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HomeMy WebLinkAboutBuilding Permit #462-14 - 25 FERNCROFT CIRCLE 11/26/2013TOWN OF NORTH ANDOVER Z APPLICATION FOR PLAN EXAMINATION I) Permit N0. H Date Received Date Issued: I24"t IMPO T: A plicant must com Tete all items on this age LOCATION 1-�VGf7��7 Print PROPERTY OW6�NERtc'teSC, Print 100 Year Old Structure yes o MAP NO: PARCEL: ZONING DISTRICT: Historic District yes- no Machine Shop Village yes no TYPE OF IMPROVEMENT- PROPOSED USE Residential Non- Residential ew Building ❑ One family ❑ Addition ❑ Two or more family [I Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: Vro1fw> Address: --cis (= Pfnrc (-0 CONTRACTOR\Nke: "At Address: Please Type or Print Clearly) O V �� A-1 I lst-r r Phone: V Phone:�1(.0 1 Lo Supervisor's Construction License: tk. Exp. Date: l0 1 120/ � Home Improvement License: Date: ARCHITECT/ENGINEER �Stca V -Phone: R_7�,, koc( q G ((o Address: QO fox \-7,2 4,(Q Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $J 2 oC.>C> FEE: $ Check No.: KnA Receipt Noz;l� I NOTE: Pers ns contra with unregistered contractors do not have access to the guaranty fund Sigriature of Agent/Owner nature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location No. Date TOWN OF NORTH ANDOVER' Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # Lo 1 �s Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE' OYSEWER-AGEDISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ .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 PLANNING & DEVELOPMENT COMMENTSp�C� 1ha1;ee:r 5 CONSERVATION COMMENTS goo` HEALTH -ti COMMENTS Reviewed DATE REJECTED DATE APPROVED 0 Signature ,V\ 210 0 200 Reviewed on Signature k tr i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: :Comments Wates' & Sewer Con nection/S_ignature & Date Driveway Permit DPW Toiv ! Engineer: Signature: Located 384 Osgood Street FIRE DEPART WENT - Temp' Dumpster on site yes. no Located -at 124 Mair, Street -Fire Departine►it signature/date ' COMMENTS w 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.$10041000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department --The fol awing 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract y o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li 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 apn,,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:?ted with the building application Doc: Doc.Bui!ding Permit Revised 2012 L Q W LL OC to tcu u } a LL Em v N (n G W a Z Z O 1 c LL m K v E U LL O d Z Z d quo 1= LL cc O N Z V w W t" O' N F LL O a t/Z� to d' LL CWC C Q 0 ii v m O Z v N ++ ai o cu Y 0 {/1 _ ° v 0 •� L 0.4) y V �:. E c. L w N _ O Mot � V L �° N J m 0a,o0t4) 0 0 o °z CL c x,00 �• 3 aCD -.0 rn i- _ H o y 0 CO W •0 --' o o .� moi,= N •� w � v.__` V 0. 0 m N 0. m > = c m m 0 W. E L a Mh co m L 0 tm c .E N as t 0 z O Q J 0 V/ co Z W w CL W N W CL L7. 0 w N 0.� v v 0 ,moil L W a W Im .a O co O CL CL m Q J 00 Z d CL C v/ N 19W W ce W U) 11 v 14 Enter construction cost for flee cal - North Andover Fee Calculation Construction Cost $ 32,000.00 m $ - $ 384.00 Plumbing Fee $ 48.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 48.00 Total fees collected $ 580.00 25 Fercroft Circle 462-14 on 12/2/2013 2432 Garage 12x16 3 season room Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 32,000.00 m $ - $ 384.00 Plumbing Fee $ 48.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 48.00 Total fees collected $ 580.00 25 Ferncroft Circle 462-14 on 11/26/13 24x32 garage The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, AM 02111 U40 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name (Business/Organization/Individual):OPaC )PS Lt ` 1 \l (X�C� L - Address: aS City/State/Zip: n() PAgoi/ek nx oft_, Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and'have no employees These sub -contractors have !or' g for me in any capacity. workers' comp. insurance. 5. F1 We are a corporation and its workers' comp. insurance quired.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. Q New construction 7. Q Remodeling 8. ❑ Demolition 9. Q Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.Q Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showingtheir workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 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 page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 o£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. I do here c i under the pains Phone #: that the information provided above is true and correct. late. ) I - a%1s Official use only. Do not write in this area, to be completed by city or town official City or Town: Penult/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 #: Information and 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 person in the service of another under any contract of hire,• express orimplied, 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 apartments 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 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 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 CmmonwoalthofMassachusetts :Department of Zn duAdal .Accxdonts Office oflnlvestigations 600 Washington Street Boston, MA 02111 TQL # 617-72.7 4900 ext 406 or 1.-877-MASSAFB Revised 5-26-05 Fax # 617-727-7749 www-mas%gov1dia Gerald A. Brown Inspector of Buildings Pleasenrint • , • DATE: / 1- aL -� 3 JOB LOCATION: -Number HOMEOWNER. I�^, TON' OF i'MTH ANDOVER OFFICE OF BU'D]N(; DFPARTMENT .:"1.600 Osgood Street Building 20, -Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Fax(978 68 HOMEMNER-LICENSE EXEWTION ) 8-9542 BJIDING PERMIT .APPLICATION aueez tiauress C. C. Map/Lot Name. Home Phone Work Phone PRESENT MAMiNG.ADDRESS lip Code The current exemption for "•homeowners" to allow su;h homeo} r was extended to include owner -occupied dtvelings to t4vo units or less and ue, u engage an i1dividua"for hire wino does not possess a license, provided that the owner acts as supervisor). State, Building (Code Section 108.3.5.1) DEFINITION OFHOMEOWNER Persons) who cjwns aparceI of land on which he/she resides or intends to reside, on which there is, oris intend be, a one or two family structures. A person who constructs more that ed to considered a homeowner. one home in atwo-yearperiod shall not e 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 th me Town of Forth Andover Building Department requirennents, minimum inspection procedures and requirements and that he/she will comply with,said procedures and • ROMEO pp ('� WNI?RS SIGNATURE Ak o l�, n 1 �A A P) 0`l "'J APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688.9541CONSERVATION 686-9530 HEALTH 688-9540 r +; PLANNING 688-9535 r CO CD zr T: 27 Z9 co Vl C-4 C13 mi cv, Z- z Cu- co Zi 0 C,— co co1. V, 2i n' Oj -partr-Lnt of P i a -c hoard of Su, iing RegOalions and S(3;+daId!z -kens: CS -082816 JOHN R LEEMAN-JR 70 PILLON ROAR hof LION MA 02186 06/1612014 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): %)4�3� Address: �o OJI,'oC 132 City/State/Zip: h.) 4,QW Cf kq . 6 S Phone 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. [5Tew construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. F1We are a corporation and its 10. El Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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' 13. ❑ Other comp. insurance required.] *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 a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. 9J}M0'QV5J_ b -7 p (Zcp ('Z Expiration Date: 11111h. Job Site Address; a5 QAC (bF 1 ST; City/State/Zip:l"J, 4 O(N J Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. I do hereby certtfy under the pains and penalties ofperjury that the information provided abovei is true and correct. Signature: Date: 11 1 -[ �o 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 M Information and 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 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 apartments 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 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 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 burn 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 Commonwealth of Mossaclhusetts Department of Industrial Accidents Office ofIuvestigations 600 washingtan Street Boston, MA 02111 Tei, # 617-727-4900 ext 406 ox 1-877-MASSAFB Revised 5-26-05 Fay, # 617-727-7749 www mass.govfdia RV A�,,,/ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 19/28/2012 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 CONTANAME: Linda Murray MTM Insurance Associates PHONE (978) 681-5700 FAX 1320 Osgood Street EMAIL AIC No): (978) 681-5717 ADDRESS: lindam@mtminsure. com North Andover MA 01845 INSURED John Leeman, DBA: NABC Inc. PO Box 132 Mu Co No Andover MA 01845 V .. C . INSURER F COVERAGES CERTIFICATE NUMBER.CL12122805269 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. NSR ADDLSUBR LTR TYPE OF INSURANCE POLICY NUMBERIPO IC YYYY MM DDIYYYY LIMBS GENERAL LIABILITY DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder as listed below. Job location: Lawrence, MA 000 ---- _- - 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 �P MacDonald CPCU, CIC JCJII!!'4 19 ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE S AMA T N PREMISES Ea occu rence) S MED EXP (Any one person) S GEN'L AGGREGATE LIMIT APPLIES PER: PRO. POLICY LOC PERSONAL & ADV INJURY S GENERAL AGGREGATE 5 PRODUCTS - COMPIOP AGG S 5 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULE" AUTOS AUTOS HIRED AUTOS No AUTOS COMBINED SINGLE LIMIT Ea accident S BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE S Per accident 5 UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE S DED RETENTIONS AGGREGATE S A _ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y I N OFFICERIMEMBER EXCLUDED? a (Mandatory in NH) If yes• describe under OESCRIPT)ON OF OPERATIONS below N/A AWC7023267012012 11/11/20 2 11/11/2013 S WC STATU- OTH- FR E L EACH ACCIDENT S L DISEASE - EA EMPLOYE S L. DISEASE -POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder as listed below. Job location: Lawrence, MA 000 ---- _- - 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 �P MacDonald CPCU, CIC JCJII!!'4 19 ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. 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