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HomeMy WebLinkAboutBuilding Permit #662-2017 - 350 WINTHROP AVENUE 12/21/2016r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: Commercial Y,Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑Well Floodplain Wetlantls ' ' V1lateAho- District, - ❑.. .. P _Water/Sewer v _ - " _ - - DESCRIPTION OF WORK TO DE PERFORMED: Identification - Please Type or Print Clearly' OWNER: Name: Q? ( ilftQ LLe Phone:l'7�� Address: '? 7,9- Eas4-, S' -i Contractor Name° u�s�;� Phone:-2.�i-�.��'.. • sAddress: (6, h k. 0 QJ +i..7vrK 7S`w- .._ ..,-.-�-,"*'�^"..,�.... ,,.. �'.,�_. - ...� ..... ... -_' .,r,•; ......-"_ .�*vr+v+"_'Mcx� "�'...a,"�ts7'=,'L`"'�'�'i ��•w+�.is r - 5 �h9t _ _ _ IVSD '- t r Exp Date IT .2 t �; Supefvisor;s'Construction;License Home,li: provement Licenser _ _ ;.. Exp ARCHITECT/ENGINEER Phone: Address: Reg. No.—,­ FEE o._ FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. r� Total Project Cost: $ 3`0o FEE: $ Y 3 Check No.: 9- i–cl ?� Receipt No.,- NOTE: o.,NOTE: Persons contracting with unregistered contractors do not have. access to the guaranty fund Si nature of._A :eritLOwner nature of contractor r Plans Submitted ❑ Plans Waived 11 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swkamuig Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales. ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature, CONSERVATION Reviewed on Sianature COMMENTS HEALTH Reviewed on Signature COMMENTS 2�nincg Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Pinning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT'- Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located M4 Usgood Street no iimension 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 ides No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc.Buildans Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r Roofing, Siding, Interior Rehabilitation Permits $( Building Permit Application V Workers Comp Affidavit cv Photo Copy Of H.I.C. And/Or C.S.L. Licenses c:V Copy of Contract em,0 n/ 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 a Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy o CContr act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 i Doc: Building Permit Revised 2014 Location 3ib LA;1,4�va or,// No. 1,7 to 7 Check # i5l�q3 Date v/ TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building inspector EIR * x = 0 'O 0 o 0 O 'Q V W LQ LL O 0Z cic 0 m U Ecu v h Z O m c O a W Z Z co a W Z V LL O W H Z tA Q LLI C Q W W LL a+ w = 6 O LL +++ Q N C 7 LL ti0 7 d' U f0 LL LW O d' _ f0 LL .p �M O d' u i (n 11 D. C' C LL � J v L co Z v N Y N D J ti N Z -: E E 1� O O Z C O = oIM yo.- 'AE,mm W a H � A foo �0CL a CL � Q o= v J 'CL O Z O U U) 0 = 'O o O 'Q V W a w = Z o .p y V � J E Q (� L O " 3 N J i �O Z Mn V _ °' 0 w J 00 �_ u U - U) 4) �- O xO =�= -Eo W o �.CL �U oo w Ma 3 W - ANEW. tm oCL 0)� = W J Qr'=rr 1 °a' w m (1L .U) 0 ti c� c = as CL N V m N O =•a O W Li G +�-� O O (a = =t O it .t .2 Z W E L 0-0c Ci m . O V U) Q 0-0 O 3 :� N J V1 -0 o = O ti N Z -: E E 1� O O Z C O = oIM yo.- 'AE,mm W a H � A foo �0CL a CL � Q o= v J 'CL O Z O U U) 0 U , BRIAN METIVIER ®_ PROJECT MANAGER EXECUTIVE OFFICES: 875 EAST ST. CELL: 978-479-8951 TEWKSBURY, MA 01876 Email: marketbasketbrian@gmail.com R, =Kf, FA .1011RIKdE "MORE FOR YOUR DOLLAR" J EXECUTIVE OFFICES 875 EAST STREET TEWKSBURY, MASSACHUSETTS 01876-1495 978-851-8000 December 16, 2016 Attention: Building Inspector Town of North Andover 120 Main Street North Andover, MA 01845 Re: Market Basket 350 Winthrop Avenue North Andover, MA To Whom It May Concern: On behalf of Market Basket, I, Brian Metivier, authorize Seppala Construction to removeland replace existing precast stairs, at the above location, for the estimated sum of Three Thousand Six Hundred Dollars ($3,600.00). If you have any questions, please feel free to contact our office. Yours truly, Brian Metivier Enclosures The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Stree4 Suite 100 - . Boston, MA 02114-2017 mss' www mass.gov/dia N�­arkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIMTTING AUTHORITY. Applicant Information Please Print Legibly Name (BusMess/Orgarizafion/Individual): Seppala Construction Co., Inc. Address: 153 Hunt Hill Road City/State/Zip: Rindge, NH 03461 Phone #: 603-899-3011 Are you an employer? Check the appropriate box: 1.5I am a emp foyer with 15 emp loyees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensurethat all contractors eitherhave workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no emp loyees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.Roof repairs 14. Rother Exterior Stair ReplacE *Any applicantthat checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy mdjob site information. Insurance Company Name: Ohio Security Insurance Co. Policy # or Self -ins. Lic. #: XWS (17) 57 00 26 30 Expiration Date: 01/01/17 Job Site Address: Market Basket #12 350 Winthrop Avenue