HomeMy WebLinkAboutBuilding Permit #668 - 550 SALEM STREET 5/3/2010TYPE OF IMPROVEMENT
PROPOSED USE
Resi ntial
Non- Residential
New Building
1,tne family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolitions ve vi,(c
Other
S.ep!ic Well
Floadplain . 'Wetlands.
Watershed,District
wateriSewer
OWNER: Name:
V 11UN Ut- YYUKK iU t3E PKEFORMED:
,I -L. A— /)L— i I -n. I_ o d i
m hPr'I,
Please Type or Print Clearly)
ARCHITECT/ENGINEER Phone:
Address: VZ/
Reg. No.
FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED ST BASED ON $925.0 P S.F.
J
Total Project Cast: $ FEE: $ Y,�i-
Check No.: 6 Receipt No.:
NOTE: Persons contracting ulfrebistered contractors do not have access to uarantl fui:d
Signature of Agent/Owner Signature of contractor
j•d 88 G6 N3AoaWU Hl escciT oZ ED Rew
0
Plans Submitted Plans Waived Certified Plot Pian 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
I
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
FIRE DEPARTMENT - Temp Dumpster on site .yes no
Located at 124 Main Street .
Fire Department signature/date
Street
r-OMMF_NTS _ i
z'd N3AOQNd HINOW eS£:IT OT 60 ReW
Location5�5yi/�
No. a Date
NORT" TOWN OF NORTH
O'.�•e
ANDOVER
:•stip
�? • . _ • pL
' Certificate Occupancy
$
of
Building/Frame Permit Fee
$
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22967
Building Inspector
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Dimension
o:�''�-
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 app,Foval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No V
MGL Chapter 166 Section 21A —F and G min.s100-s1000 fine
Doc.Building Permit Revised 2010
6'd 2bS6BB96L6 83AOQWd HIdOW eSE:TT OT 60 ReW
Dropo y,vr Page No. of Pages
?=VrOpuu hereby to furnish. material Wd labor - complete ,in. accordance with Specifications below; lar the sum of: • ,
dollars
aymem to be n:aao as Iollows:
One Third Deposit One Third Mid Job Balance Upon Completion, OR
NOTICE: All home improvement contractors and subcontractors engaged In home Allt .
improvement contracting, unless specifically exempt from registration by provisions Signa Ure
of Chapter 142A of the General Laws, must be registered with the Commonwealth.
^J
of Massachusetts. Inquiries about registration and status should be made to the
Director, Home Improvement Contract Registration, One Ashburton Place, Room 'trfl'f r %I IT." ofpropose, f may bet'
1301, Boston, MA 02108. withdrawn accepted within days.
We hereby submit, specifications and estimates for, ROOF WORK_,
.+,•
[TRIP ROOF OF 144/ �- � LAYERS OF ASPHALT SHINGLES, COVER EXTERIOR WALLS AND
—/FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ADDITIONAL LAYERS WILL BE EXTRA, SEE BELOW
It� OVER DECK WITH UNDERLAYMENT FELT. 1w f, ,`� Mt:rR1 ,t3;or 0 4> x ( tfytq
NSTALL ICE & WATER SHIELD AT LEADING EDGE, VALLEYS AND ALL ROOF PENETRATIONS.
�TANDARD APPLICATION AT EAVES IS 3 FEET. ALL LOWER SLOPED RO EAS TO RECEIVE 6 FEET.
OVER ALL PERIMETERS WITH 8 INCH ALUMINUM DRIP EDGE, COLOR: WHITE BROWN SILVER COPPER
INSTALL RIDGE VENT OR ❑ ROOF LOUVERS FOR ADDED ATTIC ILATION.' i '
STALL SOFFIT VENTS WHERE NECESSARY. SOFFIT SIZE TO DETERMINE SIZE OF VENT.
Ly.11C
OVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS.
.OUNTER FLASH CHIMNEY(S) WITH ALUMINUM FLASHING AS NEEDED.
01
RELEAD'CHIMNEY. CUT ALL EXISTING TAR AND LEAD FROM 1_ CHIMNEY(S); C T E REGLET CEMENT
AAZA NEW LEAD IN PLACE WITH MORTAR. IF NEEDED FOR A WATERTIGHT JOB,}TfYPF{f�`�.
EBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD "'I' TO ABOVE PRICE.
Er REPLACE DEFECTIVE ROOF DECKING WHERE NECESSARY AT CONTRACTORS DISCRETION.
DEFECTIVE ROOF DECKING REPLACED WITH SPRUCE, FIRST /�2%� FEET FREE AND THEN � PER
FOO -r THEREAFTER.
PLYWOOD DECKS REPLACE SHEET(S) FREE THEN: PER., SHEET, BUY,AND,INST LL,
HICKNESS
COVER ROOF SURFACE WIT
STORM NAIL ALL SHINGLES WHEN APPLICABLE SEE'MFG: IN R(TCTIO S).
INSTALL SKYLIGHTS PROVIDED BY CONTRACTOR OR CUSTOMER; FRAME ROOF DECK' 'As 'NEEDED,
PROPERLY FLASH UNITS WITH FLASHING KIT(S) PROVIDED, ADD TO PRIC.E.FCUSTOMER TO DO
•;INTE;RIOF{FINISH WORK,,JNLESS SPECIFIED OTHERWISE. �s
Id IF MORE LAYERS ARE FOUND THAN INDICATED ABOVE, AN ADDITIONAL CHARGE.01` : - S�S0.21.I WILL
BE ADDED PER LAYER. IN THE EVENT OF MULTIPLE LAYERS IN RANDOM AREAS OF ROOF,.COST IS
PER SQUARE (10'X 10 AREA TO REMOVE AND'DISPOSEIOF ADDITIONAL LAYERS.
[CLEAN ALL•JOB RELATED DEBRIS FROM OUTSIDE WORK AREA. OBTAIN ALL PERMITS AND CARRYALL
NECESSARY INSURANCES AS REQUIRED BY LAW. WE CANNOTACCEPT RESPONSIBILITYPOR DEBRIS FALLING
LN.IQ37J1C AREAS CUSTOMER SHOULD COVER VALUABLES GREAT CARE WILL BE USED TO PROTECT rrrF
ST UC RE AND LANDSCAPING DURING THE STRIPPING HOWEVER SOME MARRING COULD OCCUR
t''•:1IEi'-:. .'1.1 ii r.rtt.,gtA it' ii+H/.
WARRANTY /All work arranteed to be free of installation defects for �d years, limited to installed Item and its repair only. Material warranteed by mfg, to
be free of defects for years, see mfg. warranty for exact warranty performance. Acts. of nature, including ice damming, are not covered under warranty.
While under warranty if the homeowner hires any other contractor to perform work which may compromise the roof system without first contacting Joseph S.
Savini, Inc. the warranty could be voided. Any repairs required due to the roof system being compromised by another contractor will be billable."
Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from acceptance jdate by mail or
telegram sent to Joseph Savini Roofing & Gutter Contractors, 40 Canal Street, Medford, MA 02155. See reverse side for'cancellation'procedures.
Once all items in this contract are completed as agreed, customer has 3 days to fulfill payment schedule or pay all attorney and legal fees incurred by Joseph
Savini with interest of 1.5% per month on the unpaid balance. All parties agree that all disputes will be settled through binding arbitration as provided by the
Better Business Bureau or the Secretary or the Executive Office of Consumer Affairs and Business Regulations, MGLC._ 142A. Please see reverse side,
Arbitration o' Disputes.
t.,,1 • , ! e,l 'u ' •n t...
Zicceptance,.of PropoSat -The above process, specifications:,. n t . ^
and conditions are satisfactory and are hereby accepted. You are authorized ,t„ ,, Signature
to do the work as specified. Paymenj will be made as outlined above.
Date of Acceptance: 7 / � Z U Signal
Joseph S. Savini Incorporated
D/B/A Joseph S. Savini
Roofing & Gutter Contractors
MASS BUILDERS
40 Canal Street, Medford, MA 02155 CONTRACTORS
LICENSE #036954
(781) 395-3954 Fax (781) 3934926 pr� REG. 135743
,�; t �d-
-- M
•PHONE
PROPOSAL SUBMITTEDJO I
DAT
STREET i
.. ,. ,.
JOB NAME-. ,..s ... �.. r. ,,.. .. .,. ., • ..
CITY, STATE M Z ODE
•.. -
JOB LOCATION r - • - - ,
Il,,
I V
ARCHITECT
ATE bFrNS .
- .. •I: ± JOB PHONE •.
?=VrOpuu hereby to furnish. material Wd labor - complete ,in. accordance with Specifications below; lar the sum of: • ,
dollars
aymem to be n:aao as Iollows:
One Third Deposit One Third Mid Job Balance Upon Completion, OR
NOTICE: All home improvement contractors and subcontractors engaged In home Allt .
improvement contracting, unless specifically exempt from registration by provisions Signa Ure
of Chapter 142A of the General Laws, must be registered with the Commonwealth.
^J
of Massachusetts. Inquiries about registration and status should be made to the
Director, Home Improvement Contract Registration, One Ashburton Place, Room 'trfl'f r %I IT." ofpropose, f may bet'
1301, Boston, MA 02108. withdrawn accepted within days.
We hereby submit, specifications and estimates for, ROOF WORK_,
.+,•
[TRIP ROOF OF 144/ �- � LAYERS OF ASPHALT SHINGLES, COVER EXTERIOR WALLS AND
—/FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ADDITIONAL LAYERS WILL BE EXTRA, SEE BELOW
It� OVER DECK WITH UNDERLAYMENT FELT. 1w f, ,`� Mt:rR1 ,t3;or 0 4> x ( tfytq
NSTALL ICE & WATER SHIELD AT LEADING EDGE, VALLEYS AND ALL ROOF PENETRATIONS.
�TANDARD APPLICATION AT EAVES IS 3 FEET. ALL LOWER SLOPED RO EAS TO RECEIVE 6 FEET.
OVER ALL PERIMETERS WITH 8 INCH ALUMINUM DRIP EDGE, COLOR: WHITE BROWN SILVER COPPER
INSTALL RIDGE VENT OR ❑ ROOF LOUVERS FOR ADDED ATTIC ILATION.' i '
STALL SOFFIT VENTS WHERE NECESSARY. SOFFIT SIZE TO DETERMINE SIZE OF VENT.
Ly.11C
OVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS.
.OUNTER FLASH CHIMNEY(S) WITH ALUMINUM FLASHING AS NEEDED.
01
RELEAD'CHIMNEY. CUT ALL EXISTING TAR AND LEAD FROM 1_ CHIMNEY(S); C T E REGLET CEMENT
AAZA NEW LEAD IN PLACE WITH MORTAR. IF NEEDED FOR A WATERTIGHT JOB,}TfYPF{f�`�.
EBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD "'I' TO ABOVE PRICE.
Er REPLACE DEFECTIVE ROOF DECKING WHERE NECESSARY AT CONTRACTORS DISCRETION.
DEFECTIVE ROOF DECKING REPLACED WITH SPRUCE, FIRST /�2%� FEET FREE AND THEN � PER
FOO -r THEREAFTER.
PLYWOOD DECKS REPLACE SHEET(S) FREE THEN: PER., SHEET, BUY,AND,INST LL,
HICKNESS
COVER ROOF SURFACE WIT
STORM NAIL ALL SHINGLES WHEN APPLICABLE SEE'MFG: IN R(TCTIO S).
INSTALL SKYLIGHTS PROVIDED BY CONTRACTOR OR CUSTOMER; FRAME ROOF DECK' 'As 'NEEDED,
PROPERLY FLASH UNITS WITH FLASHING KIT(S) PROVIDED, ADD TO PRIC.E.FCUSTOMER TO DO
•;INTE;RIOF{FINISH WORK,,JNLESS SPECIFIED OTHERWISE. �s
Id IF MORE LAYERS ARE FOUND THAN INDICATED ABOVE, AN ADDITIONAL CHARGE.01` : - S�S0.21.I WILL
BE ADDED PER LAYER. IN THE EVENT OF MULTIPLE LAYERS IN RANDOM AREAS OF ROOF,.COST IS
PER SQUARE (10'X 10 AREA TO REMOVE AND'DISPOSEIOF ADDITIONAL LAYERS.
[CLEAN ALL•JOB RELATED DEBRIS FROM OUTSIDE WORK AREA. OBTAIN ALL PERMITS AND CARRYALL
NECESSARY INSURANCES AS REQUIRED BY LAW. WE CANNOTACCEPT RESPONSIBILITYPOR DEBRIS FALLING
LN.IQ37J1C AREAS CUSTOMER SHOULD COVER VALUABLES GREAT CARE WILL BE USED TO PROTECT rrrF
ST UC RE AND LANDSCAPING DURING THE STRIPPING HOWEVER SOME MARRING COULD OCCUR
t''•:1IEi'-:. .'1.1 ii r.rtt.,gtA it' ii+H/.
WARRANTY /All work arranteed to be free of installation defects for �d years, limited to installed Item and its repair only. Material warranteed by mfg, to
be free of defects for years, see mfg. warranty for exact warranty performance. Acts. of nature, including ice damming, are not covered under warranty.
While under warranty if the homeowner hires any other contractor to perform work which may compromise the roof system without first contacting Joseph S.
Savini, Inc. the warranty could be voided. Any repairs required due to the roof system being compromised by another contractor will be billable."
Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from acceptance jdate by mail or
telegram sent to Joseph Savini Roofing & Gutter Contractors, 40 Canal Street, Medford, MA 02155. See reverse side for'cancellation'procedures.
Once all items in this contract are completed as agreed, customer has 3 days to fulfill payment schedule or pay all attorney and legal fees incurred by Joseph
Savini with interest of 1.5% per month on the unpaid balance. All parties agree that all disputes will be settled through binding arbitration as provided by the
Better Business Bureau or the Secretary or the Executive Office of Consumer Affairs and Business Regulations, MGLC._ 142A. Please see reverse side,
Arbitration o' Disputes.
t.,,1 • , ! e,l 'u ' •n t...
Zicceptance,.of PropoSat -The above process, specifications:,. n t . ^
and conditions are satisfactory and are hereby accepted. You are authorized ,t„ ,, Signature
to do the work as specified. Paymenj will be made as outlined above.
Date of Acceptance: 7 / � Z U Signal
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofi Siding, Interior Rehabilitation Permits
ilding Permit Application
orkers Comp Affidavit
jhoto Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
❑ Floor Pian Or Proposed Interior Work.)V/, -
❑ Engineering Affidavits for Engineered products /V/,
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
1U114,
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
❑ Fioor/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
u Photo of H.I.G. 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 mast stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy- and proof of recording
must be submitted with -the building application
Doc: Building Permit Revised 2008
S -d 2i►S68898L6 d3AOaWd HINOW ege c t T 01 60 ReW
The Conimoti wea tli of .4lassach usetts
Department of In<lustrial AccMents
Office of Ili l,estiaatioiis
600 Washington Street
Boston, I fA 02111
��='�'s�� rvww,IllltSS',oOt�/tlil!
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunlber•�
Applicant Information Please Print Legibly
Mille (Business Oreanizanon Individual):
Addt'ess: : -(o I ..
City/State/Zip: Phone #;
Are ypIdan employer? Check the appropriate box:
I. 1 am a emplcyer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).`
-- have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
i ship and have no employees
These sub -contractors have
working for me in any capacity,
workers' comp, insurance.
fN'o workers' comp. insurance
5. ❑ We are a corporation and its
i required.)
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
i myself. (No �.,orkers' comp.
e. 152, §1(4), and we have no
insurance req.,ired.)'
employees, [No workers'
comp. insurance required,]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additio:•,
I l.❑ Plumbing repairs or addition.
12.7 Roof repairs
13.❑ Other
*Any applicant that chcc;;s box 91 must also fill out the section below showing their workers' compensation policy information.
' Homcossners who submit :his affidavit indinting they are doing all work and then hire outside contractors must submit a new affidavit indicating sucn.
Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infomtation.
I am an employer that is providing workers' compensation insurance for mY employees. Below is the policy and job site
information. , _
Insurance Company Nlame:
Policy k or Self -ins. Lic. 9: C_ 95S 3a Sa,A Expiration Date: ,�o10
Job Site Address: 5�So &Nefn SA- City/State/Zip: b64 -4X, �;aJ e V—
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 MCL c. 152 can lead to the imposition of criminal penalties of a
Fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the foal( of a STOP WORK ORDER and ; fne
of up to 5250.00 a da . against the violator. Be advised that a copy of this statement may be forwarded 4o the Office of
Investigations of the DIA for insurance coverage verification,
I do hereb.t' certify " the pains and gnalties of perjurl' that the information provided above is true and Correct
n
Official use only. Do not write in this area, to be completed b.p cith or town official.
Ciry or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3, Ciry/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
� •��,V!G.r, I �\ � li i � !fit �i�`%4`y � �� " `r i� �'7`�y ,r •. �,�t�. , :-` j�i4'.'-
rK f,,�{1�i,'i,.7i ltl�:r lYa�l i ly' ` �f I '�`5�P',•,;Jx�
.f
i
1jOIv1E MPROYEIY= CONTRACTOR LAW
Supplement to Permit Application
MGL 1.124 R'-�uires U} u u1.1___�_It
G CER25"T'��_�aion rcnpvatiQD, =air, mpdMizarion 4o��n¢ imoro�cmcnt rtrnov-e
dcnwlidpnQr coruuvstion of �n WN n w ury zlnina oWnct-4c iso �,Adjn¢ wn;4nins u Isw ons bus w mors char
four �weilin¢ wiu or M"VZ mss. which vs �d;.; ne W such r,s*WSMa or buildlrm be done by rvy sTcr coaoaenrz w,�
• � .-,.•,'...:, ilan� vetch. j ,
.� � rtgtjrcmcna.
T oca�on ofProperry:
c
Owacr Name and An nav) b
Da: c
of P crr-t A.pp k at i o a: Est_ Cost: i � �l 9
Typc of Work:
I Eby certify that:
RFGiSTR MN IS NOT REQUIRED FOR THE FOLLOWNG REASONS:
work =hLdcd by law
job under S 1, 000
buLdmg not owner -occupied
1�:.�ir.�j:i.. �Y::��, ... .... ,� �,',�.�r'+.4'd^"fit ''�`�`?.yl', '°•"' ', �/ ..
other tspcct<y
Notitt is h.crcby given tfr�
.. �.••'J.:•J`f is �, �• .: •,�
OWNERS., PULLING THEIR OWN PERlvff' .0R DEALING �TTH UNREQI�
`CONTRACTORS��FOR"APPI.�CABa'
�£ HOME 2 RQY��NT WORK DO NOT HAVE
ACCESS TO TSE AR.BITR.ATION PROGRAM OR GUARANTY FUND MGL c 142A.
S4ncd Lmdcr peashics ofprr7uzy, I hs�reby'apply for a permit as the agttrt of LHC owner-
-
Cmautyr Name (print) Daze
:2
C-0
Co aczcto r S igrartzrc _ Rcgistratio n N umbe r
OR
Norwkhs ai the above notice, I hereby apply for a permit as the owner of the above property:
Owner Name (priest) Dtzc
Ow= S ignazurc
�... � it � al�if� �'�'•!:. ,
' .•. .. ✓rk l�J(YJlliJll(YJZCU2CLGlIl 4��!'GCi06CLCIGG[O(KGo .^_�—_. _.... -
_ Oflice of Consumer Affairs &Business Regulation
License or registration valid for individul use only
—�` before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
kJ f?egisiration::— 135743 10 Park Plaza - Suite 5170
E'ixpiration: 5)3/2012 Tr# 294393 Boston, MA 02116
7YPe
JOSEPH S. SAVINk.CONTRACTING CO.
JOSEPH S:,VINI
40 CANAL:]"' O
MEDFORD %1A 02155 Undersecretary of valid with ut signature
,.a
r 1VVIa ct►usettx ` .'0epartment of Public SufeO,
iw
$oard`:of Building Regulations and,Standards
U pu�jp1 ervisor .7.
LlUcense
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ssess a current'edi on`of the r lrl
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Massachusetts State Buil 1
x
is cause for revocation of this license.
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U V Y CHAU C:7
ACORD. ,: CERTIFICATE OF LIABILITY INSURANCEiDAT TER ice»
VANU0El1, , Phone- 508-651-7700 Fax: 309-653-9009
Eastern Insurance Group LLC-Commerc+al Linos
233 West Central St-eet
-
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick MA 01760
Y XPIRATION + LIMITS
VEPsys
POLICY NUMBER
INSURERS AFFORDING COVERAGE NAIL #
INSURED
INSURBA:Max Specialty Inslarance Cc
INSUIPIER&HanOver insuranceco. 22292
Joseph S. Savir,i, Inc.
40 Canal Street
Medford MA 02155
IARC. 1 E USA
INSURER D:
INSURER E:
r4
V
U V Y CHAU C:7
THE PJLICIES 0? INSURAi�C? LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED.
N0:'AI:HSTANDING ANY REQUIREMENT, TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUISNT WITH RESPECT TO WHICH THIS
ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, SHE I'�suRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN :S SUBJECT TO ALL THE
TERMS,:EXCLUSIOVS AND CONOIT.CN9 OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Y XPIRATION + LIMITS
VEPsys
POLICY NUMBER
TYPF OF INSURANCE
GFNERALUABIUTY
bLA]C013100vG1667
.0! 21%20'G9
1G 21 J2O� O ; EACHOCCURRENCE
11. 00,31 000 _
COAA)11ERCUU GEN ErTAILJAEILRY
PREMISESIEa00a
s ' 1
S 5. 000
CLA!►/SUAOEI� OCCUR
11EDEXP oro
i 1. 0 3. 000
I
I
: PERSONAL a ADV IMURY
I
; GENERAL AGGREGATE
s2;000,000
AGCiftEGATE LILU T APPLIES PER:
s'00 -.00c
I
PROOUCYS • COMPIOP AGG
FGENL
POUCY PRO LOC
AIITOMMLELIABILITY
i•L2N870061:02
4/251-'20L9
4i25/2010 COMBINED SINGLE U.aTI
I S 1, 00'J, +� v+-
ANYAUTO
(Eaacddwi)
ALLOWIEDAUTOS
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s
(Pat PocuU
SCHEDUUEOAUTOS
IL HIREOAUTOS
j GODLYKAAtY
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fu &ODOM)
i S
GARAGE LIABILITY
ALITOONLY •EAACCIDENT s
ANYALrrO
} OTHER THAN EAACC S
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; AUTOONLY: AGG S
EXCESSUWSRELLAUA84UTY
HOCCURRENCE S
OCCUR CCW 1 tS MADE
AGGREGATE S
,
S
+ DEOuCTiaLE
is
RETENTION s
S
C :WORKERSC011PENSATSoNAho
C4583282A
9!12/2009
9 /12 /2010 IX } "-
EYPLOYERr U&NUTY
ANYPROPRI TOWPAXNEN1-: ECUTIVE
E.L EACHACCIDENT 3 tk��...._.._
i OFFICERAAEMBEREXCLUDED?
E.L. DISEASE • EA EMPLOYEE S 500. 22 00 -`-
: B ds FRONT m 09Uw
E.L. DISEASE • POLICY LIMIT ssoa. 500
'OTHER
DESCIVIVN OF OPERATIONS 1 LOCATIONS 1 VEiCLES I EXCLUSIONS ADDED BY @LOOMMENTY SPEC ALPwwwo"s
i
�iI33�1�T�711Td'_Gl<n N��rN�urc.r.
AC DRD 25 (2001 /081
O AGORD CORPORATION 1985
+
SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES HE CANCEL -EC
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILT, VINDEAVOR TO MAIL 30 DAYS WRITTEN ?NOTICE TC 711E
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILUR2 TO W '0
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
AC DRD 25 (2001 /081
O AGORD CORPORATION 1985
+