HomeMy WebLinkAboutBuilding Permit #297 - 38 HAROLD STREET 10/28/2008 BUILDING PERMITO� NORT#1 q
TOWN OF NORTH ANDOVER or o�
APPLICATION FOR PLAN EXAMINATION 7°
Permit NO: Date Received �f4A°Nwreo �y
/n �•V�/ �SSACHU`���
Date Issued:
ORTANT: Applicant must complete all items on this page
LOCATION -:-'19*Va 0J S'l Ree
r Print
PROPERTY OWNER eg"'e ,
Print
MAP NOPARCEL: 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:
dentification Please Type or Print Clearly)
OWNER: Name: 6?n DZ��l�-'� :.��
Phone ?�Y/
Address: �Q -,"a S,;—
CONTRACTOR Name: Z 7-- =. Phone:
Address: GC/fi�%�'r2 ST'Cc C- cr ,g /�
Supervisor's Construction License: g/ } Exp. Date:
Home Improvement License: Exp. Date: ���-'y
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: $ ?� �� FEE: $ /01'x/'
Check No.: ( `I Receipt No.: Q-( (e,3
NOTE: Persons contracting with unregistered contractors do not have access to the ra ty fund
signature of Agent/Owner Signature of contracto
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
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
4 rR
Fire Department signature/date ; ,, , _
COMMENTS
i
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
❑ 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
o Photo Copy of H.I.C. And C.S.L. Licenses
o 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
❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Locations„
No. .2/ Date /_0
MOD TOWN OF NORTH ANDOVER
F s
9
Certificate of Occupancy $
Must<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # (i
216J5
Building Inspector
NORTH
Town of
ti .
Andover .
No. q Fla,
: dover, Mass.,�0
LA
COC MIC KE WICK -t
7 AORATEO P'P? �
'9S E BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING .INSPECTOR
THIS CERTIFIES THAT......
.404........ch .. A............................................................ Foundation
n� ��has ermission to erect........................................ buildings on .�.. ... .............../.................................... Rough
P
......................................................
t0 be OCCUPIed as.... Chimney
provided that the person accepti this permit shall in every respe conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
000* s PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI ST TS . - Rough
................... .
Service
BUILDING INSP Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
_ Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
i
i
The Commonwealth ofMassachitsetts
Department oflndustrial Accidents
1 Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organ ization/Individual):
Address: c9 5 fi 1;l e S�—
City/State/Zip: Qve ,� Phone#: �37 as
31
Are you an employer?Check the appropriate box:
1.VQ I am a employer with ae
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. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance. 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I 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.E]Roof repairs
insurance required.]t c. 152, §1(4),and we have no
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.
$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. 1f 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 and job site
information. /
Insurance Company Name:
.Policy ti,of Self uis Lic.#: '
Q/!
� ! 7 %/��f DQ Expiration Dater
Job Site Addiess � tgee 7 Ci, /Stafr
it e/ZP. �
Attach a copy of the workers'
corn pensation policy t)eelai-ationpage(showrng the policy nuniber 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.
Ido hereby certify crud -theains andpenalties P p s of perjcrry that the information provided above is true and correct.
Signature:
Date:
Phone#:
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 S.Plumbing Inspector
6. Other
Contact Person: Phone#:
GLRC Inc® dba Lambert Reefin g Company
In Business Since 1032
October 23. 2008
Name: Mr. Dan O'Brien
1p
Address`F Har old Street,North Andover,MA. 01845
f�
Job Site dress: Same as above
Phone: (508) 641-6200 Salesperson: M F'iscel
New Roofing System Proms
TGLRC Inc. dba Lambert Roofing Company will provide certificate of insurances demonstrating
that we are fully insured for workers compensation, general liability, automobile liability and a.
$5,000,000.00 umbrella,policy. This documentation will be sent through the US mail or VIA E-
MAIL/FAX to the above named party if not already provided. upon completion of the roof and
final payment, a shingle manufacturers warranty and our executed two (2) year workmanship
warranty will be sent to the named party.
Work to be Performed And Materials to be Utilized
Conditions:
A Standard two (2)year workmanship warranty applies in addition to a(30)year
manufacturer's warranty.
® Under no circumstance will the watertight integrity of the building be in any
way compromised.
c All work will be performed to the standards and expectations dictated by
the ?t" edition building code and proper roofing practices founded in NBCA roof
covering and waterproofing manual..
1) A pre-roof walk around will be executed to observe and document any pre-existing
conditions and or any special considerations.
2), Ensure landscaping and dwelling is and will remain properly protected.
