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HomeMy WebLinkAboutBuilding Permit #531 - 200 BRADFORD STREET 1/10/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: 1 rr _-\ , Date Received I IL IMPORTANT: Applicant must complete all items on this pane I LOCATION O V� ti-jJ S7 Print _PROPERTY OWNERPP%J\, Print MAP NO: & PARCEL: U d ZONING DISTRICT: Historic District yesno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building E�Sne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alt ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Se tick ®W.ell v i, P 4 _ (DaFlood ;laui s®"Wetlands! s _ ? p i `®�iVVatershedtDist�' ctx -.� Y ®Water/Sewer; - � a DESCRIPTION OF WORK TO BE PERFORMED: 0 �JJ k u cx�S Identication Please Type or Print Clearl OWNER: Name: QP"J\ Phone: Address: D oc� C3KLP�r3,fo S� } CONTRACTOR Name: J� 7 J J t So r J Phone: Address: Otis ` v) Supervisor's Construction License: i 0% Exp. Date: �/ k //0) Home Improvement License: I LI Cl (e o ( Exp. Date: /bqll� ARCHITECT/ENGINEER Phon 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: $ ��, 3� FEE: $_Q . 00 Check No.: 9-,5-(3 h Receipt No.: lq `l 5 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature_of,�Agent/Owner ' ���. r:0�n- Location U �`a f SL No. -? Date / w /U —/27 NORTh TOWN OF NORTH ANDOVER a ; . Certificate of Occupancy $ a s,Argo I t� Building/Frame Permit Fee $CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C'J Check # SUo 24945 t Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Pools El Art ❑ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COM�VIENTS DATE REJECTED DATE APPROVED El Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition Planning Board Decision: Com Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & 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.$100-$1000 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) ❑ Muss 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) o 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 In 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 nust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi E 4 O ora w2 v U) z r� -d w° x a°G G U .� w a°' w O W w -C v cn w a C7 -� w w w 6 cn Q v ° cn rA W .CD c C y O c O v V r� •n C CLo ev CD c ;yam % � ¢ CC Z p W ; Y O: o n J u F' �e OA co p CD c E CL mm a CD 3 y :gym � Cc CA 0 Em 3 mo CL L m :y0; ac =s o rn : CPS •� d co •� O m O f m 'v•� O. O Z oCD c n Q y m C O = m Q= 0 N O H O m COD m _ uiCL.= O C Z "r m •y O_ W E. O m g CL y d m.fl O.0 3 CO C N O CL=*- m r U 0 Z O U C O L O O v Z O CL O CO) D C I Ccm co 0 'D La O O m m CD 3� as O � i envo a a cma C = c c ev � V J.O O C ca ZCl O C.i ca O C C COCL uj 0 U) W W W C4 09/29/2007 01:35 9782785010 JOHN BEAVER PAGE 06/06 104 Otis St., Northbomurh, MA 01532 J&L WINDOWS, IN(:., D/B/A !� MA Home Improvement Contractor (508) 919-0980 • Pax: (77q-) 987-301:3 Renewal License #199601 (Expires 1/24/201G) byAndersen. q — Federal Tax IV #33-0404201 WINDOW REP A6LIDRNT �n,Ai,d—C,—p,e CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s) hereby jointly and severally Agrees to purchase the products anal/or services of) & L Windows, 111C. d/b/a Emewal by Andersen ("Contractor"), in accordance with the terms and conditions deacrily d on the front and the reverse: of this agreement and on the atinehe-d specification shect(s) (colleel.ively, this "A,groement"). Buyer(s) hereby aWccs to Sign n completion certificate after Contractor has completed all work under this Agrcemcnt, a �, 83 `d Total Job Amount:__.___.._Esrimoted,Strorting Deposit Received (33%): 0QQ. Balance at Start of job (33io);:76100 - ro: t - !-5.-. ❑ Method of Payment: Check ❑Cosh ❑Financed Credit Cord ore accepted for deposit ( Balance on Substantial�f �3� Completion of job 133%): / j. .....__._ Est noted Completion Date: n 1__ --- — mVm ��3 Of til@ project COSI. Pleose see Credit Card Payment Form, By signing this Agreement, you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion of job cannot be made by credit card and must be made by personal check, baptlx check, or cash. Buyer(s) agrees and understands that this Agreement constitutor the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alteration to or deviation 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 TkIERE ARE ANY BLANK SPACES. J & LV(�= y Ander9en By; Si atur of Pr Tlust ManaPer Print Name of Produrt Manager Buyer(s) Rv.yer(s) Siena. Sicnarure aVI Print Name Print Namc 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 TI E ATTACHED NOTICE OF CANCELLATION FORMS FOR AN. EXPLANATION OF THIS RIGHT. NOTICE OF CANC TION X Date'of TransactionYou may cancel i this transaction, without any penalty or obligation, within three business days from the above date. if you cancel, any property traded in, any payments made by you under the Contract of Sale, and any negotiable instrument executed by you will be returned within 10 days following receipt I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at your residence, in substantially as good condition as when received, any goods delivered to you under this Contract or Sale; or you may, if you wish, comply with the instructions of the Seller regarding the return ' shipment of the goods at the Seller's expense and risk. i If you do make fere jb�IdS'tsvnileblt'�tttR-5eller>and-the-••t Seller does not pick them up within 20 days of the date Df your Notice of Cancellation, you may retain or dispose of tete goods without any further obligation. If you fail to make the goods wadable to the Seller, or if you agree to return the goods to the Seller and fail to do so, then fou remain liable for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a :iggred and dated copy of this cancellation notice or any ather,:written notice, or send a telegram to Contractor. J k L Windows, Inc. d/b/a Renewal by Andersen, 104 Oris itreet, Northborough, MA 01532, BY NOT LATER THAN AIDNIGHT OF — ! . (Date) HEREBY CANCEL THIS TRANSACTION. - — — — — — — �j— — — )NOTICE OF C C_ zl0 Date of Transaction You may cancel this transaction, without any pens ty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the Contract of Sale, and any negotiable instrument executed by you will be returned within 10 days following receipt by the Contractor. ("Seller") of your cancellation notice, and any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at your residence, in substantially as good.condition as when received, any goods delivered to you under this Contract or Sale; or you may, if You wish, comply with the instructions of the Seller regarding the return shipment of the goods at the Seller's expense and risk. If you do make -the-goods-available to the Seller and the Seller dcles-nc* pick them up within 20 days of the date of r Native f t Of Cancellation, you may retain or dispose ohe goods without any further obligation. If you fail to make the goods available to the Seller, or if you agree to return the goods to the Seller and fail to do so, then you remain liable for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Contractort J & l Windows, Inc. d/b/o Renewal by Andersen, 104 Otis Street, Northborough, M 01532, BY NOT LATER THAN MIDNIGHT OF �'- _2 . (bate) I HEREBY CANCEL THIS TRANSACTION. ___ ttuyor': Signaroro • Print NDm� �� 6010 Boys.'. Slgnatur` Prim Nomo pDl� Rl!�A Copy • White Buyer Copy • VCllow Buyer Copy - Pink 09/29/2007 01:35 9782785010 JOHN BEAVER PAGE 05/06 I04 01is Su•cet, Norh,frorough, p4A Ot ,y2 Phone 50$.;319.0})00 -Fax 774.98"r.,{013 j A L Windows, lac. d/b/a Renewal byAndersen. WINDOW REPLACEMENT nnAjj,, nCn p,, OF GREATER W%ACtiU.gMS AND NEW HAMPslimE WINDOW SPECIFICATION SHEET Date of MA HIC License # 149601 (expires 1/24/12) Fedcrni Tax IDip 83-0404201 The Myer(s)listed above here oinil and acvcrall a� a to urehasc the odds and/or selviees listed below, ir� eco` net with the prices and terms 1 Y Y ¢r P g dcscribcd on the Sp0cification Sheet and the dont and the reverse of the aceompanyi%'i CUSTOM}. WINDOW AND DOOR REMODELING AGREEMENT, Of which this Specification Sheet is a part, WINDOW DETAILS] . Contractor will Install a total of windows in Owner's home, using the :followin+g individual quantities: Double Hang (DB) [j qua.l sash 0 Cottage sash (1 /3 top, 2/3 bottom) ❑ Onel sash (2/3 top. 1/3 JXXjorn) Casement (CW) ❑ 1•Iittgc right ❑ Hir,%c left (as viewed from exterior): ❑ Standard handle [j Metro handle Doublc casement (CDW) ❑ Standard handle ❑ Metro handle Casement / Fichzre /Casement (CPM❑ 1;1:1 or [)1:2:1 ❑ Standard handle [I Metro handle 2 Lite Gliding Window (GW) Glider / Picture / Glider (GFW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window (AW) Picture Window (PW) lay or Bow Window Fafio .Ch10rs (scc sepnrate Door Specification Sheet.)1 2. Ycv ❑ Qty of Windows to be Cullom Fit Replaccmcnt , � yl..�•@, �/ roti ��•. � _,f ❑ Yes � Qty of Sills to be replaced by Contractor: 4. ❑ Yes Qty of Windows to be New Construction Full frame (inclodes new interior & exterior casings) and aeU,lal. exterior cal gs: ❑ Fine ❑ Maintenance - free material ❑ .Factory applied 908 Fibrex brickmold 5. Glazing to be: FZ 144I.o F-4 ElOther If other, please specify: 6. Exterior color to be: rte ❑ Sand ❑ Canvas © 'I'cr•raigne ❑ Cocoa Bean 7. Interior color to be: E7Whjtc ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note.: Cale Ar color can only be. white, wood or stems color as exterior. Wood interiors need to Pinish.ed by Owner. 3. Ha ware; VWhitc ❑ Stone anvas ❑ Brass ❑ r5tatcl-lardwarc: tyle: 9. Yes E) No install iJ(ts w(th utile Flung Windows ©�% – S 10. Screens: windows to have: Half or ❑ Fill) serecns Scrccns to be: ❑ Fibcrglaala &eAluminum ❑ Tnl5cene GRILLE DETAILS Windows have grilles: 9 Yes ❑ No if yes: Op"Grille Between Glass (GnG) ❑ Removable Interior Wood (1m,w) ❑ Full Divided Usht (mr.l Qty: J-1 Qty: Qty: Qtv: Otv: Otv, 01v -- --`" DH DH DH DM CW/pIcium 011dar Pw oro Draw grille patterns above `Use additional Sheet if needed Owner approved ADDITIONAL WORK DETAILS 12• ❑ Ycspk, Contractor will remove meted frames of windows, Qty of Units: 13, Ycs N- ontractor will install new paint -ready or stain -ready casings. Intcrio •asing qty of openings: Exterior casings qty of openings: ❑ Fine ❑ Maintenance -free material 14. ❑ Yes No Contractor will install new paint -ready or stain • or Outside stops qty of openings: Interior slops qty of openings: Exterior stnLAq'Loning ❑ Fine ❑ Maintenance -free material 15. Owner is aware that Contractor docs not do any painting.Owner Initials 16.