HomeMy WebLinkAboutBuilding Permit #517 - 35 MEADOWOOD ROAD 4/2/2009"
BUILDING PERMIT o`,0 6g1r0
TOWN OF NORTH ANDOVER c2 4;''- -*' °�
APPLICATION FOR PLAN EXAMINATION 70
n e
Permit NO:rDate Receivedw�°
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 3S r ,Wow000t Rd
Pant
PROPERTY OWNER
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
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 PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: A kt
//6m-s0%R. Phone: 976 - 376 -57.5.5
olieid 1'-)d
CONTRACTOR Name: 41PIa
Phone:
ff
Address: II7�{ cr�P d�9 !
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp: 'Date:
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: $ /;0n�p FEE: $�o�
Check No.: 7 �-� ( Receipt No.: &(010-3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractorGt;�!
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer V--
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
r
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Comments
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 Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
u 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/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
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 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 2008
Location 170—
M e Ado vv V,1-0 4:�
No. S� Date
�aRTM TOWN OF NORTH ANDOVER
w
a
Certificate of Occupancy $
00 1P
cMu9
cBuildin /Frame Permit Fee $ 10
sAsa
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #vH l
21903
Building Inspector
HIC #154326
EIN# 56-2618812
OLYMPIC
Painting, Roofing & Siding office 978-535-0943
515 Lowell Street —Peabody, MA 01960 facsimile 978-535-2008
March 13, 2009
Mike Consoli
35 Meadowood Dr.
North Andover, MA 01845
(978)376-5755
Dear Mike,
The following estimate is for the roof installation for the property located at the above address. The following paragraphs
describe the work that will be performed.
Installation Procedure
A, Strip existing roof on the entire house down to the plywood deck
o Doing this will allow us to properly inspect the substrate and replace any rotten or damaged decking
(we allow 30LF @ no charge, $ 6.00/FT thereafter)
4 Install an 8 inch drip edge on all leading edges
Install 3' ice & water on all leading edges & valleys
o transitional walls are optional and incur an additional cost for the siding repair
o NOTE: the transitions at the entryway porch roof will be sealed with caulking only
4 Install new vent pipe flanges where needed
o Also at the solar panel flanges
■ Removing and the reinstall of the panel is homeowner responsibility
46 Install new lead flashing to the chimney that has stucco applied to it only.
o The other chimneys flashing will remain and be reused.
46 Install 15 pound felt paper on all areas that is not covered by ice & water shield
46 Install new 30 -yr Architectural shingles
4 Install new ridge vent system only to areas that call for ventilation
4 NOTE: Alpine will remove the satellite dish from the roof, but we will be unable to reinstall due to not having the
proper equipment.
Additional Specifications
4. Homeowner to choose color of shingles COLOR: t
4 Dumpster to be placed in an area that is designated by the homeowner
o Our dumpsters are sent to a recycling facility; therefore no additional trash may be placed in them. The transfer
station will charge us a fee which will be passed on to the homeowner.
4 We will remove all of the job related debris
44 All work will be done in a professional manner, and timely basis
o Exception: weather
4 We are not responsible for any of the cracks that may arise in any walls or ceilings
4 Please cover all your floors in your attic to protect from dust and debris
4 `All Roofer are OSHA trained and Master Elite Installers from GAF
4 Permit costs are not included in this bid, due to the variation of cost from town to town
.11.f A,
Est 1959
Roofing Siding Nlintirl
9
Initial the options you are choosine below:
Cost for Labor & Material for Roof $ 6,000.00
Payment Terms:
1/3 deposit upon signing contract
$_19ft
1/3 work in progress
$
1/3 upon completion
$tp�J
Total Amount Agreed To Be Paid:
$
Remit to: Alpine Property Services Company, Inc, Sl S Lowell St., Peabody, MA 01960
The following schedule will be adhered to unless circumstances beyond Olympics' control arise:
Work Scheduled to Begin: `( �1 (upon homeowner removing the Solar Panels)
Expected Date of Completion:
Please make payments to Alpine Property Services Company Inc. Alpine will hold this price for 90 days from the lasted date stated above
Warranty: Alpine Property Services Inc. guarantees all work performed for a period of one year. If any problems occur we will cover
the cost of all labor and material to correct the problem and meet the customers satisfaction.
Do not sign this contract if there are any blank spaces.
(additional provisions follow and are incorporated herein by this reference)
David Ranson, Construction Manager Mike Consoli
Alpine Property Svcs. Co., Inc. d/b/a Olympic Homeowner
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Board of Building Regulatio s and Standards
Construction Supervisor License
License: CS 98534
W—W011 Tr# 98534
cid X70;_
DAVID RANSON ry
12 RICHARDSON COURT.,_-�-
i
METHUEN, MA 01844""Commissioner
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c`OSea sQaee
35,Da� et
was°�a icy°m tait�o� °S i
1A 1 ZF c�<<e� Coae
A'G ossess a .B��ia�o
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wwrc=.mass.; ov/dia
Workers, Compensation Insurance .Afficiavit: Builder
DIicant Innation s/ContraciorslEieeiriicians!Plumbers
for
Name (Business/Organiizabon/Individual):
Address:
City/Slate/Zip: Phone #: FM
Are ou a j
J n emp oyer. Check the appropriate box:
1. Z l
The Commonwealth of Massachusettic
- r
Department of jndustri& Accidents
have hired the subn-con rtractorstractor and l
Office of 1"nvestigations
listed oM the attached sheet I
600 Washinjon Street
These sub -contractors have
Bostosz, MA 02111
workers' comp. insurance.
5.. ❑ We are
required.]
3. ❑ I am a homeowner doing all
wwrc=.mass.; ov/dia
Workers, Compensation Insurance .Afficiavit: Builder
DIicant Innation s/ContraciorslEieeiriicians!Plumbers
for
Name (Business/Organiizabon/Individual):
Address:
City/Slate/Zip: Phone #: FM
Are ou a j
J n emp oyer. Check the appropriate box:
1. Z l
an, a employer with
4. ❑ I am a a—
p y,.,, (' p
em IO tes Hill and/or part-time).*
2.7 1 am a sole
have hired the subn-con rtractorstractor and l
proprietor or partner_
listed oM the attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5.. ❑ We are
required.]
3. ❑ I am a homeowner doing all
.a corporation and its
Officers have exercised. their
work
myself. [No. workers' comp.
right of exemption per MGL
c. 152, § l (4), and we have no
insurance required.] t
employees. [No workers'
comp, insurance re ui d
Type of project (required):
6. ❑ New construction
7• ❑ Re -modeling .
S. ❑ Demolition
9. ❑ Building addition
10:❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12:❑ Roof repairs
q re ] 1.3•❑ Other
*Any ap WRer t.that checks box # 1 .must also fiil out the section below showing their workers' compensation policy mrormation.
+ Homeowners whe submii •flus aifde.vtT itidieariag tiiej- Ere a uittg ' r -or}; at d pert hi au tae cnntrEciurs rnusi su'mnii a new atnriavit
XConuactors Thal check, this box must attached an additional sheet showing the name indimur.
of the sale ocnsaetors and their work' ,._:_ a n.
w., Lin, entptoyer that a providing workers' co enation i
information l/ assurance for �, employees. Below is the policy and job site
Insurance Company Name: - t l Q rl I CA 4 r4 ?101" it
Policy # or Self -.ins. Lic. #: 10O V Q Q % S C� 2D�
e / Expiration Date:
.lob Site Address:_ .
City/State/Zip:
Attach a copy of the workers.' compensation policy decEaraion page (showing the policy Dumber and ex iratio
Failure to secure coverage as required under Section 25A of lea� P n flare)
fine up to SI,500.00 and/or one-year imprisonment as well as civil pim
e can
the to
of a STOP WORD ORD alnes of a
position of criminal pen
of up to .S250.00 a day against the violator. Be advised that a copy of this statement ma ER and a fine
Investigations of.the DIA for insurance coverage verification. } be forwarded to the Office of
I do herebp cerg6u er the paain-sand panaLdes of perjurf) that the information provided above las true and correct
�:--� -- ./% /1 ZD. __ . .His
------------
Official use only. Do rent write in this area, to be co►npleted by city or town offtciaL
City or Town:
�
Issuing Authority (circle one): PermitlLicense
I. Board of Health 2. Inspector
Building Department 3. City/Town Clerk 4. Electrical Inspector 5- Plumbing Ices
6. Otherp
Contact Person:
Phone;
intormanon .nd 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 ".. -.very 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 inclutii-na the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house having not more than three ap art ments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maint--nance; construction or rair 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 a r local licensing agency shall withhold the issuance or
renewal of a license or permit to operate s business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence mfcompliance 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 contrasting authority." .
