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HomeMy WebLinkAboutBuilding Permit #673-14 - 538 WINTER STREET 4/2/2014j TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: — Date Received 'y Date Issued:�2 / `( / IMPORTANT: A2plicant must complete all items on this page LOCATION. -_ 13 .�.r' Print PROPERTY OWNER , �� , Print 1'00 Year Old Stru MAP NO / PARCEL ZONINGIDISSTRICT .� 'Historic'District C .... v p Machine. Shap_ yesno - 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 0 Septic q Well :0 Floodplain E Wetlandsc ❑ Watershed District ❑ Water/Sewer_...._-- DESCRIPTION OF WORK TO BE NtK1-UKMhU: Identification Please Type or Print Clearly) OWNER: Name: Phone: f4 f4 CONTRACTOR shame Address: Sgpervisor's Construction License - s� ,� � _ Exp Date-_ A_ A/4Home Improvement ensL- icea .1 __ .3 , _ - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CO�S°T ,BASED ON $125.00 PER S. F. Total Project Cost: $ ' Z4 FEE: $ � --- Check No.: Receipt No.:a -,)-3q NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ", i Plans Submitted L.J Plans Waived ❑ Certified Plot Plan ❑"� Stamped Plans ❑ r' Plans Submitted 'Plans -Waived -11- . --.,.Certified Plot Plan ❑ Stamped Plans ❑ ;TI'PE OF":SIWERAC3E DiSPO�AL _ - . Public Sewer ❑ Tanning/Massage/Body Art ❑ .. .Swimming Pools ❑ Well ❑ Tobacco.Sales Food Packaging/Sales ❑ :T.ivate.(septic tank, etc._ Permanent Mimpster 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: Conservation Decision: Comments :Comments Water & Sewer Connectionisignature & Date Driveway Permit DPW TowA-2 Engineer: Signature: Located 384 Osgood Street FIRE DEPARTNI T Temp Dumpster on site yes no Located Fire-Departme►it si-j--4 eldate -ti, r {. COMMENTS r, , .. , .•, . �:-. ;{, -Dimension - Number of Stories: Total square feet of floor area, based on Exterior dimensions. _Total land area; sq. ft.: -ELECTRICAL: Movement of. Meter.locatton, mast or service drop requires approval of Electrical Inspector Yes No DANGER..Z®NE LITERATURE: Yes No MGL -.Chapter 166. Section 21A -F and G min.$100=$1000 fine NU 1 Lb ance UA I A — (t -or ciepartment use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department `~the fol;"wing is"a list of the required -forms to befilledout'for:the appropriate. permit to be obtained. Roofil1g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp -Affidavit a Photo Copy Of H.I.C. And%O'r 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) 2 ❑ 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 tti'e decision from the Board of Appeals that the apo•-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doe.Building Permit Revised 2012 t ' .� Location � --31 3 � l�� I , S^ 1 No. '� Date Lit [ Check #� .739 TOWN OF NORTH ANDOVER Certificate of Occupancy $ r_ Building/Frame Permit Fee $ �2 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 5'52,300.00 m $ - $ 627.60 Plumbing Fee $ 78.45 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 78.45 Total fees collected $ 884.50 538 Winter Street 673-14 on 4/2/2014 Basement Remodel 0OF -+ 0, 2 0 N 5! 6 m N O > �. O CD C7 • v CD O .o M n m -- - Z C 3a" IN FD. m o �� N O O C L O m cn O W N � � O -q O CD o• to H• C .� CD Z O W CD O rt Z N C c CD o� ZQ- --lo� N 93 o CD= Cl) Z 0 CD (Q. too n 0 n c CL 0 cu O v CD cZ O o — �' < CD o �� O �• �i�Tl U �a)C C Cl) CD ? Q• CrCD CD Ap s acJ'1: r.qpL —i-0° a) CD cDo� O � rt ��� _ O -T 0 � c�N� W o .a � O CO) 11Z CL co. cfl I b cn � �• CD = o v p Z C . CDN �M S s (p r o O G: D(D 7 CD Z °o MR O rn- 0 CDo o = = CL N q O (D a N q,C (D �' z O W 3 (D 7o m v D z0 T 7 N Zo O3 C G) H N T D1 N O < O �] O C r.. m n M m T 3 Dl .Z7 O C r C W M m T j N n S `(D O C OIQ T O C a O W C G Z Z m 0 N (D 'a N I (D 3 T O O O 3 O D 70 0 m D 2 It R.S. HEBERT Construction & Remodeling Inc. 102 Adams Ave. No. Andover Mass. 01845 (978) 686-0786 Phone/ Fax Lic. #:058241 Reg . #:153811 DATE 3/28/14 Job: Cynthia Parent 538 Winter St. North Andover Ma. 01845 Phone # 978-685-3948 PROJECT: Water Damage Basement remodel I. PARTIES This contract (hereinafter referred to as 'Agreement") is made and entered into on this 28 day of March. by and between Cynthia Parent (hereinafter referred to as "Owner"); and R.S.Hebert Construction & Remodeling Inc., (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work, subject to the terms and conditions below: II. GENERAL SCOPE OF WORK DESCRIPTION Supply all material and labor required to build the following. 1. Demo. Laminate flooring, sheetrock ceilings, walls, closet walls and brick Veneer from sides of fireplace. 2. Frame new walls on sides of fireplace for built in shelving. 3. Frame new closet wall with sliding doors. 4. Frame in new shower in existing bathroom. S. Tile shower, bathroom floor and entry floor. 6. Sheetrock ceilings and -walls where removed. Contractor Owner wner I 7. Replace rear window. 8. Replace rear exterior slider with a Harvey French door. 9. Install new glue down engineered hardwood flooring. 10. Paint all walls, ceilings and trim. ( color by owner) 11. Install new 200 amp service. 12. Install 13 LED recessed lights. 13. Upgrade plugs and switches. 