HomeMy WebLinkAboutBuilding Permit #630-2016 - 46 RUSSETT LANE 11/19/2015/I-2 S- 1,5-
Permit
S
Permit NO: 0 b
Date Issued:
LOCA
s �
BUILDING PERMIT
TOWN OF NORTH ANDOVER
l' n APPLICATION FOR PLAN EXAMINATION
'f' Date Received
IMPORTANT: ADDlicant must
nt
all items on this
PROPERTY OWNER k. -149D) l a m f nGAI A
ID f /p4.4 ~Doq - Print
MAP NO: 104A PA CEL:DoaD•DZONING DISTRICT:Historic District
Machine Shop Vil
yes no r
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Re 'dentia)
Non- Residential
❑ New Building
Vone family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Iteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
Others:
❑ DemoRion
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
REPLACEMENT OF 14 WINDOWS - NO STRUCTURAL CHANGES
Identification Please Type or Print Clearly)
OWNER: Name: CAROL ZAMPROGNA Phone :978-886-1211
Address: 46 RUSSETT LANE NORTH ANDOVER, MA 01845
CONTRACTOR Name:
JAMIE MORIN Phone: 508-351-2200
Address: 86 GARDINER ST LYNN, MA 01905
Supervisor's Construction License: 090125 Exp. Date: 10-6-16
Home Improvement License: 170810 Exp. Date: 12-23-15
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
01%-6Total Project Cost: $ 23,372.00 FEE: $ U
Check No.: '1 Receipt No.:
NOTE: Persons contracting wit unre 'stered contractors do not have access to the guarantyfund
ature of contractor
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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
Wates' & Sewer Connection/Sic
nature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
E D,EPAR°' T ENT TCemp D`umpsteron#site�es, y i "' Y` ��
3tedt24ICIUlaihS�frge`r
e part entsi f'
d t
atu re f77
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
MGL Chapter 166 Section 21A —F and G min.$100-$1oo0 fine
NOTES and DATA — (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
DOTE: 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
TOTE: 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)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
TOTE: 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 Clerics 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 2014
Location
No. Date
Check # 1 T�
TOWN OF NORTH ANDOVER �
Certificate of Occupancy $- j
Building/Frame Permit Fee $2&Lr—
Foundation Permit Fee $—
Other Permit Fee $
TOTAL $
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Renewal
byAndersen.
WINOOW RE►eACENENT .t.Anlerv,.t_...,a"t
'Buver(s) Name
MA (Home Improvement Contractor
Renewal b Andersen Corporation License #170810 (Expires 12123120' 5)
Y Federal Tax ID #41-1918413
30 Forbes Rd. Northborough, MA 01532
(508) 351-2200 Fax (508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Date:
I CAROL ZAMPROGNA - TRAVIS HOLLAND OCTOBER 28, 2015 1
IBuver(s) Street Address Citv State Zio Code I
I 46 RUSSETT LANE I NORTH ANDOVER MA I 018415
)Email Address Home Telephone Number Work/Cell Telephone Number I
TRAVISOTRAVISHOLLAND.COM 978-886-121 / I 978-486-4048
,er(s) hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation ("Contractor'), in accordance with
terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively, this "Agreement").
