HomeMy WebLinkAboutBuilding Permit #936 - 39 UPLAND STREET 9/27/2012qPermit NO:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROAMENT
PROPOSED USE
1'7 Ue 0
S�r.p 5t-
Residential
Non- Residential
New 13uilding
One family %..-'
N "a'
CONTRAC R'. me:
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement,,�
Assessory Bldg
Others:
Demolition
Other
tebtic �We'll
F'16adplain Wetla ri&
Watershed! D ittrict-
Wat er/Sew0r
Exp.- D -q e --
t
Lit
OWNER: Name:
DESCRIPTI?N OF
9
TO BE PREFORMED:
- I , A—A% at
I e- LS YS 4-e P&I .
Please Type or Print Clearly)
I
C
�9a
Address: -�>tl tf4l),
KC -4 -
1'7 Ue 0
0
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N "a'
CONTRAC R'. me:
bbe�.
Add ress:
LJ
tr
-supervisor's-,�Cbn!strucb on License-
Exp.- D -q e --
t
I 1 0,
,,Home,im-pr,oyetnent,'Li.Gense:
ARCH ITECT/ENG I NEER A�IAI 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: $ q,6
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th!�_guarantyfund
J
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 DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
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 P�6Fmit
DPW Town Engineer: Signature:
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 21 A —F and G min.$100-$1 000 fine
NOTES and DATA - (For department use)
U Notified for pickup - Date
... . . . . . ............. . ..... .. ... ..... ............................. . ... — - - - - - - - --- - - - - --------- --- - ------------------------------------------------- - - - . . . .. . ............................... . ..... . . . . ..... ........ ........................................ . . .. ..... . . ..........................................
Doc.Building Permit Revised 2010
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
M orkers Comp Affidavit
I hoto Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work V/A
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
/V/-4 '
Addition Or Decks
• Building Permit Application
• Certified Surveyed Plot Plan
Li Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Callculations (if Applicable)
u Mass check Energy Compliance Report (if Applicable)
u 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 Fa mily)
o Building Permit Application
Lj Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
L3 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li 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
Doe: Building Permit Revised 2008
Location
No. Date
Check e��Z(9
25462
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
eAo�7��
Building Inspector
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AFFIDAVIT.
14ONE IMPROVEMENT CONTR ACTOR LAW
Supplement to Permit Ap
ph 6 n
MGL'I 42A requires that the reconstruction,, alteration,: renovationtepai - rj �modemization,,coV.erin&.�i�nprbvemeht,� removal,
demolition of, Construction of, in, addition to -any existing owner, occu pi edbuil din g.66ntahiing at 16ast one but not more than
four dwelling units or structures,,which are adjacent to. such,resi�ehce of �,Ufldifij� be done . by registered contractors, with
certa-in exceptions, along with other requirements.
Location of Property:. 0 e 16,Vl\ Aj MA
Owner Name and Address: K<--,J�K aV-;C-%'1N :Aq VjQ I&. -J
Date of Permit Application: 19� (b Z/a 15st� cost:
TyPe of Work.: 3+,r, %0 W Z�� —V-6 I
I hereby certify that:
REGISTRATION IS NOT REQUIRED FOR THE FOLLOWING REASONS:
work excluded by law
job under $1,000.
building not oumer�occupied
owner pulling own permif
other (specify)
Notice is hereby given that:
OWNERS PULLING T.HEIR.OWN PERMIT ORDEAL *VWT- I RE D
ING
HUNREGISTE
CONTRACTORS FOR APPLICABLE HO1vfE
IMPROVtMENtV, ORK DO NOT IIAVE.
ACCESS, TO THE ARBITRATION PROGRAM OR GUARANTY FUND MGL c. 142A.