❑ Yee ❑ No Contractor will wrap exterior• casings with stock of color. /Note: Wrapping may be required with storm window rein oval; removal of storm windows will leave screw holes in casing. 17.Y • El No Conlraclor will insulate, caulk and seal windows with 3 -point: system to prevent water and air infiltration. I S. V ❑ No Ctcan up all.job related debris inctud.ing old windows will be removed. Vacuum niglhtly 19.. ❑ No A li.n.ited warranty shall be issued to Owner upon completlon of thejob and payment: in full. 20• es ❑ No Build Petxttit—Contractor will secure any and a)1 necessary permits. The fee for the per nit(s) is not ncluded in the Contract Price and a separate check is required at the time 01's& (Or this fee. d% 21. Yes ❑ No All disrnUlks h1v. 13 n ahhlied to this eernCnl price. Q /d - + /d 22. AdditionalJobelctails:�X�S?-- 23. VYcs ❑ No Ovmer agrees to be present cal the final day of, installation for final inspection and to deliver final payment. Ary final payment •shall /.x dennvrded until t1le CQtrtrrJUt is completed to 111-- .4,0100011 vfd/1 ptrt•hcV, It is agreed and understood by and between the parties that this Specification Shcct, along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT', constitutes the entire understanding between the patties, and there are no verbal urrderstandings chan#ig or modifying any of tho terms- Thls Specification Sheet may not bo changed or its terms modified or varied in any way unless such changes are )n writing and signed by both the Buyer(s) and tor. Buyer(s) hereby acknowledge that Buyer(s) has reed this Specification Sheet. Renewal y e of Greater MA and NI -I 15uyer(s) I Buyer(s) By: Srt-r f . oduct managerSignature % r — n ICGY?/yu// °1 ,t��) Print Name of Product Manager Print Name Print Name Tfse Conzrtsmsweaitfs of Maggachuseitr Deparimisd of industid ticciiienfs pc� of FitPesfi�¢iiatss' . SDd J�irsfun�tan �Lreef •, ' Bnsion, htll ff�111 . . , .wDrii`err' Campensafi.on iasirrsnce Af�bs� $cii�.ders/Canfracf�rcl�Ie Pkzce em{Lea— ,kpoRmnt Iafnrmsf�an ' N m e c3uimmdorganizefic nlfndividuats; . e er ro riBtaban Z`ype ofprtiject (rrigtured�; Are you m erapinper? Check the aPP P 4, []'I aaen end I co =Id contractor fi [] 90W nstruction L -I am a cmpioyor wifit D _ ng � • 'bow hired the sub••confractnrs �` dciing . employcos (Elf aniltor pert-time). m t� attached sheet Z. ❑ I em a soleproprietor orperfner- Tnase•sub-contffictata have S, DomolitiQn ship end have nn empioyoes i ,-c8' DCiM iastusaoe. 4. ❑ $u1 g a ddtroa working far me fa eay capacity. rkung 5, ❑ We arc a aorporatioa end its in.E] Electrieal rmpaira m adatdonr [No WMkerP' comp. saattraace ofiicea havo �orcismd fhniL rD4T 0d-� ' t of e==.V ion per MCsL Plnmhing rmpeir� or addibone 3rQ I am a hom=er doing an work c iS2, @1(�and we have no LZ.[] Roof imps T,l �ayseli �o �aor�' comp. oo* m�ac r � 4n rt�*+�o rLgimzd-j t ' Yhe� wn�' oompen�on p6iie� tafntime6� k.+.ny tapli�t tip CheG�I hriz #I ni�o fm ratthe Fee[ioa 6 a �� hiicc outside oonhsiir� �� taeav ainriav3t inciioabnE . t F�tnaenwnea who zu6mitfhic>tg �Oa3ii� ander' C°�P Pone}infi�'°a as additional dMjar the Wane o€ the �vb-oomtn- +�nntadntt rim rhrsY thu hot � atbr�ed pb site I ane as cncpiaj�er thatiapraYid"utg.N'arkr.'ra' campaarafian Insrvante far my aacplayars ;$elmv, is the poFsry tired j , Insurance Company Idamc; n •� Paiicy or saff-ins, Lin. # (� ! �d JF Jab' Or, Addrass, � �O [� •— .