HomeMy WebLinkAboutBuilding Permit #609 - 461 SUMMER STREET 4/12/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Coy Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
MAP NO: 1 P
Print
:ELS _ 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 PERFORMED:
Idgntification Please a or Print Clearly) `� v
OWNER: Name :��J1ti`'�,�(=��C� PI -
Address: s
CONTRACTOR Name: Phone:
Address
Supervisor's. Construction License: �� Exp. Date:.
Home, Improvement License: L'%; ri 'Exp. Date
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASAD ON $125.00 PER SA.
Total Project Cost: $ �l �lo� FEE: $ �� r
Check No.: �`i7� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
X
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:
a
i
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
L ocatea st54 uS ooa Jtreet
EIRE 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
❑ 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: Doc.Building Permit Revised 2008
Location
No.
Date
14ORTf4 TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
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Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
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04/07/2010 14:04 lbu"lybyUs KbA war ®vim
MAII1C.ix:cm+cM 11tIW1 (axpa•%v/7d/rnI
renewal RENEWAL AY Aw. FT -REN Fcderal7n> Intl 83•t1abA201
�f1Rd@iSe�. OF .,RrA� MMSACNUiMS AND NEW HAMM111KE
,�� ••�u"•"� a M^"�""c"""" I M 063 StreQ • NMIh(MtAU�h, MOS!aehnSCR3 01532
phone 50$,914,0900 •Fns 508.919.0903
gpECin ros 3k1Err
Dote of Agecement
lvcr*) Name It,
n accordance with the plicas
t Nuyer(•111 ttcd vc hereby jointly and aover'stly agh e r nt slid
the. goods andthelOr ac;COMPlisten � "OM WINDOW AND DOOR
a) d enmu deteribed on the Specificild0" Sheet and the front and the reverse of the aCCom}Anyi Z
Krh4LIM INGACVxM Of which thi+S `lfleation $heat is s )art.
Uowing Idividual quantities
1, trac or will IM4011 A total of _ w) ows in owncr'g home, I), In,,, the fOn
tsge sash (1 /3 tops 2/3 botimn) [j LNicl �nah (2/g top. 113 bottcon?15
Dtatillc bung Mll) 4 -;'r/un! !ash Cutndm:d hnndle. Metro handle
Casema)tt (CW) ligrV
e right lunge 1cR (es viewed ham ezp r�r):
Double C1lsemcnt (Ct)W) (1 Stendaxd handle [] MOMhandle Motor handle
�� Casement / Ficture / CAscmcnt (CFW) C31:1.1 or Q 1:2:1 ❑ Standard hendk Q
2 Lilt Gliding Window (GW)
Glider / Ficture / Glider WPW) Q 1:1:1 nr ❑ 1;2:1
Awning window (AW)
11crurr,. Winslow (rvV)
tiey or Dow Window
olio [+opts (tete separate Door Specification Sheol
2. 1rf��Y�y3 Qty of WindoWR to be Cu�t.mtt Fit. R
gcplaeeM)ent:
, C]Yes LTJ N/o Qiy of Sills to be replaced by Cal .6ctrn^ --
exterior cnsin
4. OYea (, 1Go Qy of Windowe to be New Construction Pull frame (includes new interim• fi ga)
rxtcti(rRina Q Maintelimce-fter. matcriAl Q Factory applied 908ritlrexbrickmold
5. (.lArang t0 be ( tF faw-It>D 5ntu��unTM (T)tr f}oelfti.�g11�k1 Q Other if ether, nlen!e y+neify. _
G. Fxterior color to be: tc Q Sand Q Cana.' [] Terrmone Q COcoa bean
1. h)tcrinr color to be: ""Hitt n Sand 0 CAnvat: [] Terratonc• Q Pine Q AAAplc Q Oak
Nate: In ' Or color can o111y be white, wnod or name color. so cxtcfiof" Wood Inluiors need m finished by Owner,
8. vnr •arc: White E) Stone 0 CanvAa Q 731.9eAA [kntble"UnIe
9. Yca Q No h)arn11 1IFq with tlontl+lc Nurnng �Winrlows AlumirnQTZPACeic
10, krccna: wil)dowa to have Q lialf or h�t'��" selects g, recta tD t,t: loco
GRILLE Db'FAnS
t r... iktwoen chane eeaatn
No if es: Grillc Gj ttcMov�L Intrrior wood moral [3 TO CNvldcd t.;ght Acta
1'I.Window.�vcgrille.+: ' • ❑ Y ��..
ox on ON CW.
1>raw grille patterAbove -Use additional shoot if needed pt°nta• nYPf'o'r�
s
AMMONAL WORK DIit'AUS
12. Q YcsfWNo Contractor will remove metal Albite' of windcn>va. Qty Of Unite:
t 3. Q No Contractor. will in3tall ncv� pmnt-ccady Or stAin-tsndy cneutgs. —
un a 9 .— Exterior casings qty of apenlnaa: _ 'nc �1 Mnintcnnncc-free material
lntc�ricKlcaaing qtv m oF`r+ 8 '
1 a. 3 Ya g3�Nc, CorteacIm- will Install new paint -ready or shun-trady inlaid ;or rnttcidc atc+p$ qfl of ne O nMa'nknence-free "atelia,
tntcrior atop,qty opcnuigs: Fxterior SIOp, qty Of
lsittlela
15. Owtttx is Aware that C-Micfar does trot de my paiskht3 color.
t d. ❑ t2e 0,00 Ctmtrnetor will wrap extraior toinga with Altunui r stock Of
Ate: Wraopittg may be requited with storM window removal: removal of stogy to nr�nt titter and 3 wit) leave retiv infiltin ration.
casing,
1 i. es ❑ No Contraetnr will insplatc, cam
and sent windows with 3-poittt!Y' p
18. Yes ❑ No A limited Warrmity Alkll be
issued to (lwrter upon completion of the job and payment in M. /D /
19. �Yca ❑ Nb Buil $ E ^�ntraetor will secure Any and all ne=3g,Y termite. The fee forfile pernutfU rpt
included in the t ontrAct 1 rice and A ecparare check la required nt the time of sate for. thin fee. Q0 C•l'1 AL
20. Additional job dCtaUs:
2 t. lea C No Qwner a&m.e' to be propmt on the final day M in;tnl101011 fm final ft>,n mr +cod to dCBvcx final pnyma+t•
Ab Awl pRp1lW1 shtl111x dwwndad and fhe eonhwre M onntlNctrd f0 fAt,rAtlrtAcriOnt of ell pAtYiet.
and between the (tint this spxifieation 3t , along with elm (:I=M WDOQW AND POOR
It is agreed and undeeteood by Pattie. the s, and tha+e are no ++uba1 underatandtttiga Nudging or
REMO17 UNG AGRZMM, conaataW the attire undo r0andtttg bctwM ptatis tartans Ingssue" u are
modif ng any of the tants. This oa Owd may trot be ehnttged or its ttttltos modified or varitld in any way
BuycrO) tees aotatowledp that BtpRt(s1 has raid this Spoat9catton Street.
in vvfitltK; and akgttAdlry bout the atter CanttAetor. B (s) basely
Reese by oderaen fes
and t (a) Buyers)
of k Manager �/ SLQtt Stigttl►tttre
Print Name Product Manger
Ptuit Name Fxint Name
RbA COPY - White Custtmter copy • Yoltow
b4/ b//'1171 i7 14.174 100071 DUJU :)
p,.,� MA Hir Utsnt, 0140401 levpitot 1/24110)
RpmeWdi �. -INFWAL By ANDERA' ' WgmlTom rots03"4201
SY/Qtldet5e11 ()r GR£ATu MAmAci;us sTTS AND NF.W H.AM'HI1n
w��enF gtrU�OtACMr ..A+�MIG.NM.