14. Install new GFI outlets in wet bar area. 15. Move hot water baseboard heat in closet area where needed. General I. Supply dumpster on site. 2. Supply building permit. A. LUMP SUM PRICE FOR ALL WORK ABOVE* $52,300.00 2. STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of Work" section above, this Agreement does not include labor or materials for the following work: Plans, engineering fees, Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA). Custom milling of any wood for use in project. Moving Owner's property around the site. Labor or materials required to repair or replace any Owner -supplied materials. Final construction cleaning (Contractor will leave site in ""broom swept" condition)., correction of existing out -of -plumb or out -of - level conditions in existing structure. Correction of concealed substandard framing. which may be discovered in the removal of walls or the cutting of openings in walls. Removal and replacement of existing Contractor Owner Oder rot or insect infestation. Failure of surrounding part of existing structure, despite Contractor's good faith efforts to minimize damage, such as plaster or drywall cracking and popped nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by loosened rust within pipes. Exact matching of existing finishes. Cost of /testing/remediating mold/fungus/mildew and organic pathogens unless caused by the sole and active negligence of Contractor as a direct result of a construction defect that caused sudden and significant water infiltration into a part of the structure. B. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION Commence work: 4/3/14. Construction time through substantial completion: Approximately 5 weeks, not including delays and adjustments for delays caused by: holidays; inclement weather; accidents; shortage of materials; additional time required for Change Order and additional work; delays caused by Owner, Owner's design professionals, agents, and separate contractors; and other delays unavoidable or beyond the control of the Contractor. C. CHARGES FOR ADDITIONAL WORK: CONCEALED CONDITIONS, DEVIATION FROM SCOPE OF WORK, AND CHANGES IN THE WORK 1. CONCEALED CONDITIONS: This Agreement is based solely on the observations Contractor was able to make with the project in its condition at the time the work of this Agreement was bid. If additional concealed conditions are discovered once work has commenced or after this Agreement is executed which were not visible at the time this Agreement was bid, Contractor will point out these concealed conditions to Owner, and these concealed conditions will be treated as Additional Work under this Agreement. Contractor and Owner may execute a Change Order for this Additional Work. Contractor is released, held harmless, and indemnified by Owner from all pre-existing mold, fungus, mildew, and organic pathogen problems and is not responsible for costs or damages associated with correcting, containing, testing, or remediating the same. D. PAYMENT SCHEDULE AND PAYMENT TERMS 1. PAYMENT SCHEDULE: * First Payment: $10,000.00 Deposit Second Payment $15,000.00 due when demo is complete. Third Payment $10,000.00 due when sheetrock is installed. Contractor Owner O er Fourth Payment $10,000.00 due when tile is complete. • Final Payment: Balance of contract amount due upon Substantial Completion of all work under contract: $7,300.00 2. PAYMENT OF CHANGE ORDERS/ADDITIONAL WORK: Payment for Additional Work is due upon completion of either all or part of the Additional Work and submittal of invoice by Contractor. E. WARRANTY Thank you for choosing our company to perform this work for you. Your satisfaction with our work is a high priority for us, however, not all possible complaints are covered by our warranty. Contractor does provides a limited warranty against material defects on all Contractor- and subcontractor -supplied labor and materials used in this project for a period of one year following substantial completion of all work. This warranty covers normal usage only. You must contact the Contractor upon discovering an item in need of warranty service. Additionally, Owner's hiring of others or direct actions by Owner or Owner's separate contractors to repair a warranty item are not covered by this warranty and will not be reimbursed by Contractor. No warranty is provided by Contractor on any materials furnished by }ho Owner for installation. No warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor within the dwelling or the property (including any warranty that existing/used materials will not be damaged during the removal and reinstallation process). One year after substantial completion of the project, the Owner's sole remedy (fnr matpraA14:z and labor) on all materials that are covered by a manufacturer's .1 �. ... ..tI. `v:-_:- ^^� ufacturer, not with the Contractor. Repair of the following items and related damages of every kind are specifically excluded from Contractor's warranty: problems caused by lack of Owner maintenance; problems caused by Owner abuse, Owner misuse, vandalism, �aaraa�r rraror'dafraiirsraaaa- alteration; and ordinary wear and tear. Damages resulting from ;thogens are excluded from this warranty unless caused by the sole and active negligence ^f contractor as a direct result of a constract, :.: 11iclf cuuSud Contractor Owner Owner sudden and significant amounts of water infiltration into a part of thr-structure. Deviations that arise such as the minor cracking of concrete, stucco, and plaster; minor stress fractures in drywall due to the curing of lumber; warping and defl;:%;V�; V; VVVVu; shrinking/cracking of grouts and caulking; fading of paints and finishes exposed to sunlight a reA_rc a.,.., MU!1 it JL I I ar, a1 =rn..