HomeMy WebLinkAboutBuilding Permit #533 - 626 CHICKERING ROAD 3/4/2010Permit N0:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
` IMPORTANT: Applicant must complete all items on this pate
LOCATION tom" C hf �'G Kt I �► R d : /U. kvdo vw� , M4.
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PROPERTY OWNER T3"0 Je-s ,'el0-- Hcvv%-c. QwNtAS A sso
Print
MAP NO: 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
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
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VU-cL�' V• G Y3. A c ► • Ole 9 AAdtt WILL COO e ne J ince- toiA s-
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Identification Please Type or Print Clearly)
OWNER: Name: 4sSa. Phone: L--t7k)ae7 •
lg4o
Address: 611-z /1,Gf' , ALJ • M A4. ols ys-
CONTRACTOR Name: iNurft0w ^4 z�At, 1000fS1 � Phone: 'q ? 0 15-6-02-0-0
Address: /k4( 16 • /Q v 6`:ov&,0vc60(-1 AJ- CAkJm5Aototd A44.
Supervisor's Construction License: C5 6 3.2- o$ Exp. Date: 07- I g l A° 12
Home Improvement License:--z!?--26>,6 Exp. 'Date: el /2-1 1-24J6
HKC:HI 1 LU I /LNUINEEK Phone:=/' /b , j a - 5 +z, r
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 Project Cost: $ 191ST 6".�,( FEE: $ � �
Check No.: _ / � C> S 3 Receipt No.: Z �
a
NOTE: Persons contracting with unregistered contractors do not have access to the guar, nal
Signature of Agent/Owner Signature of contractor
(�,-/d!t'
Location
No. Date /,v Ik ld
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ r°
Building/Frame Permit Fee $ �—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Z -
230.x/
Building Inspector
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
K
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
Reviewed on
DATE REJECTED DATE APPROVED
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Usgood Street
yes no
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-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
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$- `Iassachwsetts - Depai-tment of Puhlic Safet-
VBoard of Building Reiulations and Sturj(lus-(i.S
Construction Supervisor License
License: CS 83208
Restricted to: 00
DEAN CONSERVA
29 CRESCENT ST
TEWKSBURY, MA 01876
Expiration: 2/14/2012
( mmi�.i �irr Tr=: 18189
Restricted to: 00
00 - Unrestricted
1G -1 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWW. Mass.Gov/DPS
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organizationadividual): N V/ /'Z G w M -E'. A/% /4 L -Poe e J s n j C.
Address: /R.
City/State/Zip: �' I-i-� I M S Fo 2 Gt. M 0i• Phone #: 9-7 S J.2 5&- o 0 0
rJ t 8Z N
Are you an employer? Check the appropriate box:
1.19 I am a employer with �,�
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I 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.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.)
'.4n;' applicant that checks box rl must also fill out the
s --ti— I -A ,,., c�� •n
Type of project (required):
6. El New construction
7. 0 Remodeling
8. El Demolition
9. E] Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12 -El Roof repairs
13.�Other1J4W OfeX,
_"' ng :heu workers' compensation policy mform-tion.
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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A jl-- lyl S 1 �! S u tZ r4 roe e_ 1020 ,y zAv M qle S , +,,VC
Policy # or Self -ins. Lic. #:_1-.1 6 27 "% l k 2 Z. ^ Q j Expiration Date:_ _-5'` t Lf / 2 d / O
d
Job Site Address: Reza& -.r # �e, 6&12 C 14 i G Kt1t iw
L_ity/State/Zip: /1J • r9 rvPOG vC%1-1 004.
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 cerci under the ns amp ffi es o ury that the information provided above is true and correct
R't8) a s-6 • 0 2.00
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):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
?ld; mo-/()
4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is 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 the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
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-contractor(s) 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 may be 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 which will 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 in (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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 40.6 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.govfdia
An Aqunteeh Builder
NAME (Buyer)
MAIL ADDRESS
JOB ADDRESS
RESIDENCE PHONE
CELL PHONE
r
ENVIRONMENTAL POOLS, INC.
184R Rivemeck Road . Chelmsford, MA 01824
978.256.0200 / 800.696.6976 / Fax 978.256.6620
Email: Jim@EnvironmentalPools.com . Website: www.EnvironmentalPools.com
REMODEL CONTRACT
Design Excellence: With dPersona[Touch
MEMBER
626 Chickering Rd. CITY N. Andover STATE Me zip 01845
626 Chickering Rd. CITY N. Andover STATE Me. zip 01845
978-687-1490 WORK PHONE
EMAIL
Environmental Pools, Inc. (hereinafter'E.P.I ") agrees with the buyer or buyers above (hereinafter the "Buyer) to remodel a swimming pool and/or spa in a good and
workmanlike manner in accordance with the following terms and specifications.
DIMENSIONAL SPECIFICATIONS
Width 18 Length 36 (107 P') Shape Gust Depth 3' to 8'
11. Type of deck ❑ Pavers ❑ Stamp []Bluestone []Other TBD
POOL PREPARATION
DECKING
1. Remove existing deck: $ 4.00
x TBD
SOFT. = $ 4,000.00 TBD
2. Number of Loads: $
x
= $•
3. Mastic $7.00 per foot
Color. TBD
14. Remove existing light nitch:.........................................................(D
4. Grading: $
P.LD. x
No.LDS. = $ owner
5. Sub -base material: $
P.LD. x
No.LDS. = $ owner
6. Concrete pumping required: ........................................................
16. Prep light area: ....................................
0 Yes ONo
7. Decking square footage: 1000 sq. feet Type: TBD
8. Other.
17. Prep main drain: ..........................................................................
9. Bond der*: ,TBD bx owner .........................
[]No
❑ Yes ❑No
10. Cantilever form for deck : TBD....................................................M
Yes
Yes El No
11. Type of deck ❑ Pavers ❑ Stamp []Bluestone []Other TBD
POOL PREPARATION
12. Remove existing coping: .............................................................
[I Yes
Ej Yes
❑No
13. Remove existing file: ...................................................................
MNo
El Yes
[]No
14. Remove existing light nitch:.........................................................(D
45. Outdoor kitchen: ..........................................................................
Yes
❑No
15. Prep return lines/floor system: .....................................................
[3 Yes
0 Yes
[]No
16. Prep light area: ....................................
I ent.....,.,.❑.
Yes
[]No
17. Prep main drain: ..........................................................................
Yes
[]No
18. Prep stairs: ..................................................................................
Yes
[]No
19. Pressure wash/acid wash: .........................................
T E .............
E] Yes
❑No
20. Pressure test...........................................................
TBD ...........
❑ Yes
[]No
INSTALL
21. Install frost -proof tile: 6 x 6
Type: TBD
22. Install coping stone:
Type: TBD
23. Install new light nitch:..................................................................❑
Yes
EjNo
24. Install Polaris line: TBD ................
................................................
❑ Yes
ElNo
25. Install new return lines: #
Size: TBD
26. Install new skimmers: #
Size: TBD
27. Install new eyeball fittings: yes
Color.
28. Install new filter: Size:
Type: none
29. Install new pump: Size:
Type: None
30. Install new Polaris pump: ............................................................
[] Yes
I]No
31. Install new heater. Size:
Type: none
32. Install auto cover.........................................................................❑
Yes
❑. No
33. Install automated system: ........................
.............................
❑ PS -4
❑PS -8
34. Install salt system: .......................................................................
El Yes
jENo
35. Install Nature 2/Chem. Feeder.
Type:
36. Install stub plumbing for future pool deaner..t?q ...........................❑
Yes
I]No
INTERIOR FINISH
37. Mul&coat pool: ............................................................................ [D Yes []No
38. Replace hydro plug; .................................................................... El Yes ❑No
39. Replace main drain cover. Yes . VGB: standards
40. White Marcite:.............................................................................0 Yes []No
41. Style: ❑ RiverRok ❑ PebbleTecc ❑Diamond Brite
Color
ADDITIONAL
42. Spa: .............................................................................................
[I Yes
I]No
43. Waterfall: ........................... .........................................................
0 Yes
MNo
44. Pool cover....................................................................................❑
Yes
MNo
45. Outdoor kitchen: ..........................................................................
[I Yes
I]No
46. Outdoor fireplace: ........................................................................
[3 Yes
E]No
GENERAL CONSTRUCTION SPECIFICATIONS
47. Access wall or fence: removed by:
replaced by:
48. Remove from site _loads of trees, shrubs, stumps, asphalt, concrete and
other debris
49. Filing of pool promptly after interior finish ................................................. BUYER
50. Electrical bonding of pool as required by town/city code
51. Payment of sales tax on pool components and accessories .......................INCL.
52. Motor vehicle insurance, workers' compensation insurance and general liability
insurance..................................................................................................... INCL.
LANDSCAPE
53.
54. Projected cost for Pool project will range between $40,000. to $45,000.
55, depending on the scope of work to be done.
56. Contract price does not include deck removal see line 1.
57, Price does include S.V.R. S. for VGB Act / town of N. Andover
58.
ADDITIONAL SPECIFICATIONS
59.
60. Price does not include electrical or water or beam repair $100.00 per hour
61.. E.P.I. on site the day of refilling the pool( Truck water)
62. Replace depth numbers in pool as well as on deck 3,4 5,6
63, Install new Tile line on break and on stairs 4" and Mastic joint
64. Upgrade pool to meet V.G.BA ( skimmers and main drain)
PAYMENT
The Buyer agrees to pay E.P.I. the following Contract Amount for E.P.I: s
performance of its obligations under this Agreement
Contract Amount $ 40,000.00 50% Start Date $ 15,000.00
Deposit $ 10,000.00 50% Finish Date $ 15,000:00
BALANCE $ 30,000.00 TOTAL $ 30,000.00
TERMS AND CONDITIONS
BUYER IS RESPONSIBLE FOR HAVING NEWLY PLASTERED POOL FILLED WITHIN 24
HOURS. FILLING MUST NOT STOP UNTIL WATER IS ON THE TILE LINE OR STAINING
COULD RESULT. NEW PLASTER OR MARCITE FINISH 13 NOT PAPER WHITE AND IS
SUBJECT TO SHADING AND COLOR VARIATION.
E.P.I. IS NOT RESPONSIBLE FOR :ANY STAINING OR DAMAGE TO POOL DUE TO
IMPROPER CHEMICAL BALANCE, BUYER NEGLECT, AND FROST OR ICE
AN ACID WASH DONE PRIMARILY TO REDUCE SIGNS OF STAINING IS NOT
GUARANTEED.
HAIRLINE CRACKS MAY REAPPEAR.
. E.P.I. DOES NOT WARRANTY CAULKING OR DECK SEAL WHEN DAMAGE IS DUE TO
MOVEMENT O F DECK.
E.P.I. DOES NOT INCLUDE ELECTRICAL INSTALLATION BUT CAN PROVIDE AN
ELECTRICIAN AT ADDITIONAL COST.
E.P.I. DOES NOT INSTALL PROPANE OR GAS HOOK-UPS AND VENTILATIONIDUCT
WORK.
ALL PAYMENTS MUST BE MET FOR WORK TO PROCEED UNINTERRUPTED. IF OWNER
SHOULD DEFAULT ON PAYMENT OF ANY INSTALLTION DUE UNDER THIS CONTRACT
AND SUCH DEFAULT IS REFERRED TO AN ATTORNEY. FOR COLLECTION, BUYER
AGREES TO PAY REASONABLE ATTORNEY'S FEES UPON THE COLLECTION OF
AMOUNT DUE, PLUS COURT COSTS. IN THE EVENT WARRANTY WORK IS
NECESSARY, E.P.I. SHALL ACCEPT RESPONSIBILITY FOR THE WORK ONLY. WATER,
CHEMICALS, AND DOWN TIME WILL NOT BE E.P.I.'S RESPONSIBILITY. ANY PARTS
AND LABOR TO RESTORE EQUIPMENT TO WORKING ORDER IS NOT INCLUDED.
BUU ENVIRONMENTAL POOLS, INC.
YER BY:
BUYER " • --_--
io a%D
DATEV
DATE
*Co(ftct co l inq-eh� upon (Asuclr-4 IVVAIvt,/- Pin5 t'rjucj � 96d'd Of
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POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
THE
OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
REQUIREMENT, TERM OR CONDITION
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
THE INSURANCE
ATE IMIT MAY A D P I
LCE
POIY EFFECTIVE POLICY EXPIRATION LIMITS
fINSR=ADD'L
TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIDD/YY
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
XXXXXXXXXX
*30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
XXXXXX
FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE
EACH OCCURRENCE $ 1,000,000
AUTHORIZED REPRESENTATIVE
GENERAL LIABILITY
Peter Godfrey
n i+/1�of1C I�TIl1A1 �eeo
DAMAGE TO RENTED 100,000
PREMISES Ea occurrence $
X COMMERCIAL GENERAL LIABILITY
MED EXP An one person)$ 5,000
A
CLAIMS MADE I OCCUR
GLP2371421-01
5/14/2009
5/14/2010
PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X1 POLICY JE LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIREDAUTOS
BODILY INJURY $
(Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA A $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR F1 CLAIMS MADE
$
DEDUCTIBLE
RETENTION
X WRYTATU- OTR -
LIMITS
$
WORKERS COMPENSATION ANDIM[
E.L. EACH ACCIDENT $ 1,000,000
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED?
WC2371422-01
5/14/2009
5/14/2010
E.L. DISEASE - EA EMPLOYEE 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
*Except for ten (10) days cancellation for non -pay. All policy forms apply. This certificate is only a
representation and may or may not comply with any written contract.
t%AKUPC! I ATIMI
GERTIFIGAI t MULUtrc
-""---- -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EVIDENCE OF INSURANCE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
XXXXXXXXXX
*30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
XXXXXX
FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Peter Godfrey
n i+/1�of1C I�TIl1A1 �eeo
ACORD 25 (2001/08) """"'""""" """"""
P.nc 1 of
1 tJCl17F in+no. no.,