HomeMy WebLinkAboutBuilding Permit #819-13 - 43 LISA LANE 5/30/2013TOWN OF NORTH ANDOVER
�-13
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 0
IMPORTANT: Applicant must complete all items on this page
LOCATION f1 . _. L o sv
` Print
PROPERTY OWNER ( I `! !/ Al' pti. . . E ✓LI c & �" d 2 ; �--
fPrinf 100 Year Old Structure yesnno
MAP NO: 1'9 PARCEL: � ZONING DISTRICT: Historic District yes
Machine Shop Villaqe v e s
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
GI -Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
UWater/Sewer
DACI,
DESCRIPTION OF WORK TO BE PERFORMED:
Aft �zoow,
Identification Please Type or Print Clearly)�j V
OWNER: Name:__ C tt g e- a L ►� v 2 EV 'L� � A 0-1 hone: �' 99_
Address: y `3 �- � S R L N c U 04
CONTRACTOR Name: KWP-7-1 �' Kc t: �-' Phoneq 7 iG?1-2� 201
Address
E,,.,J ,411 A VIE;
,Itln _ q d -J J e ✓ 11?1f O i�YS
Supervisor's Construction License: --5 A 2 Exp. Date:. %
Home Improvement License: /0 S 3 S,:5
Date: 9 - l
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CQST BASED ON $125.00 PER S.F.
Total Project Cost: $ �i ,S� ,�I Y ° FEE: $ -6. 04 O
Check No.: ��� �� Receipt No.: 2- A 3
NOTE: Persons contracting with unregistered contractors do not have access to the guar mty fund
'Signatureof Agent/Owner Signature of contrac
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans ❑
--w
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
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
Planning Board Decision: Comments
Conservation Decision: Comments
Wates` & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer:
Locatea jts4 usg000 btreet
FIRE'DEPARTMENT - Temp Dumpster on site yes no
Located at'124 Main"Street
Fire Departinent,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
E3 Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
Li Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Li Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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 Family)
o Building Permit Application
o Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
L3 Mass check Energy Compliance Report
Li 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 appal 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: Doc.Building Permit Revised 2012
Location 4 ✓
No. 19 — ` 3 Date
Check #–I
26453
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $, v�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
I I-rw
f
/Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 45,517.00
m
$ -
$
546.20
Plumbing Fee
$
68.28
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
68.28
Total fees collected
$
782.76
43 Lisa Lane
819-13 on 5/30/2013
Remodel 2 Bathrooms
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KEEN CONSTRUCTION CO. GP PROPOSAL
21 HEWITT AVENUE
NORTH ANDOVER. MA 01845
Tel (978) 691-5201 All home improvement contractors and subcontractors
engaged in home improvement contracting, unless
Fax: (978) 682-3231 specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered' with
Submitted h; 1,9 , the Commonwealth of Massachusetts. Inquiries about
To: IV4.1 -_0_ 4 _—___�_ registration and status should be made t the Director,
/ Home Improvement Contract Registration, One Ashburton
-_... ... .__..... ..... .... Place, Room 1301, Boston, MA 02108 (617) 727-8598.
Owners who secure their own construction related
permits or deal with unregistered contractors will
-----�(- - -- be excluded from the Guaranty Fund Provision of
MGL c. 142A.
PHONE DATE REGISTRATION NO. EIN No.
J�I/�,� �� MA. H.I.C. 108383 L26-0462904
C/S =Customer Supplied S + I =Supply +Install L' See Attached Appendix A
We hereby submit specifications and estimates for work to be performed and materials to be used:
..._
r �
-- -- - - ---- — -- _._.. - -----
> Construction related permits: -- ---�---------'"' ---
................_..___........................._..__._....-.....___._......._._............__._....._....._...................................................._.
WORK SCHEDULE .................................
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or
about (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (date). The Owner hereby
acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement.
