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HomeMy WebLinkAboutBuilding Permit #516 - 40 MEADOWOOD ROAD 4/2/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 5Date Received Date Issued: v �tLev ,6' ryO\ of IMPORTANT: Applicant must complete all items on this page LOCATION iP Jj Print PROPERTY OWNER M or& ' all Print MAP NO: PARCEL: ZON1N'G 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 V ---Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: l,' an -9 In c -f— // /.40,) <,k r,-� OWNER: Name: Address: �16 CONTRACTOR Narne:14forke, Address:// � 7 Please Type or Print Clearly) 1i7a r� V /; p -' Ph( 041 ,r Supervisor's Construction License: % Exp. Dater t� Home Improvement license: Exp. Date: ARCHITECT/ENGINEER Phone: I 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: $ Check No.: %� Receipt No.:—,,� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 COtdMENTS 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 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 0 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 ❑ 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 ❑ 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: Building Permit Revised 2008 Location No. ` Date" NpRTh TOWN OF NORTH ANDOVER F Certificate of Occupancy $ CMUBuilding/Frame Permit Fee $' sASE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7 L? 2! 964 �( Building Inspector HIC #154326 BIN## 56-2618812 OLYMPIC Painting, Roofing & Siding office 978-535-0943 S15 Lowell Street — Peabody,MA 01960 facsimile 978-535-2008 4 Mark Gotobed Nexus tl Carpentry and Construction Design P.O. Box 2823 Woburn, MA 01833 (781) 760-2031 or (781) 760-2030 (978) 975-1263 (fax) Email: nexuscarvent aol.com Job Location: 40 Meadowood ir. tZI . North Andover, MA Dear Mark, March 13, 2009 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 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 32SF @ no charge, $60.00/sheet thereafter) L Install an 8 inch drip edge on all leading edges and rakes (color TBD) 4, Install 3' ice & water on all leading edges & valleys o transitional walls are optional and incur an additional cost for the siding repair (included in the price below) k Install new vent pipe flanges where needed 1. Install 15 pound felt paper on all areas that is not covered by ice & water shield l< install new 30 -yr Architectural shingles -,6 Install new ridge vent system only to areas that call for ventilation Additional Saecilrcauons Homeowner to choose color of shingles COLORckc-Q�-c.J\ +� DumjWer 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. We will remove all of the job related debris All work will be done in a professional manner, and timely basis o Exception: weather 1 We are not responsible for any of the cracks that may arise in any walls or ceilings . Please cover all your floors in your attic to protect from dust and debris l 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 6'd £9U 5L6 8L6 seoimeg 11 snxeN dL0:Z0 60 l0 jdV OLYMPIC Painting, Roofing & Siding office 978-535-0943 515 Lowell Street — Peabody, MA 01960 facsimile 978-535-2008 Initial the aft you are cl+oosln below.- Cost elow: Cost for Labor & Material for Roof: S6,600.00 Payment Terms: l 1!3 deposit upon signing contract S S• C"^�" 1/3 work in progress S n C C ' 113 upon completion S W Total Amount Agreed To Be Paid: $ •t' Remit to. Alpine Property Services Company, Ing, SISLowell St., Peabody, MA 01960 The following schedule will be adhered to unless circumstances beyond Olympics' control arise: Work Scheduled to Begin: 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 customer's satisfaction. Do not sign this contract if there are any blank spaces, (additional provisions follow and are incorporated herein by this reference) 9Z1,G4,t-� C-01-Va rL- David Ranson, Construction Manager Alpine Property Svcs. Co., Inc, d/b/a Olympic Mar bed us [I Carpentry Z'd MU 9L6 8L6 swimeS 11 snxaN clL0Z0 60 60 AV q • d QU X w v cn A w w U Cd w O o r� Cd a w" x o w �n c w" x o r� Cd w ZW w w v m z cn v cn c o m c w C c y I CS C c A O o m iy- 0 c o n 'uQ�fq o m O 0 ti 0 *� p * * os A� CD c E CL= o Z' �3p L_ Co y _m o a :_ CO) CA R O Ey v o ydV m y m rL... O O O C H Q L c 0 f m • V ,� O 0 Coc H a O � 1tOq m c c m ail CL. 0 N CD L WCO2 W 0 H •y m E Z CCm y O W •E Q •p C7 0 h O• cc O fl O F- t 2 d r=.. Cl 5 T Cf) O U Cf) 2 m ay CD 0 E L O Z CD D. O y Q C C I C C Ca Q y O O ._ m CO 0= Q L Cc 0 d a CMa c C* 4- c c O V J 'C7 CD ts Co C Z � V H O C C cc CO3 Cl O W W W U) s� The Commonwealth of Massachusetts Department of Industrial Accidents i ii rte. L Office of Investigations 4� 600 Washingo e n Street `• �. BOStO K, MA 62111 WWR'.mass.gOvldjQ Workers' Compensation insurance .Affidavit: guilde ArrpIicant Information rs/Contractors/Electricians/Piumbers Name (Business/Drganiztion/lndividual): Address: �/ City/StatelZip: �Gn � OHM Are you an employer? Check the appropriate box:' I an a employer with ,,5 4. ❑ I am a a =.,-neral contractor and I employees (full and/or part-time).* have hired the sub -contract 2. ❑ I am a sole proprietor or partner_- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work Myself [No. workers' comp. insurance required.] t Phone #: WS _c,9z3 ors listed on the attached sheet # These subcontractors have workers' comp. insurance. 5.. ❑ We are a corporation and its officers have -exercised. their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No .workers' comp, insurance re ui d Type of project (required): 6. ❑ New construction 7• ❑ RernodeIing . S. ❑ Demolition 9. ❑ Building addition 10:❑ Electrical repairs or additions I1.❑ Plumbing repairs 'oradditions 11D Roof repairs q re ] 13.7 Other *Any appiicant.thar checks boa # i .must also fill out the section below showing tieeir work6n compensation policy mrormation. t riomcowuei& whu submit .f lis atiidavit iuuicating 8iej' art; duiEtC' i :. , . `� a"u Even hi coniraeiurs roust su'omii a new xCrac[ ontors that check this box must attached an additi°nal sh°• • b ide eet showing the name. fthe -u atndavir indimting such. c naetors and their workers' ....l Uri. empwyer rnal U provudine WOlkerS' COmpetlSatlOK LoLSlllanCe information .for n9' employees. Insurance Company 4 Below is the policy and job Site Policy # or Self .ins. Lic. #: 4 6 vo o 75 y /o j ,�/ Expiration Date: / 5- /d . .lob Site. Address: liL�.tJ�/%Ll� � ,�e� City/State/Zip:_,&/_ lam/ Attach a copy of the workers.' compensation policy 8eelaration page (showing the policy Dumber and expiration date). Failure to secure coverage as required under Section 25A of imposition of crim - fine up to $1,500.00 and/or one-year imprisonment; as well as civil pe aloes in thleade to of a STOP WORT inal ORD penalties of a of up to 5250.00 a day against the violator. Be advised that a co ER and a fine Investigations of -the DIA for insurance coverage verification. of this statement ma} be forwarded to the Office of I do hereby certify "der the pains and panalda of perjurJ, that the information provided above is true and correct Signature: Date: DciaL use orelp. Do not write in this area, to be Completed h3, city or townfes[ City or Town: Issuing Authority (circle one): PermitlLicense * 1. Board of health 2. Building Department 3. City/Town (. Other Clerk 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone #: Information C. . d 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 ".. ever -y person in the service of another under any contract ofhire, 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 includirzg the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associafi on 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 ma-int,-nance, 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 v r local licensing agenc} shall withhold the issuance or renewal of a license or permitto operate s business or to construct buildings iu the commonwealth for -any applicant who has not produced acceptaf',ie evidence af compliance 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 ofthis chapter have been presented to the contracting authority." . Applicants Please fill out the workers' compensation affidavit comp,Vetely, by checking the boxes that apply to yoLr situation nd if necessary, 6n supply sub-ctractor(s) name(s),address(es)and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the members or partners, are not -required to can? workers' compensation insurance. if an LLC or LLP does have _ employees, a policy is required._ Be advised that this affidavit may submitted to the Departrnent of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffidavitshould 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 giiestions reg* rdirg the iaw or if you are r--qui:-ed to obtain a workers' compensation policy, please call the Department at the nm nbcr:iis+.ed below. Self insured co„ �panies should enter their self-insurance license number on the appropriate. line. City or Town Officiais Please be sure that the affidavit is complete and printed leg1 . 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 appiicant. Please be sure to fill in the permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitAiceme applications in arty given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Adcl -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 forfuture permits or licenses. Anew affidavit must be Riled out each year. 'A/here a home owner or citizen is obtaining a Ii cem— 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 like 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 Commonwtalth of Massaehus.tts I3epartm=1 OfL►dustrial Accidents Office of Lavestieations 640 Washington Street Boston; MA G21 l 1 Tel # 617-727-4900 e)ct 406 or 1-5.77-MASS.4FE Revised 5-26=05 Fax # 6.17-7-7-7749 www.mass.Dovldia ± 0 § .. 2f\ k)k »�7 . k]] - k k § k2 c 2-/Q y u Q \)2■ ;\ 7= - ®®2 a•©� o • « /2■0= \ ] \ �\ �) �\ ■ ■ � 0 ) F-cu \ c / u Q @ ) § z n � w M�,� » ■ Lon t > � »y« a ƒL §^ LU »§ ~W z � § z / I) \ u 'amo \ E5 \ D < o TIM ammommlld ollwawa t. Board of Building Regulatio s and Standar�ds� Construction Supervisor License Lice03e• .CS 98534 ' P ^,o �i�28/201I Tr# 98534 �t DAVID RANSON 12 RICHARDSON COURT METHUEN, MA 01844 Commissioner ' ,0gea c e{ a o�{y es the � ,k has°n :`y °m ate°� °{ iPs- 1 FSS evtre+�tk Code \ �G' ossess � $��{ato� t{ee°se 1V{assa {o�' tee ' is e��se 1 i OWWIffi CERTIFICATE OF LIABILITY INSURANCE °AT01103/2009- `' PRODUCER Phone: (617)8575110 Fele (897)657 112 THIS CERTIFICATE IS ISSUED AS A'MATTER;OF INFORMATION KNIGHT INTERNATIONAL. INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON' TME CERTIFJCATE 500 VICTORY ROAD HOLOER. THIS CERTIFICATE DOES NOT AMEND, EXTENp OR MARINA SAY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, QUINCY MA 02171 I INSURERS AFFORDING COVERAGE NAIL # INSURED ALPINE PROPERTY SERVICES GO.,INC. DBA OLYMPIC INSURER A. FIRST MERCURY INSURANCE CO. CERTIFICATE MAY BEISSUED OR INSURER B: SAFETY INSURANCE CLUSIONS AND CONDITIONS OF SUCH 11 WILSON STREET INSURER C: SALEM MA 01970 INSURER D: �. DAMAGE TO RBNrM $ PRU1Isw MA o0ao " 50,000 INSURER E: c occn row.0 I. ..t INSUHEU NAMED ABOVE FOR THE POLICI ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THII MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, E: POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR AOD LTR MS POLICY NUMBER TYPE OF INSURANCE POUCYEFFECTivE POLICY EXPIRATC DATE OAT/? MMA7 GENERAL LJABILJ7Y FMMA00186 06/14/08 06/14/09 X COMMERCIAL, GENERAL LIABILITY CLAIMS MADE a] OCCUR A X Blanket Ad6dionallnauredIncluded X Waiver or Srmroga0on included GEN'L AGGREGATE LIMIT APPLIES PER - POLICY PRO - X JET MLOC auTOMOUIL.EUA21LITY 2702661COMOO 01/09/09 01109/10 ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS B X HIRED AUTOS X NON-OWNEDAUTOS GARAGE LIABILITY ANY AUTO EXCESS I UMBRELLA LIABILITY CUMA000117 06/14/08 06/14/09 X OCCUR Fj CLAIMS MADE A 4E0'rIDEDUCTIBI.E eRS'1JABIUTY RETENTION s 10,000 OMPENSATION ANO Oescdm —aer AL PAOWMONS OAow DESCRIPTION OF OPERATIONSALOCATIONSAtEHIC(.FSAFTrr1 I.ICLONS ADDED RY ENDORSEMEN PERIOD INDICATED, NOTWITHSTANDING CERTIFICATE MAY BEISSUED OR CLUSIONS AND CONDITIONS OF SUCH UMITS EACH occuRREkE S 1,0001000 DAMAGE TO RBNrM $ PRU1Isw MA o0ao " 50,000 MED. EXP (Awry one person) g PERSONALS.AIDV•INJURY s -.1,000,000 GENERAL AGGREGATE IS 2,000,000 PROOUCTS�OMPlOPAGG. 5 1,000,000 COMBINED SINGLE LIMIT (Es accident) S 1,000,000 BODILY INJURY (Per Oersdn) $ BODILY INJURY (Per accident) g PROPERTY DAMAGE g . (Per socidcnl) AUT00NLY-EAACCIDENT - • S OTHER THAN EAACC g' AUTO ONLY: AGO S EACH OCCURRENCE $ 5,000,000 AGGREGATE s 5,000,000 s S WC $TATU- O1 -R TORY UMrr E.L. EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE-POLIC•YCIMIT S $10,000 DEDUCIBLE PER OCCURRANCE / SPECIAL PRnVLRIAAIs• SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAX 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT; SUT•FAILURE, TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY FOND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES, Attention: _ I ACORD 25 (2001108) _ Hardd &gh)t�� O ACORD CORPORATJON 1988 ,p I�•,,g6ylLUUy ud:4s ACORD CERT'IFICAT'E OF LIABILITY INSURANCE • ' HATE (MNUDD/YYYY) ' 01/06/2009 TM. EXPIRATION DATE THEREOF, THE ISSUING INSURER WILLENDEAV•ORTO MAIL10 DAYS PRODUCER Plane: (617)657-5110 Fa)c (617)657-5112 KNIGHT INTERNATIONAL INSURANCE GROUP 500 VICTORY ROAD MARINA BAY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIOWS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT.AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EACH OCCURRENCE S PREW ES ftz!ED 3 PAEMIB 9 Ea ocmla¢Q QUINCY MA 02171 AUTHORIZED REPRESENTATIVE } Harold igh��is�V INSURERS AFFORDING COVERAGE NAIC # INSURED ALPINE PROPERTY SERVICES CO., INC. INSURER A: Atlantic Charter insurance Company INSURER e: INSURER C: - DBA OLYMPIC 11 WILSON STREET SALEM MA 01970 IN ' INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE—P­OLICY PERIOD INDICATED, NOTWITHSTANDING ANY REOUIREMENT, 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 HEREM IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOUCED BY PAID CLAIMS. INSR TYPEOF INSURANCE POLICY NUMBER PGUCY EFFECTnIE POWCY EXPIRATION LIMITS LTR GATE WDO DATE AIWD GENERAL LABILITY EXPIRATION DATE THEREOF, THE ISSUING INSURER WILLENDEAV•ORTO MAIL10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE • LEFT, BUT -FAILURE TO DO SO SHALLIMPOSE NO OBLIGATION OR LIABILITY OF ARY ioNO UPON TH9INSURER, EACH OCCURRENCE S PREW ES ftz!ED 3 PAEMIB 9 Ea ocmla¢Q COMMERCIAL GENERAL LIABILITY AUTHORIZED REPRESENTATIVE } Harold igh��is�V MED. EXP.(Aeycnc parson) S CLAIMS MADE OCCUR PERSONAL & ADV INJURY $ GENERALAGGREGATE S PRODUCTS-COMP/OPAGG. • S GEN'LAGGREGATE LIMIT APPLIES PER - POLIGY JPROECT F-ILOC AUTOMOBILE LABILITY ANY AUTO COMBINED SINGLE LIMIT (Es exidenl) $ BODILY INJURY (Per person) S' , ALL OWNED AUTOS SCHEDULED AUTOS' BODILY INJURY , (Per Eaidem) 5 HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE 8 (PerEccident AUTO ONLY-EAACCIDENT OTHER THAN EA ACC S rA.'GELIABILITY AUTO AUTO ONLY: AGG S EXCESS I UMBRELLA LABILITY EACH OCCURRENCE 5 OCCUR ❑ CLAIMS MADE AGGREGATE S S ' DEDUCTIBLE S RETENTION $ S' ' WORKERS COMPENSATION AND • EMPLOYERS• LIABILITY A ANY PROFflM70RIPARrNEW0oXUrnE OFRCERnueNSEREXCEMED? WCV00754902 01105(09 01/05/10 TowumrB OTHER El, EACH ACCIDENT ' S $00,000 E.L.DISEASE-EA EMnOYEE S 500,000 "Y144/101 un4OVIeXO1rtiB BPECIALPg011ov EL DISEASE -POLICY LIMIT 5 .500,000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001108) Certificate # 8149 ID ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13;FORETHE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILLENDEAV•ORTO MAIL10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE • LEFT, BUT -FAILURE TO DO SO SHALLIMPOSE NO OBLIGATION OR LIABILITY OF ARY ioNO UPON TH9INSURER, TrS AGENTS OR REPRESENTATIVES. Attention: AUTHORIZED REPRESENTATIVE } Harold igh��is�V ACORD 25 (2001108) Certificate # 8149 ID ACORD CORPORATION 1988