104 WR.Su o • Nnrthbravgb- MA 01:32
Phone 50R.91;1•0900 • Fox 308.919.0905
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
+ryr;r(s) hereby,joindy and uwtr111): agrees to purdmat. &w., products and/or aerviwx of J t@ L 4Yndowi, for,. dl)a Renewal by Andr.men of rn:an r
lawachimcmi ant{ New Hampshire ("Conrractor'j, in accardanco with the terms and rondidons described on the fronr anti die reverse ill" tii%
;mcmcnt and on thy. stlwhrd spcafication shccgx) (w0ectively,. this "Aprr1:tnent'7. Buyer(s) hereby agrees to sitni a completion rx,:rt+fir,:t ! t1Rc.•r
ontraetor has ornpletcd till work under thus Agreement.
rr 6? !1
Method of Pymnt: 0 Co.sh Q Check Q Mastereard O VISA
Total lob AmountlJ4 4'
Palma d 5lortme lo;
rz�
o Discover need. AppO
I �.
Deposh Racelved (33X):
-- - •
Nome on Credlt Cord:
Crcdlt Card 0:
Balance of $tort of ,lob (33%1:----.
ComPlm on Dob
Balance of Svbssa /'
� � LCA
Completion of 106 133%):., .._/_..__.
CC Eng. Dab,:
CC Sccuriy Code:
By initiaiint hrrr„ you AcknowledaC than the Balance at St.. Of Joh anrd d1c BatnncC nn SUbita.nlial Conipleaon
Soyer Haiti of 3„t1 rannot be made by rrr,64 yard and must be aimir by personal check. bank cht t;h. or cash.
oyer(e) agrceiiand understands that this ASrecmcat constitutes the eatirc understanding between the partiess and that.
;ere are no verbal understandings changing or modifying any of the terms of this Agreement, No akersdon to or de"PAon
om this Agreement will be vr&d without the signed, written content of both Buyer(a) and Controto"r. Buyer(s) hereby
toovardges that Buyer(s) 1) has road this Agreement, understands the tercets of this Agreement, and has received a
nnpleced, el"ed, and an” copy of thio Agme meat, including the two naached Notices of CnnCcllRtion, on the due first
ritoen abe.re ned 2) was orally informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF
HERE ARF ANY BLANK SPACES.
mewN by Andersen of Greater MA and NH Bayer(!+)
ipiaturc of Prodmt Manager K7 Si >x
Fr;nr N: Ire of Fro ret i +grr Print Namr.
Boycr(5)
SipAturr.
Prim Na.mr,-
)U, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MiDMGIIT OF THE THIRD
1SINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
)R AN EXPLANATION OF THIS RIGHT.
- - - - - �4TIC� OF CANCELL- ON - - - - - x - - - - --�SLOLC4NCELU_TIOtW - - - - -
tte of Transaction You may cancel I Date of Transadion You may cancel
is transaction w01of any penalty or obligation, within t this hanseefi wit�pentt�ti er ebllgation, within
ree business gays from the above dote. Oyou cancel, any three bushtos from the octave date. If you cancel, any
eperey traded in, any payments made by you under the i frD in, any payments mode by you under the
intrad of ale, and any ne�otiable instrument executed i Coritrai of Sale, and any negotia�bfe inskCA exowtod
will be reMntod within 10 days foilQvrirtf� receirt t isy xou well be rentrrted wt11►rn 10 days following race
the Senn of your cancellation notke, ata any security i by fhe Seller of your canceltoiian notice, and any sew
forest arising out of the transaction will be canceled. i interest arising out of the transaction will be cancel
you cancel, you must make available to the Seller at if you cancel, you must make evai'lable to the Seller of
err residence, in substarilially as good condition as i your residence, in substantially as good condition as
hen received, any goods delivered to you under this i Mien received, any goodsto you under this
intact or Sane; or yet may, ify ev wish, comply with the i Conhct bor Sale- or you may, s res; v�vish, eomplit with the
Wucl ions of the Seller regorubng the return sh of instructions of 16 Seller regardng the return ihipment of
e goads at the Stollens expense and risk. If you do make R the goods at the Seller's expwtao arxt risk. if you oto make
e goods available to the Seller and the ler does not the goods available to the Solley and Nie Seller does nest
dothrril up within 20 days of the date ofyour Notice pick them "'P within 20 days o6 the date of your Notice
Cancellation, you ttwy retain or dispose of the goods 1 of Cantel)p�, you may retain ar dispose of the goods
thout or obrgiation. If you fail to make tie i without art ► further obligation. If you fail to mance the
eek available to the Sugar, or if you agree to return the i goods available to the Senior, or if you agree to return the
ads to the Seiler and fail to do so, then you remain liable jods to the Seller and fan to do so, then you remain liable
r performance of aN dons under the Contract. tor performance of all obGgo/i ra; under tlt.e Contract.
