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Home My WebLink AboutBuilding Permit #Exception - 23 STACY DRIVE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION � ��`f YUet. N c�_ A vi)Icasv WA , -- Print if L PROPERTY OWNER v L c 19 C #,jM l 1 D u LF Unit# a3 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes CR Machine Shop Village yes �o it 100 year-old structure yes CD TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial P-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other SSeptic Well ❑Floodplain ❑Wetlands U. Watershed District Water/_S_ ewer _ I DESCRIPTIO OF WORK TO BE PE ARMED: (L )til VK_� (Identification Please Type or Print Clearly) OWNER: Name: C-✓1d �L)�C" Phone: 9��6��'1 Dyy Address: S�� D)e• . 6 �Oy(ne CONTRACTOR Name / ch;� e IS C,4 Ax_ Phone: q02 24.3 9 Address: Supervisor's Construction License: Exp. Date: Home Improvement License: a 4 eAK Exp. Date: 7)dt d! 0/,2- it /,zit ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERFIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ '5 $�� FEE: $ Check No.: 616 ? Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/ wr _. Signat re of c ntracfor 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 t Zi-Dning 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 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 2011 June/mi 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 a' Building Permit Application Gir--Workers Comp Affidavit a- Photo Copy of H.I.C. And/Or C.S.L. Licenses Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pern Addition or Decks ❑ Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi New Construction (Single and Two Family) a Building Permit Application o 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perm 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 2008mi Date. .v ..� !.!. ..... NORTIy ,tiTOWN OF NORTH ANDOVER p� e` a p� PERMIT FOR MECHANICAL INSTALLATION ri r �,SSACeHUSEt�y ? " G !— V This certifies that 4 — .�� . . . . . . . . . . has permission for mec nical installation . .,. -. . . . . . . . in the buildings of . , -. . . . . . . . . . . . . . . . . . at .r I;J�►'" . . . . . . . ., North Andover, Mass. Fee 9.". . Lic. No.. ! �5-a. .z. . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. IPINK:Treasurer pofums in Efte W"ing lbgetWr Gas Account No- Audit Request No. 4 619M.1; 2 PRELIMEN'"Y AGREEMENT READ THIS AGREEMENT A;NV IMAKE.SURE YOU UNDERSTAND IT BEFORE SIGNING. -MAKE SURE ALL BLANKS ARE COMPLETED AND ALL PROVISIONS THAT DO NOT APPLY ARE CROSSED OUT.THIS AGREE-MEiNT HAS LEGAL FORCE A 'D 811-DS THOSE WHO SYG'N--. .14 This Agreement is made onitXk� between tione"vell of 65 Shawrrnutt Rd. Unit 4,Canton, Massachusetts 02021.(800-247- 4112) Yreafter called"Admini""ative tractor"or"Honeywell-and ti -rc r Jf (Customer) aaressl (-Address cont.) (Telephone) Hereinaftei called"Customer."The Customer is the 1 =nes errant of the above mentioned Premises. DESCRtPTION OF WORK TO BE PFRFOP�M- ED In consideration of the Administrative Contractor's agreement to select a qualified Installation Contractor to perform in a good workmanlike manner all work("the Work`)set forth in the attached Work Order(s)-the Customer agrees to the terms and conditions of this Agreement.No work may be performed without the written consent of Owner.Customer under-stands that calculated energy savings are estimates only and are not guaranteed_ PRIG For the Work describqcUn the Work Order(s)and shoum on the accepted Offer Sheet,attached hereto,the Total Estimated Cost is S The Total Due at the time of Installation from the Customer for- Insulation Measures Hearing System Measures Other S Total Customer Cost for the Work to be performed is S If the Instaffaden Contractor determines that the Work-cannot be provided for the Price quoted above,all parties weft have the right to terminate this Agreement. Price quoted is valid for 90 days. Z-1 Owner of the Premises agrees to pay, prior to the commencement of the Work.and Administrative Contractor accepts, in full satisfaction-for the Work the Price set forth above. Q Tenant agrees to pay, prior to the commencement of the Work, and'Administrative Contractor accepts, in full satisfaction for the Work the Price set forth above. RIGHT TO CANCEL THE CUSTOMER -MAY CANCEL TIUS AGPXErdEk-f IF IT HAS BEEN SYGNED AT A PT-ACE OTHER TjE4_NT AN .4DDRESS OF THE ADNEUVIIS717RAUVE CONTRACTOR, WMCH MAY BE M NLAIJN OFFICE OR ORAUNCR MEREOF PROVIDED THAT TIM ULSTONIER NOTIFIES THE AVIWINI-Ir-MATIVE CONTRACTOR IN WRITING AT ITS MAIN OFFICE OR BRANCH BY ORDINARY 10-41L MSTED. BY TELEGRAM SEIN-T OR BY DELIVERY,NO LATER THAN MIDNIGHT OF THE THMR BUSINIESS DAY FOLLOWING THE.SIGNUqG OF TMS AGREEMENT_SEE NOTICE OF C-%NCEL-,,ATIONVIN DUPLIC-4714AHEXED FOR AN VCPLA'�NATJON, OF THIS RIGHT_ 44 PMPORTANT.ADDITIONAL TERMS A-N.D CONDMONS ARE ON THE REVERSE SIDE By signing below you,the C-4itorner,represents that(I)You read and understood both sides of this Agreement before you s-z gmeedw agree byto be bound the terms and conditions set forth on the front and back of this Agreement;(3)The��dListratit e Contractor(directl-y or indirectly)has made no representations or warranties regarding-the Wckk,other than finose contained in this Agreement,(4)That at the time you signed the Agreement, it has been signed"' Administ-rative Contractor or its admirtrative resentative,there were no blan-ks that had re not been compfii,gd'and that the Wst bested-eras prover)y4[escv6- ei love. Hdneyvvell Signature Date Owner tgFtature /f)ate Tenant Signature Date Honeywell-White Installation Contractor-Yellow y Customer-Pink 1/09 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www mass gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organizatiorAndividual): p CA f2 E/I K Sefey 1)U C, Address- O.t ka . QLD V City/State/Zip: Phone#: FEII employer?Check the appropriate box: _ em to er with 4. Type of project(required): P Y ❑ Iam a general contractor and Iyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1. sole proprietor or partner- listed on the attached sheaet.t �• ❑Remodelingd have no employees These sub-contractors have 8. ❑Demolition g formein any capacity. workers'comp.insurance.rkers' comp.insurance 5. �'We are a corporation and its 9 ❑Building addition d.] officers have exercised their I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no insurance required.]t employees. 12❑Roof repairs [No workers' 13. Other COMP,insurance required.) �►W' [ *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 anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_±VLAy e f=i,i S (� �(Q� O Q r-. 1 Policy#or Self-ins.Lic.#: j� Expiration Date:_ Job Site Address: City/State/Zip: 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. fP ! �' Ido Izereb certify u r the pains and penalties o er'u that the information provided above is true and correct. Si nature: Date: Phone#: 14 a?` ?6 , / FOther only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one): I. Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: Information and Instructions coons 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 apartinents 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 confirmation 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 permit/license number which will be used as a referencd number. In addition,an applicant that must submit multiple pennit/liceuse 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 permits or licenses. A new affidavit must be filled out each year. Where 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 bum 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 Coro.-nonwea,'.th ofPViassacnttsetfs Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA,02111 Tel.#617-727-4900 ext 406 ox 1-877-MASS,AFE Revised 5-26-05 Fax#617.727-7749 www.mass.g-ov/dia 1,2 Office of Consumer A fairS and Business Regulation -- _- 10 Park Plaza- Suite 5170 =tea =- Boston,Massachusetts (P-1 16 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7MO12 Tri 298090 POLAR BEAR INSULATION GO. _ -- -- - Vincent LeBlanc — P.O_ BOX 958 _ ANDOVER, MA 01810 —" U idate Address and return card.Marl:reason for change- _P —. Address - Renewal 7 EmPlopsaent Lost Card License or relation-valid for individul use on[y _- Office �> � R _ >HOME IMpR{VEmENT CONTRACTOR before the tion date If found reusrn to: '= =Rsg ttabort: 1Q2725 Type: office of Consumer Affairs and Business Regulation , - iratiarr 71212012 D8A 10 Par!:PEaaa-Suite 51?© - - _ Boston,N-LA.P-116 FIMBEAR INSUi AT ION Co- : 1 Vincent LeBlanc j. 51 S4-CANAL ST.95A LAWRENCE,MA 01841 indersceretarr Not valid without signature _ 3 i F)a!- i) 3 c1. na i i1,2tt 73a F.i#i at Intl t tJ Cs Si_ 99352 Pest tciea tG. WS g ;4 VINCENT LEBLANC 24 LANDING DRIVE METHUEN,MA 01844 - _ OP m:SS �f£' CERTIFICATE OF LIABILITY I SURANCEmoniff 03r�,o'-m` ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TAUS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ANMD, EXTEND OR ALTER THE (AVERAGE 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 pormy(ies)mid be endorserL if SUBROGATION IS WAIVED,subject to the terms and conditions of the Policy,certain Policies may require an endorsement A stateinent on this certificate does not confer rights to the certificate holder in fief,of such endorsement(s). PRODUCER 978-688-7080 Cs Durso&Jankowski Ins Agcy LLC 978-688-7�1 PxoNE 498 Massachusetts Avenue North Andover,MA 01845 ADS Charles S.Randone PDDDUM CUSTOrrtaz Ia::POLAR-4 AFFORO(NG COVBikW f NAIC O INSURED Polar Bear in WaVon Co.Inc. OWM A:Penn America POBoxM i,MA 048'18 wwRERa_Satety Insurance Co_ 3364E wWRER C: INSURER D- INSURER E: INWRER F- COVERAGES CERTIFICATE NUMBS-- 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. NOTOA THSTA.NDING 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. RM; TYPE nLsuRAnu� PDLiCI(NUa� POLrCY Eym FF POLICY EXP tmmS GENERAL LIAIM Y j EACH OCCURRENCE S 1,000, A X COWAEeCIAL GE NERAL LIABILITY PAC68MO84 I 031W11 03124)12 PRENSPs gam,) s S,00 01 Cwnis-WDE rX-1 OCCUR MED orn(any am PFJ S sv PERSONAL&ADV INJURY a 1,000,000 GEtNE RALAGGREGATE S 2,000, PRODUCTS-COMPIOPAGG S 1,000, Ow GEWL AGGREGATE UMrr APFUEES PER I{ POLICY; PRO-JECT i FLOC I { iS AUTOMOBILELIABiLriY } SINGLELMIT S 1,008,0 B ANY AUTO 02$ 011341'14 11 01104M2 BODILyKKRY(PlrPer=j is f I r ALL AWNED AUTOS } BODLY I43URY(Per a=dm*4 S X SCHEDULED AUTOS PROPERTYDAMAGE X HREDAUTOS IS X NON-0uwvED AUTOS Is ` is UMBRELLA LIAR I X OCCt312 i EACH OCCURRENCE Is 11000100 UAS CLa6N5 t,iADE ( AGGREGATE s 03124341 03(24!12 �q t AC686� i i s DMUCrIBLE RETEtNr1ON $ s WORiamcowrENsATaoN X WCsr ANDEIRWYERSUABILFY YIN , I aNY PROPMETOR/PAR; Lr-iVE , =AC..nccuisvT !s y �Y OR4CERR R EXCLUDED? N!A i (yypp,ss�y R,Niel EL OCAS`-EA EMP; S DESCRPTI ewider OPERATIONS heliw I I EL OLSS.ASE-POLICY LWT 5 DESCRIPiiON OF OPERA"rioKSrrDGA7rONSlYBIICIFS{Afficl�AC07�107,AC Renals SGseQntc,W=ore spa=is requhvM G.LC%C.,NatioI Grid Corporate Services LLC DBA National Grid,Action Inc,Boston Gas Company,Colonial Gas C ,Essex Gas Comp�y 8 Bay State performed ad�f for behalf by theOYegeneral 3"a�IGty with respects to work CERTIFICATE HOLDER CANCELLATION GLCAC44 SHOULD ANY OF"THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE G.LCAC_ THE EXPIRATION DATE THEREOF, NOTICE WILL Bc DELIVERED IN 8:Bay State Gas Co ACCORDANCE WITH THE POLICY PROVISIONS_ 350 Essex Stmt Lawrence,MA 018" AUTHORIZED REPRESENTAMVE 1 ©4988-2009 ACORD CORPORATION_ All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ig#TtFax N1-1 1/19/2011 10:14:22 AM PAGE 21002 Fax Server ACARD. CERTIFICATE ©F UABIL1TY INSURANCE DATe(w&wmm 01/1912011 INSCERTIRCA*TEMISSUED ASA MAIM W NFORKA'iM OMY ANF!COWFERS MO RiC3MW UPOK M CERTMAiE TM CRATE DOES NOT AF ARYATLVELY an NEQATtiIELY AMMO,EXToM Oi:3 ALTER7HE COVERAGE AFFORDED By 11-M POLICIES BUOW. TM CERMFMA750F eISUtANCE DOES Nar co 1STT uM A CONRAC SETWEE d3HE iSSONG Rte.AU'THORMED REPRe;$OAMVE OR PRD .ANDM E AT HOLDER ftnm of ',:asaas f dw�pdU% nt cm miPeSe�s=j r*q�s�d� AstotmawSmOts ea55enc*confors m IbD ll0ldtf iD�Ytrai SDCIt 6SSds). PRODUCER CONTACT i FAX P� DURSO$kkNmV1 E wS {A1C,No.Eg# FAX {AfC.Ho): 198 MASSACEMEME AVENUE E4WL ADDRESS: PRODUCER NORTH ANDOVER,MV1A. 01845 CUSTOUMtD O 22PM INSUREPA%AFFORDING COVERAOE 11AfC# R49WRED DMURERA: TR&VEdERSIISDENrnTYCOMPANY INSURER 8: POLAR BEAR IIRSU3LATTON CO INC RMURER C: 0=RER D: F.O.Rox 958 INSURER£: ANDOVEK MA 01810 R F: COVERAGES GERICATENJJNn3 Ei: REYI5it3NI BEEC 3iF TH6SSTOCHtSSFYTSikT7FlE➢ of S.SSTEDe�RAVEOMNSSUEDTOTHE1t25[1R�NASAt30YEFoitTHEPOLLGYPEF80nn�CATE�. NCr44iT}3�.Af�IDAKiANY RES .1TMWOR Corto M OFAKY COMPAMORCIMMD IEI�TN4L7'i RPSPE�rTO WtBCFlTFQ9 +EWAY 3EI59CE"D ORl6Att P9tTA1N.7HE1t�SiTRA�A�r DRD�8Y7NE POtIC(ES HE�GS138.IE�70lLL7t�TEn^16. AND fX�D1TtONS OFStJCki POtIdPS. LjlMStWM UAYKAYE OEM JW=W BY PAID C1 4M am AVOLSLISR POLICY EFF DATE POUC f EXP DATE iltdtS TYPEOf PDL.iCYML"iBLSt (ii�mY) (d31DD1YYrYI LTR ASR wvo EACH O $ GENERAL I.LABtl.i11f COUBNERCIALGENERAL, DAMAGE TOPENTE33 $ CLAWSMASTS OCCUFL PRE (Eacam) MED EXP(Arty Gm S>OSWO $ PERSONAL SS ADV 8MURY S GraMAGGREGATELWTAPPLIESF� GENERA!AGGREGATE S POLICY PRDJwr LOC PRODUCTS CQI�/DP AGG 3 fAOSDLELIA811TTY COMWEDSWGLE AUTO $ At�t SME LMI T{Ea��) ALLOWNSDAUTOS (per W $ SCHEDULEAUTOS BO ) Y $ M�AUTOS (pe"Gc Jeno NON-OWNEDAiffOS PROP DAMAGE 5 (Pare UL48RELLALEAS OCCUR EACH OCCURRENCE $ EXCESS LIRE CLAVAS-MADE AGGREGATE DPDUCTISLE 3 RETiR1nDx S yitCSTn3UTORvueFls aFr�t WORKER'S oMPEN"MON AND EIdPLOYER'S UASIUTY Y/N E)6�39tEt 098 i2 OVD 2011 411012012 E L EACH ACCtD8a S Af.1f PRCPErZ�GH/PARTs El f'iIr Y E.L DISEASE-EA EMPLOYEE$ 1.000,000 o rF e�Q11DID7 E.L DISEASE-POLICY LMNT 3 1.000.000 SUt M0 n yes.aeustm atesr Ct£SCxBFROxE7F OPEWQ701'LStwter DESCR[P fWM.OF SLC E3CtAL rTEYB TMSR ANY PRSIRCSCA'IELSSUWTO1MECMMMCA7P-BO1DStA WOEXERSCORSSAGE CERTMATME tEC1WER CANCELLAT ON G L C A C&$AVS TATE GAS co SHOULD ANY OFTHE ABOVE DESCRIBED POLLEXES BE CANt BEFORE Tie EXPIRATiEIVI I}ATE Tmemw, ti mL as DariEFtED VAS AtxORdAHCE 350ESSEKSTRrEEi T SA M THE POLICY PROVIMONS. AUTHDRE2ED REPRESENTATIVE LAWRENCK A" 01840 Charles J Clark 1988.2009 ACORD CORPORATM. AN right resn►ed- ACDRD25(2949109)