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Home My WebLink AboutBuilding Permit #417-11 - 520 FOSTER STREET 11/15/2012 * ao 06 AORTH BUILDING PERMIT 0 ,L 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received CHUS Date Issued: 1414 -1 IMPORTANT:Applicant must complete all items on this page # �LO cAtldh A w 111, Pea A, lk 'V.NERTI� S' J�,�WWI- 4", Z,IPN, is 6ridZ.1itrkot 'I iTo �1 MAP N"O.iTQ-Q--41'i; G �IN F TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building Kone family 11 Industrial [I Addition 11 Two or more family 0 Alteration No. of Units: 0 Commercial �Repair, replacement 0 Assessory Bldg 11 Others: El Demolition 0 Other 4 7777, 1 d tefified'bis"tri 0 sdotl 1, 01 welt.-, t ab s �A a W, DESCRIPTION OF WORK TO BE PREFORMED: e LkJ 6v1 Identi icatton Please Type or Print Clearly) OWNER: Name: 4_1V e.� MA hone: Address: 59C� J QIR CX*t Q & M 4, J 4,7��-7 Ad rA 4� N, - - onsui �., xUpervisOr s ornM eJ n ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: FEE: $ Check No.:—/ 'd-6 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - "natUre of c6nfii r Signature 6 -q Location No. Date l NORT1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame(Frame Permit Fee $ s+cMusa 9 Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # flc as 23761 Building Inspector 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 4 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 Located at 384 Osgood Street FIRE flEPAR'flltfENT Temp Dempster bn slte des nn Located at 124 Main Street-'z^ Fire Depai meet siginature'/date ' _ w COMMENTS R ' Dimension Number of Stories: Total square feet of floor area based on Exterior dimensions. Total land areasq. 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 2007 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 o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 P. 1 104 Otis St.,Northborough,MA 01532 JAL WINDOWS,IINC.,D/B/A MA Home Improvement Contractor (508)919-0900•Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012) byAndersen. Federal Tax 1D#83-0404201 WINDOW REPLACEMENT ..A.&.Cam V CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer{s)Name Dote of Agreement Buyers)Sheet Address,City,Stcte,and Zip Code a s-I- IV ,, dC,,e-,z n oe,:�-Ys E-Mail Address me Telephone Number Work Telephone Number Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen (`=Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification shect(s)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: Estimated Starting Date: � Method of Pymnt CI Cash U Check D Mastercard VISA _ Deposit Received(33%):_0(. ^�" - /-//-(0/� 7 iDiscover ❑Financed,App#: Name on Credit Cord: Balance at Start of job(33%): F Estimated Completion Date: Credit Card#: Balance on Subs ntial !1� + 4 Completion of fo (33'):- [ — - CC Exp.Date: CC Security Code: By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion rBuyerInitials of Job cannot be made by credit card and must be made by personal check;bank check,or cash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there arc no verbal understandings changing 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 of both Buyers)and Contractor. Buyer(s)hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received 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 orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. J&L Windows Inc.d/b/a Renewal by Andersen Buyer(s) Buyer(s) By: 4WI Signa u -of Produc .tanager Signature Signature Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO 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. — — — — — — — — — — —X- — — — — — — -- - — — — — — — — — — — _ _ _ _ _ NOTICE OF CANCELLATION NOTICE OF CANCELLATION - Date of Transaction . You may cancel i Date of Transaction • You may cancel this transaction,without any penalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any I three business days from the above date.If you cancel,any t property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will I and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply I Contract or Sale;or you may,if you wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.if you do make Ifyou do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them u)a within 20 days of the date of Your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the��ods without an further obligation,ff you fail to without a further obl'gation. If you fail to make the make the goods available to the Set eI r,or ifagree goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to dorso, then I oods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I for performance of all obligations under the Contract. the Contract.To cancel this transaction,mail or deliver a I To cancel this transaction, marl or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice,or send a telegram to Contractor.J I notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/o Renewal by Andersen, 104 Otis I Inc. d/b/o Renewal by Andersen, 104 Chis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF *(Date) OF .(Date) 1 HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Date I Buyer's Signature Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink ORTH TO" Of : 0 Andover 0 J� Q -o dower, Mass.,��• Is ` ICS �J COCMICKEWICK yt 7�ADRATED `S BOARD OF HEALTH Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .4 %9j#.r4r..........:. ...PERMIT h4105................ . Foundation has permission toOct.... .............. ................ buildings on .......50.......... �.. ............... .QA...�............ Rough to be occupied as.. ... ......... ........... ... :�.......... ..� �................... Chi y C e provided that the p rson a Opting this permit shall in every respect conform to the terms of the application Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS Rough Service BUILDINSPECTOR Final Occupancy Permit Required to Ocatpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 104 Otis Street,A'orthborou;h,&M 01332 I'll one 508.979.0900• !&L Windo P-2 Fax%74.987.3013 ws,Inc.d/b/a bRenewal l1vL4IilCLiccns;#149601(expires 1/24/12) 'Andersei ederal Tax ID# 83-0404201 WINDOW REPLACEMENT en gndgsen Or GRrA-MR MAssACIitTSr�•rg qND NEW FIAMPS,, Buyers)Name WINDOW SPECIFICAITON SHEET t^Q11 ii i Dat�ASre The 6uyer(s)listed ataove hereb �� ment descr bed on the Specification Sheet anydathe front and gie rtoerse of the heco oof which this S Purchase the goods and/or services listed below,ittcordancetu g the pecification Sheet is a pad. the CUSTOM WINDOW Prices and terms 11 AND DOOR REMODELING AGREE�IENI I. Con actor Y,6711 Insta11 11 ll a to11 tal of�� WINDOW DETAILS Double Hun windows in Owner's home,usin Hung(DR) Equal s]`sh ❑ Cottage sash(I/3 top 2/3 bottom) individual Casement(CW) El Hinge ri quantities: Double Casement ❑ Htrige left(as viewed f ❑ Oriel sash(2/3 to (CDW) ❑ Standard handle rom exterior): ❑ Standard handle P I/3 bottom) Casement/Picture/Casement(CPI4 1: ❑metro handle ❑Metro handle —_—2 Lite Gliding 1Vitldow(GW) ❑ 1:] or❑ 1:2:1 [�Standard handle❑ Glider/Picture/Glider(Gr�V) Metro handle Awning WindOw(AW) ❑ or❑ 1:2:1 Picture Window(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2 ❑ Yeso Qty of Windows to be Custom Fit Replacement; 3• ❑ Yes[�-No Qty of Silts to be replaced b d ❑ Yes❑No y Contractor: Qty; Windows to be New Construction Full frame Gncludes S. Glazing to be: free material new interior&exterior casings) 6. Exterior color to LOW-EO Sm artSunrM (yam.� t ❑Factory applied 908 Fibrex brit White ❑ Sand ❑ 1i1e) ❑Other If other, Mold �. Inferior color to be:,�,i Canvas Please specify: Ian White❑ Sand ❑Terratone❑ Cocoa Bean Note: nteriorcolor El ❑ ED E] pine S. Hardware; � can le be whife,wood or same color as exterior.❑ild int Vhite❑ Stone ❑ Oak 9. ❑ less�'o Install Lifts with Q Canvas❑BrassWood interiors need to finished b 10. Screens: Windows to Double HWindows ❑ Estate Hardware: Style: y Owner. have: ng N incree ❑ Half or �11 screens I Screens to be; 0 Fiberglass ❑Aluminum QKTruScene 1 1.Windows have S1'e grilles: GRQLE DETAILS s ❑ No If yes: e.rille Between Glass(cru:1 I Q(Y�� I Qty:_ Qt,, ❑ Removable Interior Wood rit rw)❑ Full Divided L —_ QIY��--- Qty:� 8ht(i•Di.1 Qty Qtyi DH DH Draw idle DH g'• patterns above DH cwp;care 'Use additional sheet if needed Glider CPW or G 12. Yes ADDITION Owner approved(initials): 13 No Contractor will remove �"1uORi(DETAILS —�—.J Yes❑No Contractor will install e Wetal frames of windows, Inlerior casin Paint Qty of Units:_— g qty of openings. p ready or stain-ready casings. Ll Yes ❑,xci Contractor will install new Exterior casings qty of o Interior stops Paint-ready or stain- openings. qty°f openings: ready inside or outside4 s o ❑ Pine ❑Maintenance-fr 15. Owner is aware that Contractor — Exterior stop s P qty of o -free material 16.[D yes does not do an P qty of openings: Penings: °Contractor Ypainting. ❑Pine will wrap exterior casings Owner ❑Maintenance-free material Note: Wrapping may be re u' gs with alu Initials 17, q ued with minum coil stock of Yes No Contractor storm Window removal; ----color. 18* Will insulate;caulkand removal of storm Windows will leave screw I9.� Yes ❑No A limited warran seal Windows with 3- y�❑ No Buil Warranty shall be issued to O point system to prevent water and holes in casing, `L— " P ontractor weer upon completion of the ail'infiltration, included in the Contract Price and a se will secure any Job and payment in full. 20. Additional job details: Y and all necessary permits. The fee for parate check is required at the ° the I, of sale for this fee, permtt(s)isnot 21yej ❑ No Owner agrees to be present on the final <<o final pa}�rrent shall dayof be demanded until the eoniractis cont iemsfallation f or final inspcclion and to deliver final It is agreed and understood b p ted to the satisfaction ofall Payment. AGREEMENT constY and between the i�ar7ies. lutes the entire understan parties that this Specification to Bu eTrhs Sl��cation Sheet may not be ch drag between the ,and Sheet Ong with the CUSTOM Wl1�OW Y ()and Contractor. ersta Bum or its terms rn � no vevaried in anrba] AND DOOR Ren:ZLse,,Ztcr _dN,. Yer(s)hereby acknowledge that Buyer(s)hasreadthis SY way pecification hs esu such chatidinnges are Siin wri-m ting��any of the of GreBuyer(s) by both By: Buyer(s) Signa of Product Manager CjvLr1 � �� Signature 7 Print Nameof Product Manager Signature I'r'irtt Name � Print Name I - I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 FF'aslzbigton Street Boston,MA DZIII .UT Wiw.mas&gav/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectriaLizu/Plumbers A:1313Ueant Information' Please.Print Leaty Mame(Business organizadonitndividuat}: Address: ' l D� vtlt` S ��Y'�� . • . City/stiit JLtp: IV Df h bo na Are you an employer?Cheek the appropriate ba:: Type of project (regzered): 1.E -i Mn a employer with Q . 4. ❑'I am a general contractor cad I 6, 0 Now construction amployees(fa rand/or part- )tame,* Im himd the sub-contractors 2.0 I em a sole proprietor or partner- listed oa the attached sheet # 'Il •ship and have no employees tese.sub-contractors kava B. Deemolftioa working for mo is any capacity. warms' camp.insurance. 9. ❑Building addition [so w:odxxs'Camp.hisurs ee S. ❑ Weare it corporation end its 10.[]E ectdcel repairs or addificm- d.}. officers bavo exercised Chair. 3:❑ I am a homeowner doing ILU work .Tight of czatri 6#per MGL II.❑Rhimbing repairs or additions myself[No workers'comp: a 152,j1(4),and we have no 12.E]Roof repairs insurance required)t employees.•[No workers' 13.[]Othar *=nea revirCE] Any appIieaat Sitar ebetiLz bol fel must ah o fIl DCII the section belox showistg their wntlae'compexsa$na poIicY iafotmatiois t gameowaen wbo submit this atUdavk iadieetiag 6q. ata doing dwoi:end thea him outside ermtaet=mutt submit"m atndavit indieatine such jQoatmotoa fhaf eh=k tbb boz meat etfaohed an adeirtional sbeet s'n ng the ttama of fm sub-eoatxectms and their wmi='wrap.Policy infim=6= I am an empkpap that is proyiding workers'cornpensadan L'Lwance for my employees -Bdow.is the pofuy and job site information. Insurance Company Name: Policy#or Self-ins;Lin.#: �� W f•��T�L___— Firatioa Date: . lob Sfte Address: .701 City/StafrlZig: Al Ail 6a1 Fl A' Attach a copy of the Warkers'caazpeasationpaIicy declaration pave(showing the policy ntmtber and ei#ratfoa date). Falum to secure covarago as required under Saction 25A of MGL c.152 can load to the imposi'On of criminal pcnal ics of a fine up to$Z,SDQ.DD and/or one-year imprisonment,as well as civil panalt>cs m$�e farm'of a SMP WORK ORDER and a fine -of up to 52$0.00 a day against the violator. Be advised that IL copy of this statameat may be forwarded to the Office of Invm1gatians of the DIA far insurance coverage verification.. Ido hereby c r the pairs andpenalties crjttry that the information provided above is true-ani and correct 5ienatnre; Data. / Phone fp Official use only. Do riot write in this area,to be completed by city or town afflcia.L City or Town PermitlLicease# Issuing Aufhority(circle ane): I.Bonen of Health 2.Building Depariment 3.CatylTown Clerk 4.Electriral inspector 5,Piumbfng Inspector 6.Other Phone Contact Person: #; z , IMissachusetts - Department of Public Safety -Board of Building Regulations and Standards Construction Supervisor License License: CS 857Q7 + BRIAN DENNISON. 86 CREST CIRCLE ° WORCESTER, MA.01603, Expiration: SWO12 Cbmmi_4sioner Tr#; 2622 J omee or Cansnmer Ausiness'Rega[:tiaa HOME IMPRO V MENT CONTRACTOR • Regls'tratio��.49 01 EXP i 12 IS t Card RENEWAL SY BRIAN DENNIS _ 104 OTIS S NORTHSOROUGH, Underseere A�>r CERTIFICATE OF L[gB[L[1-y [NSUR,gNI^_ Keone OYCE v E DATE(Iby/DOn,YYYJ JP McKeone insurance A RTIFICATE IS ISSUED 02/10/2010 P.O. CK 333 Agency, Inc. HOLDER D CONFERS NO C; A MATTER OF INFORMATION Ann Arbor ALTER TI E COVER�gGECATERDO�NOTON THE CE MRCATE INSURED , MI 48106-0333 AFFORDED S, AMEND, E>r>�No OR Renewal b THE No BELOW. J and L n Andersen INSURERS AFFORDING CO Windows, Inc. vERAGE 104 Offs , . ' III A: �g Insurance Com an NAIC# Northborough,MA' 01532 INSURER B` Nautilus INSURER C. COVERAGES INSURER D: THE POLICIES C, INSURANCE LI INSURER F. ANY REOUIREMENT, QED BELOW HA OR MAY PERTAIN,THE INSURANCE CONDITION OF BEEN ISSUED TO THE INSURED NAMED POLICIES.AGGREGATE LIM AFFORDED ANY CONTRACT OR'O ABOVE INSR ADO.L ITS SHOWN BY TME POLICIES D ER DOCUMENT FOR TME POLICY PERIOD INDICA ESCRIBED HEREIN IS SUBjVE�T TD APECT To WHICH �.NOTW AY HAVE BEEN REDUCED BY PAID CLAIMS. ALL THE TERMS THIS CERTIFICATE MAY BE S UEO IN B GENERAL LIABILITY POLICY Nuns IS AND CONI ER POLICY EFFECTT�,E POLICYEXPMONS OF SUCH i cOMMERCIA LGENERAL LIASIUTY NC958461 IRATTDN CLANS MADE 1:1 OCCUR 1010112010 10/01/2011 EACH OCCURRENCE LIMITS PREMISES i 1 000 ODO cmurence i MED E GEN 1 DO ODO L AGGREGATE XP(AnY one penton) S LIMIT APPLIES PER PERSONAL R ADV INJURY 5,DDD POLICY PRO- i 1 ODO A AUTOMOBILE LIABILITY LOC C'ENERALAGGREGAT'E ODD S ANY AUTO 35MCC PAODUCTS_COMp/OPAGG 2 DDD DDD X ALL OWNED AUTOS XD 6390 10/01/2010 i 2 DDD DDDD 10/01/2 SCHEDULED AUTOS 011 COMBINED SINGLE LIMIT (Ea eocldenp HIRED AUTOS i 1,000,ODO NON-OWNED AUTOS BODILY INJURY (Per penton) i I BODILY INJURY. (Perecgdenq i GARAGE.UABILtTY. ., ANY AUTOPIE (Pe�Ocriden9 DA i EXCESSIUMBRALIT,ONLY-EA ACCIDENT ELLA LIABILITY i OCCUR OTHER THAN EA ACC i CLANS MADE AUTO ONLY: AGO S OCCURRENCE 'DEDUCTIBLE EACH OCCUS i RETENTION AGGREGATE S i A WORKERS COIIIPENSA770N pND S EMPLOYERS'UABILr y . ANYPROPRIETOFVPq 35 WECPP 1444 S If :ER/MEMSER OCCLUDED?EDUTTVE � 02/17/2010 02/17/201.1 IF Yes,desPRO under WC STATU I i SPECIAL PROVISIONS below OT?+ OTM� El EACH ACCIDENT EL DISEAS 500 DDD BE EMPLOYEE i SDO ODO • F—L DISEASE_POLICY LIMIT i OESCRII OF OPERATIONS/LOCATIONS IONS/ 500 000 VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTiFICA7�HOLDER CANCELLATION INSURED COPY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANC • DATE THEREOF,THE SUING INSURERELLE7)BEFORE THE EXPIAATION NOTICE WILL ENDEAVOR T 0 MAIL y • TO THE.CERTTFICATE HOLDER NAMED TO THE �_•DAYS WRITE, IMPOSE ND OBLIGATION OR LIABILITYLEFT,BUT FAILURE 1T)DO SO SHALL REPRESENTATIVES OF ANY KIND UPON THE INSURER,ITS AGENTS OR ACORD 25 MOMS) AUTHORIZED REPRESpNrATI� 0 ACORD CORPORA-nON 1988 t . _ d 6rb-erL 3fi1 G`Q=II'7GF�,fIf X'3 0 ir auk ki •� : r V ' G3 l�VMSf�ElE�f t