Applicants
Please fill out the workers' compensation affidavit compi-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) 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 oth-� 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 afficl avit maybe 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 nmzmber:lis+.ed below. Self-insured companies should enter their
self-insurance license number on the appropriate ime.
City or Town Officiais
Please be sure that the afndavit.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 permitAicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/heense applications in any giver, year, need only submit one affidavit indicating current
policy information (if necessary) and under ".lob Site Adm-ess" 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. 'Arhere a home owner or citizen is obtaining a Iicens- or permit not related to any business or commercial venture
(i.e. a dog license or permit to burnleaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would iike 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 Massachusetts
Department Of Ladust ie l Acci dents.
Office of Licvestigationtcs
600 Wash ngton Street
Boston; MA G2111
Tel. # 617-727-4900 Crt 406 or 1-8.77-MASSAFE
Revised 5-26=05
Fax # 61 7-727-7749
ujutu.mass.govldla
ACORD CERTIFICATE OF -LIABILITY INSURANCE 7�ATE(MMrp°"�`
PRODUCER PHOne:RN (TION 75110 Fax (817)657-5112GROUP
THIS CERTIFICATE IS ISSUED AS A'MATIER;OF INFORMATION
KNIGHT INTERNATIONAL INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON' THE CERTIFICATE
500 VICTORY ROAD
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MARINA MAY
QUINCY MA 02171 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
--_.
INSURERS AFFORDING COVERAGE NAlC #
INSURED INSURER A: FIRST MERCURY INSURANCE CO.
ALPINE PROPERTY SERVICES CO.,INC.
DBA OLYMPIC INSURER B: SAFETY INSURANCE
11 WILSON STREET INSURER C:
SALEM MA 01970 INSURER D: —�
INSURER E:
Inc rVUkAts VI. 114SUFANGE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS -OF SUCH
POLICIES. AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L.T R ADD TYPE OF INSURANCE POLICY EFFECTIVE POLICY FSFIRATION
LTR nvs POLICY NUMBER DATA ��ATF MrNo LIMITS
GENERAL LIABILITY FMMA00186 06/14/08 06/14/09 EACH O—CI1RRENCE g 1,000,000
X COMMERCIAL GENERAL LIABILITY DaMaaETO:;E
�1 X1 oRUIIEEs (Ea �zae Ice1 S _ 50.000
CLAIMS MADE 21 OCCUR MED. EXP Om one mon) S
A X Blanket Additional Insured Included PERSONAL a AOvrNJURY g 1,000,000
X Waiver Or S�rngatlon lnchrded GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
POLICYX PRO- PRODUCTS-COMP/OPAGG. 5 1.000 000.
JECT MLOC
AUTOMOBILE LIABILITy 2702661COM00 01/09/09 01/09/10
ANYAUTO COMBINED SINGLE LIMIT
(Es accidern) S 1.000,000
ALL OWNED AUTOS
BODILY INJURY
B SCHEDULED AUTOS (Per person) S
X HIRED AUTOS
X NON-OWNEDAUTOS BODILY INJURY
(Per accident) S
1 -
LPROFERTYDAMAGE g
GARAGE LIABILITY eccidcnt)
ANY AUTO AUTOONLY-EA ACCIDENT S
OTHERTHAN EAACC S'
AUTO ONLY: AGG S
EXCESS IUMBRELLA UABIUTY CUMA000117 06/14/08 06/14/09 EACH OCCURRENCE $ 5,000,OOp
X OCCUR � CLAIMS MADE AGGREGATE
A g 5,000,000
HxDEDUCTIBLE
RETENTION S 10,000 S
WORKERS COMPENSATION AND g.
wC STaTU-
EMPLOYERS'LJABILfiY yL, OTri=R
ANY VROPRIETOR/FARTNEft-XFCUnT VE E.L. EACH ACCIDENT g
OFFICER/MEMSER EXCLUDED7
s yea, oescaba=oor E.L DISEASE -EA EMPLOYEE S .
SPECIAL FR(NIMCNS Wow
EL DISEASE-POLICYLIMIT S
OTHER: GENERAL UABRITY
A $10,000 DEDUCTIBLE. PER OCCURRANCE
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICI..FSYFrrI l.1GIONS ADDED RY ENDORSEMENT/ SPECIAL PRnvLClArils•
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE
I EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TU •MAIL 10 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE, TH
LEFT; BUT.FA)LURE
TO DO SO SHALL IMPOSE NO OBLIGATION OR LIASIIiry OF ANY KIND UPON E INSURER,
ITS AGENTS OR REPRESENTATIVES.
Attention:
Harold
ACORD 2S (2001!08)
igFlt
O ACORD CORPORATaON 1988
b.ZUU9 Ut1:Y3
ACORD TM. CERTIFICATE OF LIABILITY INSURANCE
DATE (MNWD/YYYY)
0110512009
PRODUCER Phone., (617)657-5110 Faic (617)657.5112
KNIGHT INTERNATIONAL INSURANCE GROUP
500 VICTORY ROAD
MARINA BAY
THIS CERTIFICATE IS =UED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT.AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
LUSIONS AND CONDITIONS OF SUCH
QUINCY MA 02171
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURERA: Atlantic Charter insurance Company
PREAlIB ocmnrec
INSURER 5:
MED. EXP•(Anyamparson) S
ALPINE PROPERTY SERVICES CO., INC.
INSURER C:
DBA OLYMPIC
11 WILSON STREET
SALEM MA 01970
—^'
INSURER D:
PRODUCTS-COMP/OPAGG., S
INSURER E:
COMBINED SINGLE LIMIT
COVERAGES
THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY F
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EX(
POLICIES. AGGREGATE LRMrrS SHOWN MAY HAV& BEEN REDUCED BY PAID CLAIMS.
�LRIMTN TYPE OF INSURANCE I POLICY NUMBER I POUCVEFFECTIVE I POUF EXPIRATION
COMMERCIAL GENERAL LUIBILITI
CLAIMS MADE❑ OCCUR
GENLAGGREGATE UMrrAPPUES PER
7 POLICY n PE 0- 1 ILOC
JEC7
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIREO AUTOS
NON -OWNED AUTOS
GARAGE LIA61LrrY
7 ANYAuTO
EXCESS / UMBRELLA LIABILITY
OCCUR F� CLAIMS MADE
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION AND WCV00754902 01/05/09 01/05/10
EMPLOYERS• LIABILITY
A ANYPROpRGTofuPARTRERYExwun`R
OFRCEROM-MBER ERCUICEO?
tryv4 aoacnoe un0oe
8PECNLPF(0MI0N8 DYI—
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENI
ERIOD INDICATED, NOTWfTHSTANDING
;ERTIFICATE MAY BE ISSUED OR
LUSIONS AND CONDITIONS OF SUCH
LIMITS
EACH OCCURRENCE S
DAMAGE TO RFJJi'FD S
,
PREAlIB ocmnrec
MED. EXP•(Anyamparson) S
'
PERSONAL & ADV INJURY S
GENERALAGGREGATE S
PRODUCTS-COMP/OPAGG., S
COMBINED SINGLE LIMIT
(EB accident) 3
BODILY INJURY
_
(Per pcmon) S'
BODILY INJURY S
(Per arcidcra)
PROPERTY DAMAGE S
(Per accident
AUTO ONLY-EAACCIDENT S
OTHER THAN EA ACC S
AUTO ONLY: AGG IS
EACH OCCURRENCE 5
AGGREGATE S
S
S .
$.
we srATy . TOOTHER
RYRJ6IRE
EL, EACH ACCIDENT S
500,000
E.L. DISEASE -EA WFLOYEE S
500,000
EL DISEASE -POLICY LIMIT S
•606,000
SPECIAL PROVISIONS
HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OESCRtam POLICIES BE cmcELLED BI:FORETHE
EXPIRATION DATE THEREOF. THE ISSUING INSURER WILLENOEAV,ORTO MAIL10 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE, LEFT, BUT -FAILURE
TO 00 SO SHALLIMPOSE NO OBLIGATION OR LIABILITY OF ANY igNO UPON THt: )NSURER.
IPS AGENTS OR REPRESENTATIVES.
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Attention: C"'LHarold fright
ACORD 25 (2001108) Certificate 9 8149 Q ACORD CORPORATION 1988