,er(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Total .fob Amount S 23,372
Deposit Received (33%) $ 0.00
urn anartcedS 23,372
Deposit at signing S 11,686.00
Est, Start Date
Method of Payment
Check/Cash
10- i2weefrs
Balance Start of Job (33%) S 0.00
Chat* #
Balance on Substantial
Alsutsaaial
Est. Install Time
Credit Card
Completion of Job (33°.6) S 0.00
Completion S 11,686.00
2-3 days
If credit card is s0lacted, please
Io teal paymort sense be demanded tral at wt; -s are saosoea
see Credit Card PaymerA form
is) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbal understandings
ling or modifying any of the terms of this Agreement No alteration to or deviation from this Agreement will be valid without the signed, written consent
h Buyer(s) and Contractor. Buyer(s)hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has
rod a completed, signed and dated copy of this Agreement, including the two attached Notices of Cancellation, on the date first written above and .2) was
Informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
by Andersen Corporation
Signature of Consultant
WILL SALEM
Primed Name of Consultant
Buyer(s)
,ature
CAROL ZAMP,ROGNA
Printed Name
Buyer(s)
Signature
TRAVIS HOLLAND
Printed Name
YOU. THE BU1'ER(S), MAY CANCEL TNS TRANSACTION AT ANY TIME PRIOR til MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
NOTICE OF CANCELLATION I NOTICE OF CANCELLATION
Date of Transaction f"Pw13 . You may cancel this
transaction, without any penalty or obligation, within three business days from the
above due. If you cancel, any property traded in, any payments made by you under
tithe Contract of Sale, and any negotiable instrument executed by you will be
returned within 10 days following receipt by the Contractor ("Setter") of Ivor
cancellation notice, and any security interest arising out of the transaction will be I
canceled. If you navel, you most make available to the Seller at your residence, in 1
Isubstantlally as good condition as when received, any goods delivered to you under I
this Contract or Sale; or you may, if you wish, comply with the Instructions of tke I
Seller regarding the return shipment of the goods at the Sellers espouse and risk. I
If you do make the goods available to the Seller and the Seller does not pick them up
within 20 days of the date of your Notice of Cancellation, you may retain or dispose
1of the goods without any further obligation. If yon fin to make the goods invariable
oto the Seiner, or if yon agree to return the goods to the Seller and faD to do so, Wen
you remain liable ror prAormeace or all obligations under We Contract. To caned
�tbis transaction, mail or deliver a signed and dated copy of this cametlation notice
or any older written notice, or send ■telegram to (:ontractor. Renewal by Andersen,1
�30 Forbes ltd. Northborough, MA0159L
1I1 H£AEEY CANCEL TiiIS TRANSACTION.
I 1
bv,ere Strom ad. Nene Dere
Date of Transaction 10/2w l5 . Yon may cancel this
transaction, without any penalty or obtigation, within three business dams from the
above date. If you cancel, any property traded int any payments made by you under
the Contract of Sale, and any negotiable instrument executed by you will be
returned within 10 days following receipt by the Contractor ("Seller") of your
cancellation notice, and any security interest arising out of the transaction w01 be
canceled. If you caned, you must make available to the Seller at your residence, In
substantially "good condition as when received, any goods delivered to you under
this Contract or Sale; or you may, if you wish, comply with the instructions of the
Seller regarding the return shipment of the goods at the Sellers expense and risk.
If you do make the goods available to the Seller and the Seller does not pick them rap
within 20 days of the due of your Notice of Cancellation, you may retain or dispose
of the goods without any further obligation. If you fall to snake the goods available
to the Seller or if you agree to return We goods to the Se11er and fail to do so, Wen
you remain liable for performance of all obligations under the Contract. To cancel
this transaction, mail or deliver a signed and dated copy of this cancellation notice
or any other written notice, or send a telegram to Contractor. Renewal by Andersen,
90 Forbes Rd. Northborough, MA 01592.
1 HEREBY CANCEL. THIS TRANSACTION.
a",ork floe
Renewal�,;
byAndersen.
winoow RErLACEMENT uI.1„J.-k.v-
Btivvr(s) Name
Renewal by Andersen Corporation
30 Forbes rd Northborough, MA 01532
(508) 351-2200 Fax: (508)-988.7072
Window Specification Sheet
MA Home Improvement Contractor
Ucense #170810 (Expires 1 2123120 1 5)
Federal ID #41-1918413
Date of Agi-c rinent
CAROL ZAMPROGNA
TRAVIS HOLLAND
I WED, OCT 28, 2015
•l`hr hupegs) listed alkwe hembyjuinth• and severally agree to purrintse the goods and/or services lismd lk-low, ill accordance i.ilh the prices and terms duscrilk-d
fill the Sprcific•ation Sheet and the front and the retelse of ille acconepanying CUS'T'OM WINDOW AND DOOR RG.\10'UL L1.N(, :1GRLEUGN`l; or which
the Specification Sheet is pan.
WINDOW & DOOR DETAILS
Alp, µ1n, App. ExtodorAntedor Cola Hardware Hardware LowN / CAse GIRb Glass
Room 11 ww-.h heWit u.L Window/Door PWe Detail Cass Ext -Int Cola Style Screeds Smartsus Guiles Sas: 1/3 Sash 2 Lifts Options
Uvinq 100 35 55 90 DB square equal full frame Ext. Wrap HNtM White Standard FTS Low -E4 GBG 4/2 4/2 No 3ot. Tem
Living 101 50 55 105 PW full frame Ext Wrap NH/WI- None tow -E4 None No Temper
Living 102 35 55 90 D8 square equal fun frame Ext. Wrap H/W White Standard FTS Low -E4 GBG 412 4/2 No . Tem
Dining 103 30 50 80 1 DB sq rail equal insert sloped sill L -Trim HNVH White Standard FTS Law -E4 GBG 3/2 3/2 No No
Dining 104 30 50 80 1 DB sq rail equal insert sloped sill L-TrimNH/WH White Standard FTS tow -E4 GSG 3/2 312 No No
Dining 105 30 50 80 OB sq rail equal insert sloped sill L -Trim NHIWH White Standard FTS Low -E4 GBG 312 3/2 No No
Kitchen 106 40 44) 80 CD insert L -Trim NHfWH White Standard FTS Low -E4 mor. No No
Bath 1 107 30 50 80 GW fL4 frame tato L -Trim NHIWH White Standard FTS Low -E4 more No No
Launcky MR 30 50 80 GW full frame Info L -Trim w4twi-il White Standard FTS tow -E4 N— No No
Family 10 30 50 80 OB sq rail 021 insert sl2eSd sill L-TrimVH/W)- White IStandard FTS Low -E4 Gas 312 312 No No
Family 110 30 50 80 DB sq rail equal insert sloped sill L -Trim White IStandard FTS I Low -E4 GSG 3/2 312 No No
Family Ill 30 50 80 DB square equal full frame Ext. Wrap White IStairdard FTS I Low -E4 GaG 1 412 412 No No
Family 112 30 50 80 08 square equal full frame Ext. Wrap HW White Standard FTS Low -E4 Gap 412 4/2 No No
Entry 113 1 24 24 48 PW full frame Ext Wrap NHM- -- None Low -E4 Node No No
'total 14 BAY BOW & BUILD OUT DETAILS
th Approx. Number Frame Window End Center LowE I Roof / Kvdware
Style W / wk /x
Room Count style Flankors hajobt Casirlfs Angle Litss Interior ExtAnt Cola Grilles sashes sashes Sailers SmartsLn Soffit Color
SPECIALTY WINDOW DETAILS
Full/ Approx. Lars/ spociatty, BAY/BOW ADDITIONAL WORK NOTES
Room Count St a insert U.I. Sma tSw Grilles Grille Style Extnnt Color t:alclnrrr 1. a1,alr Ih.%, illi, Ira,/Ix ria Niniki unrk'r 72 in 1—
Illrre al ill 1—it,06 — RL- lane.
ADDITIONAL WORK DETAILS:
` I No Contractor will wrap exterior casings with coil stock color of
2
Owner is aware that Contractor does not do any painting/staining or removallinstallation of alarm system or window, freatments/hardware. it is the responsibility of
the homeowner to have the alarm system and window treatments/hardware removed prior to installation. We make no guarantee as to whether alarms or window
freatmentslhardware will tit after replacement Customer fs also aware in some cases there will be glass loss. If there is, the amount will be dependent on the type
of existing windows, type of Installation and window style. We make no guarantee as to the amount of glass loss. Customer is aware and understands any and all
unseen rot is not included In this contract. Should any rot be found there will be an additional charge for time and materials unless so stated in this contract
3 yes Contractor will Insulate. caulk and seal windows with 3 -point system to prevent water and air infiltration. Removal and disposal of all job related debris•
windows, doors, storm windows and vacuum nightly included. Upon completion of the job and payment in full, a limited warranty shall be issued.
I Yes Building Permit --Contractor will secure any and all necessary permits. The fee for the permit(s) is included In the total contract price.
i Yes All discounts have been applied to this agreement.
ei 1i•v No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment /finance form(s).
Ili k agnrd :uul unrk• 1-1 In and 1.1—m 101' par4rc llcu Ihis SIN•rifta Galion Sheii. along t ith the CUSTOM WINDOW AND DOOR RE\1017MA'NG At:REh,\JI7, L. t'mmimifs III,-
hrany tarry uul", "Kil clw kg; :Ile in acriiing and .signed 1>,- INalt cite Rulrn; l and Contruvor. Higt- sA Rent) arknot,led{e ilial Ru) -Ksl ha.. n-rA 116a SIN•rilh-Alien sim.l.
any
Renewal by Andersen Corporation Buyrr(v; Ru)eYel
Signature of Consultant z Signature Signature
WILL SALEM CAROL ZAMPROGNA TRAVIS HOLLAND
Print Name of Consultant Print Name Print Name
Renewal
byMdersene
W1NOOW' REPLACEMENT Rn Mdetaen(;nmgany
N,Ie Fv*moo,, Wood/Vinyl Composite IF
Dual Argon Low E4 StnartSun
••�,,��••, *� Double Hung
100-00473518-010
.ENERGY PERFORMANCE RATINGS
U-Factor (U.S)/I-P Solar Heat Gain Coefficient
0m29
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ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0.42
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ENERGY PERFORMANCE RATINGS
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Workers' Compen adon Insurance Affidavit: Builders/Contmetors/ElectritlQnal?lumbers
Amlicant b- for-m4don ,.. p1a ,Lunt Lbiv
Name (Busit=0ganizationtlndividual): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
City/State/lip: NORTHBORO,MA 01532 Phone : 508-351-2200
Are on an employer? Check the approprtate bo;:
L moi 1 snit a employer with30�µ 4. ❑ I am a geltor oontrerand I
employees (full and/or part-time) *
2. ❑ I am a sole proprietor or partner-
ship and hove no employees
working fbr me in any carAcity.
[bio worker' comp. insurance
required.)
3. ❑ 1 am a homeowner doing all work
myself [No workers' comp.
instn� ....ce required.] t
have, hired the firth -contractors
listed an the attached smart. t
These sub-conttu/ors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of o mption per .MQL
c. 152, § 1(41, and we have no
employees. [No workers'
coma. insurance reauired.]
Type of project (ftgttir am:
6. [:]New con uction
7. V41temodeling
S. Q D4mo ition
9. ❑ Haikling addition
10.0 Fiertrii-al tapairs or additions
1 i.[] Plumbing repairs or additions
12.❑ Roofrtpairs
13.0 Other
*.My aphluaaot Ohm decks box # I mast aise flU our the sadioa tmlOW shnwing their worker' eonrpeasaliorr PolixY bdoraartioe,
t Howeawom who submit brit affidavit indicKins they aro doing AU work and Oben him outside a nnutacs osier submt a ma ad &vit tfts lft snob.
$;ontraators dost dr -a d is box must %tathed an additmw s metshowing the name of the aab-eoa� and ow waakm , am* poiiey ht =gtjam
1 ant an engdayer that & pnoviAW workers' compensation li=rence for rig+ J'M Bylaw b the policy dud job Oft
lnjbrmatiorr.
Insurance Company Name: OLD REPUBLIC INS. CO.-__ �4
Policy # or Self4ns. Lie. 0: _MQ 3054, _ _ JAphbon Lupe: 10-01-16 _
Job Site Address: 46 RUSSETT LANEC NORTH ANDOVER, MA 01845
ity StateOp:�a
Attach a copy of the workers' compt:usatba policy deeImflon page (showing the polky number anad expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pengitks of a
fine up to $1,5;00.00 and/or o46 -year imprisonment, as well as ch -11 penalties in the firm of a STOP WORK ORDER and 8 fine
of up to $250.00 a day aping 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.
608-361-2200
0,,�/ickl swe only. Do not wrote in 10 array to be caor*60d by c*. or Moan oJj'irlaL
City or Towa:
PermitaAcesse #
Inning Authority (circle one):
1. Board of Health 2. Building Department 3. City,/Town Clerk 4. Electrkal inspector S. Plumbing Impactor
6. Other
Contact Person: Phone
—'—,,w4R ANDECOR-01 YADAVYO
'4� �� CERTIFICATE OF LIABILITY INSURANCE °"�''11201f1YY'
10H12015
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: M the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed, N SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policy may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endo sement(sl.
Fnocuof Minnesota Inc NAMCER E Whits Certificate Center
CIO 26 Century Blvd PHONE• (877) 945-7378 Nc)• 888 487-2378
P.O. Box 906191 : certificateelamills.corn
Nashville, TN 37230-5191 AMNM
AFFORDING COVERAGE NAIL s
INSURED ER
INWRA:01d Re ublic Insurance Company 24147
INSURER 0:
Renmal
-
Renmal by Andersen LLC INSURER C :
30 Forges Road INSURER D;
Northborough, MA 01632 INSURERS. _
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 WTH RESPECT TO WHICH
THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TERMS,
ILTR
TYPE OF INSURANCE
POLICY NUMBER
M
LIMITS
A
X COMMERCIAL GENERAL LIAMUTY
CLAIMS-MADE III OCCUR
305140
10/01/2015
EACH ocCLxmoNcE =
1,0001
PREMISES Me oaaurlerge t
500.000
10101@016
MED EXP (Any am param) $
10,000
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1,000,
GEML AGGREGATE LIMIT APPLIES PER;
X POLICY JECT � LOC
GENERAL AGGREGATE !
4,000, 00(
PRODUCTS - COMPIOP AGG b
4,000,
OTHER
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AUTOMOBILE
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A
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6,000,00
BODILY INJURY (Perpanwn) $
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ANY AUTO
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10/0112015
10/01/2016
ALL OWNEDSCHEDULED
BODILY INJURY (Per mwkW t) S
AUTO$ AUTOS
HIRED AUTOS NON -OWNED
AUTOS
=
Per atriderlt
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UMBRELLA L1A8
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EXCESS LUIB CLAMS4IADE
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AND EMPLOYERVLUU31UTY YIN
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ANY OFFICEOPRIET R EXCLUDE �'
I N� NIA M30�700 1D10112015 10101
E.L.12016 EACH ACCIDENT
(Mandatory In NN)
Myn, deaorbe under
SCRIPTION OF OPERATIONS below
E.L. DISEASE - EA EMPLOYEE $
1,000
EL DISEASE -POLICY IJMR :
1,000,
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD I In. Addtlaral Ram ft acMdule, may ye aKaet" B mom apace Is roquYad)
RO07ICV-A'M Ur%1 nen
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATM
of Insurance I 1W9 �a
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered martcs of ACORD
r
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen-isor
License: CSMI25
AAM L 1110111M.%'
>t6 CARDEM Sr
LYNN MA 01995
Expiration
Commissioner 701088018
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'2t5 3upplemwit. r'
'1R O&WAL 8Y Ai+o"tll lOC Rftl tiilfi`bit�i
JAW MOM
104 0TIS STREET
WORThIBOROIgH; MA 02532 ,