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HomeMy WebLinkAboutBuilding Permit #206 - 206 APPLETON STREET 8/30/2010 NORTH BUILDING PERMIT oFtt��o .b�ti TOWN OF NORTH ANDOVER or h�: �-�-•6 0°, f APPLICATION FOR PLAN EXAMINATION b4 * _ Permit NO: Date Received 4SSACHU`�E� } Date Issued: s Z I IMPORTANT:Applicant must complete all items on this page t"t$ ".c`*°'Ti ";1w3-:kr'• :t",�r,'sy1'�?%51�.�'1" e4l lf' :Yr.'>�-r cu�qN°Sx�' L,,.`;5.5uVi�i'_ 3F r+ � .s.,i . Cl, -'+e a'-a^•"-- �� MI s a,- a ? rim `oTq,L3yi� rM �I I'll -' r; -�.. `'�, ri' �'k 'P •� f ;� 'y} '"¢`, "�'-'- � .�rk`�� r fi '�fi1T1 S. �p ,.. ._ata` -Lt�' ± x �_ei !s "Dw �1� F� .'mom.r, uxnbsx mit' "5�7F'x ..r I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: jij&rowA/lL Demolition Other I (140L o -'�s� t t -._ } rr+ ";S? ;, ''�� 7z" Gr`-�`..x+'-..;4. �Jm ...c+ 7t,;""� F � 4.• r kscWg _,.a..,��:�.._ .. .�. ... Tst �v.,;,F� °x. .T._-_y t"'�r cr, z, '.'� .. -.� ?.. ..;;'�. �6W.�:..,.... ,^.��J. ..�.•1 _ p DESCRIPTION OF WORK TO BE PREFORMED: �L ��S /,ILL Qe✓L- �� x �0a %ulIto L).-i& C--ci f Yz- -S %AA _ Identification Please Type or Print Clearly) OWNER: Name: .fa•^,i s I Si,tAtC—i CrasKieliKIJ Phone: fr•'6� - ' Address: 04. L 'i©1f 'rrk. m�- "4s- aNI- , , ^a -z+"may. i� r`Eyy' �"xtk. P � S.•ys-i.n+l�.*� x'6 � p 1�- '�'1 '�+�6^i� ���v'�''` �xi rgoggf ts��S"L"r-f'C-}.�r•�%�'S� NOM ?_ t L"• .3F.� wli' N _��1 ��,• �!q�� ee--���� �-�' '"°ar �t1!1: �. faS" Es=�¢Ss `U 'k�iris� ` �a mlla pggr4 Sr'Ci`W n�51^dl^S' 924 A% ` r `cx - �.,. ;� i ��`�R"�' �x �f`t _-_ ��� ��a�,��;, �r�+•'Y"�°i:rs�..�a-5'��c,.�r,,�� t�aa;4"-�`'*a;,'�!. 7F}�', F`'���„'}'`tt�''1.�d �" �� I +53r {,�,, �L` `� '�7" �,ru�' i `�Y�nm kSF c.��� 4 "`'-•/1f�w ? � �. dl� s'ff Y•*J.��+ ��,,.u,.:i?r.. rc``'�4 <^g1''1r,u"5a� �-Wrti5 � ' .�Q:��`tr" ..t..,, r_ti.�`.'rS�'�fif; r, r-Jr --,r1'Yv I ARCHITECT/ENGINEER j � Phone: it Address: Reg. No. s FEE SCHEDULE:SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS SED ON$125.00 PER S.F. Total Project Cost: $ `'�'/.� t� e� FEE: $ j Check No.: G � Receipt No.: NOTE: Persons contracts g with unr stered dntractors do not have access to the guaranty_fund g — — ; Location ' m ,_.,r_ No. Date ) MORTM TOWN OF NORTH ANDOVER F w 9 • s ; ; Certificate of Occupancy $ s�CMUs t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 234 : x; Building Inspector Plans Submitted Plans Waived Certified Plot:Plan Stamped Plans J 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 i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS j CONSERVATION Reviewed on U Si nature I COMMENTS l Y\__ I HEALTH Reviewed on Signature , ure COMMENTS IZoning Board of Appeals: Variance Petition No: Zoning Decision/receipt submitted yes r Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/Sic nature sate Driveway Permit DPW Town Engineer: Signature: ` Located 3840,1 ood Street �i � �4RlilE " rer�n "TSup,ter � �te Desi r�o �Liacated�t�1��1�lain�fr-ee# � i F�r� e� a �en �s r 'F E } 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 U Signature 1 l COMMENTS nu-t fy� HIALTH Reviewed on Signature CO�MENTS 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: Signalure: 1 �DEiP�A �1�1F3 r h Located 384 Os ood Street erns Dumpster pn�to e r{ + s lzocatedt�� an #rye# x� 4 r k a �r1r �r ' r /'� 9 r _ .. .. _..,., �c .. - -- _ NORTy x.14, Dimension Number of Stories: Total square feet of floor area, based on Exterior di Total land area, sq. ft.; mensions. ELECTRICAL: Movement of Meter locati Electrical Inspector tion, mast or service drop re Yes p quires approval of DANGER ZONE LITERATURE: No MGL Chapter 166 Secfton 21A—F and G min.$10 -$e000 fine No NOTES and DATA_ (For department use) ❑ Notified for pickup - Date Doe-Building Permit Revised 2010 Plans Submitted Plans Waived_- Department Building e appropriate permit to be obtained. is a list of the required forms to be filled out for th The following interior Rehabilitation Permits Roofing, siding, permit Application ❑ Building Affidavit ❑ Workers CO opyOf H.I.C. And/Or C.S.L. Licenses ❑ Photo of Contract ❑ Copy proposed Interior work. r )ducts issuance of Bldg Permit ❑ Floor Plan Or neered P a�ment prior to iss ❑ Engineering Affidavits for Eng,from Fire Dep NOTE All dumpster permits require sign Addition Or..D.eCks Permit Application ❑ Building -plot Plan ❑ Certified Surveyed Affidavit Licenses ❑ Workers Co oPH.I.C. And C.S.L. Llc ❑ Photo COPY work With Sprinkler Plan And ❑ Copy Of Contract Proposed Crossect•►onlEleVat'►on Plan Of o Floorl licable) If Applicable) Hydraulic Calculatioompllan Ce Repo ( PP gid Permit ineered products ❑ Mass check Energy its for Eng ire Department prior to issuance of ❑ Engineering A require sign off from F NOTE: All dumpster permits req ingle and Construction (STwo Fami1Y) ❑ it Application Building Perm osed Plot Plan. ❑ Certified Prop And C. Licenses S.L. rinkler Plan And ❑ Photo of H.I.C. Affidavit o Be Returned) to include SP ❑ Workers C P dilg Plans (One T ❑ Two Sets of B1 Calculations (If Applicable) C Hydraulic Ca ❑ Copy of Contract Compliance Report perm Engineered products . ❑ Mass check Energy its for Eng Depart prior to issuance of Bldg �� Engineering Affidavits n off from Fire Pof Appe ° Perm require sig All dumpster p the decision from and Proof of recon NOTE: of Deeds. One copy permit was required the Town Clerks office must stay 'L`OC2 special p et this recorded at the Reb stry hcant must then g In all cases ieS peraod is over. Theo aP lication. that the appeal with the buildin,, PP must be submitted poc:Building Permit Revised 7008._ NORTH Tovm of oAndover . ®® o ii 110 - d� _ o __ o " dover, Mass., COC NIC ME WICK y�. 7�ADRATED P? CO S$ ` BOARD OF HEALTH Food/Kitchen Septic System .PERM IT T D BUILDING INSPECTOR THIS CERTIFIES THAT............. . .G. !--r!�.......C�.�.j... ;.......... Foundation has permission to erect........................................ buildings on ..o.b......... .......� Rough T �!!..K.�....... N... .l...� .. ...... � —�._�, Chimney I be occupied as...p�.. .... � .... �.................................... provided that the person accepting this permit shalt 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 CONS TR TI STARTS Rough . . .............................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. I �10RTy BUILDING PERMITofttLE� TOWN OF NORTH ANDOVER o �_ - :. APPLICATION FOR PLAN EXAMINATION _ 3 b6 * " Permit NO: Date Received - r oR � / �SsArno CHUSE� Date Issued: IMPORTANT:Applicant must complete all items on this page y Fez, a �_ r-.1^�^T�-3-„--NIX r Esq s f s ' `�.� "r� ^-'` �. r P'.ss Nh �... � ,:ytC-'C Jr's .y' .. C 3. v'-h. +' red.:.M�VS, eL- _ "' - r - --' r'rn.z'F y S'IjSF"F' izr KI--?.t d a: pp r r ,.2Ay :L� �i1r�1tM -.�4i.. - t¢ m sa- J f fisc ,,a ;P�"• .w�ra �r"r eF 3" ^4s'�•'3.�"t2i4-' 3`"',rte inn rraa.�c '7- ia; s M '.�- r'FEr�' xb - ---" '^fffl Ry��+}�pp A 7x . 1P �i.UT+A9.�, - �, -a ,- d -» - i.^'�r.* -r P S4 ., '>0r.Of'-a �' ;'f°,ly-�L•�°�.r�.�;r.� i:�•ia-x aF.ttSF��a .�-'�`'^_-w ei�tajs�i; 1LT"��• `5"4 .St�'-'''.4 cell,.�`-i�- ...y ..,J4'a''sy",µ�mL_�.-'� - ,�$.� ��'"�y�.`�t=�"y�i�'�^w�� � .Y9f �- � � ^.-�L�- FYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: lia cw1oL AiL Demolition Other "4fE= ^si Lr...raj- - Y - ��..�°� DESCRIP i Locations --�— / Date No. - Identificatia NORTM TOWN OF NORTH ANDOVER � OWNER: Name: J m s O y kddress: Certificate of Occupancy $ ����p� ���k,,;� � �: �.�'�•...o��'� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ --- 4gFYa 0 4' �, liYriuwe Y �_. � � TOTAL $ ------- LIAM IB � 171 I � rv� Check # .cvr..m...,�,.. d....ene.•,,w_.u.:,:..o-<,..�.w-.:aom-e_: r 2341 ARCHITECT/ENGINEER 44 Building Inspector ►ddress: rteg. Ivo. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST SED ON$125.00 PER S.F. 'otal Project Cost: $ / ; [zt%a FEE: $ :heck No.: G ( Receipt No.:_9 31419---"1 TOTE: Persons contractitig with unr ered -vntractors do not have access to the guaranty.fund r .It�n tnrrP to 'Ru _ ry _ w. f�17wnPr �.. �..- nnaff�Yro�� xrnn .�rfnr:, oF µpRTM TOWN OF NORTH ANDOVER ,"I"! " . OFFICE OF tizb o� BUILDING DEPARTMENT * e� 1600 Osgood Street Building 20, Suite 2-36 North Andover Massachusetts 01845 �SSgcHuSE� ' Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: �2(� f�ff'LO�( ST �'�( ����✓�j ,� Number Street Address Map/Lot IiOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor), State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and tha h she will mply with said procedures and requirements. HOMEOWNERS SIGNATURE I APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 689-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Alassachuseas I Department o f Industrial_9ccidents Office of Ln veto atwns 600 Washington Street Boston, 112.4 02111 Workers' Compensation Insurances`zsse ovidia Analicant Informafion Builders/Contractors/Electricians/Plumbers Please Print Lem Name (Business/Organization/Individual): Address: city/state/zip: Kt pw /" MA- 17'4 Phone#: �—�� s—`'7 Are you an employer?Check the appropriate box: 1.0 I am a employer with 4• ❑ I am a g TyE f project(required): "neral contractor and I 2.[] employees(full and/or part-time).* have hired the sub-contractors 6 NeuJ construction 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These mob-contractors have working for me in any capacity, workers' coin . ' g' ❑Demolition p insurance. NO workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.0 Electrical r 3- I am a homeowner doing all work riQ t of ex epos or additions / myself [No workers' comp. c- 15", �mption P�MGL 1 i.❑Plumbing repairs or additions ce re uired t ' I(4'),and we have no insurance q ] employees_ , 12.0 Roof repairs [No workers comp.Msurance required] 13.0 Other Iicant that checks bo: �,aso .t �Fiomeown .` rYr:c_ Ehc 8=-'6=beeoR•e.:nY W,. ers who submit this affidavit indicating they 2,-L dc. g a: we; and r r wor:ers' -, +Contractors that cbeck this box must a ached an additional sheet showing the men hire outside contractor�i ;Shiner a new amdavit indicating such. same of the sub_contractors and their workerscomp.policy licy information. I am an employer that is providing workers'compensaiion insurance or MY info" adore f employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration pane(showing the policy number.and expiration date). Failure to secure coverage as required under Section 25A ofM ) fine up to$1,500.00 and/or one-year imprisonment,as well as Glc. 152 can lead to the imposition of criminal penalties of a Of up to$250.00 a day against the violator. Be advised that a co Penalties m the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. Py of statement may be forwarded to the Office of I do hereby certify under th s an eiialties o er , fP IBJ tiiitt the Siffiature: information provided above is true nd correct � Phone#: Official use only. Do not write in this area, to be completed by cam,or town ofJiciaL City or Town: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3. Citv/Town 6. Other Clerk 4.Electrical Inspector 5.Plumbinb Inspector Contact Person: PhonC n: Information an- d 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 pe=rson 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 ensagedin a joint enterprise,and including tlae legal representatives of a deceased emplover, or the receiver or trustee of an individual,par tnershin, assocation og other legal entity,employing employees. However the owner of a dwellinghouse having not more than three P artn1 ap cuts and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte:mance,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 bean 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 c onstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of comupliance 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 utlt:il 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 employers other than the members or partners,.are not required to carry workers'comp cnsation 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 confirmation of insurance coverage. Also be sore to sign and date the affidavit. The affidavit should be ivtua'IIed t6 the city or town that the appllGaLLD •for the perL�lrt or l:CP1n-se.:g being requested,not the.D�a�eni.of Industrial Accidents. Should you have any questions regardi�b the law, or ii you ap;�, ;; obtain a worters' 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 legrbly, 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 permit/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 perxnrits or licenses. A new affidavit must be filled out each year.When a home owner or citizen is obtaining a license or permit 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 Ofnce of Investigations would like to than 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.._ T'he Commonwealth cif Massachusetts Department of Industrial Accidents Office of Inresfzbaf ads 600 Washing-bn Street Boston,MA 0.2111 Tel. 617-727-4900 ea.-t406 or 1-8 77-IVL4SSAFE Revised 5-26-05 Fax #7 617-727-7749 Wvr%K-Mass-gov/dla DATE(MM/DD/YYYY) ACORQM CERTIFICATE OF LIABILITY INSURANCE F08/31/2010 PRODUCER 207.646.7118 FAX 207.646.8294 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Peoples Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 1336 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Ogunquit, ME 03907 INSURERS AFFORDING COVERAGE NAIC# INSURED Mark Bibeault INSURERA: North East Insurance Company 24007 1 Idlewood Lane #36 INSURER B: Kittery ME 03904 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADWL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR N R DA /Y MM/D YYY DATE MM/DD/YYYY GENERAL LIABILITY B18-3167915-03 05/31/2010 05/31/2011 EACH OCCURRENCE $ 300,000 DAMAGE TO-RENTEU- X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE I-XI OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 300,00 GENERAL AGGREGATE $ 600,00 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 600,00 1-1 POLICY JEO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS. BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - -OTHER THAN EA ACC $_ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F_]CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION. IV - - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER- ANY PROPRIETOR/PARTNER/EXECUTE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTIONOFOPERATIONS(LOCATIONS/VEHICLES-/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BIEFFORE THE EXPIRATION n DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sharon Coskri n IMPOSE NOOBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURLAYMAGFNW"R 208 Appleton St. REPRESENTATIVES. North Andover, MA AUTHORIMoREPRESENTATIVE jTimothy Pinkham/SGL ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD