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HomeMy WebLinkAboutBuilding Permit #119-13 - 660 GREAT POND ROAD 8/10/2012 B.UILDING PERMIT of N°DT b TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION eyh Permit NO: Date ReceivedVol �9SSAC H�1`-+' Date Issued:, — 0 t 12,— Iq�MPORTANT:Applicant must complete all items on this page ;. .ra-.._6..Try"t��''"�:> 3r. ..`P 7'4a 4^'iy p-x'.� zap i ♦...:'L'Yi- "F-: r5*`c d,}"x.4L tw k^.c.,w.. �rj`4 .+Cr .'x.trt,TM <:.,�a�4 wr srv.y+av -r ?t N _ P V �mCgG�"LOGATt c �� jPROPERT�Ya®WNER N MAP.�'NO tNJ���-PARCEL ��� ZONING�'DISTRICT����,��� �Histonc�D stncf; � ��-� ye :�n - I•'�T{,., _:�;:� ..��:... � � �;� F.� _,-r�£.:�� -,. 4• `�' ��;:� . ,Machine':Shop�,Village'<kdY s� �'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 eptc �`* Weljn ' FloodplaimFx ' 4Wetlands ri4Wafershetl ©istrict; a `5' V1later/Sewer !.X-. ay,+,r 4-+•--�,..,.:.t« :.a.`��:...,r.+ ''+s.,r�_ r� .Jsti -..ix�„rX+;.,i.n.-"..!'a-'+.: '_r"''�" ". ...t'Y+. ..'ti`r .x DESCRIPTION OF WORK TO BE PREFORMED: G�ale end Ar\ 2 O 'e- i Ye e SC vtLam a �� Lace- Identification Please type or Print Clearly) OWNER: Name: , �7 f n er7Ce 0-c On° e� Phone: Address: - xi xj b•?+ S.,i: .P- '_. ,q. 4*..FY- ,{'+ 9`'� ;CONTRAC�T®Rr�Name tr��Y tt is 2— IAddress V21n. t�S � 'rZD. E � ` ti`� °_ �' R ®S gam , > ,:.Y°. � � i -;.:"`''t"` »,p,' ."wN'r'�fi"•.:'ate- - `t^Lax'-w`� t.,. .Y +P."f.�..... .^e„,;'.•. ,.ac 14, Supervisor;s Construefion License}C� v0$8 �j2� ' ' ,;EXp IDa-te,a„.f2 e t `Home�lm+provement License` �t(v:2=ym�{Z.; ` r �~Exp' 'Date aw�-sL4+ai�...k ty ARCHITECT/ENGINEER Phone: 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: $ S C FEE: $ (7 Check No.: / y Receipt No.: J� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner 'Signature of contract 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 i 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 Fire Depart' t signature/date .COMMENTS.,- f t 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use) ® Notified for pickup - Date t 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) d ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 II 4 /� LocatioN/'l/o No. Date . - TOWN OF NORTH ANDOVER LEDI-�� e r Certificate of Occupancy $ - Building/Frame Permit Fee Foundation Permit Fee $ ', Other Permit Fee $ f TOTAL Check 340 25605 Building Inspector NORTH Town of �. ndover No. 10s2o(2w LAN, h ver, Mass, coc»IcNewIcK A0RATE0 S U BOARD OF HEALTH Food/Kitchen PERIT T Septic System � �. � ' THIS CERTIFIES THAT BUILDING INSPECTOR ....... ....:.......... .......... .. .... ...... ......... .................. . .. . ........ .... ....... .. Foundation has permission to erect.. .................. buildings on ..� .. .�� .. .. . ... .. * Rough to be occupied as .. .................................... Chimney v provided that the person acce ti this permit shall in eve respect conform o the terms of the application p p 9 p every p PP 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 M0N S ELECTRICAL INSPECTOR UNLESS CON TR CTIO AR 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 Final No Lathing or Dry Wall '1 0 Be Done FIRE DEPARTMENT To Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE y W� V taut � � � • _ � '� $RJiJ�C7 � � t .+.,�� oft -` Ai+ Client ID: 15660 Contac Name- Keith Bridges Date: 05/14/2012 Address: 660 Great Pond RD N. Andover MA 01845 Work Phone: 978-682-8816 EXT: 14 E-mail: facilities(a-rollingridcte.org Inspector: Ernie Guimaraes kmbridae(cD-hotmail.com South East Fire Escape Proposal: rk a i =f 1 -, .O V Y l i' 1, � S UL'J rd�L1l ` �• 660 GREAT POND RD N. ANDOVER MA 01845 South East Fire Escape Proposal: Work Descriptions Repairs 5 years warranty, (Option # 1 • Replace nuts and bolts on all handrails which are 3/8 is required by code. • Replace nuts and bolts on supports as necessary which are 1/2 is required by code. • Remove corrosions by scraping all gratings are required by code. i`�/ • Replace nuts and bolts at ladder are required by code. • Scrape and remove rust and flakey paint on entire fire escape are required by code. • Spot paint at the work was performed with oil base gloss black or the color of the existed fire escape. Work Descriptions Repairs 10 years warranty: (Option # 2 $2,875.00) • Replace nuts and bolts on all handrails which are 3/8 is required by code. • Replace nuts and bolts on supports as necessary which are 1/2 is required by code. • Remove corrosions by scraping all gratings are required by code. • Replace nuts and bolts at ladder are required by code. • Scrape and remove rust and flakey paint on entire fire escape are required by code. • Seal with (silicone 50 years warranty)major and minor connections. • Primer& paint the entire fire escape with one coat of oil base gloss black or the color of the existed fire escape. Work Descriptions Repairs 20 years warranty (Option # 3 $1,350.00) • Take down and dump the existed fire escape. • Fabricate and install new black steel. Additional to the price above($4,950.00) • Fabricate and install new galvanize. Additional to the price above($5,775.00) All permits and engineers or architect fees scaffolding,any additional insurance as well sales taxes are not included in the quoted price. (Price valid for any option onlly 30 Days) - 5 - �., A+ E1��3 GCAPIt,a°�'�1R b E 660 GREAT POND RD MANDOVER MA 01845 South East Fire Escape Proposal: Any Balance not paid Within 5 Days Of Completion Is Subject To 20%Additional Charge On Balance Owed And 20% Thereafter Every 30 Days Unpaid. All material is guaranteed to be as specified.All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard practices.Any SIGNATURE alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikers,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by Workmen's Compensation Insurance. Note:This Proposal may be withdrawn by us if not accepted within 30 days. The client will be responsible to pay the permit fee with the city,scaffolding;and or if necessary engineers or architect and or addition insurance fees as well sales tax will be charge at contract agreement. ACCEPTANCE OF PROPOSAL.The above prices,specifications and conditions are hereby accepted.You are authorized to do the work as Specified; payment will be made as Payment Schedule: 40% -Deposit s 40% -First Milestone 50%Completed 20% -Project Completion S Signature: ERNANI F. GUIMARAES 2 A+ Fire Escape Repair Inc. Date Signature: Z OW ER0A AU ZED SIGNATURE D e - 6 - AMI+ awe • • • � /t � ., ° ✓� *"7�a cac a aca*L t i ti i o o o o Client ID: 15660 Contac Name: Keith Bridges Date: 05/14/2012 Address: 660 Great Pond RD N. Andover MA 01845 Work Phone: 978-6828815 EXT: 14 E=mail: facilities _rollingridge.org Inspector: Ernie Guimaraes kmbridQe(a)-hotmail.com South Fire Escape Proposal: 44 At 3 1 t Ag- 00 660 GREAT POND RD N. ANDOVER MA 01845 South Fire Escape Proposal: Work Descriptions Repairs 5 years warranty: ((O:p:tiio:n #=$6,49-5.00) • Replace nuts and bolts on all handrails which are 3/8 is required by code. • Replace nuts and bolts on all treads which are 3/8 is required by code. • Replace nuts and bolts on supports as necessary which are 1/2 is required by code. � (J • Replace nuts and bolts on entire fire escape are recommended to upgrade not required. r / Additional to the price above($1,200.00) • Remove corro:,ions by scraping all gratings are required by code. • Scrape and remove rust and flakey paint on entire fire escape are required by code. • Spot paint at the work was performed with oil base gloss black or the color of the existed fire escape. Work Descriptions Repairs 10 years warranty: (Option # 2 $8,795.00) • Replace nuts and bolts on all handrails which are 3/8 is required by code. I Additional o the rice above $2,300.00 Re lace all treads to new black steel as an optional. t P P P ( ) • Replace all treads to new galvanize as an optional. Additional to the price above($2,950.00) • Replace nuts and bolts on supports as necessary which are 1/2 is required by code. • Replace nuts and bolts on entire fire escape are recommended to upgrade not required. Additional to the price above($1,200.00) • Replace all gratings to new black steel as an optional. Additional to the price above($1,000.00) • Replace all gratings to new galvanize as an optional.Additional to the price above($1,200.00) • Scrape and remove rust and flakey paint on entire fire escape are required by code. • Remove any obstructions from balconies by a fire code,wire,plants,garbage,satellite,ac unit etc. • Seal with(silicone 50 years warranty)major and minor connections. • Primer& paint the entire fire escape with one coat of oil base gloss black or the color of the existed fire escape. Work Descriptions Repairs 20 years warranty QOption # 3 $7,750.00) • Take down and dump the existed fire escape. • Fabricate and install new black steel. Additional to the price above($22,350.00) • Fabricate and install new galvanize. Additional to the price above($27,875.00) All permits and engineers or architect fees scaffolding,any additional insurance as well sales taxes are not included in the quoted price. (Price valid for any option only 30 Days) - 5 - a �" _ k A is i t.—) 5 r 'Yr�•5+(: "SS 4 Alp i 660 GREAT POND RD MANDOVER MA 01845 South Fire Escape Proposal: Any Balance not paid Within 5 Days Of Completion Is Subject To 20%Additional Charge On Balance Owed And 20% Thereafter Every 30 Days Unpaid. All material is guaranteed to be as specified.All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard practices.Any SIGNATURE alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikers,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by Workmen's Compensation Insurance. Note:This Proposal may be withdrawn by us if not accepted within 30 days. The client will be responsible to pay the permit fee with the city,scaffolding and or if necessary engineers or architect and or addition insurance fees as well sales tax will be charge at contract agreement. ACCEPTANCE OF PROPOSAL.The above prices,specifications and conditions are hereby accepted.You are authorized to do the work as Specified;payment will be made as Payment Schedule: 40% -Deposit $ 40% -First Milestone 50%Completed $ 20% -Project Completion s Signature: ERNANI F. GUIMARAES A+ Fire Escape Repair Inc. Date Signature: OWNE R AUTHORIZED SIGNATURE D e - 6 - .. t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supers icor License: CS-088732 ,+` x:•, ERNANI F G ,LIIIVIARAES` �'� 41 SEVEN SISTERRD , IiAVERIML MA! 018 0 a i, 3` Expiration Commissioner 11/1212013 Y`i 1 � hV I III �I O y. :.ot 'k Vic OCE�COv , H 830NVX3717, S83NIWVX3 d0 CHVOB PF F SSOK'3h1 jOSNO1Sl/y023d_a3obOM i QOi3` a.'-5c1'''4�5 as "-�"'f`'•71l At I .. �avavrfrIfig, IKv�aa - "` ONIN3W W SVWOHl S83N.IW`dX3 �.0 aL1t'l013 £Zt619 ® 1 � NOISOH JO A110 /ze �ar���rorur!ea/�/�o�✓�aa� lZ�A� License or registration valid for individul use only Office of Consumer Affairs&B siness Regulation i before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR I Office of ConsumeraAffairs and Business Regulation m Registration:,162442 Type: 10 Park Plaza-Suite 5170 s Expiration: 224/2013 Private Corporatior P _ _ Boston,MA 02116 A+ RE ESCAPE REPAIR INC ERNANI GUIMARAES 41 SEVEN SISTER�RD= HAVERHILL,MA 01830. Undersecretary Not valid without signature i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 uv� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � � {� Please Print Legibly Name (Business/Organization/Individual): o4'- rs-tzf ECyC /per- 1'�CD� Address: City/State/Zip:IWC(L(1 i fig- Oi'ViO Phone#: 7 SI Are you an employer?Check the appropriatepox: Type of project(required): 1.❑ I am a employer with 4. H1 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.� Other Fj'(�E *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '1 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:� T�('j L%91Y" (l'(tAVA r! Policy#or Self-ins.Lic.#: C -g1 S T Expiration Date: 41,---O—Z 012 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 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 certify under the pains and penalties of perjury 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#: 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 burn 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 Tele # 61.7-727-4900 ext 466 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www,mass.gov/dia A� CERTIFICATE OF LIABILITY INSURANCE ��` �e;;/'12 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 CONTACT NAME: RIBEIRO—DESOUSA PHONE FAX Cambridge Insurance Agency EMaL (617) 497-2100 No: (617) 497-6711 ADDRESS. 1092 Cambridge Street INSURERS)AFFORDING COVERAGE NAICN Cambridge, MA 02139 INSURER A:ENDURANCE AMERICAN SPECIALTY INSURED INSURER B:LIBERTY MUTUAL INSURANCE CO. A+ FIRE ESCAPE REPAIR INC INSURER c:EVANSTON INSURANCE CO 41 SEVEN SISTER RD INSURFRD: HAVERHILL, MA 01830 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. rLTRA AtADD SUER POLICY EFF POLICY EXP TYPEOFINSURCE POUCYNUMBER MIDDY MNIDDrYYYY LIMITS cEN ERALLIABILITYY CMC/100010373-01 11/3/11 11/3/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAFMGE TO RENTEDPREMISES(Fa occurrenW $ 100,000 CLAIMS-MADE LIOOCUR NE EXP(Ary one person) S 2,500 PERSON4L&ADV INJURY S 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE L IMITAPP LIES PER PRODUCTS-ODMPIOP AGG $ 2,000,000 POLICY PRO_ECT FLOC $ AUTOMOBILE LIABILITY co IINEEDISINGLE LIMIT $ ANYAUTO BODILY INJURY(Per parson) $ ALLOWNED SCHEOULs;D AUTOS AUTOS BODILY INJURY(Per accidenl) $ HIREDAUTOS ^AUTOSWNED P a'aoESdernDfvfAGE $ $ A X UMBRELLALMAB OCCUR XONJ419611 9/23/11 9/23/12 EACH OCCURRENCE s 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTION$ S B WORKERS COMPENSATION WC1-31S--367235-031 11/10/11 11/10/12WCSTATU- OTH- AND EMPLOYERS'LIABILITY — AWPROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACCIDENT 100,000 OFFICERWEMBMEXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ifnes descriheunder DESGIRIPTIONOFOPERATIONS trelow EL.DIS EASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 107,Additional Remarks Sche(ule,If more space Is regtJrod) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF 111E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 660 GREAT ROAD ACCORDANCE WITH THE POLICY P OVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTAn V ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: (203) 333-3643 Fax: E-Mail: ELMER@WILDERREALTYLLC.COM