City/State/Zip:North Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the patins wtd pettaldes of pedwy that the informaaion provided above is true wtd correct December 15, 2016 Phone k 063-899--x3011 Q(j"rcial use only. Do not write in this area; to be completed by city or town q,(j'teiad 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 #: 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 arty 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 foryou 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 arty 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/clia ACOORtf CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/19/2016 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 FIAT/Cross Insurance NAME CT Jennifer Galante PHONE (603)669-3218 Fax (603) 665-4331 _W_C _W_._Eat)' A/C No): 1100 Elm Street E-MAIL alante@crossa enC ADDRESS: 7g g y• COm INSURERS AFFORDING COVERAGE NAIC N Manchester NH 03101 INSURERAAmerican Fire & Casualty 24066 INSURED INSURERB:Ohio Security Ins CO 24082 Seppala Construction Co., Inc. INSURERC:Ohio Casualty Insurance Company 24074 153 Hunt Hill Road INSURER D: INSURER E: Rindge NH 03461 INSURER F: COVERAGES CERTIFICATE NUMBER -16-17 All lines RFVICIr1Al "I IMRCD- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYYYI POLICY EXP (MWDDfYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR J Harrison, V.P./JSC A"""^+-� EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 X BKA55358735 1/1/2016 1/1/2017 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 1 JE � � LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO ALL OS SCHEDULED AUTOS AUTOS RAW55358735 1/1/2016 1/1/2017 BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ Medical payments $ 2,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS -MADE AGGREGATE $ 10,000,000 DED X RETENTION$ 10 000 $ X US055358735 1/1/2016 1/1/2017 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? a (Mandatory In NH) If yes, describe under N I A XWS55358735 (3a.) NH MA VT NY SC ME All officers included 1/1/2016 1/1/2017 X STATUTE EORH E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1 000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Various Work Market Basket #12 North Andover, MA. Market Basket #12 and Delta MB LLC are included as additional insureds with respects to General Liability and Umbrella when required by written contract. I.EK l IrIt..A I E HOLDER CAAlrl:l I ATIr1Al ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD NS025 r9014nn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Market Basket #12 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 331 Fletcher Street ACCORDANCE WITH THE POLICY PROVISIONS. Lowell, MA 01854 AUTHORIZED REPRESENTATIVE J Harrison, V.P./JSC A"""^+-� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD NS025 r9014nn ACOR 1 0 C40 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/19/2016 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER FIAI/CrOSS Insurance 1100 Elm Street Manchester NH 03101 CONTACT NAME: Jennifer Galante PHO(AICNE (603) 669-3218 FAC No: (603)645-4331 E-MAIL ADDRESS: jgalante@crossa eI1C COm g y INSURERS AFFORDING COVERAGE NAIC # INSURER AAmerican Fire 6 Casualty 24066 INSURED Seppala Construction CO., Inc. 153 Hunt Hill Road Rindge NH 03461 INSURER B Ohio Security Ins CO 24082 INSURERC:Ohio Casualty Insurance Company 24074 INSURER D :- INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER:16-17 All lines REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDD�Y LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE � OCCUR DAMAGE(RENTED 300 000 PREMISESSEa occurrence $ � MED EXP (Any one person) $ 5,000 BRP55358735 1/1/2016 1/1/2017 PERSONAL & ADV INJURY $ 1,000,000 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT� LOC MOTHER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BAW55358735 1/1/2016 1/1/2017 BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS Ixaccident)X AUTOS PROPERTY DAMAGE Per $ Medical payments $ 2,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 _ AGGREGATE $ 10,000,000 C EXCESS LIAB CLAIMS -MADE DED I X I RETENTION$ 10,000 $ US055358735 1/1/2016 1/1/2017 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? N❑ (Mandatory In NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below NIA XWS55358735 (3a.) NH MA VT NY SC mE All officers included 1/1/2016 1/1/2017 X PER OTH- STATUTE I I ER E.L. EACH ACCIDENT $ 11000,000 '— E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: Permit - Market Basket #12, N. Andover, MA CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014101) INS025 1201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Commonwealth of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department of Industrial Accidents ACCORDANCE WITH THE POLICY PROVISIONS. 1 Congress Street AUTHORIZED REPRESENTATIVE Suite 100 Boston, MA 02114-2017 J Harrison, V.P./JSC �l�"�•"'••• ACORD 25 (2014101) INS025 1201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD