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Home My WebLink AboutBuilding Permit #006-14 - 25 CEDAR LANE 6/29/2013 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received A Date Issued: IMPORTANT:Applicant must complete all items on this page L_ QCATION'_. . .S Print .. f // PROPERTY OWNER, _- �_U iGY 6 �'�`Qt/ _ri4S h R_Y 1g_� Pr,nt 100 Year Old Structure ' yes, no,: MAP NQ'`o 6 __-PARC ELI ZONING DISTRICT: Historic pistrict yes Machine%Shop.Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial R1.Repair, replacement ❑Assessory Bldg ❑ Others: UZe-molition ❑ Other ❑ Septic ❑Well' 0 Floodplain; ❑Wetlands ❑ Watershed District? . ❑Water/S,ewer DESCRIPTION OF WORK TO BE PERF RM D:, ;_ a o d sc2 F 2.k-) Ry,0 rn fq /70 Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTORName:_Ks Ep iu l X_ E Phone:01 72'6 q l- d o I 1 J� nn Address ot- t Gc w r. T7 ✓tAJ•14uud0 , /Y` Supervisor's Construction License: Eicp, Date: Home. Improvement License: Exp: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$12&00 PER S.F. Total Project Cost: $ oZ FEE: Check No.: Receipt No.: �0 5 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Slgnature�of Agent/Owner Signature of contras Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans ❑ r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received ®� Date Issued: IMPORTANT:Applicant must complete all items on this page V P,nnt � 4 / S h i +PRO,PERTY ®V1(NER _,RT �' �6f c � R 1 Pr r t 1 OOj'ear Old St u tU`re yes3 no; MAP�N®- 6 :ZONING DIST RICT �NstoricDst�ict yes no:, iMac ;ShopVillage� yes nod TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial C Repair, replacement ❑Assessory Bldg ❑ Others: E-E)emolition _ _ ❑ Other s` ®`Septi ;❑Well, _ +TJFloodp W tl na ds� 0 Wa et rsh d Dist it ct T r DESCRIPTION OF WORK TO BE PERF RM D:' 41, � �w ��Ai✓ZS �2aM �x�riS��"ter ��2.k Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: �.4. C;ON�TRAIGTae 4d�d�es�s ►u 1: �Ju r §QpervisConstructien� Lense' �� 10 it ,Home1"Im rovement License _ _ - �,��. �..�P�..y,.,� 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: $ FEE: $_ p Check No.: ��q Receipt No.:_ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r � ' k",te'-'PK �R++is�-ass.p�s,e`-.w.�.�ar�Iry�apycy � ;Slgnature�of,Agent/Owner ;.;. �. .�. � ,:ti. T iSignature ofcor trac i -� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans ❑ Location 7 ! No. �/UCO— Date f • - TOWN OF NORTH ANDOVER • 5'��r��►rr: � .: Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# jr 2 6 7 4 Building Inspector _ -- - _ - - , - ' . .;.., . - . ..-. . _ r,,.:..� .. . : :, - , . . - - ,�_',1_',,__.�'� I...... . . -, -I I' . " I . . . I : . � �..I I I � ,,_.,�,,' ...... . . : :- ..: - .: 1. .:. .: .1. . .. .� � .1 . . . . . . -.�I I .. .I.:.'w : : I . - . � . af_l !: .: ....J �.r S l 1. .. _... _. d _ ,r '' , s - .. - X t_ M . - 41- _. ._,_._.- .._.a -_ 1 .�:. - Z - - - T. .. .. - .. .:. .....r. .. r-. ..>,.... .r .- ._._- ,a] r - 1 JP�T - Location ��o—f c.� Date �2 �� s No. f 1 - I . • TOWN OF NORTH ANDOVER _ I ' . I �`" Certificate of Occupancy $ _ : . Building/Frame Permit Fee $ . Foundation Permit Fee $ Other Permit Fee $ I. TOTAL $ 11 •,- - . r h . Check#�5`9 � - '-:�I�:�''�'��,'�..,*',"�_ ;�I-:. /4 �.—1 2 6 5 7 �I / Building Inspector _ o' e -. -y . � : . _.— . .. . . . . . Y:_r. . - �Ilyxl , . .. . .. _. . ..` - _ .' Y 'ti _1- ni v 3 .. r r - -. . _ 4 ._: - ^. . 11 _: h- .. ^_ ' o..: . , .. - ..-_'... ...,. - .. i. % .. y - ... .Sa'.r a._ ._ _�. .. _.. .. -. ... - - 4,> z _ - Y v 1. - .y' ic.-.. - - J 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 Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY I INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature j COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I I Planning Board Decision: Comments Conservation Decision: Comments Water & Severer ConnectioniSignature& Date Driveway Permit DPW Towi., Engineer: Signature: Located 384 Osgood Street FIRE''DEPARTMENT -.Temp Dumpster onsite yes no Located at'124.Main Street Fire Departm`ent-signature/date COMMENTS i 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 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i G' Water & Sewer Connection/Signature& Date Driveway Permit f DPW'J<bwo, Engineer: Signature: Located 384 Os ood Street FIRE''DEPARTMFNT -.Temp Dumpster on site yes no Located at 124)Main Street Fire Department=signatureldate 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.$100-$l000.fine NOTES and DATA— For department use I EJ Notified for pickup - Date Doc.Building Permit Revised 2010 I 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 = I F Doc.Building Permit Revised 2010 J 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 o Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit Li 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) Li 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) o Building Permit Application ❑ Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 Li 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 subm;tted with the building application Doc: Doc.Building permit Revised 2012 7 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 rtment prior'to issuance of BldgPer 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 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. Thea applicant must then en et this recorded at the Registry gof Deed s. One copy and proof of recording must be submitted with the building application Doc: Doc.Building permit Revised 2012 OORTH Town of E ndover O _ No. 14 }� sh ver Mass \/&N •2#,O LANE COC MICMEWICM 1 7.e�AORAreD 1"P�`,��(5 S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ...........19►! G........ ......: l...sY.............s.... .a. ..................... BUILDING INSPECTOR has permission to erect.......................... buildings on ..Z.f...0#1d4ot.... ...N....t............. Foundation Rough to be occupied as Retomh..S? r'/t .:S��MIA'J Chimney provided that the person accepting this perdWshall in every respect conform to the terms of the application *04. Final on file in 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 CONSTRUCTI N TARTS �Rosgh Service ..........,.... . .. ... ... ....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE KEEN CONSMUMON CO. 21 HEWT rr Ate: N. ANDOVER, Mt 01845 978-691-5201 Pashayan, Betsey&David 25 Cedar Ln. N.Andover, MA 01845 978-683-9223 Contract#5057,Appendix A June 25, 2013 Remove sunroom: ® Remove existing 12'x 17'sunroom and dispose of debris Install screen from sliding door on swing patio door • Supply& install %"x 6"cedar siding to match existing • Supply&install 36"stairs from existing.deck to back yard Total Price:$8952.00(eighty nine hundred fifty two dollars) Price does not include cost of permits,.painting,electrical work,railing or repairs to unsafe, insufficient or unusual conditions Payment Schedule:$2000 due upon signing contract $2500 due when building is removed $3000 due when siding is installed $1452 due at completion of contracted work I� J✓..1 /�� f I j s / 1 Cu tomer ,' Robert A. Keen r / r Date Date Pa.g�e,z oft i Board of Building Regulations and Standards• " Constr:uction Supervisor License License: CS 76691 ROBERT A ,KEEN 12 E WATER ST N ANDOVER, MA 01845 Expiration: 8/16/2013 ('ununissiuner Tr#: 3772 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supet-N icor License: CS-058245 KENNETH B IEN 21 HEWITT N ANDOVER W 0 845 6 Expiration Commissioner 03/24/2014 . � C�e�ie�arruncai2ulea�o�C�acrc�uael� Office of Consumer Affairs&.Busifibess Regulation — OME IMPROVEMENT CONTRACTOR egistration: fiJ8,383 Type: xpiration: 8/1E3Z201.4 DBA 71 KEEN CONSTRUCTION-COQ ,~ t� Kenneth Keen 21.Hewitt Ave No.Andover,MA 01845 Undersecretary i i KEEN CONSTRUCTION CO. GP ®�®�� 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978)691-5201 All home improvement contractors and subcontractors engaged in home improvement contracting, unless ll Fax:(978)682-3231 specifically exempt from registration by Provisions of Submitted �J D \ Chapter 142A of the general laws,must be registered with i J:, - 1 / the Commonwealth of Massachusetts. Inquiries about To: JC\ r / ' registration and status should be made to the Director, Home Improvement Contract Registration,One Ashburton ---------.-/-------- r. _�-_____--._.— Place,Room 1301,Boston,MA 02108 (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PHONE DATE 2 , REGISTRATION NO. EIN NO. MA. H.I.C. 108383 26-0462904 j > C/S=Customer Supplied S+I=Supply+Install ❑ See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: I .. — ---- ---- - — --- = i i ---- .--.—____...__......_...____——_._..............._--__._._.._._..,._._._.__.._.._—..__-....................................................._......._....-..............................................................................._.._.............,__.............._............. ....._____—.___..__.......,......__. WORK SCffDVI_E Contra cto ly nota gin the work or order the materials before the third day following the signing of this Agreement,unless specified her C r)travtor will begin the work on or about /, I / Z(date). Barring delay caused by circumstances beyond Contractors control,the work will be completed by f (date).The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY / /r_ The Contractor warrants that the work furnished hereunder shall be tree from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor, is subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose heraby to furnish(material a d lab r-complet in accordance with above specifications,for the sum of:q ,; VI PJ f I�cn� C.� �I � dollars($ c J�Z, U Payment o be mad as follows: _ ) % ($ ) upon signing Contra t;. r � KENNETH B. KEEN/ROBERT A. KEEN ','Ll � Name of Contractor/Designated Registrant % ($--{`upo`n cotln /1–' ,` 21 HEWITT AVE. 4�� Street Address °}° {$t� L r completion of N. ANDOVER,MA 01945 1G l City/Slate I ($ ) shall be made forthwith upon (978)691-5201 (978)682-3231 completion of work under this contract. Ph?-1 / / Fax Notice: No agreement for home improvement contracting work shall require a 0 LSF h P vl n!S e's an >down payment(advance deposit)of more than one-third of the total contract price Name or the total amount of all deposits or payments which the contractor mustmake,in advance,to order and/or otherwise obtain delivery of special order materials and Aulh°zdd ignalure — equipment,whichever amount is greater. Note:This proposal may be withdrawn b y y us if not accepted within days. Acceptance of Proposal-I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signi this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer,may c ncel this transaction at any time prior to midnight of the third business day after the date of this tran action,Cancellation must be done in writing. .0 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature \ J,./�..._�%.�J L /��•�,,� +- ,��r l g k Date - Signature Date IMPORTANT INFORMATION ON BACK The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): k- (� E i.1 1.,J S 2 V CO tQ I � Address: l �'"1 e i 71- -A t1 e City/State/Zip: ►Q r1 Dtl Irl, 8J S Phone#: 01? $' 6 0/! ' a O Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with ( 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 101-1Electricalrepairs or additions 3.F_1 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 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.[�]'Other �£�J � ��,� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance far my employees Below is the policy and job site information. Insurance Company Name: —[`(Z q VIC I�_Iz s Policy#or Self-ins.Lic.#: 60 14 U0 -X 80!7t-,26-A Expiration Date: Job Site Address: L Li 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. Ido hereby cern under the pains ndpenalties ofperjury that the information provided above is true and correct Si nature: Date: Q 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#• U4/16/2013 U8:2t1 t•AA 7b1 842 222113 GILSERT INSURANCE 10001 A a® CERTIFICATE OF LIABILITY INSURANCE 1/1ei2o1 ) 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 j REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 AC Barbara McDonough Gilbert insurance Agency, Inc. PHONE (781)942-'2225 FAX No:(7e1)942-2226 137 Main Street AIL a.Rs, bmcdonough@gilbertinsurance.com INSURERS AFFORDING COVERAGE NAIC 4 Reading Ate, 01867-3922 INSURERA:NORFOLK 6 DEDHAM INSURANCE 23965 INSURED INSURER B:Travelers Ins. Co. 0031 Keen Construction Company INSURERC: 21 Hewitt Avenue INSURER 0: INSURER E North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER;CL1341800232 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 ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBERMMIDO rr LIMITS GENERAL LIABILITY EACH OCCURRENCE I S 1400,000 X COMMERCIAL GENERAL LIABILITY PRrMISES REND 1EE14WuKrqncial g 100,000 A CLAAAS-MADE FT OCCUR -P-010078/000 /13/2013 /13/2014 MED EXP(Any One Person) S 5,0()0 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 nGEN'L AGGREGATE LIMrT APPLIES PER: PRODUCTS-COMP/OP AGd S 2,000,000 X POLICY 7 PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Pe,acckfk S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE 3 HIRED AUTOS AUTOS Para[cdont S UMBRELLA LIAR OCCUR EACH OCCURRENCE j S EXCESS LIARCLAIMS-MADE AGGREGATE b OFD RETENTION S B WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y I N TOR FR. ANY PROPRIETOR,PARTNER,MXECUTIVE E.L.EACH ACCIDENT 5 100,000 OFFICERIMEMBEREXCLUDED7 NIA (Mandatory In NMI 6RL7B-58026-A-12 /3/2012 /3/2013 1 ry E.4.Di$E1SE•EAEMPLOYEE S 100,000 if Yes.describe under DESCRIPTION OF OPERATIONS OelcW E.L DISEASE-POLICY LIMIT $ 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,A04HI MI Remarks SGhedule,If more space Is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 199 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROV1310NS. ! ' AUTHORIZED REPRESENTATIVE M Gilbert, CIVEARBi4R 1 ACORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved. INS025(Za10ono1 The ACORD name and logo are registered marks of ACORD