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HomeMy WebLinkAboutBuilding Permit #361-14 - 57 DAVIS STREET 10/17/2013 X. NORTH q BUILDING PERMIT o:°�s`."10 =`•.�o TOWN OF NORTH ANDOVER ; APPLICATION FOR PLAN EXAMINATION Lb Permit N0: Date Received 3,ss^AYEP Date Issued: (� /7 c►+us I ORTANT:Applicant must complete all items on this page 44 Ffi - FLOCAT ON. e e '. ' ti Onto . PROPERTY OWNERftJ Ff „ POOL � T � a �MAP.NCYFARCEL ZONING D#STR#CTH�ston �strtct es n 411 - Mach�he (I I ' � yes iso x _ S TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Nepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 'D Septic t7'We[I ❑ F#oodplain' p Wetlands Lt 1lVatershed Distr cf” Y p Water/Sewer, & Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: G RACTOR Name phone R :. e �Kln Address 5xr r 5upervisot'�.Ct�nstvctlon Lcese Expo Date= � Home rnprovefti ib se Y ,YQ I ARCHITECT/ENGINEER Phone: Address: Reg. No. t FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $__�,�_enn Y� FEE: $ Check No.:_ 7.�QQ Receipt No., ���' NOTE: Persons contracting with unregistered contractors do not have access to the gua ty fund 5� nature ent/0 nw er � " ' contractor - E v L e TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION-_-:r -Print PROPERTY OWNEROld - - - _ 100 Year Structure yes no. Print MAP NO: PARCEL:- ZONING DISTRICT: —Hi storic District yes no - Machine Shop Yillage yes no_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) Phone: OWNER: Name: Address: CONTRACTOR Name: Phone: . Address: . - Supervisor's Construction License: Exp. Date: Home Improvement License:_ 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. ra Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access-.110 the guaranty fund Si nature of contractor Signature of Agent/Owner_i_ g �,,,r� c„k:r;++o,a F-1 piano XA►aivPri Fl C't-rtifiPcl Plot Plan ❑_ Stamped Plans ❑ _� Location No. Date IVI "7 1 i • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 Check# 7� 7� G t 0 " Building Inspector f Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ .-TYPE-OF°:SEWERAGE:DISP:OSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. . ..Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc.. ❑..- Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM :.. DATE REJECTED: DATE-APPROVED PLANNING & DEVELOPMENT- COMMENTS -CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Consdrvation Decision: Comments lAilater & Sewer Connection/Signature & Date Driveway Permit DPW Tow Engineer: Signature: Located 384 Osgood Street ' FIRE D'EPOTil E�'NT =-Temp Dempster on site yes no Located-at 124 Main Stc_-et r . Fire'Departmerit signatureltlate j COMMENTS_=- 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 ❑ ❑ COMENTS CONSERVATION ❑ ❑ I CD) COMMENTS -r- DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street t FIRE DEPARTMENTernpDurnpste onslfe `�{es fs h a x :(warnQa 4 x * a caEed of,,24,Mairr street . ' ire bepartmant s gnature elate " rr c s any ''5.� , :_. COM MIE108 ?3,; 'mss a ,am a `- a c•. x ' 9 } 34• a' ,'; W, x* . e x --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 MGLChapter-166.Section 21A-F and G min.$100-$1000.fine NOTES and DATA— (For department use El Notified for pickup - Date ( E Doe.Building Permit Revised 2010 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 2012 a. e or t ` Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 Insall 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 DEPARTMENTWITORM07 Revised 2.2007 t , J Building Department >`rhe foil ing is'a list of the required forms to belilled out for the appropdate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits u-' Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) • Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products -NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bP subm.tted with the building application Doc: Doc.Buhding permit Revised 2012 NORTH Town of , ? E ndover O No. /© /7 o KI , ver, Mass, �� A- COCNIC Nl W.C. 7�p�4ATED ►P���,�5 S 11 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .. ....t. BUILDING INSPECTOR has permission to erect .......................... buildings on ... z. ..llila....5� ......................................... Foundation Rough to be occupied as ................. . :.C. l.�s. jr.<..r. :vcvv�... /.'.�.ear. .. . .::^r. 1. ....�'Q.t:: : ....... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 CONSTRUCTION TARTS Rough ........................ Service ......... ...�. ... .. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' 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. Massachusetts-Department s and Standards ! Board of Building - Construction SuPer%-isor _ License:CSS-00 '116 GUY J DpNEL . �s, PO BOX 314 R1 1 AYER MA 4432. r O Expiration i Cornmissioner 03/14/2E114 Office of Consumer Affairs and ffusiness Regulation 10 Park Plaza- Suite 5170 Boston, Massac usetts 02116 Home Improvement (460,11AS or Registration Registration: 142042 Type: Prorate Corporation DONELL & SONS, INC. a 3 r ;^ M Eviration: 3/812014 Tr# 222033 GUY DONELL PO BOX 314 AYER, MA 01432 Update Address and return card Mark reason for change. i 0 E] Address [] Renewal �+-o9/oa-Gtor2rs � Employment E] Lost Card �'1ee�n - - a+s*r9rrtsnu /in� Office of Consumer Affairs&>i rfsincss Rnua License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return'to: Registration: ; 42042 Type: ©Bice of Consumer Affairs and Business Regulation F Expiration: -302014 Private Corporation 10 Park Plats-Suite 5178 Boston,MA 021.16 �r DONELL =_ F VRIGHT RD R,MA 01432 — L®dersemiary valid without signature .r rr.. r Pages. :. DONELL CONSTRUCTION, It'► . l'i Fletci`. tStreell k-,-I ViA Q 1 43, f 830 . �+q(,9y7+ ) 772 ,1348 348 efSWar 852.7012 !SUB"TTP E[?T4 PHONE DiITE STf{EE`r iC)9 htA► CtTY,3TA7E and kfA''WUE X*LOCATON s ARCHITECT DATE OF PIANS JOB k'Ht tE We hereby submit specifications and estimates for: { t y` •, ham ! - �5 r t r" `` 1 -`_ L 3Y- Jr 4 m e k x We Propose hereby to furnish material and labor--complete in accordance with above specifications,for the sum of: - a ; dollars($ ). Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed In a workmanlike r manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature ¢ charge over and above the estimate. Ali agreements contingent upon stakes, accidents or delays beyond our control. Owner to carry fire• tornado and other necessary insurance. Our Note:This proposal may.be workers are fully covered by Workman's Compensation insurance, withdrawn by us if not accepted within days. Acceptance of Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature work as specified.Payment will be made as outlined above. Date of Acceptance: Signature FA M1PO 'o R( 11 "I 11L . (�fiA/OVI if , QQ L MX-T/ 14 ki- fox sax. r At vjc V ' `- —_ 1 --�► cr A I C' 4 -L - �► r. 1 1 W/lb �l I ZIA i i t t I t r r - -i r -i F-1 r -, -� ILT 6 PAA f t S , `r s WOF Ova 4 AAJ �. VN PP,-QQT AVZ Snf 5 Af -�xto ROM x_-Py, I'am m l� + � r r" ROOF AG {� 7r' K To Ho( STA L r APl� 6�6 t�9sT N aU . �.. r -i r --r r -1 r 5- LAMTP rr) N '' S�k�1, Irl 1 — ��c6 ►�• �'t� '. Pro 1�.�1�f Cir . , comer; PAD-ma��.�_�i�� T' Rightfax C1-1 10/16/2013 7:08 : 45 AM PAGE 2/002 Fax Server i CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) RTIFICATE 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: MARKHAM PRIEST INSURANCE PHONE FAX 20 CENTRAL AVE (A1C,No,Ext): (AIC,No): E-MAIL AYER,MA 01432 ADDRESS: 27HTH INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA TELEX DONELL CONSTRUCTION INC INSURER B: INSURER C: INSURER D: 23 FLETCHER ST INSURER E: AYER,MA 01432 INSURER F: , COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: - F79ff"t FLUMS UF INhURANLE LISTED 13ELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVEFOR THE POLICY PERIODINDICATEQ NaMTHSTANDING ANY REQUI REIMENT,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 POUCI ES DESCRI BED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONS AND CONDmONS OF SUCH POLICI ES, LIMITS SHOO MAY HAVE BEEN REDUCED BY PAID CLAIM& INSR ADD SUB POUCY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MIR DD�YYYY) (M ADD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F-1 OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY E]PROJECT❑LOC PRODUCTS-COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION ANDWC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-56400976-13 05/26/2013 05/26/2014 `Y UMITS ANY PROPERITORIPARTNER(E(ECUTIVE Y WA E.L.EACH ACCIDENT OFRCER4NEMBER E(CUJDED? ❑ $ 500,000 (MardatoryinNH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRI PTICN OF OPERATIONS below ATLE.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION GREG AND JENNIFER DAIGLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 57 DAVIS ST. BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAVVE NORTH ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. A CERTIFICATE OF LIABILITY INSURANCE DI TE 0/4/2013 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(ies) 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 CONTACT Lori Wong g Markham Group, Inc. PHONE (976)7]2-0800 FAX (978)772-9506 IC No 20 Central Ave. E-pAIL .LoriW@markham-Group.com INSURERS AFFORDING COVERAGE NAIC# Ayer MA 01432 INSURERAMain Street America Ins Cc 11066 INSURED INSURERB: Telex Donell Construction, Inc. INSURER C: 23 Fletcher Street INSURER D: INSURER E: ,Ayer MA 01432 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1312100658 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ADD R POLICY NUMBER MM/DD/YYYY MMI D/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence) $ 50,000 A CLAIMS-MADE 1_X_1 OCCUR MS047826 /15/2013 /15/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS accident Per BODILY INJURY( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N T "IMANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Carpentry "Coverage as an additional insured is provided if required by written contract." CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Greg and Jennifer Daigle ACCORDANCE WITH THE POLICY PROVISIONS. 57 Davis St. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE J Harrington/LORI ��j'f7 �-- "/�°+7 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD