Loading...
HomeMy WebLinkAboutBuilding Permit #806 - 19 MEADOW LANE 6/1/2011Permit NO: Date Issued: s TOWN OF'NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION IMPORTANT: LOCATION Date Received must complete all items on this Print MAP NO: �PARCEL:_ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building gOne, family ❑ Addition EPFwo or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial jKRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other `IS_eptc �'1We11 { ;�+Floodplain I�'Wetlands `I!J, Watershe{dIDistrict ,[]Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print CIearly) OWNER: Name: 71-0V, in gzj o n e Phone: 77A 6,P3 C Address: 117 ME ldo 4.,/ 6,7, do Lf CONTRACTOR Name: &e©C'aoJ i S CaitS�-�� � �•--, C Phone: cl7e- 1/cs7- 41o6fl Address: 76 !%.�s �fC.� -P ✓✓HCl c Q —7 v n%�' a SSupervisor's Construction License: Home Improvement License: // % <9'io Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. N FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ /0, -3 D. 4� FEE: $0 (O ` Check No.: 0 Receipt No.: orb NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 COMMENTS HEALTH c COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ Planning Board Decision: Comments Conservation Decision: Comments Wates' & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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.$10041000 fine NOTES and DATA — For department use ® 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/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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Location 1I M64-JOW JQI-C, No. Date �ORTM TOWN OF NORTH ANDOVER O 9 a : ; Certificate of Occupancy $ Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ �— Check # 24�-u Building inspector m m X m m c �=r.,g. a fA o cr H O. o C CC CA CD m O O H CD C.+C Z ?moo H _I y o� o o T 'v ? m CL CL. y C co -4C�H o O N Cpm` 0 g > > Co c d 0 � A CO) Cl) O y CD 'v O c s�� CD HCO) pa CL O O 'v. C/) U2 o � �. CD CZ r' C/) m �' 0 CD n CL CO) o ccD 34 go C42 C7 CL .o O C-3 v CD `n y 9 m _ rr^^ �- �' fl. �• � VJ CD CD CD CD O Co .. o O �o c CDCD CO) CD Z CL a) CO)CDO SCD: CD ;wy o CO) O CIS : CD o. 'I 'CD Z CD W 1 CD Gq� : a C.)S inn o C �o� CD n c) O = O C CD -Cr. 7 cn 0 0 cn 0 bd It - d ►-H ?i w' gi OGQ a- b ?r cp ; �o A x t" Z CA ro y0 Ix PCI OCG�- x ro �' p JQQ x atv o. r d "z C' G O cn 'Y y al O.. x r to Cl o x z �J y 0 0 c *4 =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Lellibly Name (Business/Organization/Individual): Address: i; S c_bA<"S+ City/State/Zip:&r., /y%l¢ Phone #: Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts l Department of Industrial Accidents have hired the sub -contractors Office of Investigations listed on the attached sheet. 600 Washington Street 11 Boston, MA 02111 *4 =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Lellibly Name (Business/Organization/Individual): Address: i; S c_bA<"S+ City/State/Zip:&r., /y%l¢ Phone #: Are you an employer? Check the appropriate box: 1. [3rI am a employer with zo) 4. ❑ I atn a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors add 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: i C. e? Policy # or Self -ins. Lic. #: f ` �� 9 �� �6� Expiration Date: Job Site Address: Z7 0W_0AZZ_1t7. City/State/Zip: jyytW V(Zl ; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties of perjury that the information provided above is true and correct. Phone Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation -for-their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." ! ' : - ,, An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia 5/17/2011 2:32 PM FROM: Gallant Ins Agcy Gallant Ins Agcy TO: 919784589997 PAGE: 002 OF 002 ACORIX CERTIFICATE OF LIABILITY INSURANCE 'DYYYY)sn 712fzo11 7.E 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 certlflcate holder Is an ADDITIONAL INSURED, the poky(les) must be endorsed. If SUBROGATION 18 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 Phone: (978) 283.3500 Fax: (978) 263-1438 GALLANT INSURANCE AGENCY, INC. 199 GREAT ROAD / P 0 BOX 975 ACTON MA 01720 cOlITAcl Gallant Insurance Agency, Inc. "0 no (978) 263-3500 (978) 2634438 ArC No E-MAIL ADDRESS: PRODUCER 36702 CUSTOMER Mr. INSURER(S) AFFORDING COVERAGE NAIC # INSlk2E0 GEORGOULIS CONSTRUCTION INC, Senega S Ins CO INsuFeRA : D INSURER C/O SCOTT GEORGOULIS INSURER C 96 ARLINGTON AVENUE INSURER Or, DRACUT MA 01826 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 24269 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, NOITIO14S OF SUCH SHOVM MAY BEEN RF IMS. dITS H&U -01 ICED BY INSR TYPE OF *=RANCE ADDIL SUSR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR INSR MIDINYYYY MMNOrYYYY A GENERAL UAettrrr SAG1004166 03fO5n1 03/05/12 EACH OCCURRENCE $ 1,000,009 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 17 OCCUR Ps EaocnuO ce $ 100,000 MED. EXP (Any one person) $ 5,000 PERSONAL 3 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,1100 POLICY PRO-JFCTLOC $ AUTOMOBILE LIAMMY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO 80DILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY. (Per accident) $ PROPERTY DAMAGE HIREDAUTOS (Per accident) $ $ NON -OWNED AUTOS UMBRELLA LLa9 OCCUR EACH OCCURRENCE $ AGGREGATE $ E%CESS LNIB CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS LIABILM YIN ANY PROPRIETORIPARTNERlEXEcunvE TOP.STYLPAITS 0TH $ FP E.L. EACH ACCIDENT $ OFFICEIMEMBER EXCLUDED? (Mandatory In NNl N7A E.L. DISEASE -EA EMPLOYEE $ It yes. OesWbe under OESCRIP71ON OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, D mon space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE John Cardona THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 19 Meadow Lane N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Attention-. The ACORD name and loco are renistered marks Ray Gallant GEORGOULIS ROOFING & CONSTRUCTION, INC. 96 Arlington Ave. Dracut, MA 01826 Al Greene - Estimator 1-978-453-4242 Office 1-978-888-1700 Cell georgoulisl4@aol.com John Cardone 19 Meadow Ln. N. Andover, MA 1-978-683-5674 jpcard@iietzero.net Scope of Work: PROPOSAL 05/06/11 Job Location: 19 Meadow Ln. N. Andover, MA Remove all layers of roofing down to wood deck on all roofs of the house. Install 6' of GAF Weatherwatch ice/water shield underlayment on all roof eaves, in all valleys, and around chimney. Install GAF Shinglemate felt paper over remaining exposed roof deck. Install 8" .025 gauge heavy duty white aluminum drip edge on entire roof perimeters. Install GAF Timberline high definition Lifetime Architectural shingles with Timbertex caps on roof. Install new stack pipe boot on plumbing pipes. Install new Coravent V-400 ridgevent on main ridges. Install new lead flashing around existing chimney. Remove all gutters, and re -install existing gutters upon completion of roof. Remove all job related debris from property on a daily basis and at jobs completion. $2.50 Per Sheet Extra Cost to replace any damaged plank board decking (if needed). $7.00 Per Lineal Foot Extra Cost to replace any damaged facial, rake, or shadow trim boards (if needed). Entire job includes GAF Systems Plus Warranty, First 50 Yrs. Is non -prorated, full labor and material coverage from GAF. WE PROPOSE hereby to furnish material and labor complete in accordance with above specifications, for the sum of. bct - 6 4530-00 - CK At aSgq s,lG�U Ten Thousand Five Hundred Thirty Dollars $10,530.00 PAYMENTTO 13E MADE AS FOLLOWS: col os '- All material is guaranteed to be as specified. All work to be completed in a substantial workman like manner according l— to specifications submitted per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. C(�a sCaa All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and'other necessary insurance. Our workers are fully covered by workers compensation ins mn . Authorized Signature This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal- The above prices, specifications are satisfactory and are hereby accepted You are authorized to do the work as specified- Payment pecifiedPayment will be made as outlined above. Signatur Signature Date of acceptance 41(-411 91te & Office of Consumer Affairs and 2usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Ctantractor Registration GEORGOULIS CONSTRUCTION, -INC- SCOTT GEORGOULIS 96 ARLINGTON AVE �= DRACUT, MA 01826 DPS-CA1 0 50M-04/04-6101216 Office of Consumer Affairs & B iaess Regulation HOME IMPROVEMENT CONTRACTOR Registration: -,1 Type: Expiration: 12/.12/.2012 Private Corporation G GOULIS CONSTRUCTION{ INC. SCOTT GEORGOULIS i 96 ARLINGTON AVE DRACUT, MA 01826 Undersecretary Registration: 117870 =- , Type: Private Corporation is Expiration: 12/12/2012 Tr# 206063 �1� Update Address and return card. Mark reason for change. ❑ Address F-] Renewal F] Employment n Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not vaIih without sign ure Massachusetts - Department of Public Safety Board of Buildinl- Re!-lulations and Standards Construction Supervisor License License: CS 58498 Restricted to: 00 SCOTT C GEORGOULIS 96 ARLINGTON AVE DRACUT, MA 01826 Commissioner Expiration: 10/2112011 Tr#: 5031 From 05/17/2011 15:37 #297 P.002/002 CERTIFICATE OF LIABILITY INSURANCE °5i,7` 20111 f 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 pof(ey(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 (978)459-2101 Albert A. Daigle Ins Agency, Inc 313 WiIlard Street Dracut, MA 01826-5099 CONTACT PHONE FAX E-11WL ----- ADDRESS:— INSURERS AFFORDING COVERAGE NAIC # e75uMR A. Aiker l Can Hone Assurance INSURED Georgou l i s Construction Inc. 96 Arlington Ave. Dracut, MA 01826 INUMER 0: INSURER C: INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED- NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE John Cardona POLICY NUMBER 1 POLICY EFF YODUMP LIMITS d OENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-1 OCCUR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EACH OCCURRENCE S DAMAGE TO RENTED PREMISES Ift occurrence) S MED EXP (Any one person) $ PERSONAL& ADV INJURY f GENERAL AGGREGATE. S GENI.AGGREGATE LIMB APPLIES PER: POLICY PRO• LOC PRODUCTS . COMP/OP AGG S $ i iWREDAUTOS � AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS _ AUTOS NON -OWNED AUTOS ! f / C CO 1 SiPXiL U I i ens BODILY INJURY (Per person) f BODILY INJURY (Per aocident) S PROPEATY DAMAGE f Per arsidem 8 UMBRELLA LIAR _ _ EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE E AGGREGATE S DED RETENTIONS f A WORKERS COMPENSATION AND EMPLOYERS LIABILm YIN ANY PROPRIETORIPARTNERIEXECUTIVEr— OFFICERIMEMBEREXCLUDED? (Mandatory in NH) dewroe DESCRIPT N OF OrPERATIONS below NIA W0009-75-2668 09/25/10 09/25/11 STATU- O - WCTH EL EACH ACCIDENT S 100 000.00 EL DISEASE - EA EMPLOYEE S 100,000.00 EL DISEASE - POLICY LIMIT f 500 000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddlUonal RamsAs Sehadula, It more spay H required) i CERTIFICATE HOLDER CANCELLATION John Cardona 19 Meadow Lane SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. N. Andover MA 01846 AUTHORIZED REPRESENTATIVE j ;(k f / C 01 2010', ORD-6AfiPb(t \ N II rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD