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HomeMy WebLinkAboutBuilding Permit #113 - 53 BROOKVIEW DRIVE 8/10/2009 BUILDING PERMITof"°RT b qti ? =A °o TOWN OF NORTH ANDOVER F - - p APPLICATION FOR PLAN EXAMINATION Permit NO: Date ReceivedAr ��SSACHUS���� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Cac a ( Print PROPERTYOWNER � �?'.{ AJSI.Sc` Print MAP NO: 4_PARCEL 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 PREFORMED: Identification Please Type or Print Cl-early) OWNER: Name: Phone: Address: S3 J CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement Licenser (OL( Exp. Date: . 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 $Cost:Project ProJj �� FEE: Check No.: 7cl S/� Receipt No.: 2 -23 6dp*" NOTE: Persons contracting with unregistered contractors do not have access to the guaran d Si nature of A entJOwner - �._g_ _.q Signature of qontractar Location 3 No. Date NORT1y TOWN OF NORTH ANDOVER 0 AL 41 Certificate of Occupancy $ — �'J�cMustt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ Check # 79 s� 226tH, /Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools I Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I ❑ 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 ConstructionSin le and Two Family) � 9 Y) ❑ 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 co and roof of recording PY P g must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORT#q ® Of 4Andover 0 LAKE dover, Mass., ell a COC H I C HE WICK AORATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... .............. GC�..� -..... ?!.. . 5 �i........... Foundation has permission to erect........................................ b ildings on...�J...... �a©. .. t 6�........�'................ Rough to be occupied as Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in 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 CONSTRUCTIO TARTS Rough ... ............... ........... ..... Service BUILDING ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. Renewal 7l T MA License#149601 (expires 1/24/10) bYAG1dE',G'SeG1. ''B" ����W�� X . E V E V AL By 1 g1V DERS Federal Tax ID#83-0404201 WINDOW REPLACEMENT ­A�d­,,CPM ,V OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE 104 Otis Street•Northborough,MA 01532 Phone 508.919.0900•Fax 508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agreepent 1 5/74107 Buyer(s)Street Address,City,State,and Zip Code l E-Mail Address .Y,'^ j 4 e "U/ii C, /-A✓cJ f-rm� elephoneNo rM1 bef b Work Telephone Number y . Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amou ' %.J} , 1,7T j c� Estimated Staffing Date: Method of Pymnt:C)Cash ❑Check ❑Mastercard (;'VISA � —mss ❑Discover ❑Financed,App#: Deposit Received(33%): t ^�� . Nome on Credit Card:',-,,r Ay/ e,,; � Balance at Start of Job(33%): vi, '` ' � �� Estimated Completion Date: Credit Card#: , ) Balance on Substantial �� �.` 7 dl's Completion of Job(33%(: CC Exp.Dote;r, L CC Security Code: 2 ` � By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion BuyerInitial `Yr n 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 are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement wPU be valid without the signed,written consent of both Buyer(s) and Commtractor.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. Renewal by Andersen of Greater MA and NH Buyer s) Buyer(s) i J Signatu of P odu-ct Manager rSignature �, 1 Signature tf! �;� ✓ lSr�Wti�;� , i4 ) G°iFr t i/- L�Jrl, ✓�fnr.!.F/`�l od � Print Name of Product Manager Print I e 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 FORMES FOR AN EXPLANATION OF THIS RIGHT. - - - - - - - - - - - - - - - - - - - - - - - - - - - - -�<- - - - - - - - - - - - - - - NOTICE OF CA tCi �dT101�l NOTICE OF-CANCELLA700M Date of Transaction c " . You may cancel I Date of Transaction z-1716 9 .You may cancel this transaction,withou an pen It�or obligation,within i this transaction,witted a p d al or obligation,within three business days froem the above dote.If you cancel,any three business days frothe the above ate.If you cancel,any property traded in,any payments made by you under the I roperty traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I ontract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security by the Seller of your cancellation notice,and any securittqq�� interest arising out of the transaction will be canceled. interest arising out of the transaction will be canceled< If you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at your residence, in substantially as good condition as your residence, in substantially as good condition as when received, any goods delivered to you under this I when received, any goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the I Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding the return shipment of X instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.If you do make I the goods at the Sellers expense and risk.ifou do make the goods available to the Seller and the Seller does not the goods available to the Seller and the Seder does not pick them up within 20 days of the date of your Notice 1 pick theup up within 20 days of the date of your Notice of Cancellation,you ma retain or dispose of the goods of Concellation,you may retain or dispose of the goods without ony� further obrc�ation. If you fail to make the I without am further oblo ation. If you fail to make the goods avaivable to the SetlYer,or if you agree to return the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you remain liable goods to the Seller and fail to do so,thenyyou remaain liable for performance of all obligations under the Contract. for performance of all obligations undler the Contract. To cancel this transaction, email or deliver a signed and I To cancel this transaction, email or deliver a signed and dated copy of this cancellation notice or any other written I dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen I .notice, or send a telegram to Renewal by Andersen of Greater Massachusetts and New Hampshire, 104 1 of Greater Massachusetts and New ElamD�shire, 1104 Otis Street, 6,lorehbor u ©15 2, B�IOT LATER THAN, Cltis Street, l+6orfh rqugh,RAA®15 2, NOTLe�TER TEI�a[� MIDNIGHT OF r -.(Date) MIDNIGHT OF i1 o .(Date) l HEREBY CANCEL HllS TRA SACTION. X I HEREBY CANCEL TEAS TRANSACTION. I Consumer's Signature Date I Consumer's Signature Date { ®iBLLP2009.RBA-Ph.MANH 1 FbA Copy ��nea9 RENEWAL BY ANDERSEN CA MA License#149607(exFires 1/24/]0) Dytndersen. ��{� Federal Tax ID# 83-0404201 WINDOW REPLACEMENT anA i-c.-, O .xFEATER(VIMSSACHUSETTS AND NEW HAMPbnIRE 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Buyer(s)Name t Date of Agreement l The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terns described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) ®,Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) L Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle =� Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(PW) f Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. ❑ Yes No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes Q No Qty of Sills to be replaced by Contractor: 4. ( Yes ❑ No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine [K Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: �Z.HP Low-E®SmartSunTM (TaxCzr&tEhog1ble) ❑ Other If other,please specify: 6. Exterior color to be: 0 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: R White ❑ Sand ❑ Canvas ❑ Ter•atone ❑ Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: ® White ❑ Stone ❑ Canvas ❑ Brass Double Hung: 9. ❑ Yes 0 No Install Lifts with Double Hung Windows 10. Screens: windows to have: ❑ Half or 5&Full screens Screens to be: 5Z Fiberglass ❑ Aluminum ❑ TruScene ° GRILLE DETAILS 11.Windows have grilles: ® Yes ❑ No If yes:g Grille Between Glass(GBG)❑ Removable Interior Wood aww❑ Full Divided Light(mu Qty: Qtr Qty Qty Qty: Qty: Qty: 1[ LH EDH DH DH ::C:Wtct]ure Glider L.,., Draw grille patterns above *Use additional sheet if needed Owner approved(initials):( ) ADDITIONAL WORK DETAILS 12.❑ Yes [�_No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes a No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: F-1Fine ❑ Maintenance-free material 14.F-1yesI No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of 6penings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any painting. �>,k r Owner Initials 16.❑ Yes (F No Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.® Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. I S. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19. Yes ❑ No Buil Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract rice and a separ to hec z is required at the tiros of,sale for this fee. 20. Additional, 1 (� ✓2 C t L r Cz r < Imo= AC /�F'�G'1 E'fir LIU,-�� A ,+ A d.r,w �w, �c ;i�+< t�`c I`TE :.07 %i s � /) �/: sGI I l� A1XV, ; V�. . 21. M Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final pgyrnent shall be demanded until the contract is completed to the satisfaction cf all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGP.EEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal Andersen of Greater MA and NH Buyer(s) Buyer(s) J") Signa e of oduct Manager Signature / J Signature Print Name of Product Manager Print Name Print Name RUA Copy The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations. 600 TVashington Street Boston,MA 02111 Y www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Colitractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ����rL' �V �11'1�i1eJ-SeY) Address:_ /D.;/ City/State/Zip:, Al bow Phone#: 6�0�) /I -000 Are'you an employer?Check the appropriate box: Type of project (required): L E-I.am a employer with Jo 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E1 I am a sole proprietor or partner- listed on the attached sheet.$ emodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance: 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[1Other comp.insurance required.] *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. I am an employer that isproviding workers'compensation insurance for my employees Below.is the policy and job site information. Insurance Company Name: . ' 114C Ke,•moo -p— )6Sa n C e Policy#or Self-ins.Lic.#: �i� �� }� !`�'f Expiration Date: Job Site Address: 1 City/State/Zip: _ 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$250.00 a day against the violator. Be advised that a copy,of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer under thepains and penalties.of perjury that the information provided P(o is true and correct: Signature: Date: oet Phone#: Official use only. Do not write in this area,to be completed by city or town official City or'Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Board of Building$egulations and Standards •Construction Supervisor License.,; ,, A- License; CS •95707 i Birth—fidt'_91171982 ETr# 95707 ,• I �piiafon^.9,78'12Q10 r0,-;pg +l ` BRIAN DENNISOt ; 85 CREST CIRCLE WORCESTER;MA 01603"' . Colmnissio.w, RENEWAL BY ANDERSON BRIAN DENNISON 104.OTIS STREET NORTHBOROUGH, MA.0.1532 . DPS-CAI C, SOM•07/67-PC8490 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR { ,t Registrafi.o?., 149601 E-x %{i_0-124/2010 /. . e-n4plement Card 7xi Yp . RENEWAL BY P:�117.E#2. 0_ r BRIAN DENNIS01� ��=• / 104 OTIS STREET` =% ;u,Q "NORTHBOROUGH,MA 01532 Administrator i Acc Dn TiF[,CATs L�ABI I INSURANCE ® /2 0 PRODUCER 02117 =09 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKsone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 333 ALTER rriE COVERAGE AFFORDED By THE POLICIES SELOW. Ann Arbor, MI 46106-0333. INSURERS AFFORDING COVERAGE MAIC# INSUREDRenewral by Anderson INSURER A: Hartford Insurance Com an J&L Windows, Inc. INSURER B: Hermitage 10400s St INSURER C: Northborough, RNA 01532 INSURER 0: I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED..MOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAN 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. WSRIr POUCYEra LTR R FCTIVE POLICYEFPIRATION a POLICY NUMBER L641TS B GENERAL LIABILITY HCP 507 404 09/07/2006 09/0712009 EACHOCCURRENCE (s 1,000 000 COMMERCIAL GENERAL LIABILITY PREMISES Eec-,=aen� S 100,000 CLAIMS MADE ©OCCUR MED EXP(An one person) S _ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGz'REGATE S 2,000,000 GENL AGGREGATE LIM IT APPLIES PEP:. PRODUCTS-COMPIOPAGO S 2.000000 POLICY n PROT T-1 LOC A AUTDM088-0 UABUTy 35 MCC AD 6390 10/01/2006 10/01/09 COMBINEDSINGLELIMIT ANY AUTO (Esawlem) S 1,000,000 X ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Perperon) S HIRED AUTOS BODILYINJURY . S NON-OWNED AUTOS (Per aeddont) PROPERTY DAMAGE S (PeraCdent) GARAGE LIABILITY AUTO ONLY,EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS1UMORELLA LIABILITY EACH OCCURRENCE I S OCCUR . a CLAIMS MADE AGGREGATE $ S DEDUCTIBLE I S RETENTION ' . S I S A WORKERS COMPENISATION AND 35 WEC PP 1444 02/1712009 02/17/2010 1 we s_A4Tu EMPLOYERS'LIABILITY ANY PROPRIETOPIPARTNERtEXECUTIVE E.L.EACH ACCIDENT S' 500,000 OFFICER/MEMBER EXCLUDED?. E.L.DISEASE.EA EMPLOYEE S 500 QOO It ee,desertoo ander 500 000 SPECIAL PROVISIONS below EL DISEASE.POLICY LIMB S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EIICLUSIONs ADDED BV ENOORSC&tENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION S.40ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL°_5D BEFORE THE 0PIRAMON INSURED COPY HATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WnMr.V NOTICE TO THE CERTIFICATE HOLDER HAMM TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OEUGATION OR UA231 tTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 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