buyer(s) Buyer( By; , , LSC` "°r rL.y Signa e o Product Manager Signature / Signature Print Name of Product Manager Print Name Print Name RbA Copy- White . Customer Copy Yellow Tile Corninonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations .600 TVashington Street , Boston,M 02111 K 6 www.mass gov/dia Workers' Compensation Insurance Affidavit: Euilders/Co: tractors/lectricialas/plumhers ADolicant Information Please Print Legibly 7) n Name(Business/Organizationdndivi dual): . y Address:- City/State/Zip:.. Al�(-,LA 1'0 , ,�� C).�,3� Phone. Are'you anemployer?Check the appropriate box: Type of project (required): L&I.am a employer with 0 D 4• (] I am a general contractor and I 6. Q New construction employees(full and/or pa-t-time).T have hired the sub-contractors —1� 2.❑ I am a sole proprietor or partner- listed on the attached sheet + .emodelin,, ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity, workers' comp.insurance g, Building addition No workers'comp.insurance 5. Q We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all workright of exe=tion per A�GL 11.0 Plumbing repairs or additions myself. [No workers' comp: c.152,§1(-^.),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp,insurance required.] ;Any applicant that check box fl must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactor that check this box must attac - Q - e attachtd an adaitional sheet showing �h-name of the sub o ntractors and th,.ir work_r'comp. _ .policy information. I am an.ennto yer that is providing =s o- �o r' Fr ,} p e workers coir irmrance for my employees Below.is the poZiz y and job site information. Insurance Company Name: J , /7 C Policy'or Self-ins.Lic.1• 2 l�y $ j`�°f�} Expiration Date: Job Site Address:_ � 3 ��1)� City/State/Zip: Attach a copy of the workers'compensation policy declaration page(shove F cr the policy nsmber and expiration date). Failure to s-cure coverage as required under Section 25.k of MGL c. 162 can lead to the imposition of criminal penalties of a. fine up'to S4500.00 and/or one-year imprisonment,as wellas civil penalties in the form of a STOP'WORK ORDER and a fine of up to$250.00 a da against the violator. Be advised - the = e Y � i ,.d that a cop of this statement may be forwarded to �.h..Olfic„of Investigate r .Y. Y ons ,, of the DLA for insurance coverage verification. Ido hereby cer� under the pains and penaldes.of perjury that the information provided above is true and correct Signature: rl/' c� Dat Phone�: >`f /��� �� 0 Clffrcial use only. Do not write in this area,to be coin leted b ci��or town o ficial p Y 'Y Tr Cl,)-or Town: IssT.Lnm c,! rtno'r?'l-5 (circle o'ne) f.c /: F N.Board of Health s.EU-cling Department 3.City/Town Clerk 4.Electrical l spector 5.?1Lmbing Inspector 6.Other Contact Person: Phone f: 6: � �'_ � :- 09T74TLO�ZCIY,,,:LL.n cam• .. i e Board afBuildingPeauIations and 5,tapdards _ 'Construction isor License—..„• - Ll e;.CS '95707 5i-h "SO Um 9Ymo 0 Timet 95/0'! .��.��-� �"'- ••.: —__-• —_' iii - BRIAIJ DEhNNISO i:; _ 51 � 85 CREST CIRCL=V WORCESTE. IvIA01503" Comm sinner l! tlllEV�lAL BY�^�1�1DERSON BRIAWDERNISON 104.0 T:IS STREET VORTHBOROUGH, MA.01532 . ' GPS-CA1 �a 5I7Ni•Di1Gi-PC8490 Board of Building Regulations and Standards 10N(B!N! ROVE V1=hT CCIITc�AC?OP. `> Registt,�ioa.; 149501 Jr12412010 tor— f =�,yp llopiement Card �i BY A-9 BRIAN DENNISO;(P;_= 104 OTIS NOR T HBOROUGH,MIA 01532 Administrator COR... 71 ?."tea- , I`'Jr� O&� vy � t.y' Vc�iLR, j2o,HZS . v. E �` 3tlan Mi�ISSUEDAS� n lU6°`�saiER .� iG�'C'J.aii.�lfJl�i. I pin N!"cr✓^> 0na - _ �F�Y AND CON ERS) NO FUGHTS U1ROM THE �� S 17zj tir:J is .� :LiCn "a'I,.{9: {�iaul I!'v: .A" aAa fir`° IrIC.. HOL E� -3a d^.r,�.:='�J�';C.�J� CCE ��T Ass Pte, � � OR d r.�. �"' i2� " LT°ER :a= y.aa:� m tiF�� DSD a s' � a iC9�r ®s �Eri k P 3 AFT;rktor, W 40�Qe-drvv. 6i FUSERS n�=C��O�G Ci r=�, 4v (E!wIC� i R ,eaiy Anderson I INSURER A: ;EEOC Ins�r=nca Corl�-� oan e V.�.��rndorus, Inc. INsrJReae !-;�-1�ai�=e= � d 1 04 Oiis$t INSURER c: _ Ncihborcugh,f IA 01 I INSURER D: COVERAGES INSURERI I THE POLICIES OF INSUPAidC:L1SE9?E'_OW:AVE SE.Id ISSUED TO THE INSUR'cD NAMED AEO\!E FOc�TIE POLICY P=r IOD IIZ,r>1CAT=O,.NO i 5N(TriSTnFiDING ANY PEGUlP,EMENT,icRM OR CONDIT1GN OF ANY -C-1 R,ACT OR OTHER DOCUM=:VT WITH RESP T TO VyH'ICH THIS C2'RTIFICAT E MAY 6E ISSUE) OR W1AY PERTAIN,THE INSURANCE AFFOF,DE EY T?IE POLICIES SE He I !� r = r POIICIEB,AGGPE'i TE 11 f 5 .u Se =ESCRf _D _RE.N SL E'vT TO ALL THE �, ' CONDI i IOF.S OF SLCx M 5 SHOWN VIA �V_ _E:q R_)UCED BY PAID CLAILIZ T=?P� =�CLLSiONS AND tH�R I e rw e= I ^`.'kUKE I POL_ I, I L7K1-S B ' CENERALLJA--IUTY HCP 507 404 03/07/2009 `:,-Irj'!2010 LEACXOSCURREINCE I s 1 Q©Q QOQ I COt i><_RC2:.LGcNERALUAe1LlTY - 1JANamCrE iUr:'�ieu g P*E ASES(Ea CLAIV.s MAD? OCCUR MED EXP(Any en>e pe,5cnl a _ 5.000 PE?SONAL.ADbINJURY Is 1.Q00.000 GENERALAG_R_GATE I S 2.000,000 GMITIL AG^R .AT°LIMRAPPLl=S PER:. PRCOUOTS•COMPiOP AGO 15 i.000.QQI0 I F7 �JE nICC POLICY rRG I . . T A LJAML:T r^ - v� .ZG lrC!IJ( �e•f11�`p1 v.J �E�Iv' J 0...,Q CCWEIN:DSINS-LELIMIT I a 4 ANY AtJ 0 5 (_e aceenq 1,000,000 r ALL OWNED AU TOS - €sODILYINJURY I .. SC FOULED AUTOS (Per pery.a) 5 HIRED AUTOS BODILYINJURY - - - . 'IN-OWNED AUTCS BO0ILY Q b PRO PR_ YCAMAGE p I {Parawdert) 5 I Ga-.aEL.2kSIL AUT 0ONLY.EAA=OENT IS nANY ALTO - OTHER THAN EA AD:15 AUTO ONLY: AG„ 15 EACH CCCURRSINCg 15 y =UR a MADE CLAIMS S . IAGGR_:A,_ IS IS DEDUCTIBLE 15 I I RET--N,c-;GN s I I S TA 1j. Gla- 2117/2010 YPJ. v3 tlcv PF I 4 02i11ILQ1y srd I ANY UTNF °j EACH Accce?,tT S 500.000 OrrIC ^SNE[B_R FYOLUC-C 7. Ea.DISEASE-EA EMPLOYEE I$ 500.000 11 vee.�ew^•�e unear SPECIAL PRDIISIO d"bet:t I E DISFAV•POLICY LIMIT OTY R 1 Oa=TipiCr7f—=L-10 DE1-47,-i0W i :^'=L-1 AM Or-'TIE SC- , O=sc;j:�c:!NSUP9L' I'c"Es asie___J na ORE THE aPSRk cm qy� C(''� uk m T E OF,Tr1E:dSUINr, P.=+,UL'11q y A 4 .R= op 7, �IO�'U R 5.7 ..'JL 1 J—S G91Flf'_. o`.q LIZ,7 B7,eA.-uRZ V.-s^.�.V �1 H. .I IMPOSE ire e,.`..x.-eN C+R L;ASILJI OP AR-KCVO IP SUER.ITS AZZ3, _CF,