WARRANTY , The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of � following completion and shall
comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contracto , his subcontractors, employees or agents, is
discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied,
repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
WePropose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of
f C ( I <ti tii'�' a tC�() 7�F'1 Fi- fc H0y,\�:dtCy Lt�V! ! C i� - _-Tollars($
Payment to be ade as follows: P ,
_ % ($ ) upon signing Cr ct; KENNETH B. KEEN / ROBERT A. KEEN
Name of Conlraclor / Designated Registrant
% ($ ) RCT
tq f S 21 HEWITT AVE.
°� Street Address
($—)tionofN. ANDOVER MA 01845
City /State
shall be made forthwith upon (978) 691-5201 (978) 682-3231
(` ! ) completion of work under this contract. Phone
Fax
Notice: No agreement for home improvement contracting work shall require a
> down payment (advance deposit) of more than one-third of the total contract price Name of sal sm_
or the total amount of all deposits or payments which the contractor must make, in
i
advance, to order and/or otherwise obtain delivery of special order materials and Aemeneeaatgna�yre� ,.; Z - —•
equipment, whichever, amount Is greater. NoteThis proposal may be withdrawn by us it not accepted within days.
Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated.
I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of
this transaction. Cancellation must be done in writing.
DO NOT SIGN THIS CONT ACT, IF THERE ARE ANY BLANK SPACES.
Pj� 1
Signature Date Signature Date
IMPORTANT INFORMATION ON BACK ►
�e+eauawx3aaWh+at�p�>.u,xkWk{Q'.uA n,xw.vr:5'Fs ay4..lau�eN3w' n.+�+oa.+k�'.�rc%"a�rl�wt�',B�iuiiSY"?.G'`»ry3'ui�ay:�".a�e"a�a^" � raft i�.;�R,Au:stw�✓.u.ciSSxR«D' :»�:W.Sr.:,.ren.r�wnvw,:mR�`sh'.sa3..'vOkaa+�u�r.i�. �X+�
KEEN CONS MUOTON Co.
21 NEWI T AVE.
N. ANDOVER, Mit 01845
978-691-5201
Kee n.Constwu,c u v cc- cane
Neyman, Laurie and Eric
43 Lisa Ln.
N. Andover, MA 01845
978-682-3544
Contract # 5079; Appendix A May 16, 2013
Remodel Bathrooms:
• Remove and dispose of all fixtures and wallboard to studs in both second floor bathrooms
• Reframe walls in main bath to outside of existing linen closets
• Supply & install insulation to code
• Supply & install blueboard on walls and ceiling and skimcoat plaster to smooth finish
• Supply & install cabinets and related trim in both baths as selected by customer on 4/28/13
from Jackson Kitchen
• Supply & install three Harvey Classic vinyl replacement windows
• Supply & install trim on doors, windows and base to match existing
• Paint walls, trim (two neutral colors, two coat finish) and ceilings in both baths
• Supply & install tile floors in both baths as selected by customer from National Tile on quote
dated 4/30/13
Plumbing:
• Supply & install all fixtures as selected by customer from Peabody Supply on quote # 324862
dated 4/22/13
• Supply & install and necessary drains, vents and supply lines for fixtures
Electrical: ($2000.00 allowance)
• Supply & install outlets to code
• Supply & install customer supplied fixtures and all related boxes and switching
• Supply & install one recessed light fixture in master bath
• Supply & install two Panasonic fan/light combination units
Total Price: $ 45,517.00 (forty five thousand five hundred seventeen dollars)
Price does not include cost of permits, lighting fixtures, work in walk-in closet, changes required by
inspectors, or any unforeseen unsafe, inadequate or unusual conditions.
KEEN CONSrFUCiION CO.
21 YE117rAVE.
N. ANDOVER, MA 01845
978-691 -5201
Xem,Co-watructwnn.Co: com
Payment Schedule: $10,000 due upon signing contract (for special order items)
$6,000 due when rough plumbing fixtures are delivered
$3,000 (plus permits) due the first day of work
$6,000 due when finish plumbing fixtures are delivered
$3,000 due when main bath has been framed
$3,000 due when main bath is finished
$3,000 due the first day of work on the master bath
$3,000 due when master bath is demoed
$4,000 due when master bath is plastered
$4,517 due at completion of contracted work
j
Customer /) Ke a hCB. Keen
i
Date ! Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ir 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibl
ky
Name (Business/Organization/Individual): _ ee-ej OD NS L /Ly r �j7�/-�
Address: a t 141^ w yc"
City/State/Zip: !`', J JQL/&. 44.4 O! SgXPhone #: 9 7<? Oy
Are you an employer? Check the appropriate box:
L [q1 am a employer with __/__—
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
rwy appucant tnat Meeks box 41 must also fill out the section below showing their workers' compensation policy information.
f 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 their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: r 2
Policy # or Self -ins. Lic. #: G I. 136 7(EDate:
/ Expiration
Job Site Address: y 3 L !t5 A Z two E City/State/Zip:-P—.
Attach a copy of the workers' compensation policy declaration page (showing the policy number 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.
I do hereby cern fyunder the pa� s and penalties of perjury that the information provided above is true and correct
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
.r'
Board of Buildin!o Re�-ulations and Standards
+' Construction Supervisor License
License: CS 76691
ROBERT A KEEN
12 E WATER ST 4
N ANDOVER, MA 01845
Expiration: 8/16/2013
( ununissiuncr Tr#: 3772
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction SuperN icor
License: CS -058245
KENNETH B KEN r- - ��✓. ;.
21 HEWITT,VE#��
N ANDOVER Mg18j4j5
ae
T t
1
. Expiration
Commissioner 03/24/2014
�efie rpan��r�ioau�seccl� o�G�acre/X�
Office of Consumer Affairs & Busifiess Regulation
OME IMPROVEMENT CONTRACTOR
1 - egistration: .08383 Type:
iration:
Kenneth Keen
21 Hewitt Ave
No. Andover, MA 01845
DBA
a
Undersecretary
U4/16/LU1J Ua:ZU YAA 761 U42 2226 GILBERT INSURANCE 19001
A�'� CERTIFICATE OF LIABILITY INSURANCE
0118/201rc3
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 terns and conditions of the policy, certain policies may raqulre an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PROULIM
Gilbert Insurance Agency, Ine,
137 Main Street
Reading MA 01867-3922
nc Barbara McDonough
PHONE (781) 942-,2225 FAX No- 1781)942-2226
anRle :bmcdoncrugh@gilbortinsurence-cam
INSURERS AFFORDING COVERAGE NAIL 0
INSURERA-NORFOLK 6 DEDHAM INSURANCE 23965
INSUREo
Keen Construction Company
21 Fiewi tt Avenue
North Andover MA 01845
INSURER B :Travelers ins. Co. 0031
INSURERC:
INSURER 0:
INSURER E: '
INSURER F :
COVERAGES CERTIFICATE NUMBER:CL1341800232 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 INSVRANCE
ADOL
UHR
POLICY NUMBER
MIO DOY EFF
POLICY E%v
LIMITS
GENERAL UABIUTY
EACH OCCVRRENCE I S 1400,000
A
XI COMMERCIAL OENERAL UASILIYY
CLAIMS•MADE FX7 OCCUR
-P-010078/000
/13/2013
/13/2014
RETE57
PREMISES iEn owirmno"I S 100,000
MED EXP (Anyom Derson) $ 5,000
PERSONAL& AOV INJURY 8 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCYS - COMP/OP AGG S 2,000,000
PRO• LOC
X POLICY 7
S
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT ,
ANY AUTO
BODILY INJURY (Per Person) I $
ALL
AUTONEO SCHEDULEDBODILY
SUT
INJURY (Pe/ accidenh i
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
tPoraccidont S
S
UMBRELLALN\B
OCCUR
EACH OCCURRENCE I S
EXCESS UAB
CLAIMS -MADE
AGGREGATE b
DED I I RETENTIONS,
>s
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY I AOPRIETOR/PARTNER/EXECUTIVEE.L
OFFICER/MEMBER EXCLUDED7 �
(ARandatory in NMI
if yes. describe Imder
N / A
6KuB-580326-A-12
-
/3/2012
/3/2013
WC STATU• DTI+
EACH ACCIDENT $ 100 000
E.L. DISEASE. EA EMPLOYEE S 100,000
E.L.D{SEASE -POLICY LIMIT 3 500,000
DESCRIPTION OF OPERATIONS Delow
I
I
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addltlenal Remarks Schedule, If more space is Iequleed)
Evidence of Coverage
GER I WICATE HOLDER CANCF1 I ATInN
ACORD 2t1 (2030/UO) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2oloonvi The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Evidence of Coverage
ACCORDANCE WITH THE POLICY PROVISIONS. !
