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HomeMy WebLinkAboutBuilding Permit #679-15 - 338 SALEM STREET 3/2/2015tSUILUINU FLKMI I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION LL Permit No#: J Date Received Date Issued: 12 'IMPORTANT: Applicant must complete all items on this page LO -CATION Print.,- PROPERTY OWNER_ -P, hht_' 100 Year Structure. - —0 'A. MAP P q- .01,STR H' ittoric, ct yes % I po, I ZONING I Machina k nn I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 0 Addition El Two or more family 0 Industrial 11 Alteration No. of units: 11 Commercial El Repair, replacement D Assessory Bldg El Others: 0 Demolition 11 Other El Septic==, DWell- 111fro Floodplain j�0 Wetlands vViJitersh, ti�tflb' ...... 9 wate(/..'S� 61 OWNER: Nam DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly ga &41�t5ex-') — )ne: (L-111 dveA2- Address:L o Addrewz S.0 ervls.or's Construction License - JH6.M,'Ipy�emq" nt!Libense-.. x, Pate rt ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDINGPERMIT., $120OPER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00PER S.F. Total Project Cost: $/038-7 FEE: $ Check No.:(do(&-z— Receipt No.: NOTE: Persons contracting with ug is contractors do not have access to th"-u-q-�qkjy 4 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plai 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 Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature_ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located' 384 Osgood Street FIREDEPARTMENT Temp Durnpsterron site yes no i kocated,1at�124 Main Street r r, e: Department-signature/date -- - �_ iF,r,)KAKAP:AITC 7 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pen -nit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ 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) o, 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 o 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 Location No. Date Check #_�/ 6�� �- 28518 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector $ I n - 0 W cn �. Z ,�... E * ® 0.0 c C r �s� EQ m •� Z V =t. 0 Z H io to v_ o m m 0 � 0 v L O CL Co Eco o AW La Z� = M 1 m V W� O,d = yrz 4 > = o._ > a tq 4� v :0 LO � N V Q c i< Z •�, Cc =a O LJJ 0 .,� Q Ecz V ��Q CL = p ami Cl) O - N W O'> c W J 00 Z O CL `a o rn cv� V v) occ= to ` Q i 0 R `0 •p 2 CL 5 N ~ H d V m LLJ - 0 •0 ++ 0 O _� LU 1F7,- .N � � N � O � •Q 0 A ;5V V o W • L: N -0 d + + Q O U) 0- ab •o = c OJ N � F- .0 0- o u > 0 0O O V rJ Z CL F- _. H N z-- N V - LLZ Q 0 Z Z U W c. -- cicm 0 J CCLU F N .. G m E m - W J .. .. 41 = d W N v _ Z Y E .i- txo cu .. O LL Q 7 t m E N O (n LLL W U LL d' LL OC (n LL LL in !% N - 0 W cn �. Z ,�... E * ® 0.0 c C r �s� EQ m •� Z V =t. 0 Z H io to v_ o m m 0 � 0 v L O CL Co Eco o AW La Z� = M 1 m V W� O,d = yrz 4 > = o._ > a tq 4� v :0 LO � N V Q c i< Z •�, Cc =a O LJJ 0 .,� Q Ecz V ��Q CL = p ami Cl) O - N W O'> c W J 00 Z O CL `a o rn cv� V v) occ= to ` Q i 0 R `0 •p 2 CL 5 N ~ H d V m LLJ - 0 •0 ++ 0 O _� LU 1F7,- .N � � N � O � •Q 0 A ;5V V o W • L: N -0 d + + Q O U) 0- ab •o = c OJ N � F- .0 0- o u > ,l no le energy 50LutionS This agreement is made by and among Larry Johansen 338 Salem St North Andover, MA 01845 Site ID: 406327 1. )ESCRIPTION OF WORK TO BE PERFORMED Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866)867-8729 06 -Feb -15 NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the work in detail (the 'Work") which are incorporated herein by reference: Description Quantity Investment Air Sealing Recommendations $900.00 Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 $75.00 Hr $900.00 Work Location: Attic Flat Whole house fan box: Thermal Barrier Polyiso 2" (Attic) 1 $209.21 Each $209.21 Hatch: Thermal Barrier Polyiso 2 inch (Attic) 1 $60.00 Each $60.00 Vent bath fan to soffit exhaust 1 $118.75 Each $118.75 IMUZODUM 100% Airsealing Incentive up to Program Max $600.00 75 % Weatherization Incentive up to Program Max $290.97 Air Sealing Remainder as 75 % Weatherization Incentive up to Program Max $225.00 -----.__._..--- Estimated Annual Energy Savings from the Above Improvements $121.00 2. 'AYMENT: CUSTOMER agrees to pay NSL for the work as follows: Payment #1: $100.00 -Credit Card or E -check deposit is due at the time the Work is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed 113 of the total retail costs. (Note: Mastercard, Visa, and Discover accepted) Additional Payments and Final Invoice: $71.99 -Additional payments for the Work shall be due upon completion of the Work. If the final invoice is being paid by check, credit card information will still be required at the time of scheduling. Notify the customer service representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. Joh Feb 23, 2015 Customer Signature [/ L.o4�fTreY /! QLL�y Date Feb 9, 2015 6 Feb 2015 n z H.,iiv(r NSL Signature Date Courtney Hally Andrew Carpentier Name of NSL Representative A640417 The Terms of this Agreement are contained on both sides of this page Next Step Living o 21 Drydock Avenue - 2nd Floor a Boston, MA 02210 o (866) 867-8729 - inquiry@nextsteplivinginc.com o www.nextstepllving.com TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.617.973.8700. 5. PERMITS NSL will be responsible for obtaining any necessary permits as the Customer's agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law, 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to one year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non -code construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not properly protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terms other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. 12.1 Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customers sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. 12.2 Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. 12.3 Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by fax, or by e-mail sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Planview Diagram Customer� J o kunsen Advisor Name: r'i6 cnt,er- Address 3.3 Sa Advisor Phone #: Town AJU, 6A Loer Any limitations to access by truck? Site ID Alo632--7 W NOTEs Any work scoped outside of Best Practices? Approved by: V w 1+ �� veri� ►� F s a;+ --1 -- 13NL5 U 2r. wH�o imer A �J(A'd Business Regulation Suite 5170 10 Park Plaza x ,a oston, M assachusetts 0211116 Home Improve ent Contractor Registration Registration: 162111 Type: Supplement Card Expiration: 1/14/2017 NE®tT STEL' LMNG M. ROGER OUELLETTE 21 ®RYDOCK AVE. 2TH FL BOSTON, MA 02210 nPS-CA', C, 50M-04;04-61.01216 ®ffioee of Consumer Affairs & Business Regulation :':E. -tlf�HOME IMPROVkMEMT CONTRACTOR L , Registrati®n: 162111 Type: '` Eacpiratiota:.111412017 Supplement Card ? L.> NEXT STEP L)V)NG-INC. ROGER OUELLETTE 21 DRYDOCK AVE. 2TH FL%��-- BOSTON: MA 02210 tinderseeretary Update Address and return card. Mark reason for change. E] Address F1 Renewal F-1 (Employment [] (Lost Card License or registration vapid for iendividul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Smite 5i19® Boston, MA 0211,4 without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Speciallh License' 55 STORM 1 w2ndc ii 02 vi 95-41 Expiration CrIMMISSmIler ii 13120 t a Rwi ATicted To: CSSWC e iRsUW' 6®n COantr@�Si Or Failure to possess a current edition OT the WI,Usachusems state Building Code is c,@use or revC cMion of this UOOEJrlse. For DPSL7ocenso'ngunf®rrr zt!OflesBsuto cqm-jz^s.RAvss.GnvIDDPS The Commonwealth of Massachusetts Department of Indus¢r°ial Accidents Office of Invesdgadons 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 www.massogov/dla Workers' Compensation Insurance Affidavit: Buflde rs/Coiatractors/Electricians/Plumbers A Rlnca»nt Information Please Print. EeAbly ® Name (Business/organization/Individual): Next Step Living Address: 21 Drydock Ave Boston, MA 02210 Phone #: (866)867-8729 Are you an employer? Check the appropriate box: 1. a I am a employer with 850 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 orpartner- listed on the attached sheet. These sub -contractors have ship and have no employees employees and have workers' working for me in any capacity. comp. insurance.I [No workers' comp. insurance 5• E] We are a corporation and its required.] 3. ®I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have no insurance required.] t employees. [No workers' coma. insurance required.] Type of project (required): 6. ® New construction 7. 0 Remodeling 8. ® Demolition 9. ® Building addition 10.EJ Electrical repairs or additions I LE] Plumbing repairs or additions 12.0 hoof repairs 13.0 Other insulation *,any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 110meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aflidal it indicating such. tcontracters 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. .Yam an employer that is providing workers' compensation insurancefor may employees. Below is the policy and job site information. Insurance Company Name: A°i°M Mutual Insurance Company Policy # or Self -ins. Lac. #:AWC-40047030025-2014A Expiration Date: 9/30115 Job Site Address: City/State/Zip: Attach a copy of the workers9 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 SWOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage fi tion. do hereby certffr under the pains and plea les peajnaa� fleet the information provided above is ta°aae and a®e°a�ec¢ Si afore: Date: I u / OffIcial ease only. dDo not write in this area, to be completed by city or town official. City or Towne Permit/License. # IIssuing Authority (circle one): t 1. Board. off Health 2. Building Department 3. City/Town Clerk 4. ]Electrical Inspector 5. Plumbing Inspector 6.Other C®untact person° Phone #e q INEXTS4 OP ID: EL DATE(MP MONYVY) L CERTIFICATE OF LIABILITY INSURANCE F90/09/2094 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O%y AND CONFERS NO RI%jTq UPON TH9 C�JtTlojCjft HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ASTER THE COVERAGE AFFORDED BY THE POLoC;(ES 131BL VV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S); A,PTH.ORIZER REP �SEINTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. QMp RT®ANT: 111 0* certificate holder is an ADDITIONAL ONSURED, the poOicy(les) must Ore endorsed. Of SUDROGATOOIN Iq WARM% Ngh Wag$ B4 the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the �9 :s.�o� I��➢�7aar in lleu of such endorsement(s). PRODUCER MCLellghlirp I suPance Agency NAME` + Erin Lyons PHONE 959-665.2775 �c No : TI99=665 2 A/ No Ent EMAIL 828 Lynn fel s Parlce113py Melrose, MA 02976 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL 0 John E. McLaughlin Jr. INSURER A: NOUtHUS Insurance Ii! VIng, Inc. INSURED Q�e%t ��I INSURER B: COMMer" Insurance Company 3475 INSURER C: A.I.M. Mutual Insurance C®. 29 DrydockAVenue, 2nd Floor INSURER D: AXIS InSUrance Company 15610 Ionto➢, ISA 022` 0 INSURER E INsuRER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY MERI®9 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T 18 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, EXCLUSIONS AND CONDITIONS POL C EFF POLICY EMP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD 9+®®®+®®® COMMERCIAL GEPIERAL LIABILITY EACH OCCURRENCETED $ 9S®'®®® CLAIMS -MADE OCCUR LXJ ECP2010198=92 09/3012094 09130/2015 PREMISES Eaoccurrence) $ MED EXP (Any one person) $ 01900 PERSONAL &ADV INJURY $ + IE9 GENERALAGGREGATE $ M1101900 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ jECT � LOC PRODUCTS -COMP/OP AGG $ POLICY $ OTHER: COMBINED SINGLE LIMIT _ AUTOMOBILE LIABII ITY Ea accident 14MM[BGKK13M 0913012094 030/2015 BODILY INJURY (Per person) $ H ANY AUTO ALL OWNED X SCHEDULED BODILY INJURY (Per acc dent) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ Per accident HIRED AUTOS AUTOS $ X EACH OCCURRENCE $ 5,000 00 UMBRELLA LIAR OCCUR [Ep 10763547092094 0913012094 09/3012095 AGGREGATE $ D EXCESS LIAB CLAIMS -MADE DED RETENTION $ WOR KERSCOMPENSATION H STATUTE ER AND EMPLOYERS' LIABILITY Y� TO BE ISSUED BY CARRIER 0913012014 0013012015 E.L. EACH ACCIDENT $ 500,001) C ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYE $ X00,®® (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 50®'®00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 909, Additional Remarks Schedule, may be attached if more space is required) FOR INFO TION ONLY HOLDER CANCELLATIONCERTIFICATE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2094 ACORD CORPORATION. ABO rights reserved. ACORD 25 (2094019) Top Agggp 9@M@ X999,, r e �����„�r�� @f AC®R