Signed under penalties of perjury,' I hereby apply for a permit as the agent of the owner:
b-7 t 64 6
Contractor Name (print)
Date
Registration Number
OR:
Notwithstanding the above notice, I hereby apply for a permit as the-owrier �of the above pro erty:
P
Owner Name (print)
Owner Signature
lk
Drovoot Page No. of Pages -
we propose hereby to furnish material and labor - complete in accordance with specifications below, Tor the sum of:
oe
d
Payllm to el laft aS fOI16WS
One Third Deposit One Third Mid Job Balance Upon Completion, OR
Plea�o.-Mo�eChec��Pa�oNetoJo�o�,WN
NOTICE: All home improvement contractors and subcontractors engaged in home Authorized
Signature
Improvament contracting, unless specifically exempt from regis�ration by provisions
.I Chapter 142A of the General Laws,�must be registered with he Commonwealth
of Massachusetts. Inquiries about registration and status should be made to the
Director ' Home, Improvement Contract Registration, One Ashburton Place, Room Note: s pr.po .1"may be
1 301, Boston , MA 02108. withdrawn by us 11 �d within days.
We hereby submit, specifications and estimates for: 4'ROOF WORK
Mr -s -TRIP ROOF OF 0 fle- LAYERS OF ASPHALT SHINGLES, COVER.EXTERIOR WALLS AND
FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ADDITIONAL LAYERS WILL BE EXTRA, SEE BELOW
4QOVER DECK WITH UNDERLAYMENT FELT.
5r INSTALL ICE & WATER SHIELD AT LEADING EDGE, VALLEYS AND ALL ROOF PENETRATIONS.
STANDARD APPLICATION AT EAVES IS 3 FEET. rALL LOWIR3LOPED- ROOF AREAS -TO RECEIVEIL�FEET
(jd/,COVER ALL PERIMETERS WITH 8 INCH ALUMINU DRIP EDGE. COLOR:)CWtIlT�E BROWN SILVER COPPER
7ki-IINSTALL RIDGE VENT OR El ROOF LO VERS FOR ADDED ATTIC'V=ILATION.
INS ALL SOFFIT VENTS WHERE NECESSARY. SOFFIT SIZE TO DETERMINE SIZE OF VENT.
COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS.
21,COUNTER FLASH CHIMNEY(S) WITH ALUMINUM FLASHING AS NEEDED.
--IE* ELE-AD-0 HtMN EY.GUT-AL-L�EX4STI NG -TAR -ANDLEAD- FROM- CHWNEY- -C-UT-NEW_J?,EGLET_f�NT
NEW LEAD IN PLACE W I ITH MORTAR. IF NEEDED FOR A WAT . EIRTIGHT JOB,
*-BEBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD TO ABOVE PRICE.
'fk- REPLACE DEFECTIVE ROOF DECKING WHERE NECESSARY AT CONTRACTORS DISCRETION " X
DEFECTIVE ROOF DECKING REPLACED WITH SPRUCE, FIRST FEET FREE AND THEN PER
FOOT THEREAFTER. Awl 40
PLYWOODDECKS REPLACE SHEET(S) FREE THEN PER SHEET, BUYANDINSTALL,
THICKNES'S -!A Maz'kA7 tg'
T(COVER ROOF I SURFACE WITH /,e 4,�e
A2*1 STORM NAIL ALL SHINGLES WHEN APPLICABLE (SEE MFG. INSTRUtTItf\1S).
'Q�INSTALL SKYLIGHTS PROVIDED BY CONTRACTOR OR CUSTOMER, FRAME ROOF DECK AS NEEDED,
7""PROPERLY FLASH UNITS WITH FLASHING KIT(S) PROVIDED, ADD TO PRICE. CUSTOMER TO DO
V IF MORE LAYERS ARE FOUND THAN INDICATED ABOVE, AN ADDITIONAL CHARGE OF r 600."o WILL
BE ER LAYER. IN THE EVENT OF MULTIPLE LAYERS IN -RANDOM AREASrrOF ROOF, COST IS
8 Wlp PER SQUARE (10'X 10 AREA) TO REMOVE AND DISIP OSE 0 r F A , D r DITIONAL LAYERS.
CLEAN ALL JOBTIELATED DEBRIS FROM OUTSIDE WORK AREA. 05TAIN ALL PERM . ITS AND CARRY ALL
NECESSARY INSURANCES AS REQUIRED BY LAW. WE CANNOTACCEPT RESPONSIBILITY FOR DEBRIS FALLING
IN ATrIC AREAS, CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE
STRUCTURE AND LANDSCAPING DURING THE S HOWEVER SOME MARRING COULD OCCUR,
a'e 4, 7 e' -r-1.1
pea -r-
441.4 7X
-T
WARRANTY
All wo
'ZA1 teed to be free of installation defects for 149 yearsi limited to installed item,and its.repair only. Material warranteed by mfg. to
be free of defects To see mfg. warranty for exact warranty performance. Acts of nature,, including ice damming, are not covered under warranty.
While under warranty if the homeowner hires any other contractor to perform work which may Compromise the roof system without first contacting Joseph S.
Savini, Inc. the warranty could be voided. Any repairs required due to the roof system being compromised by another contractor will be billable. ,
Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from acceptance date by mail or
telegram sent to Joseph Savini Roofing & Gutter Contractors, 40 Canal Street, Medford, MA 02155. See reverse side for cancellation procedures.
Once all items in this contract are r completed as agreed, customer has 3 days to fulfill payment schedule or pay all.attorney and legal fees incurred by Joseph
Savini with interest �of 1.5% per month on the unpaid balance. All parties agree that all disput6Swill �be settled through binding arbitration as provided by the
Better Business Bureau or the Secretary or the Executive Office of Consumer Affairs and Business Regulations, MGLC. 142A. Please see reverse side,
Arbitration of Disputes.
ZIrceptance Of ift-OP05al - The above process, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Pa7yent will be made as outlined above.
Date of Acceptance: Signature
Joseph S. Savini Incorporated
tboale
D/B/A Joseph S. Savini
6/1ZIT
A44ve, Tl�j
Roofing & Gutter Contractors
%.
MASS BuL61ERS
-55
40 Canal Street, Medford, MA 021 CONTRACTORS
LICENSE #036954
(781) 395-3954 Fax (781) 393-44926 REG. 135743
PROPOSAAL,MI;,IIID TO
oar
1AW
SMEET.
CITY, STAT ed PIP
ARCHITECT
rE OF PILANS
"ott PHONE
we propose hereby to furnish material and labor - complete in accordance with specifications below, Tor the sum of:
oe
d
Payllm to el laft aS fOI16WS
One Third Deposit One Third Mid Job Balance Upon Completion, OR
Plea�o.-Mo�eChec��Pa�oNetoJo�o�,WN
NOTICE: All home improvement contractors and subcontractors engaged in home Authorized
Signature
Improvament contracting, unless specifically exempt from regis�ration by provisions
.I Chapter 142A of the General Laws,�must be registered with he Commonwealth
of Massachusetts. Inquiries about registration and status should be made to the
Director ' Home, Improvement Contract Registration, One Ashburton Place, Room Note: s pr.po .1"may be
1 301, Boston , MA 02108. withdrawn by us 11 �d within days.
We hereby submit, specifications and estimates for: 4'ROOF WORK
Mr -s -TRIP ROOF OF 0 fle- LAYERS OF ASPHALT SHINGLES, COVER.EXTERIOR WALLS AND
FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ADDITIONAL LAYERS WILL BE EXTRA, SEE BELOW
4QOVER DECK WITH UNDERLAYMENT FELT.
5r INSTALL ICE & WATER SHIELD AT LEADING EDGE, VALLEYS AND ALL ROOF PENETRATIONS.
STANDARD APPLICATION AT EAVES IS 3 FEET. rALL LOWIR3LOPED- ROOF AREAS -TO RECEIVEIL�FEET
(jd/,COVER ALL PERIMETERS WITH 8 INCH ALUMINU DRIP EDGE. COLOR:)CWtIlT�E BROWN SILVER COPPER
7ki-IINSTALL RIDGE VENT OR El ROOF LO VERS FOR ADDED ATTIC'V=ILATION.
INS ALL SOFFIT VENTS WHERE NECESSARY. SOFFIT SIZE TO DETERMINE SIZE OF VENT.
COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS.
21,COUNTER FLASH CHIMNEY(S) WITH ALUMINUM FLASHING AS NEEDED.
--IE* ELE-AD-0 HtMN EY.GUT-AL-L�EX4STI NG -TAR -ANDLEAD- FROM- CHWNEY- -C-UT-NEW_J?,EGLET_f�NT
NEW LEAD IN PLACE W I ITH MORTAR. IF NEEDED FOR A WAT . EIRTIGHT JOB,
*-BEBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD TO ABOVE PRICE.
'fk- REPLACE DEFECTIVE ROOF DECKING WHERE NECESSARY AT CONTRACTORS DISCRETION " X
DEFECTIVE ROOF DECKING REPLACED WITH SPRUCE, FIRST FEET FREE AND THEN PER
FOOT THEREAFTER. Awl 40
PLYWOODDECKS REPLACE SHEET(S) FREE THEN PER SHEET, BUYANDINSTALL,
THICKNES'S -!A Maz'kA7 tg'
T(COVER ROOF I SURFACE WITH /,e 4,�e
A2*1 STORM NAIL ALL SHINGLES WHEN APPLICABLE (SEE MFG. INSTRUtTItf\1S).
'Q�INSTALL SKYLIGHTS PROVIDED BY CONTRACTOR OR CUSTOMER, FRAME ROOF DECK AS NEEDED,
7""PROPERLY FLASH UNITS WITH FLASHING KIT(S) PROVIDED, ADD TO PRICE. CUSTOMER TO DO
V IF MORE LAYERS ARE FOUND THAN INDICATED ABOVE, AN ADDITIONAL CHARGE OF r 600."o WILL
BE ER LAYER. IN THE EVENT OF MULTIPLE LAYERS IN -RANDOM AREASrrOF ROOF, COST IS
8 Wlp PER SQUARE (10'X 10 AREA) TO REMOVE AND DISIP OSE 0 r F A , D r DITIONAL LAYERS.
CLEAN ALL JOBTIELATED DEBRIS FROM OUTSIDE WORK AREA. 05TAIN ALL PERM . ITS AND CARRY ALL
NECESSARY INSURANCES AS REQUIRED BY LAW. WE CANNOTACCEPT RESPONSIBILITY FOR DEBRIS FALLING
IN ATrIC AREAS, CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE
STRUCTURE AND LANDSCAPING DURING THE S HOWEVER SOME MARRING COULD OCCUR,
a'e 4, 7 e' -r-1.1
pea -r-
441.4 7X
-T
WARRANTY
All wo
'ZA1 teed to be free of installation defects for 149 yearsi limited to installed item,and its.repair only. Material warranteed by mfg. to
be free of defects To see mfg. warranty for exact warranty performance. Acts of nature,, including ice damming, are not covered under warranty.
While under warranty if the homeowner hires any other contractor to perform work which may Compromise the roof system without first contacting Joseph S.
Savini, Inc. the warranty could be voided. Any repairs required due to the roof system being compromised by another contractor will be billable. ,
Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from acceptance date by mail or
telegram sent to Joseph Savini Roofing & Gutter Contractors, 40 Canal Street, Medford, MA 02155. See reverse side for cancellation procedures.
Once all items in this contract are r completed as agreed, customer has 3 days to fulfill payment schedule or pay all.attorney and legal fees incurred by Joseph
Savini with interest �of 1.5% per month on the unpaid balance. All parties agree that all disput6Swill �be settled through binding arbitration as provided by the
Better Business Bureau or the Secretary or the Executive Office of Consumer Affairs and Business Regulations, MGLC. 142A. Please see reverse side,
Arbitration of Disputes.
ZIrceptance Of ift-OP05al - The above process, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Pa7yent will be made as outlined above.
Date of Acceptance: Signature
The Commonweam of A4swo
Department: tfZ d� -s...
PWAOd
W. n w
... Office qf1nV&fig'
we
I.c ress S
BO
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surance Nd
W.6, rk-ersl. engatt'611 111
ndividua-1):
Address.,
citylstateliz..
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Phi
Cal
aff-M ?Cheek the appropriate box:.
Are you.,
TM
U.
'a: gene I ral..
1. with 4*. 1.am av genera P1rA
have hired the.
enl0by es �(fiifi andlor part-time) ev
2. El i a'� listed on. the attach R,
ain e1bro, partner -
.to'
ship. -ai�OFfiav�:Xicv otTloyees These sub-contrac rs, aw . .....
77,1�
Or. any capacity. nP
WOrkh me-iti- e loym and;have-Wp
Ug
[No O&WW Po insurance comp, insuranceJ
Its
req4ited.) We am- a corporaWa4hdi. ....-.47-Motrical repags� d*
3. 1 &.-g all w ork officers have exet-ciged.
eir lu.in
IMP' 6,irig.te -§,6.r ad
myself ,.[No, w6rk�i`S right of exein��.--peu Pik
comp� MOL.
c. 152:§1(4), �and;" :re
t -dof pairs
in'surance,required] We
V
empl
oyees. [Nowwbr6ii
re
'Any applicant that: checks box #1 �4
must also fill out the section belaw showing their workers 06 fbm"UIDA
fidavi
Homeowners who submit this'af t indicating they are doing all work and then hire putkidO.V040*4 i�t.suibmit a:
lContractorr, that chook
must attached an additional sheet showing the -name *f the!sr* ornot
employees. Ift =tors. have employees, they must provide.their workeWcomg . . Wbether
am an eftoto*thw'�4 providing workers
compensation insu
infio.rmad6iL the rjob site
Oaipaft` N Y-
Insuranc
ame:
Policy # or:.&61f�ins. - Lie,.:#:
XPArAtio
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Job Site Afttss: 2
Attach.steo-PyOf-the'W,,Orkerecompenssttionpoficy-declar lonpa.ge�fsh Y11 -ft am- e V'* Ir ift�
"date)
Failure to 8eCj)r.e'r*ftjP,, as required under Section 25A -of MGL. c... -15ic�.I' d ih S-1 of cri n*iinal. peholb
. ..... CAMPO
esofa
a fine
fineupte's,13 66 and/or one-year imprisonment, as well as civifp�n , e T
.-V
W 41 OP WORKORDEIZ
of to S250,00.
t .!Wth i-.Qffl� P. .
UP a.'d&Y -against the violator. Be advised that a copy: ofthis 4
Investigatip �bflhe�:.DIA for insurance coverage verification.
I do hereb
pains and Penalties offt
:true
Za
Phone #:
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use -onry: Dv not write in this area, to be comp
letedby-cityd ito 0 -
city or. UW -U,
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Issuink.-Authotity: 61e one):
I - RO'Ard 4 -Health 2. Building Departm-ent 3.
6. Other City/TOVMCler k:: A���'
.04b
44 '-40Jzb' ERTIFICATE OF LIM ITY INSURANG
C E
'41L
. DATE (MMIDDNYYY)
[4 012
C I :ISSUED AS A MATTER OF INFORMAT16N ONLY A RiGHTs UPON THE CERTIFICATE HOI QER_ THIS
THIS - t t
CERT1 CA S NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE+CdVERAGE AFFORDED BY TH97POLICIES
BEELOW. TH(b: CtWhFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE .,ISSUING INSUR ER(S)y � AUTHORIZED
REPRESENTATIVE OR+PF�tIPUCER, AND THE CERTIFICATE HOLDER%.
IMPORTA97 !tWMtIt4date holder Is an ADDITIONAL INSURED, the polGOR Mstl)b :MT—MF if SUBIR . OGATION IS WAIVED, subjeetto
the terms and conditions of the policy, certain policies may require an endorsernerit, A.statement chAbIstertIfIcate ftes notconfer righti10 the
certificate holder In Ileu of such endorsement(s).
PRODUCER
Eastern insurance Oroup LLC - Main
233 West Central Street
Natick MA 0 1760
NAM
FRUONLEX0,508-6 . 51 -7700 . JFAX
jCi No):508-6�3�:8089
fA
&MAJL
ADDF;Ess:selectwotkaeazternirrsurance.com
INSUR ER(,S)WFFORDING COVERAGE KAIC#
MAX013100005261
INSURER A:Han.oVer InSU rar.jCe Co.
16121112012
INSURED 31298
INSURER.13: ar Insurance Company
INSURER c:Alterra Excess-& Surplus Ins
Joseph S. Savint.,.1ne.
INSURER D:CoMrngrce.jnsu ran= Company .34754
INSURER E:
40 Canal Street
Medford MA 021-56.
INSURERF: .
PRODU TS - COMPIOP AGG $Included
COVERAGES CERTIFICATE NUMBER: 362000128 REVISIONNUMBER:
THIS IS TO CERV7 THA I T THEPOLICIES OF INSURANCE LISTED BELOW HAVE BEENISSUED. TO THE. INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTwrrHSTAI4bING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE 1SWED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS, SUEWECT TO ALL:THE TERMS,
EXCLUSIONS AND.6ONDITIPNS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCEDBYPAID.CLAIMS.
INISR
LTR
TY EOPINSURANCE
ADOLSUDR
POLICYNUMBER
POUCYmEW
IWAIDDN_Mj:�
-POLLCYFXP
(MmIDDIM-Y)
LIM111
C
Ix
GENERAL LIA*UTY
COMMERCIAL GEiI'ERAL,UASIL_ITY
1
CLAJMS4�E Fx ]OCCUR
MAX013100005261
10121/2011
16121112012
EACH OCCURRENCE $1,000,000
I U HtN I tU
PREMI 8 (Ea coavrrence) $50,000
MED EXP (Any ona.person) $5,000
PERSONAL & ADV INJURY $1,000,00v
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
I POLICY I I PAR
PRODU TS - COMPIOP AGG $Included
$
D
AUTOMOSILE�LlAkUTY
ANY AUTO
ALL OWNED SCHEDULED
A AUTOS
UTOS ION -OWNED
X HIRED AUTOS. ' UTOS
A
AFN012383605
BDNCVK
4/25/2011
4/25/2012�
/�W20 I 2
2'013
b
13INtU INULtLINIII I
Ea aocIdert? $1,000r000
BODILY INJURY (Per person) $
BODLYINJURY(PeraccIdent) $
PRO TY DAMAGE
(Per :gQ) $
$
UMSkELL4.UAEI
EXCESS UAS
Rr;TENTIQN.$
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED ]-.I
B
WORKERSCOM PENSATION
ANDEMPLOYEAS'UABIUTY YIN
ANY PRoPniEToR0AA*Emxr=cuT1VE r --I
OFRCERJMEMBEREXCLUDED?,
(Mandatory In NH)
stdoscribo under,
D RIPTION OF OPERAT ION& betow
N/A
4C0690570 .9/12/2011.
3/102012
. .
;S-T—A
X LIMT� I H-
I 1WCR OET
E.L. EACH ACCIDENT $50Gt0D
E.L. DISEASE - EA EMPLOYEE $500;0Q0_
L. DISME - POLICY LIMIT $5QQj00
DESCRIPTIONOF I LOCATIONS I VEHICLES (Attach ACO RD 101, Addlilonal Remarks. Schedulo, III more spa oe larequiredi
0
CERTIFICATE HOLDER CANCELLATION .
0 1988-1010 ACORD CORPORATION. All rights'rtserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED2EFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE wrrH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
0 1988-1010 ACORD CORPORATION. All rights'rtserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD