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HomeMy WebLinkAboutBuilding Permit #110 - 67 CHESTNUT STREET 8/10/2009 NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * Permit NO: l/ Date Received r„I �SSACHU`+�C Date Issued: C>Y I ORTANT: Applicant must complete all items on this page i LOCATION Print PROPERTY OWNERr~ � � 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 Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: U C. UC V- Identification Please Type or Print Clearly) OWNER: Name: C:"V- l(-- -1� !��,(^ Phone: Address: CONTRACTOR Name: P., ]�A;n ANP r`J 'Phone: Address: ' Ctl CS� k J Supervisor's Construction License: Exp. Date.. 1 Home Improvement License: 0 L Exp. Date: I /a�l, 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. Total Project Cost: $ 15CA1 0G FEE: $ Check No.: �T-�-� Receipt No.: P2 30 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of icinature of contraeft, Location 67 ( �ls74z S� No. Date 0.1 NORTN TOWN OF NORTH ANDOVER 3: i • O IO41 . 9 Certificate of Occupancy $ �'�S'•••"E Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # y�3 223LjS ilding 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 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT I� 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 --i r 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 i 4 6 S ❑ Notified for pickup - Date _....._...._....._......................_..........._...................._...._....—._-.._-----------_._—....-........_..............._............-----._^_...----_......-..................................-.... ---...__.—...._............................................. Doc.Building Permit Revised 2008 i Building Department m to be filled out for the appropriate ermit to be obtained. The followingis a list of the required formsp q 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 L 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 Application Revised 2.2008 XAORTH Town of : 4 - Andover . No. / /p E dover, Mass., � COC HICHEWICK SIT ADRATED p �C:) S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... `%<!%..��-� �/ C� l.................................................................................................. Foundation C"'S / has permission to erect......................... buildings on ..... .... e fI /— �....�...... ................. p ............... buildin � ...................................... Rough tobe occupied aS .1...... ........ . ................................................................................... Chimney provided that the person accepting this permit shall i 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service BUIL INSPECTOR Final Occupancy Permit Required to Omipy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. MA License#149601 (expires 1/24/10) Renewal _ENEWAL BY ANDERS_ ' Z Federal Tax ID#83-0404201 byAndersen. WINDOW REPLACEMENT ..A.d—c­ OF GREATER MASSACHUSETTS AND NEW HAmpsHIRE 104 Otis Street•Northborough,MA 01532 Phone 508.919.0900•Fax 508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agreement �— ,t C /a . Buyer(s)Street Address,City,State,and Zip Code ,rf �/)s,,. .r 1fV! E-Mail Address Home Telephone Number Work Telephone Number Cc: I✓? 17 h'= lei`+;d r''7: - _�,; Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Method of Pymnt:❑Cash ❑Check ❑Mastercard 4XVISA Total Job Amount. 'L J. Estimated Starting Date: C7 �-/� ❑Discover ❑Financed,App#: tri : ����� Deposit Received(33°/D): Q\ Name on Credit Card: F;—AIVI pk: 4/ Balance at Start of Job(33%): O ' Estimated Co letion Date: Credit Card#: y/y7 XJ'—, -3 Balance on Substantial � Completion of Job(33%) ��� CC Exp.Date: W/o CC Security Code: By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer Initi of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Renewal by Andersen of Greater MA and NH Buyer(s) Buyer(s) Signature o rod tanager vv LSignaturel ature alt"a !24U zA ��� F -�A-4r'4 lAnd�/- Print Name of Product Manager Print Name Print Nam g r e YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. - - — — — — — — — — — — — — —�<- — — — — — — — — — — — — -�— — — — — — — — — — — — — — — � NOTICE OF CANCELLATION XNOTICE OF)CANCELLATION Date of Transaction ) .You may cancel I Date of Transaction y .You may cancel this transaction,withoufanypendior obligation,within this transaction,witho a penalty or obligation,within three business days from the above clefs.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security I by the Seller of your cancellation notice,and any security interest arising out of the transaction will be canceled. I interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at your residence, in substantially as good condition as I your residence, in substantially as good condition as when received, any goods delivered to you under this I when received, any goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the I Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of the goods at the Seller's expense and risk.If you do make theoods at the Seller's expense and risk.If you do make the goods available to the Seller and the Seller does not the goods available to theSellerand the Seller does not pick them up within 20 days of the date of your Notice I pick them up within 20 days of the date of your Notice of Cancellation,you may retain or dispose o the goods I of Cancellation,you may retain or dispose of the goods without any further obligation. If you fail to make the I without any further obli ation. If you fail to make the goods available to the Seller,or if you agree to return the I goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you remain liable oods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract. for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written I dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen l notice, or send a telegram to Renewal by Andersen of Greater Massachusetts and New Hampshire, 104 l of Greater Massachusetts and New Hampshire, 104 Otis Street,Nort borou h,MA 01532,NOT LATER THAN I Otis Street,Northbogh,MA 01532, NOT LATER THAN MIDNIGHT OF .(Date) MIDNIGHT OF .(Date) I HEREBY CANC L T S TRANSACTION. x I HEREBY CANC L IS TRANSACTION. I Consumer's Signature Date I Consumer's Signature Date I ®J8LLP2009.RBA-Ph.MANH RbA Copy Re ewal �;��� RENEWAL BY ANDERSEN MA LicenseF#149eral 01 1D#(expires 83-040420) byAnderSen. ' G, .xREATER MASSACHUSETTS AND NEW HAMi._.RE WINDOW REPLACEMENT a A,,d..Company 104 Otis Street-Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Buyer(s)Name / Date of ASreement The Buyer(s)listed above herebyjointly and severally agree to purchase the goods and/or services lis/ted d1ow,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) ❑ Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(FW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. ❑ Yes RJ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes&I No Qty of Sills to be replaced by Contractor: 4. X Yes ❑ No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine K Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be:K HP Low-E®SmartSunTM (Tax Czv tEGgible) ❑ Other If other,please specify: 6. Exterior color to be: fo White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: ❑ White ❑ Sand ❑ Canvas ❑ Terratone jK Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: ❑ White ❑ Stone ❑ Canvas K Brass Double Hung: 9. ❑ Yes 2 No Install Lifts with Double Hung Windows 10. Screens: windows to have:'^- t� u'f c eens Screens to be: ❑ Fiberglass ❑ Aluminum ❑ TruScene GRH1E DETAILS I I:Windows have grilles--8--Yes_❑ NgoIP yes_❑ Grille Between Glass(CBG)❑ Removable Interior Wood aNtwi❑ Full Divided Light(FDL) Qty: Qty: Qty Qty: Qty: Qty: Qty: DH DH DH DH CW/Piclure Glider CPW or GPA Draw grille patterns above `Use additional sheet if needed Owner approved(initials): ADDITIONAL WORK DETAILS F 12.❑ YesNo Contractor will remove metal frames of windows. Qty of Units: 13.El YesONO Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Yes �'No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qtypenings: ❑ Pine ❑ Maintenance-free material 15. Owner is.aware that Contractor does not do any painting. Owner Initials 16.❑ Yes [WNo Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17. Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19. Yes ❑ No Buil ' Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract Price and a separate chec is equired a the ime of sale for this fee. 20. Additional' b tails: /4 u o �� Gd dr P a &C- en dt Z 21.4 Yes No Owner agrees to be present on the final day of installation for final inspectiond to deliver final payment. !� No final payment shall be demanded until the contract is completed to the satisfaction of all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this S ification Sheet. Renewal by Andersen of Greater MA and NH Buyer(s) Buyer(s By: C Zi%���/TMJ Signatur of ct Manager Signature r Signature Pint Name of Product Manager Print Name Print Name RbA Copy 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/Colitractors/Electricians/Plumbers Ai3plicant Information Please Print Legibly Name(Business/Organizadon/Individual): Beacom -/14 d e Y-S e YI Address: 1 D City/State/Zip: ND>' h bo 1'a , Phone#: Are'you an employer?Check the appropriate box: Type of project (required): 1. I.am a employer with 4. ❑ I am a general contractor and I �' �.J D g 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. t ? modeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance:~ 9. E]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.❑Roof repairs insurance required.]t employees.[No workers'. 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below1s thepolicy and job site information. Insurance Company Name: J 114 Ke-o r)-e— )n S tfa n C £' Policy#or Self-ins.Li+c.#: � ��� � � lyLf Expiration Date: 1 Job Site Address: 7t' l �` City/State/Zip: l 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 cerpjTunder the pains and penalties.of perjury that the information provided above is true and correct: Sienature• (� 0 Date / f!0 ( �} ,r• Phone#: �U f l F 0�(,� 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#: i ''' die �a9ninzaurseal�!a/✓�aeaar7ivaeCr� = v: Board of Building Regulatipns and Standards ' C©nst;uction Supervisor License •:; Llcgat;:CS 95707 � _ 8irttid'a�tei�'_'9l8/1982 • ' Trn 95707 i 1E� i�65q i^.9�8/2010 BRIAN DENNISO 86 CREST CIRCLE';: WORCESTER,MA 01603 Commissioner RENEWAL BY ANDERSON BRIAN DENNISON 104 OTIS STREET NORTHBOROUGH, MA.01532 . DPS-CAI Ca 50M-07/07-PC8490 • ✓die&mmrwvzcuea c�./ aJaac�ivaeG7ii Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registi-&O i 149601 _ E;-,( 'irat►oi_-42412010 �r— .Hype-supplement Card . RENEWAL BY P i`11�E_i ON , BRIAN DENNISO , = i=! ---; 104 OTIS STREET`'., `NORTHBOROUGH,MA 01532 Administrator ACCRD,., CERTIMCATE OF UABILITY INSURANCE DATE(M=wvrm 02/17/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS. NO RIGH'a.S UPON THE CERTIFICATE e HOLDER. THIS CERTIFICATE DOES NO JP MCKeone Insuren n T AMEND, EXTEND OR ce Agency,c , Inc. 9 Y ALTER THE COVERAGE AFFORDED BY Ti�E POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 46106-0333. INSURERS AFFORDING COVERAGE MC# u`51�0 Renewal by Anderson INSUR=_RA: Hartford Insurance Com any J&L Windows, Inc. INSURER B: Hermitage 10400s SI INSURER C: Nolthboraugh, TINA 01532 INSURER 0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED..NOTWTrHSTANDING 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. WSR 7L POLtCYE�CTTVE POLICY EXPIRATION POLICY NUMBER U+UTS g GEfdERALLlAB1LITY !-ICP 507 404 09/07/2006 09/07/2009 EACHOCCURRENCE s 1 000 000 COMMERCIAL GENERAL. LIABILITY - PREMISES EB c==aancab 100,000 CLAIMS MADE ®OCCUR MED EXP(AnIr one Person) S 5.000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AG_REGATF S 2 000 OQO GEPILAGGREGAT-e LIMTAPPLIES PER:. PRODUCTS•CONIP/OPAGO S 2.000 000 POLICY F7Pc OT LOC A atiroraoen_I.IaetLaiv 35 MCC XD 6390 10/01/2006 10/01/09 COMBINED SINGLE LIMIT ANY AUTO (EaBcaeent) s 1,000,000 X ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED ALTOS BODILYINJURY . S NON-0WNED AUTOS (Per s=iCent) FROPERTY DAMAGE S (Pecedtlenq GARAGE l IA81LrrY AUTO ONLY.EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGO 5 — EXCES81UMBRELLA UABILnY EACH OCCURRENCE S ro OCCUR . Q CLAIMS MADE AGGREGATE s S DEDUCTIBLE I S RETENTION S I$ A WORXERS COMPENSATION AND EUPL.0YERV LIABILITY 35,11VEC PP 1444 02/17/2009 02/17/2010 WC STATU• I0�?H• ANY PROPRIETOk-PARTNE'n/E`ECUTIVE E.L.EACH ACCIDEAT S' 500.000 OFFICER/MEMBER[~CIUOcD7. E.L.DISEASE.EA EMPLOYEE S _ 50O,OQ® It qee,tlesormo under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONS f DATIONS 1 VEF4tCLE5 f Er CLUSIONS ADDED BY ENOOPSc'PfENT 15PEC"PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ExpMATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 90 DAYS WRTT-r.+11 NOTICE TO THE CERTIFICATE HOLDER NAMM TO THE LEFT,BUT FAILURE TO OO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVEES. 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