=r; defei-8 t in construction and are strict°= I have read and understood, and I agree to, all the terms and Agreement above. 317 ATE 'S SIGNATURE ER'S SIGNATURE The Customer has three days from date of signing to void this contract. 4e Contractor Owner 4--- Vwmer The Commonwealth of Massachusetts - Departin ntoflndustriglAccidie is Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass gov/ciia ,Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Leaibiy Name /1?s Address: City/State/Zip:OPhone #: Are you an employer? Check the appropriate box: 1.64 I am a employer with 3 4• ❑ 1 am a general contractor and I employees (fall and/or part-time).* have Hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet, t ship and'have no employees . These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurancerequired.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F] Electrical repairs or additions 11.❑ Plumbingrepairs or additions 12.❑ Roofrepairs 13. F1 Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. -Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self-ias. Lic. Expiration Date:, Job Site Address; 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 requixedunder Section 25A of MGL e. 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 fume of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Phone #: pains atutp enaldes of perjury that Elie information provided aboveistrue and correct. Oficial use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 #: Information and Ins4ructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...everyperson in. the service of another under any contract of hire,• express or implied, oral or written." An employeils defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a -deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However th6 owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/license number whichwill be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations i a (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office bf investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Cox onwealthofmussachwottq Depattment of WwWal ,Accidents Offlee ofTnvestigations 6.00 Wasbiapa Ste -t Boston} MA 02111 TQL # 617-72'x,400 W406 ox 1-87`��:l�A SA F Revised 5-26-05 Fax # 617-727-7749 www-ma5%ggv1da Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-058241 RONALD S HEBET 102 ADAMS AVE: a r; N ANDOVER Mk 01 5 ,; Expiration Commissioner 01/08/2016 ,tom . C -_'/gaze �p�;�n�duoea� �C�aaaaclZc�aet(a �\ Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistration: „j5S811 Type: xpiration: : 119/1pa5.- , Privata Corporatij R. S. HEBERT CO. &1REMoDUNGIhC. RONALD HEBERT =_ _'�' r 102 ADAMS AVE. NO ANDOVER, MA 01845 f 4 Undersecretary - s RSHEB-1 . OP ID: JY ACORLX CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNM) 03/31/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978 688 8829 NAME CONTACT Michaud, Rowe And Ruscak Ins. Fax: 978 557 2130 P.O. Box 188 North Andover, MA 01845 Lawrence R. Michaud, CIC aO No Ext): .v No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Guard Insurance Group EACH OCCURRENCE $ 1,000,000 INSURED R S Hebert Const & Remod, Inc. INSURER B: Commerce Insurance Company 34754 102 Adams Avenue N Andover, MA 01845 INSURER C : GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRO JECT F7] LOC INSURER D: INSURER E: B INSURER F: CnVFRAnPA CFRTIFICATF NI IMRFR: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER EFF MM/DDfYYYY MPOLICY LICY EXP /DDfYYYY M LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_� OCCUR RSBP404812 05/11/13 05/11/14 EACH OCCURRENCE $ 1,000,000 pREM SES ea occurRENTErence) $ 50,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRO JECT F7] LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS X HIRED AUTOS X NON -OWNED AUTOS BBCM08 12/19/13 12/19/14 (Ea aEeDtSINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ IR or dentDAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A RSWC465974 01/01114 01/01/15 STATU- OTH- TORY LIMITS ER E.L.EACHACCIDENT $ 100,00 E.L. DISEASE - EA EMPLOYEE $ 100,00 E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) f'P0TIGI('_ATI= 1-Inl nFR CANCELLATION ©1988-2010 AGORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cynthia Parent ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE'.. ©1988-2010 AGORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD F a N LM N L = L V i 0) N vii 4' W L IA O 3 O Q on G1 +r v 4+ cu +' L v Q) v c � 'L UA -a 0 u H Vl w L L -0O O C y M Q L t z o LU C L N W1I O O U N cL6 > m U E E O a •� L1 LJ N tLnCU Y 4-J U H •X ii a (D o W -0 W