AUTHORIZED REPRESENTATIVE
M Gilbert, CIC/BARBAR !
ACORD 2t1 (2030/UO) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2oloonvi The ACORD name and logo are registered marks of ACORD
U4/16/2U13 U8:26 YAA 761 842 2226 GILBERT INSURANCE io001
'4CORIG�® CERTIFICATE OF LIABILITY INSURANCEF4/10/2013
��
DATE(MIWODMIYV)
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 pollcy((es) must be endorsed. If SUBROGATION I$ 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
Gilbert Insurance Agency, Inc.
137 Main Street
Reading MA 01867-3922
="'Barbara McDonough
PHONE (781) 942-2225 FAX
AIC No -11B1)942-2226
E-MAIL :bmcdonough@gilbertinsurance.cam
INSURERS AFFORDING COVERAGE NAIL q
INSURER AXORFOLK & DEDH M INSURANCE 23965
INSURED
Keen Construction Company
21 Hewitt Avenue
North Andover MA 01845
INSURER B :Travelers Ins. Co. 0031
-INSURER C:
INIURER0
INSURER E
INSURER F,
COVERAGES CERTIFICATE NUMBER:CL1341800232 REVISION NUMRFR-
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 AFKORDED 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
SUOR
POLICYNUMBERMIOUODYEFF
/13/2013
POLICYEYP
/13/2014
LIMITS
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
-P-010078/000
EACH OCCURRENCE I S 11000,000
RENTED
tmcA a b 100,000
MED EXP (Anyone perben) S 5,000
PERSONAL &ADV INJURY S 1,000,000
GENERAL AGGREGATE b 21000,000
GEMLAGGREGATE LIMrYAPPLIES PER:
X POLICY 7 P1EP1 1:1 RO LOC
PRODUCYS- COMPIOPAGd b 2,000,000
b
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED H SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person) S
BODILY INJURY (Pel accidenlj S
PROPERTY DAMAGE
Pa,mrddont)b
8
UMBRELLA UAB
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE j S
AGGREGATE b
DFO I I RETENTION
S
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIFTOPUPARTNEII&XECUTIVE
OFFIGERIMEMBER EXCLUOE07
(Mari Lary M NH)
It yes. describe under
DESCRIPTION OF OPERATIONS Wow
NIA
6RUB-SE0126-A-12
/3/2012
/3/2013
WC STATU- OTM-
E.LEACHACCIDENT 5 ZOO O00
E.L DISEASE • EA EMPLOYEE S 100,000
E.L. DISEASE - POLICY LIMIT 3 500,000
I
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It mon: space Is required)
Evidence of Coverage
CERTiFiCAT t HOLDER CANCEL I ATlnhl
ACORD 25 (2010105) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2a1Dv5),9i The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Coverage
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVIg1ONS. I
AUTHORIZED REPRESENTATIVE
M Gilbert, CIC/BARBAR
ACORD 25 (2010105) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2a1Dv5),9i The ACORD name and logo are registered marks of ACORD