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HomeMy WebLinkAboutBuilding Permit #37 - 62 Kingston Street 7/14/2009 BUILDING PERMIT ot VtORT 6,"'�'o TOWN OF NORTH ANDOVER ��L'; '''- °p APPLICATION FOR PLAN EXAMINATION Permit NO: Date ReceivedA°AArea �SSACHU`+�� Date Issued: ' IMPORTANT:Applicant must complete all items on this page LOCATION eDQ Vida&pz"l— PROPERTY OWNER t ((� Print MAP NO:�1b PARCEL: ZONING DISTRICT:,Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building x 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 DESCRIPTIQUAGIF WO BE REFORM D: f VA, or'�5 bf5Tr'_1 Idntifi 'on Please Type or Print Clearly) OWNER: Name: ki IE6 Phone: AddressV17,32 CONTRACTOR Name: Phone: Address: f '� Supervisor's Construction License: " ' I Exp. Date: Home Improvement License: Exp. Date: ' ARCHITECT/ENGINEER Phone: f Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1�( '�-- FEE: $ Check No.: c� jU Receipt No.: 2 Z4-- NOTE: Persons contracting 4th unregistered contractors do not have access to g ara fund vignature of Agent/Owner Signature of contra o 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 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 I 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 ❑ Notified for pickup - Date _................_...._............--..................._....`..........._............. _...._..---.._................ _--............._......__ ........_-.._...._ _._..............._.. _............_...._.... --— .._....__...._.—................... Doc.Building Permit Revised 2009 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 PP 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 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:Building Permit Revised 2008 NORTH Town of 4Andover . Op..4Ws `..4.,• ..� No. 37 , R , o A K E dover, Mass., C OC N,C.E WICK ADRATE D PPS` �C) `s E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ............................g.b.. . ............................................................... .. ........... Foundation has perinission to erect................... ................. buildings on ....�j. ..............xf ...... ......... Rough to be occupied as % .. ,. � 1 Chimney �t.... ......-........................................................ provided that the person accepting this ermit 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 3 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU TARTS Rough ............. .... ............................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy 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. rA HOM.F.IMNROVTmMCNT CONTRAC'C PLEAR.READ THIS Sold,furnished and Ltstailed by: Branch Name. Sinton Date: k�/��- THD At-Home Services,Inc. d/b/a The Hoare Depot At-Homc Services 345A Greenwood Street,Unit 'Lr Worcester,MA OJ G07 Branch Numhet:31 Toll Piro(8005 657-5182; Fax(508)756-8823 Pctfcp,l 1D#75-26911460:ME Irc#C 02439;RI Cont.Litt/16421 n CT i.ic f1565'22;MA Home Improvement Contractor Rep,,#126l;9. Installation Addrear: r l�l�y�t City S zep 1&�� ✓ Purchaser(s): Work(Phone; Home Phoa: _ Cell Phone: f ] [tel 176o-If6 flume Address: (If different from Installation Address) City' Stats Zip E-mall Address(to receive project communicationh and Home Depot updates): — 100 NOT wish to receive any marketing ernails from The Home Depot Pruieet ldforrnsdiun! Undersigned("Custmner"),thr,owncn;of die.ptOtx.rty located at the above installatiOD address,%,agrees to buy, ;and'Dir)At-Hoine Sr•,rvires,Inc.("The Home Depot")agmes to furnish,deliver and arrange.for the installation(`'Installal.i0►1")of all matcrialg described on the below and on the referenced Spec Shcct(s),all of whichare incorporated into this Compact by this "roference,along with any applicable.Slate Supplement and Payment Suamlittry Miched hereto and any Change:Orders(collectively, Contract"): , Sol,#- (w­a uWX�..l •i car c a: __Sjx c SJtcatUt—ft Pro ect Anlona,t ✓r J EDRooftng []Sid;n) wirw wniiacinr, IOU �j I $ r.IGutrers/Covers (]Entry Donn ❑....... — !�j / 7 f._.... []Roofing OSiding 0 Windows r, htsada(ioll � �1Gtttters l CnVcrI I__II>ttn y 1)OW-N L..J....,....—----- ° R.00fin10S14i„L: I�wludow.c []L vulntiun 1 [-Kotler;/Covers I,;II.'.nlryDoorsO--••--.--. ._...._._. -- - - C]Sidinl,,n Windows DIncula1Eun -------'' --'-- DGutters/Covers t—II:Ptry.P(ior.q [1 _ Minimum 25%LXV.Wtof Cuotnict Almn,at doe upon execatlnn of this contrad. (fatal C;onlr'4ct Amount $ f WS,liadep chima mV not deposit more Ilona oac•tWr4 ofthe ContractAmount v Customer agues that,immediately upon completion of the work for each PI'oduct,Customer will execute a Completion Ccrtiriicaate (orae I'or each Product as defined by un individual Spec Shcet)and pay any bal,mct:doe, As applicable,each Cluseumrr u,tdtr this Contiactagrccs W be jointly and scyctaJly obligated and liable hemuh&'. mc;Home Del.)otre.r.rvr:g tht:right to issnc n Change Order or teratinate this Contract or imy iudividval Product(s)iticludcd herein,al its digcrolioo,if The Home Depot oc)tg nutllofi6P•iI g:l-viec provider detenuiueg tivu.it enonot porform its obligatiioug dui;to n etructun it ptublem with the home,environmental hazards such as ahold,agbcsto9 or lead paint,olhFr safety conc:crns,pricing errors ur b cs lw.' wat'lt required tO complete the job was not included lit the Contract. • Payment Suintnarv: The haylreat Sunnll;h'y - _._.....—___. i,aclndal lasp tut of this l-,unb•;u:J,,Nos forth the tott:l Cowraot mllolmt,ind p:ayl',7011lf 1r:y0ired.folil)e(li:pOSit6 and final payments by Producr(as applicable). NOTI(I TO C:USTOMCR. YO1:.tre:etttiVE d toil Cotttl:trt at thr.tirao yeti:B:l;It. CAo t)nf 5irn st t;u:tatticiiirti C'r.y'tif5t.atr.(note:; thw: --;s clraet cm)),plolit,)t C'urtificaw fc).e::aeil Rvf.odl nl'o( lief as donned by iutliviowd spne tihrvts)hc.cur-c wovIi,Oil t.bat 11roduct i is cgmplete. list alt:J oyt fit-Al turnimloon of tlris C:usilratt,Customer agrees 40 puy'('iw Iivilm:Depot 6w.Costs of materials,labor,f:.x'F*las('% and scvvicca provided by The Home 1)kpIA Or Author•Ize(1 Service pi-ovicier't rinigh dw(lot(:of tc:rurinaflon,plus;:any obis:,. :atmountr sci forth lit this,Agreelilelll 0."11111)wcd Butler applicable law. T1:12 II<)ME DEPOTMAY Wf'I'f1.010)AMOUNTS 4)1R'1SED '1'(P 'ffi.la IIOIvf[: I)epo' IrltCtM1r 'I'dCI; 10f,PC?uIp l'AyN,7`.1.';N ,y OR 0110'1� t'AYNI N'tiS MADE, lhli'VIR)UT t,;1M1'1'INce'!'Itf I1C)M[l;1DI?I'CyE".S 11't'ttlsil lil:1t41!-Tilk?�;1?O•I:l'tI's('.`.DF�d?.l'!ti';;�'t�Eli::C:Ah4O�1Rl'Gf.;. '.ccl:nixiicq.._tnc;Authorization, C't,slnrni,i%!:rens tract uu.Qarstauuh;Ilan lhi:: ;\n rt,ten; is::ir.:esti,,: agrcr. tuhl'l'h'(Pante Depot with It:giird to the Pr011aGN and IRS111thliUn Rlvvicrs:ut i supero-:cdis zll(*in,cli;i:usinn.e>uid❑gr_cnnnt(s,e:i(lu<r orul or written,ivlating ut said Prntluulti tend llllllrtllaliml,This Agrttontepr.c;innot he asigncd or anumded eill by a wrili,ig sig"od by Customer awl T'he Honln I)epot.Customer adolowlyd);rs an(I agrees thus Cus(oo,er hax head,understands,vulunlai ily occepas the } Iain,of and has received a copy of this Agreement. Ac epttr by• Sub ilt'• b CLIStOnICIA Signature Dale, S: C:onsultimt's Signature —1:'aI h....._...._....._.._._...---- .......__._....._........_ _ 1's,.cphonc No.—_. ..__._ — Cuxtumcr'%Signature Olar Soles Conraltamt l..icchsC No. _ ... cAN(ELLATIONt CUSTOMER MAY CANCEL THIS (08app11r.nfi1c) AGREEMENT wrilio113'PENALTY OR OBLIGATION IIP DI1dVl:R1N(, WRITTEN NC)TU.71.;TO Tlf1', HOME DIQ1OT BY MIDNIGHT ON THE THIRD BlISINENS uAY Al+'I'lAt SICNINC TJIIS AC:ltEVVIl'N'J'. '1'11(4 STATE SUIT'(.UMI-;NT A17AC HEI) HERETO CONTAINS A FO)1tM. TO USE Ili ONE' IS -Sl'F t71l'IC.'ALLY 11RF.S ItIItE1) 111' (,AIV IN t7d Wd8V:Zti 600E zz -unf Sz96Z92209 : 'ON Xdd A-19WIA WOdd SCAM,,(2111 iUaR itegalodon6 sad Swoolordo I Conetruedon Supetvlsor Liesn■o j License. CS 88766 BYpimdom: 3129!2010 Tre 20262 Resttl0tion: 00 SCOTT A MACMILLAN 10 PARK AVE SALEM.NH 09079 Comml9einner i S t�esrd sf Brlldlag Regslstiose and 8tsndsrdf License or regbtrstlon valid fer iad vidul use only HtOM!IMpApyEMlNT CONTRACTOR beforo the expiation data If buad return tot Baro of Buildiog RopladAae and Standards Rpf♦tmm".1 189348 One AshbdKdd!lace ilia 1301 F.ep WW', 1/712010 Tr11 282849 tostoo,Ms.•02108 Type: OBA TIN© r� �•r~�� MACMILLAN COMMC , ! 1 SCOTT MACMILLAN ,' 10 PARK AVE. valid without,p8t+eture SALEM,NH 03079 AdmioUtrotoNot v i r i N all '_. The Commonwealth of Massachusetts Department of Industrial Accidents - -- Office o0livestigations 600 Washington 0.treet Boston, MA 02111 www.anass.gov/di>;z Workers' Compensation Insuraiiee Affidavits Build ers/Contraetors/Electricia$Is/PluMbers Applicant Information i Please Print U14ibly Name (Business/Organization/Individual): 1' Address: 11 b-le-0 ®'-e- City/State/Zip: ' Phone.#: � ,�� i Are yo an employer?Check the appropriate bog: Type of project(required):. 1. I am a employer with 4. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have S. ❑ Demolition working for me in an capacity. employees and have workers'. g Y P h'• 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ - ' 10. Electrical repairs or additions required.] 5. �]Ve area corporation arid its 0 p 3.E] I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Ro repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other comp. insurance required.] "Any applicant that checks box#I 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: 1 (� Job Site Address: V ywtlyl City/State/Zip: Attach a copy of the workers' compenAdion 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$:1,5.00.00 and/or one-year imprisonment,as =�tton a�G . efa z�Tr'pd��RBBR and a f�ae 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 cern un r e p s an penalties ofperjury that the information provided above is true and correct. Signature: Date: _ 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#: Cl i3-1-,1'3 13-43 DH �F�n.L I .Vialia iC . 5=1] {u1� I '1:...1n1 'Lt Scb12 ?ui1L�:11 NaticralFrestlil<en 3,'32' 2.34 xn VidrLJ Rs*.Gcards No L:x:latad CLal9 I gLn �i L--.o lau n13o ® 91n cajiLils ENERGY PERFORMANCE RATINGS ey/,L1JApaN DE PENDtbtlEMO QJFRclETit� . I U-Factor Solar Heat Gain Coefficient cru Code.n=G,na%da de Ertergia Solar. :0 . 32 1 . 8 0 29 ADDITIONAL PERFORMANCE RATINGS eVlALIIA=N SUPLEMENTA UA De Pz4otkGD= Visible Transmittance TranRnb)on de I=Vuld i 0 . 52 �4csdia4rer>tlp a Qset Tea ra* arum b 901c"SRC X=dM hor detmm. *TW pr AZ De br&'ca WC tarn, ,ue d,>nrrntned for attend at ar ffMMrme�.=xftn r,d, produd�.WX doss.rot rWMnrtWa.arty xuld and dose not warren Tse SLAM Of?RY D�hr n is&Gonad nern4dr"Bmrffita hr attffi prodxi vsrromarm tntcrmanon.wMnv.rdr�ar9 EsW r jb k;ree.W plea am a�-N*m=dr mn be P de NRC P"d,term d mn&nwft bW dd WOMffi La wee useaoe p"WC=detmmkudn Par u+=*ft V de aadttt ren v w ma Y un terrano de uW-ka.t FRC no re=nlerde*9M0dXZ Y ro Wvtm qW d DfOd'ct 81i��pn Un M. UpWAM CDnR&mn d .. U to dd htctartEe Pn d two WW"de ab prodtc3a**&"Lary unit cualifiaf foc EN£RCY STIR cagion(,) : Noctharn, North Cunt.al, 90.,th Cant.a1, 90.thv.n. ck£R6fSTAR Li unldAd o�lliic�_pa.a 1.3 ciglsn(as) QNOROY,STAR: Norte, Norte Cantcal, 94c Central; Sur. IND: Eia.Ln 00/Cla2s 3/31"/H-Ro3 . Tastad 9L:a: 36' x 63' IND: Rafuarso QO/V1dzlo 2.39 nm/H-R43 Tlxa�o pcobado: 91.4 M x 164 CA' DP ' �-45/-45 669649�JC� 447.73 . H9 Hollxan 1931120. Krep the a6e1 for paa6 ENERGY SibJ?'n6otes.To mare man AR v*V.v4M tjN. Gumde IM soqueto porn posib c nerMm ENERGY SARs hen COMM mas Doan h tM,vWIj evkans7yVmVk , ,per ✓2 le, it \ Board of Building Regulations and Standards License or registration valid for individul rise only HOME IMPROVEMENT CON TRA&TOR before the expiration date. If found return to: Registration:, 126893, Board of Building Regulations and Standards One Ashburton Place Rm 1301 Expiration;. 6/3/2010 Boston,Ma.02108 Type' Supplement Card The Home Depot At=Home Service 9 RICHARD FALLONE f" 3200 COBB-GALLERIA PKWY#20 ei TLANTA,GA.30339 Administrator Notout signature I ACORD,M CERTIFICATE OF LIABILITY INSURANCE DATE02/20 /DD/YYYY) 02/20/09 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:steadfast Ina Co 26387 THD At-Home Services, Inc. INSURERB:Zurich American Ina Co 16535 2690 Cumberland Parkway INSURER C:NATIONAL UNION FIRE INS CO OF PITTS 19445 Suite 300 Atlanta , GA 30339 INSURERD:New Hampshire Ins Co 23841 INSURER E:Illinois Nati Ins Co 23817 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDI POLICY EFFECTIVE POLICY EXPIRATION LTR N RD POLICY NUMBER DATE IMMIDD[YY) DATE M DD LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4;000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS DAMAGE TO RENTED 1;000,000 PREMISES Ea occurence $ CLAIMS MADE FxDOCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) '$EXCLUDED ` PERSONAL B ADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $4,000,000 X I POLICY PRO El LOC B AUTOMOBILE LIABILITY BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person)- $ HIRED AUTOS BODILY INJURY (Per accident) $ NON-OWNED AUTOS i X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN - EA ACC $ AUTO ONLY: AGG $ - A EXCESSIUMBRELLA LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $5,000,000 X I OCCUR D CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE $ RETENTION $ $ TH C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 X WCSTATI IT ER T ER EMPLOYERS'LIABILITY RY D 3566915(AOS) 03/01/09 03/01/10 E.L.EACH ACCIDENT $1,000,000 " ANY PROPRIETOR/PARTNER/EXECUTIVE E OFFICER/MEMBEREXCLUDED? 3566917 (FL) 03/01/09 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, ) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)ckomraue_hd ©ACORD CORPORATION 1988 11172180 Location (D ZhgjTvN `sIF � No. a_;� Date —� �oRTM TOWN OF NORTH ANDOVER 0 9 Certificate of Occupancy $ Y bis',^°•'t�' 9 Mu Building/Frame/Frame Permit Fee $ , s,+csE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Aar 2 n LL Building Inspector