Please take special note that during demo of the existing roof system all valuables non-
fastened are subject to falling during demo and debris will fall in the attic so preparing
for this will reduce a disappointment and inconvenient clean up. Lambert Pooling
will not be responsible for the above mentioned preparation.
3) Prepare for re-roofing by ensuring all safety measures are taken in accordance with
OSHA and CMR Standards.
t
EIAT 4 51-05033313 255 Winter St Haverhill,.VA.
YM Reg. Hic 9 149221 Phone(978)374-9224 Fax(978)521-5791
-7 c t J S 078130 E-iia l at
--�.
4 1711 Please visit ass on the
TGLRC Inca dba Lambert Roofing Company
In Business Since 1932
4) Remove existing layers of shingles down to the wood roof decking and properly
disposed of debris from the jobsite. T'.G.L.R.C., INC. will arrange for disposal.
5) Inspect wood roof decking, if we discover any rotted wood, removal and replacement will
be performed at an additional cost of-
* $3.95 per foot foe rough pine removed and replaced
® $50.00 per sheet of CDX Plywood(4'x 8'sheet over existing boards).
6) Inspect Fascia and Rake boards, if we discover rotted wood, removal and replacement
will be performed at an additional cost of:
$6.00 per lineal foot of Fascia and rake board, pre-primed pine up to 1"x 8"width
m Crown and Cornice Molding will be custom quoted depending on the
material required
All removed, disposed of and replaced If wood roof decking and trim is sound, we will re-
attach any loose wood to the rafters, sweep deck and prepare for installation.
7) Inspect any and all siding that lies on the roof line if it needs to be replaced it will be
billed as Time ($50.00 per hour per man)plus Material.
8) Apply Ice&Water Shield Underlayment 6' up roofs transition, around all roof
penetrations including chimneys, skylights, pipes and base tie-ins to walls.
9) Attach premium felt paper to the balance of the wood deck.
10) Furnish and install:
® Shingle Type: "Timberline " 30 Year Architectural style shingle accompanied
by premium hip and ridge caps
o Color: To Be" Pewter Grey "
We use, as our standard, a hurricane mailing system recommended in northeast
regions. This means, we install six (6) mails per shingle to reduce the risk of shingles
being damaged by high winds and the weather changes we encounter.
11) Chimney Re-beading
o Chimney re-leading will be included in this quote if required.
12) Roof Flashing:
o Re-flash all 'base tie-ins using(5"0") Step Flashing of counter flashings as
needed if required
® All roof penetrations will receive new Flashing or Pipe Boots as required
and dictated by proper roofing practices
13) Ridge Vents - Roof dents:
Cut back roof decking a minimum of 2" as per manufacturers specifications
® Furnish and install new"Air gent" Shingle Ment II shingle cap over style Midge
Vent System.
2
EIN 4 51-05033313 265 Winter St Haverhill,MA
AIM Reg. Hic 9 149221 Phone(978)374-9224 Fax(978)521-5791
kM f ic. 14 EIC7S 078130 E-Dail at
ir?r -E I j 1iC. k !711; Please:rsft us O,n EVle V-/e`:at
TGLRC Inc. dba Lambert Roofing Company
In Business Since 1932 -
1 4) All debris generated by TGLRC Inc. dba Lambert Roofing Company will be
cleaned up on a daily basis and properly disposed of from the jobsite.
Roofing Warranties:
UPON COMPLETION AND RA.YME NT IN FULL A TWO YEAR NON PRO-RATED
GAURANTEE ON ALL WORKMANSHIP WILL BE HONERED AND ISSUED BY
"T.G.L.R.C. INC". A THIRTY YEAR PRO-RATED WARRANTY WILL BE ISSUED ON
SHINGLES BY MANUFACTURER.
TGLRC Inc. dba Lambert Roofing Company agrees to:
• Commence the described work on or about OC'T'OBER.2008
• The described work will be completed in about(2) working days
• Shall not be held liable for delays due to circumstances beyond our. control
• Shall not be held liable for any damages to landscape, attics and or fixtures due to
circumstances beyond our control
• Shall not be held liable and roofs are not covered under the workmanship warranty,
for pre-existing conditions including but not limited to:
o Mold and or wood rot
o Defective, faulty, rotted or worn building counterparts such as, but not limited to:
siding, gutters, masonry,plumbing and windows, all of which may jeopardize the
watertight integrity of the structure if rot in sound condition
• Unless otherwise noted within this document,the contract shall not imply that any
lien or other security interest has been placed on the residence
Required Permits
A building and dumpster permit may be required to remove and replace your roof It is
our obligation to secure these permits if required as the homeowner's agent.
Note:Homeowners who secure their own permits or deal with unregistered contractors are excluded
from the Guaranty Fund provisions of MG1_c. 142A
Additional Attached Documents,Agreements or Provisions
• Insurance Documentation if not already provided
• Arbitration Agreement
• Contractor Registration Infonnatior
• Notice of Cancellation Form
This contract is the complete contract unless a signed Change Order has been executed between
TGLRC Inc.dba Lambert Roofing Company and the Homeowner
3
EMI 9 51-05033313 265 Winter St Haverhill, MA
MA Reg. Hie# 149221 Phone(978)374-9224 Fax(978)521-5791
A11f1 Lie. m Ui is 0 7813 0 .E-Mail at l,i ➢ ta_ a!
Si gte-rlj ic. 4 1-/I] Please visit a»s on the Web at - r,
TGLRC Inc. dba Lambert Roofing Company
In Business Since 1932
Contract Price and Customer obligations
The total cost for all permits, warranty, labor and materials is: $8,900.00
Payment 'leans: a deposit of 1/3 is due with the signing of contract
® Upon completion, Balance is due in full
® A finance charge of 1.5 %per month(18%per year) will be added to all invoices
on the 31 day. All legal and or collection fees will be paid by the binding holder
of this contract
® The law requires that any deposit or down payment required by TGLRC Inc. dba
Lambert Roofing Company before the work begins may not exceed the greater of-
* 1/3 of the total contract price or:
o The actual cost of Special or Custom made materials which must be
special ordered in advance to meet the completion schedule
Acceptance of the Contract Proposal
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES OR ANY
UNRESOLVED ITEMS
NOTE: Due to volatile pricing on building products,this contract is valid for 15 days of receipt.
1bu may cancel this agreement if it has been signed by a party thereto at a dace other titan
an address of the seller, which may be the main office or branch thereof,provided you notify
the seller in writing at the main office by ordinary avail posted, by telegram sent or by delivery,
not later titan midnight of the third business day following the signing of the agreement.
Because of the three (3) day Notice of Cancellation, work may not commence for a
minimum of seven (7) days after we receive this signed contract unless the contract is signed
at our office.
Signatures Bate: ,2:z9-7 zO 3'
Please sign, keep a copy anti return Daze copy upon acceptance.
"Quality Workmanship You Can Trust"
Thank you for the opportunity to provide you with this proposal and or contract.
Sincerely,
Marc Fiscel
TGLRC, Inc. dba Lambert Roofing Company
4
EIN#51-05033313 265 winter St Haverhill, SAA
A11A Reg. clic# 145221 Phone(978)374-922.4 Fax(978)521-5791
9 UCS 078130
,3i.g1e-Pb;Lee. # t 711 Tease visat as on ase`Yeb at
The Commonwealth ®f Massachusetts ,
Department of Fire Services
Office of the State Fire Marshal
`
P.O.BoN1025St,ate Road,Stow,MA 01775
PERMIT Date:
North Andover JlermitNo
Ci of Town Dig Safe Num er
(City ) (If Applicable)
In accordance with the provisions of N L G.L14 8 Chapter1(Z as provided in section S 7 7 (',M R 34 Start Date
This Permit is granted to: �i9.l7ds�i �e�o�/�
Full name of person,Firm or Co oration
Pennissionto locate dumpsterfor construction/renovation/demolition of building.
Comments dumpster, must be . 25 ' from structure if unable to place with required
Restrictions:clearance dumpster must be covered with ply wood or tarp end of work -day
at
(Give location by street and n .,or d c-be in such r ,to pro ref[adequate identification of location)
FeePaid$ 50 .00 �� �. Fire Chief
This Permit will expire - v- (S ignamre of offical granting permit) Offrcal granting permit (Title)
i
FI - Boar o Building Regulat ons an tandards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reqistration: 149221
Type: Private Corporation
Expiration: 12/6/2009 TO 262486
LAMBERT ROOFING CO
RICHARD LAMBERT ---- -----_-------_ .------------
265 WINTER STREET ------ -- --- _..-- ---- - --
HAVERHILL, MA 01830
Update Address and return card. Mark reason for change.
-1 Address i Renewal ! Employment Lost Car
JPS-CA; 0 SOM-07/07-PC8490
}= \lu..achu.ctt, Urlt.trtrnrni lit i'uhlit �afct�
Board of Building 111ti Ntantlards
Construction Supervisor License
License: CS 78130
Restricted to. 00
RICHARD J LAMBERT ,
95 MAPLE AVE
ATKINSON, NH 03811
Expiration: 6/2/2010
Munn, n'nor Tr= 27762
8 / 25 / 20k08 83 : 07 : 46` PM _ 8740 0, 02 / 02
T `` (EE� DA
\_ E 08/2512008 p C 00
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PRVDIJCL=R � h �Y ,f .. .,.�R•. ,.x .t.:,, ,. ...., , , 4!,i.���.r.,•...,..?.,., _ _ _ _
THIS CERTIFICATF I.S ISSUED AS A MATTER OF INFORMATION ONLY AND
\Ilan In urance Agency 1110 CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CEKTIFICA GE
jP 0 P)ox 511 DOES NOTAMEND.EXTEND OR ALTER THE COVERAGE.. AFFORUF..D BY`CHI:
POLICIES BELOW.
jSalem,MA o 1970 ----
__ I COMPANIES AFFORDING COVERAGE;
(INSURED _— __.---------....—.--
�FC;LRCInC
Idba Lambert Roofing Co. COMPANY A A.I.M. Mutual Insurance Co
1265\I iter Street LETTER
jHaverhill,MA 01330
»'.,. Gt ,;.oS.!RY ;`5'ttiy:F`\,t'•tG'Cwit'C�xi»€ra�`<54k:�€2.eJ.k�4.i!44�t:�5i.,y41S't'sk4�,:»{t,`d5b.,45a{i<�it°y .44:'41't�ItNos St`. 11i,y0»31"xlk't<A't `\4•k81,»,.»<r�eat.i�s,k.t`.»•t4A,t?:,e'A.,<.�.o,ht1•1,s'�»;i.1t"5x)R. »1F.4st<;�,4sA,`zwsisbr}fhR:s'1@
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- '?"o"�'i'zn�—.r.•r,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED DOCUMENTWITH DOABIi RFSPEC'OVE FOR THE POLICI'
PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT'OR
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TFIE POLICIES OTHER DO DESCRIBED HEREIN H SUB IEC
I'0 ALL THE'GERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAR)CLAIMS.
-
!
CQ TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION Y —
POLICY DATE(NIM/DD/YY) DATE(MMIDD/1'YI LIMITS
i
GENERAL LIABI LIT(' GENERAL AG:RE:•F.1'IS �i
__ _
l'�IEIi=1AL!;ENEf 4L LIABILITY PRi ipil!�-Fa.i.!:!M1,1P/i:iF
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PER:`IIAL&AD:' II1IIF;1' M1
1
�':'LAINIS MADE r�0i!]11R
PR,,T
E.crH:•:.r!1 RRF.H0:E... .1..
FIRE DA.t:AA.!;E
MED E?:PENSSF.(Arynr,e(,rnoni
AUTOMOBILE LIABILITY -
7:!MBItJEG..^:•i hl rJLE
LIMIT C
ALL OWNED AUTOS BODILY INJURY
S:HEDULED AUTU_e, (Per person) 1
I liIRED AIITDS _
IK-H jWNED AUTOS BODILY INAlry
3Af A i'E LIABILITY (Per actd-0 Il
PROPERTI'DP.tAAGE
E\CESS LIABILITY
_ EACH i f-CURRENCE
� IM
AGGREGATE
DTH ER THAtJ UA48 RE LLA FORM /y.Iaie 'itt111tt,;, tt.4,x�t °tsk*� kat j k +y» \, .•
�_WORKEIiS COMPENSATION AND C,;s. ,.�,,>> xa a J„/ 1 -.. z'r .s., ,.,,.r r Yip, •�}r... '-=
STATUrORY'LIMITS t -(HER
EMPLOYERS LIABILITY X
HE PROPRIETOR/ -- -`
1 A ARIJERSIEXECUTIVE EL EACH ACCIDENT $ I,000,00(
i!FFlCIEP.S ARE
=E:{CL EL DISEASE--POLICY LIMIT 6009966012008 08/28/2008 08/28/2009
IIL;L
EL DISEASE--EACH
[C'OMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: — EMPLOYEE �� 1,000,000
iWORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES ONLY
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I
HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
u1 THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE'I O THI C.'ERTITIC AT
OLDER NAMED TO THE LEFT.BUT FAILURE TO MAB,SUCH NOTICE SHALL IMPOSE NO OBLIGATION
OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESEN"IEA I'IVES.
LITHORIZED REPRESENTATIVE ell
4791