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HomeMy WebLinkAboutBuilding Permit #682-15 - 215 HICKORY HILL ROAD 3/2/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: 1 J IMPORTANT: Applicant must complete all items on this LOCATION = -- CAg - print PROPERTY OWNER -_ _ A__ --. Pant �4 -100 Yeai MAI - PA, RCE ING t L _ DISTRICT ..Historic t qr M'ni-zhR1 0 �tLED 16 e '6 0 L o fn Zi ED ATED yes no Ye nom 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: ❑ Demolition ❑ Other Septic❑ 1Ne16 ❑�Floodplah ` ❑ Wetlantls i Watershed Distract 11 Water/Sewe.r' DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: 1 a , 4y" Contractor+Name: ihone,:- _ - - - - a n - Adtlress: -� j �'.t ,ZQ `�l'l -nAd.. 0&7-!;D Supervisor's Construction�License Home lmgravemen# License:— /_/nill'l iF)(n ,nate- /11�/�-7 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. Total Project Cost: $ 9�--7 FEE: $ Check No.: l,�a l CvC�2 Receipt No.: " �I NOTE: Persons con ratting with unregistered contractors do not kaxe-a-ccess 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 0 Tobacco Sales ❑ Food Packaging/Sales El Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature Reviewed on Siqnature Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments a Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: i FIRE PEPARTMENT , Fernpp Dumpster�ont si 'Locafetlat 124;Man Street 5irelDepartm-gift hat re/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 Call Email 3 Date Time Contact Name Doc.Building Permit Revised 2014 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 o 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 Li Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/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) or Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li 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 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: Building Permit Revised 2014 LocatFtion No. �Y 2' `7 Date Check #L-'" 2- S'21 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $3b — Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector r v C � n p CD n Z N CD 0 CL r- F)• �o CL co y 'a:2� O � vCD CL cr CD (D O 00 CD C a CL 0 C y• CQ CD � v 0 CD 0z n O C CD c� A L �d r v Q Z cn n z m cn O c m —I m O O Z o. CD N O to O W CD cm 0 0. U) y CD o0 -o 0) x p7 N =� <. caD y Cl).a CD. 0 T n Q 0 m c � 3 � -n R - c Z7 O S T O O •-• C V1 m n y m CO) W��to c m E-' CL W 2 -% -4 O n U Q ,OO .-+ O S ''- COy r+ =r r O CD CD AL O0 < CQ -,cn.a 00,�� cr 5. L. S. D CD a. =r: QQ�o cn <CD 0 CD CO) < CL ID ? • DO On 'O0 ionr tU O N cD rt - m C i C ort CD CD Cn CnC: CD �� C.) > CD n� CD w. - O � 0 rt O � Q L 3 o N 0 V1 1-C m rY Z p7 T m Z1 O S T V1 O0 < CS Z1 T 5. a ;;o' O S -n R (� _S 3 7 m Z7 O S T O Q p V1 m n y T O n \ 7o m m y m -Zi G) H cZi� O 70 m m f1 00 C W Z V 0 O C Z C -mo 0 3 S lD O D O O D S ori a: next step living® home energy solutions This agreement is made by and among Dan Fay 215 Hickory Hill Rd North Andover, MA 01845 Site ID: A773147 1. DESCRIPTION OF WORK TO BE PERFORMED Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866) 867-8729 20 -Jan -15 NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the Work in detail (the "Work") which are incorporated herein by reference: Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 6 $75.00 Hr $450.00 Weatherization Recommendations Work Location: Attic Flat Insulate Wall From Interior With 4" Dense Pack Cellulose 138 $1.85 sgft $255.30 >100%>Airsealilg Incentive up'to Program Max $450.00 75 °Io Weathenzation Incentive up to. .rogram Max $1,093 23: Estimated Annual Energy. Savings from the Above Improvements $2.15:00 2. PAYMENT CUSTOMER agrees to pay NSL for the work as follows: Payment #1: $100.00 -Credit Card or E -check deposit is due at the time the Work is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed 1/3 of the total retail costs. (Note: Mastercard, Visa, and Discover accepted) Additional Payments and Final Invoice: $264.40 -Additional payments for the Work shall be due upon completion of the Work. If the final invoice is being paid by check, credit card information will still be required at the time of scheduling. Notify the customer service representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. - r ao lS customer Signature Dat 20 Jan 2015 William Calder NSL Signature Date Name of NSL Representative A773147 The Terms of this Agreement are contained on both sides of this page Next Step Living = 21 Drydock Avenue o 2nd floor a Boston, MA 02210 a (866)867-8729 o inquiry@nextsteplivinginc.com - www.nextsteplivins•com TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.617.973.8700. 5. PERMITS NSL will obtain any necessary permits as the Customer's agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save® Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to (1) year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non-oode construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not properly protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terms other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. You may cancel this Agreement if it has been signed at a place other than the NSL's normal place of business, provided you notify NSL in writing at its 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 attached notice of cancellation form for an explanation of this right. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customers sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch 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. Mass Save Planview Diagram Customer INIV,Advisor Name: 1A) 6, c Address 1` �111Advisor Number: Town Any limitations to access by truck? Site ID �l-�"?�j UlCAII� NOTES /f� 3 pfopm, veA /—Oct 1�7�- 6,41- 06 15 u iu 1 c (.vGt 11d ,- IN 'GCf1E�C�� �.�� 'd Ice, 10 Park Plaza o Suite 5170 Boston, Massachusetts 02116 Home Imprr®vement'Contract®rc Registration Registration: 162111 Type: Supplement Carol Expiration: 1/14/2017 NE®CT STEP LIVING INC. ROGER OUELLETTE. 21 ®RY®®CK AVE. 2TH FL BOSTON, YEA 02210 APB -CA' 0 50M-04104-GG10�12166 ..� ./ 1tA. l:'d9Y24771.02(/f!'•2�C/1 4 ;.,.. ®fftoee of Consumer Affairs & Business Regulation Lim F1OME IMPROVEMENT CONTRACTOR Registration:162111 Type: Expiration: 1/14/2017 Supplement Card NEXT STEP LIVINGM. ROGER OUELLETTE. 21 DRYDOCK AVE. 2TH FLS BOSTON. MA 02210 Undersecretary (Update !address and return card. M21rk reason for change. 0 address [] Renewal ❑ Employment E] Lost Card License or registration valid for individug use omiy Ibeff®re the expiration date. If found return to, Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suitg 5l 70 Boston, MA 0211t6 without signature s.• ' .. Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super4isor Speciattti License ROGER r E. LEITTLI 55 STAM®1i44E rA V V c°f�rCV�Q k R 102,13 j G Expiration Re fided To: CSSWC e MWEIuoru C Ontfrr@' CoG Failureto possess a current edit'lorn O the Gu1assachusens state Building Gods is cause for rrevocOorn 0, this Ikenseo For ©ps d6censing un orpu zAO-Ta VIeotl e e�e�-jtvAQSs Gnv1DP5 The Commonwealth of Alassa¢ehusetts Department o f °Industr al Accidents ®fee of Investdgations 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARRlicant Information Please Print Lege Name (business/Organization/Individual): Address: 21 ®rydock Ave Next Step Living City/State/Z] a®st®n, NIA 10 Phone #: (866)667-6729 Are your an employer? Check the appropriate box: Type of project (required): 1. 1 am a employer with 650 4. ® I am a general contractor and 1 6. 0 New construction employees (full and/or part-time).T have hired the sub -contractors listed on the attached sheet. 7. E] Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees 'These sub -contractors have $, ®DemOlfltflOffi working for me in any capacity. employees and have workers' comp. insurance.t 9. ® Building addition [N® workers' comp. insurance 5. ®ale are a corporation and its 10.[] Electrical repairs or additions required.] 3. ®I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself [No workers' coflnp. right of exemption per MGL, c. 152, §1(4), and we have no 12.®1�oof repairs insurance required.] t [No workers' 13.90 Other Insulationemployees. coma. insurance required] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Iiomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afiidarit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or iaot those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer Haat ds providing workers 9 compensatdon insurance for my employees. Below is the policy aid,®b site information. Insurance Company Name: A.I.ivl Mutual Insurance Company policy # or Self -ins. Lic. #:AWC-400-7030025-2014A Expiration Date: 9/30/15 Job Site address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration elate). 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveralge fttion. 7 do hereby certify gander Ilea peens and7ee�ae des perjury Haat the ln,�onn atdon provided above is trace and correct. Si afore: Date: Rhone # Official use only. Do not write in this area, to be Completed by City or town official. City or Towne P'e;rmlt/l..icenase. # issuing Authority (circle one): 1. board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: NIEs=1 OP ID: EL "LL CERTIFICATE OF LIABILITY INSURANCEDATE ® (MMIDDIYYYY) 10/01/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON�y AND CONFE115 NO RIGHT4 UPON T01g CUkT_IFICATP HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY AMEND, EXTEND OR A¢ TIER THE COVERAGE AFFORDED BY THE POLICIES BELOVy. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), 40THORIZED RIgP FSENTATOVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IROP RTANT' Of the 9ertl0cate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. Of SUBROGATION Iq WAI�fRP, �B��$ �� the terms and conditions of the policy, certain policies may require an endorsement. A st6tement on this certificate does not confer rights to ghp certificate holder in lieu of such endorsement(s). PRODUCER MgLaughlarp I�ysuranc0 Agency 829 Lynn $el0s Park wpy Melrose, MA 02176 John E. McLaughlin Jr. ACT NAME: Erin Lyons HONE (AIREd:751-605-2775 �c No):71)1=565=®2 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIL 0 INSURER A: Nautilus Irlasurance CLAIMS -MADE ®09/3012014 E(PP2010193=12 ®9/30/2014 ®9/3®12015 INSURED Next Step I-iving, Inc. 21 Dryd®cls Avenue, 2nd FI®®r Boston, MA 02210 INSURER e:COPP McPCE Insurance Company 34754 INSURERC:A.I.M. Mutual Insurance Co. INsuRERD:AXIS Insurance Company 15610 INSURER E: INSURER F : 1,299,0go �P�YIFif���aY1 uf�uauuo uvru.�..a....�m.—. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY gRIQP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT T( WHICH I» INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. O R POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER MMIDD/YV __ MMIDD LIMITS LTR A X COMMERCIAL GENEPIL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ®09/3012014 E(PP2010193=12 ®9/30/2014 ®9/3®12015 AMAGE TO RENTED PREM SES Ea occurrence $ 19®,®®® MED EXP (Anyone person) $ 0,000 PERSONAL &ADV INJURY $ 1,299,0go GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ $1111010 POLICY ❑ PRO-JECT LOC PRODUCTS - COMP/OP AGG $ �,�W�rQPp $ OTHER: LIMIT $ Ea AUTOMOBILE LIABILITY SINGLE (Ea accident) B 14MMBGKKOM 09130/2014 09/30/2015 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS AU NON OWNED PROPERTYDAMAGE $ Per dent HIRED AUTOS AUTOS acc $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5y000 Q0 AGGREGATE $ ® EXCESS LIAS CLAIMS MADE CEp U733047012014 09/30/2014 09130/2010 DED RETENTION $ $ PER OTH- WORKERS COMPENSATION STATUTE ER E.L. EACH ACCIDENT $C: ®®a0®® AND EMPLOYERS' LIABILITY Y❑ TO BE ISSUED BY CARRIER 09/30/2014 00/30/2015 ANY PROPRIETOR/PARTNER/EXECUTIVE N I A E.L. DISEASE - EA EMPLOYE $ 500,000 OFFICERIMEMBER/EXCLUDED? (Mandatory In Nil) E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 909, Additional Remarks Schedule, may be attached if more space is required) E°OR 1NIFORMT%Oft➢ ONLY INFO -01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN For Information Only I ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD CORPORATION. ADI rights reserved. ACORD 25 (2014/91) T(IP AggRp ���� I�� erre fff AC®R�.