HomeMy WebLinkAboutBuilding Permit #775-15 - 306 HILLSIDE ROAD 4/10/2015�II015 q-�Q,c�aeQ �o LF
Permit No#:
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BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
16
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UP
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7.O A�RArED I.Pj�7
IMPORTANT: Applicant must complete all items on this page
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LOCATION
PROPERTY OWNER �r�✓ G�
Print 100 Year Structure yes n.o
MAP 3 PARCEL: ��/U ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
fiPTwo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑Wetlands
❑ Watershed District
❑ Water/Sewer
OWNER: Name
Orlrlrcee• I->' y
DESCRIPTION OF VVU
1 U bt't Ft:K1-UKIVItU"
Aentificatio Please Type or Print Clearly
Au A/�A 4 Phone: !0l75�
x/Cit pq /'InI S e .-f Ave
Contractor Name: T 1041P ��2e,.c,. Phone: b(7 `76 6 D V/:2--
Email:
l2-Email
Address:
Supervisor's Construction License:.6Exp. Date:
w y
Home Improvement License: 170 _ Exp. Date
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $�12.y000 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �(� % i4 • 4), FEE: $ y d -O
Check No.: 9 4 a 47 < 0 Receipt No.: % '�r(p 21
NOTE: Persons contracting with unregistered contractors do not have access to the muarantv_fund
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 prior to issuance of Bldg Permit
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/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)
❑ 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. 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
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
NU i Ls and UA I A - (f or department use
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
Reviewed On Signature.
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
4
I
Planning Board Decision: Comments
t
Conservation Decision:
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Qump-ster on.1 site yes = no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Location`�'—TNo. :2 7 L ' /.5 Date
Check # 1031 ('0 1
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee$ o
Foundation Permit Fee $
Other Permit Fee $�
TOTAL $
f. l_ Building Inspector
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Renewal MA Home Improvement Contractor
Andersen. License #170810 (Expires 12/23/2015)
Renewal by Andersen Corporation
wrnoow REPLACEMENTmAndc"cn Ci.mryrry Federal Tax ID #41-1918413
30 Forbes Rd. Northborough, MA 01532
(508) 351-2200 Fax (508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s) Name Date:
SUSAN PAPALIA -
MARCH 20, 2015
Buyer(s) Street Address City StateZi Code
24 RICHARDSON AVE.
NORTH ANDOVER
MA
01845
Email Address Home Telephone Number Work/Cell Telephone Number
SUE.PAPALIALZRAVEIS.COM
978-685-9191
508-451-3575
Buyer(s) hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation ("Contractor"), in accordance with
the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively, this "Agreement").
Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Est, Start Date
Method of Payment
Total Job Amount $ 16,998
Amount Financed $ 0
Check/Cash
Deposit Received (33%) $ 5,666.00
Deposit at signing $ 0.00
8-10 weeks
Balance Start of Job (33%) $ 5,666.00
Check #
Balance on Substantial
At Substantial
Est. Install Time
Credit Card
Completion of Job (33%) $ 5,666.00
Completion $ 0.00
1-2 days
If credh card is selected, please
No final payment shall be demanded until all parties are satisfied
see Credft Card Pa mertt form
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbal understandings
changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed, written consent
of both Buyers) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has
received a completed, signed and dated copy of this Agreement, Including the two attached Notices of Cancellation, on the date first written above and 2) was
orally Informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation Bu s) Buyer(s)
UL27�PI 4�.1
By: ✓aY171�
Signature of Consultant Signa e — _ Signature
X JOHN BEAVER SUSAN PAPALIA
Printed Name of Consultant Printed Name Printed Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT.
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — r — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
NOTICE OF CANCELLATION NOTICE OF CANCELLATION 1
Date of Transaction 3/20/15 . You may cancel this I Date of Transaction 3/20/15 You may cancel this
transaction, without any penalty or obligation, within three business days from the transaction, without any penalty or obligation, within three business days from the
above date. If you cancel, any property traded in any payments made by you under 1 above date. If you cancel, any property traded in, any payments made by you under
the Contract of Sale, and any negotiable instrument executed by you will be I the Contract of Sale, and any negotiable instrument executed by you will be
returned within 10 days following receipt by the Contractor ("Seller") of your 1 returned within 10 days following receipt by the Contractor ("Seller") of your
cancellation notice, and any security interest arising out of the transaction will be I cancellation notice, and any security interest arising out of the transaction will be
canceled. If you cancel, you must make available to the Seller at your residence, in I canceled. If you cancel, you must make available to the Seller at your residence, in
substantially as good condition as when received, any goods delivered to you under I substantially as good condition as when received, any goods delivered to you under
this Contract or Sale; or you may, if you wish, comply with the instructions of the 1 this Contract or Sale; or you may, if you wish, comply with the instructions of the
Seller regarding the return shipment of the goods at the Seller's expense and risk. I Seller regarding the return shipment of the goods at the Seller's "pen" and risk.
If you do make the goods available to the Seller and the Seller does not pick them up I If you do make the goods available to the Seller and the Seller does not pick them up
within 20 days of the date of your Notice of Cancellation, you may retain or dispose 1 within 20 days of the date of your Notice of Cancellation, you may retain or dispose
of the goods without any further obligation. If you fail to make the goods available of the goods without any further obligation. If you fail to make the goods available
to the Seller, or if you agree to return the goods to the Seller and fail to do so, then 1 to the Seller, or if you agree to return the goods to the Seller and fail to do so, then
you remain liable for performance of all obligations under the Contract. To cancel 1 you remain liable for performance of all obligations under the Contract. To cancel
this transaction, mail or deliver a signed and dated copy of this cancellation notice 1 this transaction, mail or deliver a signed and dated copy of this cancellation notice
or any other written notice, or send a telegram to Contracton Renewal by Andersen, I or any other written notice, or send a telegram to Contractor Renewal by Andersen,
30 Forbes Rd. Northborough, MA 01532. 1 30 Forbes Rd. Northborough, MA 01532.
1 HEREBY CANCEL THIS TRANSACTION. 1 I HEREBY CANCEL TRIS TRANSACTION.
I
Buyers Signature Prim Name Data i Buyer's Signature Prim Name Data
Renewal Renewal by Andersen Corporation MA Home Improvement Contractor
�vAndersen. ` 30 Forbes rd Northborough, MA 01532 License #170810 (Expires 12/23/2015)
wraoow (508) 351-2200 Fax: (508)-986-7072 Federal ID #41-1918413
Window Specification Sheet
Buyer(s) Name Date of Agreement
SUSAN PAPALIA
FR1, MAR 20, 2015
The buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed below, in accordance with the prices and terms described
on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which
the Specification Sheet is part.
WINDOW & DOOR DETAILS
App. App. Mpx FxteriorAnterior Color Hardware Hardware L—E4/ Grille Grille Glass
M width hN ht U.I. Window/Door a Detail Casings Ext -IM Color le Screens Smartaun Grilles sash 1/3 Sash 2 Ufts Options
101 31 43 74 DB rail ual Insert slo sill ------- H/W White Standard HAL martsu GBG 3/2 ----- No
ERoom
102 31 55 86 DB s rail ual Insert slo ed sill ------- White Standard HAL martsu GBG 3/2 ----- No
103 31 55 86 DB rail ual Insert slo ed sill ------- H/W White Standard HAL martSu GBG 3/2 ---- No
104 31 55 86 DS s rail equal Insert slo ed sill ------- H/W White Standard HAL martSu GBG 3/2 ----- No
Bed 2 105 31 55 86 DB s rail equal Insert sloped sill ------- HMI- White Standard HAL martSu GBG 3/2 ----- No
Bed 2 106 31 55 86 DS s rail equal Insert sloped sill ------- White Standard HAL martsu GBG 3/2 ----- No
Bath 1 201 31 43 74 DB rail equal Insert sloped sill ------- White Standard HAL martSu GBG 3/2 ----- No
martsu GBG 3/2 ----- No
Bed 1 202 31 55 86 DB rail equal Insert sloped sill ------- H/w White StandardJHAL
Bed 1 203 31 55 86 DB rail equal Insert sloped sill ------- White StandardmartSu GBG 3/2 ----- No
Bed 2 204 31 55 86 DB s rail equal Insert sloped sill ------- White StandardmartSu GBG 3/2 ----- No
Bed 2 205 31 55 86 DB s rall equal Insert slo ed sill ------- H/W White StandardmartSu GBG 3/2 ----- No
Bed 2 206 31 55 86 DB s rail a ual Insert slo ed sill ------- HWY White StandardmartSu GBG 3/2 ----- No
Total 12 BAY, BOW & BUILD OUT DETAILS
Style Detail / wIdthh// Approx. Number Frame Window End Center LowE / Roof/ Hardware
Room Count Style Flankera h.l.ht caeln a An le Utes Interior ExVim Color Grilles sashes sashes Screens Smartsun Soffit Color
SPECIALTY WINDOW DETAILS
Full/ Approx. LmE/ Specialty RAY/ B OW ADDITIONAL WORK NOTES
Room Count Style Insert U.I. SmartSun Gilles GrilleStyle_ ExtAnt Color Customer is aware that with ba /bow windows under 72 inches
there will be significant glan lose.
ADDITIONAL WORK DETAILS:
I No Contractor will wrap exterior casings with coil stock color of
2 W
Owner is aware that Contractor does not do any painting/staining or removal/installation of alarm system or window treatments/hardwere. It is the responsibility of
the homeowner to have the alarm system and window treatments/hardware removed prior to installation. We make no guarantee as to whether alarms or window
treatments/hardware will fit after replacement Customer is also aware in some cases there will be glass loss. If there is, the amount will be dependent on the type
of existing windows, type of installation and window style. ft make no guarantee as to the amount of glass loss. Customer is aware and understands any and all
unseen rot is not included in this contract. Should any rot be found there will be an additional charge for time and materials unless so stated in this contract.
3 yes Contractor will insulate, caulk and seal windows with 3 -point system to prevent water and air infiltration. Removal and disposal of all job related debris,
windows, doors, storm windows and vacuum nightly included. Upon completion of the job and payment in full, a limited warranty shall be Issued.
4 Yes Building Permlt--Contractor will secure any and all necessary permits. The fee for the permit(s) is included in the total contract price.
5 Yes All discounts have been applied to this agreement.
s Yes No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/ finance form(s).
It is agreed and understood by and between the parties that this Specification Sheet, along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT; constitutes the entire
understanding between the parties, and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in
any way unless such changes are in writing and signed by both the Buyer(s) and Contractor. Buyer(s) hereby acknowledge that Buyer(s) has mad this Specification Sheet.
Renewal by Andersen Corporation Buyer(s) Buyers)
Be"er tin—P'- r • t,// . - 4,
Signature of Consultant Signatuld Signature
JOHN BEAVER SUSAN PAPALIA
Print Name of Consultant Print Name Print Name
comp. insurance required.]
*Any applicant that checks box 41 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: OLD REPUBLIC INS. CO.
Policy # or Self -ins. Lic. #: MWC 30293800
Expiration Date: 10/01/15
Job Site Address: cW /f /c,,f4 'WA J,0r,- Al City/State/Zip.o Are
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.
I do hereby certif ur r�thepains and penalties ofperjury that the information provided above is true and correct
Phone #: (SOT -351-220
/o _-, /-1—'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
The Commonwealth ofMassachusetts
Department of Industrial Accidents
O,fffue of Investigations
'
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass gov/dia
Workers' Compensation Insurance
Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legiblv
Name (Business/Organization/Individual): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
City/State/Zip: NORTHBORO, MA 01532 Phone #: 508-351-2200
Are you an employer? Check the appropriate bog:
1. ® I am a employer with 30 4. ❑ I am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
have hired the sub -contractors
6. ❑ New construction
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
7. 0 Remodeling
ship and have no employees
These sub -contractors have
g, ❑ Demolition
working for me in any capacity.
employees and have workers'
9 EJ Building addition
[No workers' comp. insurance
required.]
comp. insurance.:
P•
5. ❑ We are a corporation and its
10•❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work
officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13.0
employees. [No workers'
Other
comp. insurance required.]
*Any applicant that checks box 41 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: OLD REPUBLIC INS. CO.
Policy # or Self -ins. Lic. #: MWC 30293800
Expiration Date: 10/01/15
Job Site Address: cW /f /c,,f4 'WA J,0r,- Al City/State/Zip.o Are
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.
I do hereby certif ur r�thepains and penalties ofperjury that the information provided above is true and correct
Phone #: (SOT -351-220
/o _-, /-1—'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
0
n
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen-isor
License: CS -090125
JAUM L MORIN
86 GARDENER ST
LYNN MA 0190.f( i t..z t
It,
/iw✓ ��^J"' Expiration
Commissioner 10/0612016 1
Bice of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
Registration: 17060
tion.' Type:
irar
1212312015 Supplement �.
RENEWAL BY ANDERSON CARPORATION
R
JAIME MORIN
104 OTIS STREET
NORTHSOROUGH, MA 01532
Undersecretary
ANDECOR-01 YADAW
CER'TIFICA'TE OF LIABILITY INSURANCE BATEON ° -M
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONI4
FERS 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( s) must be endorsed. N SUBROGATION IS WA—M—W
the terms and conditions of the policy, certain Policies may require an endommnent. A statement on this certlRcate does not cooter � 1 � to the
cwditats folder In lieu of such endorsemengs), Ng
PRODER NAIa cr Cerlifi Ilis.rom
11181k of Minnesota Inc.
:/a 28 Century OR mONE (877) 945-7378
kO. Box 30511" No - (BBB) 457-2378
tashvfile. 71137230-5191
Nfflk :
Renewal by Andersen Corporation
30 Forbes Road
Northborough, MA 01532
F
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED nuraesER.
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERGA OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT�� FOR THE POLICY PERIOD
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJER T OTALL TH IEI�S
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM&
TYPE OF INSURANCE
X�=MS4
GENERA.LIABulTY POLIOYNUAEERi1,000.6
AOE X OCCUR 02940 IOXIno14 1010112015 tee., ,------ - ----.
L AGGREGATE LIMITAPPLIES PER:
POLICY ❑ ❑ LOC
MXOTHER:
rutbOUALaADVINJURY $
GENERAL AGGREGATE :
TS
PRODUC-COMMP AGG $
AUTON013 LE LIABILITY
i
-
A X N& AUTO
UNIT
02575 101012014 10101/2016 BODILY INJURY
ALL OIMED sCFmim
(wr pawon) _
AUT06 NAOI OYmm
BODILY iNA1RY (Peraaotdeipl S
HIREDAUTO9 AUM
i
Ui mm" LJAB OCCUR
i
EXOESS LMB CWMSMADE
EACH OCCUmNCE Is
ttin err�►nvu.a
AGGREGATE S
A 1=CEWM=&=rWMJE If N 1IN /A 1 02'3800 110101120141101012015
DESCRIPTION OF OPERATIONS I L OCATIDNS I VENICLFs IAcom Tor, Additmr R.m.Na Sd"d., my be aped" rI
imae apes Is 1e
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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