cancel this transaction, iiia or deliver a signed and 1 To cancel chik tranagction, mail or deliver a signed and
hard copy of Nis conceSation notice or any other written i doted copy of this cancellation notice or any ether written►
tiee, or send a telegram to Renswal by Andersen i notice, or send o telegram to Renewal by Andersen
fsreoter MaasathuseNs and New H'�hire, 104 1 of *mow Massachusetts and Now Hampshire, 104
Is Strom' Nor" 0 AA 01532, NOT t,ATSR THAN l Offs Street, Notthbafoujh, MA 01532, NOT LATER MM: OF +� (Date) , MIDNIGHT OF —, . i (Date)
MMY CANCEL THIS— NSAIMON. I HEREBY CANCE(THIS TRANSACTION.
wanr► zWA" ore. l reseiuuart Sionotwa of"
MA Copy. Whitc Cm-twtner Copy - Yellow Cu3tonier Copy - Pink
The Commonwealth -of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
c www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Business/Organizadon/Individual):
Address:. . z✓i� ---
City/Sfate%Zip: /VOf � bo ro , ,� Q1. �� Phone #: U��
Are you an employer? Check the appropriate box:
L aI am a employer with JC)
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, *§. l (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7.modeling
8. Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other .
*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 their workers' comp. policy information.
Iam an employer thatisproviding workers' compensation insurance for my employees Below. is the policy and job site
information. nnnn j�
Insurance Company Name: �,' J1 / (' f)2 n» l f1 Cts ✓G Y1 C t�'
Policy # or Self -ins, Lie. #: �J 1�J�c� �� /`%`f Expiration Date:
La�.
Job SiteAddiess:q(d (,L✓h,/rLEf City/State/Zip: /V.. aGV00( LE /1717
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 cerj ytj�un4er the pains and penalties.ofperjury that the information provided abovy is true and correct
F)qj9a o
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License 4-
-Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _
Contact Person: Phone #:
d
Massachusetts - Department of Pubfic Safety
Board of Building Re- lations and Standards
Construction. Supervisor License
License: CS 101952
Restricted to: 00
DAVID BANCROFT
5J0HNSTON AVENUE
WHITINSVILLE, MA 01588
Expiration: 3/19/2012
Commissioner Tr#: 101952
✓!:e for✓:c�rsw,:� w lC/a o� ✓lZcuaa-Eucmt
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
Registration; 9601
Expirali
t Card
RENEWAL BY
DAVE BANCROFj
t_
104 OTIS STREET',,,
NORTHBOROUGH, Undersecretary
ACORD., CERTIFICATE OF LIABILITY INSURANCE °0ii0/2 0'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
CONFERS mn RIGHTS UPON THE CERTIFICATE
Joseph McKeone ONLY AND
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
JP McKeone Insurance Agency, Inc. I At THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106-0333
INSURED Renewal by Andersen
J and L Windows, Inc.
104 Otis St
Northborough, MA 01532
INSURERS AFFORDING COVERAGE
INSURER A• Hartford Insurance CorLlp
INSURER B: Nautilus _
INSURER
NAIC #
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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ _-
INSR
D L
OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
B
mcan
TYPF
GENERAL LIABILITY
CO MMERCIALGENERAL LIABILITY
CLAIMS MADE F-1 OCCUR
NC958461
10/01/2009
10/01/2010-WWGE
EACH OCCURRENCE
S 1.000.000
TO REM ED
PREMISES ES Q=nf=I
S 100,000
MED EXP (Any Ona parson)
$ 5,Q.00
S 1.000.000
PERSONAL& ADV INJURY
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMPIOP AGG
S 2,000,0 OOO,
GENL AGGP[SATE LIMIT APPLIES PER:
17
PRO LOC
POLICY 17
A I
AUTOMOBILE
LIABILRY
35MCC XD 6390
10/01/2009
10/01/2010
COMBINED SINGLE LIMIT
(Ed acdden)
$ 1,000,000
ANY AUTO
X
ALL OWNED AUTOS
BODILY INJURY
(Per person)
S
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accident)
i
S
_
NON�OWNED AUTOS
PROPERTY DAMAGE
(Por acadent)
S
GARAGE LIABILITY
ANY AUTO
AUTO ONLY • EEA ACCIDENT
S
S
OTHERTHAN EAACC
AUTO ONLY: AGG
S .'
EXCESS/UMBRELLALIA81LnY
EACH OCCURRENCE S
OCCUR CLAIMS MADE
AGGREGATE S
S
DEDUCTIBLE
RETENTION S'
WORMRS.COMPENSATION AND
EMPLOYERS' LIAB'LirY
35 WECPP 1444
02/17/2010
S
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WCSTATU• DTH•
02/17/2011
E.L. EACH ACCIDENT S 5Ol),OOI)
A
ANY PROPRIETORIPARTNER/EXECUTNE
OFFICER/MEMBER EXCLUDED?
nes. desr under
SPECIAL PROVISIONS below
E.L. DISEASE - EA EMPLOYEE S 500 ,000
E.L. DISEASE - POLICY LIMIT S 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
INSURED COPY
ACORD 25 (2001108)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAR. _ 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTATIVE Cl
m ACORD CORPORATION 1988
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Wood'llryl Comp st IF
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Double Dung
100-00414525-007•
• PR°T °1 �^ �I�'t
l 'EX,� E'Ef�M4Y fl E. F��S��?9N � f is � IN,
U -Factor (U,S)Ji r
ScIar ems: Gain 0ca1 icif crit
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U U
M�'+RgGwwy
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pOaa1'' 71822a++HFEp
• 1
Visible T rcf,SM1T:_ncy '
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y
Msnuhe:urarstlatstas tfiet these ralings rrtann us??Iluhla N�nC pradures tdr aatemtnma :uncia pmcu_:
partannsnca. NF.RC mtlnp are datarminad tore toad sat of anvlrnmantal eandltlens and a raelfic pr --duet sta.
NFnC does not ma.mmsnd any pr -duct oral docent warrant the sullai:MFj o; any prddu:t lar any speaaa use.
Caneult manutaCmar's Rtamium for nL4sr=d:.tpsrtcmanea lntemmticn.
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,gt;=.,:rte._ tom•..=.;:��-c..:. = =-a-
�, This produ&meetCrc�° I�"�i it t, rlwr r�l.is::lr r:•�°�
stand2rds eovemin;
-Z has
i en2r� elciency, ,
IRA � me-�!s in the fr2ma an f
4aa s20 mamia!s F .
� and canau �`
p2c!;2gin?,
Rid educationma�dala,>;tu;;l: s.`itSl: 'p�
DESIGN FFicoSUr,e (PEF)
wmncxumuum g� g:fA'iJ �
ey '� Cpl oai�i Mnux ne Asc on 6 willV
7a '-idms_c
;bA,6 g_pa p.d S, lI B;i .N
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-en-d�V,n--0lvr �?:.1„rNDM�ri_'Ad711!5�;_M!S.
MrtnuEner_^_r rtieulnte:n^_ion.+ccmthe nue"ue�hie.anadnrdt.
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Wood'llryl Comp st IF
1
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Double Dung
100-00414525-007•
• PR°T °1 �^ �I�'t
l 'EX,� E'Ef�M4Y fl E. F��S��?9N � f is � IN,
U -Factor (U,S)Ji r
ScIar ems: Gain 0ca1 icif crit
,
U U
M�'+RgGwwy
a
pOaa1'' 71822a++HFEp
• 1
Visible T rcf,SM1T:_ncy '
y
Msnuhe:urarstlatstas tfiet these ralings rrtann us??Iluhla N�nC pradures tdr aatemtnma :uncia pmcu_:
partannsnca. NF.RC mtlnp are datarminad tore toad sat of anvlrnmantal eandltlens and a raelfic pr --duet sta.
NFnC does not ma.mmsnd any pr -duct oral docent warrant the sullai:MFj o; any prddu:t lar any speaaa use.
Caneult manutaCmar's Rtamium for nL4sr=d:.tpsrtcmanea lntemmticn.
,gt;=.,:rte._ tom•..=.;:��-c..:. = =-a-
�, This produ&meetCrc�° I�"�i it t, rlwr r�l.is::lr r:•�°�
stand2rds eovemin;
-Z has
i en2r� elciency, ,
IRA � me-�!s in the fr2ma an f
4aa s20 mamia!s F .
� and canau �`
p2c!;2gin?,
Rid educationma�dala,>;tu;;l: s.`itSl: 'p�
DESIGN FFicoSUr,e (PEF)
wmncxumuum g� g:fA'iJ �
ey '� Cpl oai�i Mnux ne Asc on 6 willV
7a '-idms_c
;bA,6 g_pa p.d S, lI B;i .N
t
-en-d�V,n--0lvr �?:.1„rNDM�ri_'Ad711!5�;_M!S.
MrtnuEner_^_r rtieulnte:n^_ion.+ccmthe nue"ue�hie.anadnrdt.
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WINDOW- R.'LAC_ Arpr acPstc_c1C mann;.
Wood'llryl Comp st IF
N ;riai ° `°"
Dual Argon, Love E
Double Dung
100-00414525-007•
• PR°T °1 �^ �I�'t
l 'EX,� E'Ef�M4Y fl E. F��S��?9N � f is � IN,
U -Factor (U,S)Ji r
ScIar ems: Gain 0ca1 icif crit
,
U U
M�'+RgGwwy
a
pOaa1'' 71822a++HFEp
• 1
Visible T rcf,SM1T:_ncy '
y
Msnuhe:urarstlatstas tfiet these ralings rrtann us??Iluhla N�nC pradures tdr aatemtnma :uncia pmcu_:
partannsnca. NF.RC mtlnp are datarminad tore toad sat of anvlrnmantal eandltlens and a raelfic pr --duet sta.
NFnC does not ma.mmsnd any pr -duct oral docent warrant the sullai:MFj o; any prddu:t lar any speaaa use.
Caneult manutaCmar's Rtamium for nL4sr=d:.tpsrtcmanea lntemmticn.
,gt;=.,:rte._ tom•..=.;:��-c..:. = =-a-
�, This produ&meetCrc�° I�"�i it t, rlwr r�l.is::lr r:•�°�
stand2rds eovemin;
-Z has
i en2r� elciency, ,
IRA � me-�!s in the fr2ma an f
4aa s20 mamia!s F .
� and canau �`
p2c!;2gin?,
Rid educationma�dala,>;tu;;l: s.`itSl: 'p�
DESIGN FFicoSUr,e (PEF)
wmncxumuum g� g:fA'iJ �
ey '� Cpl oai�i Mnux ne Asc on 6 willV
7a '-idms_c
;bA,6 g_pa p.d S, lI B;i .N
t
-en-d�V,n--0lvr �?:.1„rNDM�ri_'Ad711!5�;_M!S.
MrtnuEner_^_r rtieulnte:n^_ion.+ccmthe nue"ue�hie.anadnrdt.
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