-- -� (-'y� \l � � � �� �ptt�,eL and ea piir"awfinn date). � Affmmh a espy of the trorkarr' enzupensrtinn policT derJ$refian patr pen= to seo= average as rmViredunder �ccfiaa25A ofl�CrL ❑, i52 can lead to thn imposition of criminal penalties of a ar iin anmrmt, as well s.s civil prna�� in flio fr�•of a 6'IY)P WdAR QRI�BR and a Erne fm6 tiprtn $1,.5DD.DD and/or ono-yo . ba forwarded to tbn Df mD of •ofup to M5a.DD a day against the violator. Sm a vbad bd a copy .of this statement rnep IavasfiaafiOW of 60 DIA for ineorancc r'DVMgc v Ida herahy the pairs and that the ircfarcrsafiaa prr*d abmpe is ir=and carred. ora tv be amplated by ccty ar tarn n f j trial off=- W resa nnEy. Da not write ih &is . City nr Tort'u: ' . • PermitlLiccuse # . � ,r1ty (rirele =tar 5, plamhing Impactor L Saard- of Health I Boding Dept 3. C3tyClovra (perk 4, IIee{ricai P , 5, c)thw Ph= Caut�c# Parsons VYt r� Massachusetts - Delnu-trnent_c)f Public Safety Boardlof Buildings RcL"uf<<tinns and Standards Construction Supervisor License License: CS 35707 BRIAN DENNISON r 85 CREST CIRCLE WORCESTER, MA 01603 " Expiration: 9/8!2012 C "I�nint isciutier 7r,: 2522 ' ,; i` ✓�eyl0om�aseo�ur�eati(h� o�✓!�L•a�¢r,�utGel�d '. : •. . Office of Consumer A.ffaii-s & Business Regulation X HOME tll1IPROVEMENT COKTRACTQF2 • Registratiot��p1' . .Expi12 t Cart RENEWAL BY y --BRIAN. DENNIS f •104 071S STRE NORTHBOROUGH,� ` Undersecretary J �® CERTIFICATE. OF LIABILITY INSURANCE DAM 0/0/20' 1 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(ies) 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 J.P. McKeone Insurance Agency Inc JP McKeone Insurance Agency, Inc. P.O. Box 333 ACT CON E: NAMPH ONE FAX AI Nc Ext: (734) 662-8100 A/c No: ADDRESS: INSURER AFFORDING COVERAGE NAIC A Ann Arbor, MI 481060333 .INSURERA: Nautilus 19662 10/01/2011 INSURED J&L Windows, Inc. Renewal by Andersen INSURER B: Hartford 37478 104 Otis St. Northborough, MA 01532 INSURER c • INSURER D: INSURER E: INSURER F: r+nvvDAr•= r=I21rl IrATC NI IRR;z=P• RFVISION NLJMh3tM: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYY POLICY EXP LIMITS Drerm A GENERAL LIABILITY NC958461 10/01/2011 10/01/2012! EACH OCCURRENCE $ 1,000,000 100,000 COMMERCIAL GENERAL UABILnY _ I PREM SES Ea occurrence $ 5,000 CLAIMS -MADE OCCUR MED EXP (Any oneperson) $ PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY 7 PROT F]- LOC - $ AUTOMOBILE LIABILITY 35 MCCXD6390 10/01/2011 10/01/2012 COMBINED SINGLE UMIT 1,000,000 Ea accide t ANY AUTO j BODILY INJURY (Per person) $ ALL OWNED SCHEDULED I BODILY INJURY (Per accident) . $ ATO S AUTOS NON -OWNED DAMAGE $ HIRED AUTOS AUTOS ' PROPERTY i $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADEI — --- I AGGREGATE $ DED RETENTION $ ---- �.--- $ A WORKERS COMPENSATION 35 W ECPP1444 02/17/2011 02/17/2012 1 1 wC STATLV o R AND EMPLOYERS' UABILnY 5DD,000 ANY PROPRIETOR/PARTNERrEXECUTWE �N ' E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) / A E.L DISEASE - EA EMPLOYEE $ 500,000 It yes, describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE - POLICY LIMIT $ B PEOOH555DO 0507 09/27/2011 09/27/2012 1 j. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) l.Ctt I ll'1L:A I C r1VLUCtt l..HrYI.CLLN i rvr� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE .WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01966-2010 AGUHU GUKI'UKA I IUM. Fan rlgnis reserves ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD cc cn LU y o C—' E=r wLo g o cc WW�j�1 a_ ►may/ z . �CA uj C.2 Q W Q. cm W cn lQ�3?E a J a „s o a - y u e �- �$ °„ a 19i��m r �U 0: 41'i. : " 0 P 41 ni >v ! • a3 d co Q E m �n�q �<<fe BVI fnNf E,,a `�. �uj ' tff iia a LL V C' ' Q®_ Ci LU cc a Z Q N 1 LLJ r•:-L>