Loading...
HomeMy WebLinkAboutBuilding Permit #412-2011 - 67 SANDRA LANE 11/15/2010 BUILDING PERMIT NoKFM ���.�Llo 10�tiO TOWN OF NORTH ANDOVER G APPLICATION FOR PLAN EXAMINATION Date Received �4"°q,T.o Permit NO: l �SSACHU`���� Date Issued: IMPORTANT Applicant must complete all items on this page xs� � � '� � �,a � �r ,�'-ted ` ����, �z- r�r r' r��a� � '�� ,�•a, Mf "✓ �, i x ria' & a - 'as'R,�, �' 1x` s r{ -a " '.,,.s e�e. N"", l�yNot", 1F,R 310 s Y,r, l 'y.� -y �M ?�' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ElTwo or more family El Industrial . ❑ Alteration No. of units: ❑ Commercial .Repair, replacement ❑ Assessory Bldg Ef Others: ❑ Demolition ❑ Other �rW`�at`� DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: r. �-rr u3clAecPhone:et311�� Address S�vt r L-c� �cax,r w�. ©.y 1 IS-3*i�a`g� "w.i" r ' y�A� '°` ha tea : AUX - ,�. '� ' xr-, tx' e ti 5k✓x� � °�"`x » ti�a ash. g ki 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: $ , �30 (.-�b _FEE: $ Check No.: 11,160 Receipt No.: ,23 G S6 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sgnatr�RTRI,of Agefle , � n�rwnVagnQ{ reoa"'.✓et-ati/tcar ; ` ��. , -- 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 [IPrivate(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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street f bEP ►�TMEN Tim g s G p rt Dumpstei�xsees � a af��. 4t�iatR `reeta�r . ^s » F►reep � � x 7,77 d,�FG�E , �� � � x r r e z 4 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.s100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date .......................................................................................... .............................................................................................. ................................................ ............................... ....................................................... Doc.Building Permit Revised 2007 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 i ❑ 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 j ❑ Certified Proposed Plot Plan o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 I ORTH 0 0 0 TAndover No. 77 LAKE O dover, Mass., %1-1-s-114 Y O tL- �J COCHICHEWICK ADRATE D P'P�,`�� `SS BOARD OF HEALTH Food/Kitchen Septic System .PERM IT T D BUILDING INSPECTOR �G�l ,iJ?�llsfy THIS CERTIFIES THAT...C.�................................................................................................................................................... Foundation .SG.�-rc�PC' .��/V F ............ Rough has permission to erect........................................ buildings on .......7.........:......:....................................................... ,c?./�cr....../-�:.... /.%1111���- :........................................................................ to be occupied as.............................�/t. Chimney provided that the person accepting this permit 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS 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. 104 Otis St.,Northborough,MA 01532 J&L WINDOWS,INC.,D/B/A MA Home Improvement Contractor (508)919-0900•Fax:(774)987-3013 RenewalLicense#149601 (Expires 1/24/2012) RS Federal Tax ID#83-0404201 byAndersen- 'RM WINDOW REPLACEMENT —And—C.m y CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agreement s' rr, r Buyer(s)Street Address,lity,State,and Zip Code 16 7 6a n doa` �n n er M E-Mail Address Home Telephone Number Work Telephone Number 9 -617 3� Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen ("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:O Cash U Check $Mastercard Q VISA Total Job Amount: 3lJ Estimated Starting Date: _e/ < ❑Discover C)Financed,App#: Deposit Received(33%):1 (a) KJ Name on Credit Card: r. Balance at Start of Job(33%(�� Estimated Cpfmpletion Date: Credit Card#- Balance on Substantial [-5� Gxl of Completion of Job(33%): 7 CC Exp.Date: CC Security Code: By initialing here,you acknowledge that the Balance at Start of Job an Elie Balance on Substantial Completion Buyer Initials '� 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 s Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. J&L windows c.d/b/a a by Andersen Buyer(s) By: Signature f roduct Manager ignatu Signature IDA Tar C � G� Print Name of Product Manager Print Name Print Name 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. �— — — — — — — — — — -�,<- — — — — — — — — — — — — -}c— — — — — — — — — — — — — — —� NOTICE OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction, . You may cancel Date of Transaction . You may cancel this transaction,.without any penalty or obligation,within 1 this transaction,without any penalty or obligation,within three business days from the above date..lf you cancel,any 1 three business days from the above date.If you cancel,any property traded in,any payments made by you under the I 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 I by you will be returned within 10 days following receipt by the Contractor ("Seller'l of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if you wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make the goods available to the Seller and the I the goods available to_the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them up within 20 days of the date of Your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the goods without any further obligation.If you fail to without any further obligation. If you fail to make the make the goods available to the Seller, or if�ou agree goods available to the Seller,or if you agree to retum the to return the goods to the Seller and fail to do so,then odds to the Seller and fail to do so,then You remain liable you remain liable for performance of all obligations under for performance of all obligations under the Contract. the Contract.To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice,or send a telegram to Contractor.J notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATERTHAN MIDNIGHT MIDNIGHT OF .(Date) OF .(Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. I Buyer's Signature Date I Buyer's Signature Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink J&L Wmdows,Inc.d/b/a 104 Otis Street,Northborough,MA 01532 Renewal MA HIC License#149601(expires 1/24/12) Phone 508.919.0900•Fax 774.987.3013 . Federal Tax ID# 83-0404201 byAndersen. WINDOW REPLACEMENT an Anda Company OF GREATER MAssAcfnj FS AND NEw HAMFaw WINDOW SPECIFICATION S=Buyers)Name Date of Agreement /O S The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,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: Jc Double Hung(DB) ®.Equal sash ❑ Cottage sash(I/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(CFW) ❑ 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(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. ®.Yes ❑ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes No Qty of Sills to be replaced by Contractor: 4. ❑ Yes ® No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Fine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: Z HP Low-E®SmartSunTM (Tax(2r d tLziphle) ❑ Other If other,please specify: G. Exterior color to be: ❑ White ❑ Sand ® Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: ❑ White ❑ Sand P4 Canvas ❑ Terratone ❑ 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 4 Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ Yes rA No Install Lifts with Double Hung Windows 10. Screens: windows to have: ❑ Half or X Rill screens Screens to be: C Fiberglass ❑ Aluminum ❑ TruScene GRILLE DETAILS 11.Windows have grilles:Z Yes ❑ No If yes:❑ Grille Between Glass(GBG)® Removable Interior Wood(Pnw)❑ Full Divided Light(FDL) c Qty, Qty: Qty Qty: Qty Qty Qty, 0 DH OH DH CW/PicWre Glider CPW orG Draw grille patterns above `Use additional sheet if needed Owner approved(initials):( ) ADDITIONAL WORK DETAILS 12.❑ Yes [IA No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes N No 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 qty of openings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any painting. ( )Owner Initials 16.R Yes ❑ No Contractor will wrap exterior casings with aluminum coil stock of color. �S� /5 on Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.KYes ❑ 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. 19.9 Yes ❑ No Building 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 check is required at the time of sale for this fee. 20. Additional job details: 21. 09 Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No fmal 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,andre are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or ed in any way unless such changes are m writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that B (s has this Spe ation Sheet. Renew n �tqNH Bu (s) Buyer(s) B Product Product Marta, er Signature Signature In 0�ho Print Name of Product Manager Print Name Print Name The CommarweaWi of hsassacltxsetts • Department of Industrial Accidents , Off ce of inveskgatiorss 600 fthington Are et Bgston,M 02111 -...UT www.m as&gov1d1a Workers' Compensation Insarsnce Affidavit Btiders/Contractors/Mr-tridaas/Plumbers Applicant Information' Please.Print LeLdbty Name(Business10rpniz6=rmdividuaD: J)e»�I�G 1 i✓ e-r-3 C,n .Address:, l D �` City/Satetp: NOcik�_Oro A4-1-0--27 Photic Are you an employee check the appropriate bom Type of project (required): 1. i am a employes wifh Q 4. ❑'I am a general contractor and I �, �]Now constzuctioa employees(fnll'atnd/orpert-time).*' have hired the sab••coatractors 7ti deliag 2.[] I am a sole proprietor or per{aer- listed on the attached sheat : ' -ship end have no employees .These.sulrcontractors have 8. Demolition _ working for meats tiny capacity, wotl�s' comp.ftW= ca g, Q Building addition [No wodm s' comp:insurance 5. ❑ wearea corporation and its i0.[]Eleetricel repairs or additions. roquired.) . officers bave exercised their. of ez iign crMGL ILL]Rhimbing repairs or additions 3.[] I am a homeowner doing all work � p _ myself[No Warkors' romp: a 152,¢,1(4),end we heave no 12.0 Roof repairs in uramo required]t employees.•[NO workers' 13-0011w_ ' DMP.4nm=mo required.] •Any applicant that eheclz hoz#1 mast ah;o jM oat the section bdow showing'bes wmr a='eomp=Lmfion policy ration• t gomeow ml whe snhmit thin affidavit ind'ienfing they are doinE alwork and then hire outside eoahaetoa mart sabmh a new en—dEmh indieatiae mch. . 4Cmt mct=that:cheek this box must aftAmA m additiamal sheet sho*the=w of the scb-eontracf�a�thea worL�es'comp Policy iafnrmatioa I am art emptopei that is proyldutg workdrs'contpensaiion insurance far my employees 'Belaw.ia the pofiry and job site ' inforntatzon. nn Insuramme Company Name: Policy#or Self ins.Lie. Sob Site Address: r � City/StatelLiP: . �tL� Attach a cagy of the workers'mmpeasadoapolicy declaration pave(showlug the policy mmber and aspiration date) Failure to secure coverage as required uadw Soction Zk of MGL c,152 can lead to the imposition of criminal penalties of a find up-to$1,500.00 and/or me-yeer imprisonment,as well as civil Penalties in the fnrm'of a STOP WORK ORDER and a fine -of up to S25f1.00 a day against fln violator. Bo advised that a copy of this statement may be forwarded to the Office of Inve,stiptions of the DIA for inmranm covetago verification. I do hereby c u er the pains and penalties erjury that the information provided above is froartd correct Sieneture• Data ' Phone Official use ortfy. Do not write in this area,to be completed by city'or town q sdal '. City or Towm Permit/License# Issuing Authority(circle one): I.Board of Health 2.BdIding Department 3,MpTowa Clerk 4,EIecfrical Inspector 5,PltrmlZia;Inspector fi.Other contact Person: Phone#. i Nlaisachasetts - Department of Public Safety •Board of Building Regulations and Standards Construction Supervisor License License: CS 35707 BRIAN DENNISON. 86 CREST CIRCLE r WORCESTER, MA•01603. " Expiration: 9/812012 Commis user Tri: 2622 • �t Office or Consumer A$iir:&Basiarss'Begai:fiaa OMS IMPRO ENT CONTRACTOR • Reglsfrafio� 01 • l •12 Card . RENEWAL BY BRIAN DENNIS 104 OTIS — --_d NORTH$OROUGH, IInderseeretuy . ACORD. CERTIFICATE OF LIABILITY INSURANCE2/1DATE(MM'°1)NYM 0 012010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP MCKeone insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC 0 INSURED Renewal by Andersen INSURER A: Hartford insurance Company J and L Windows, Inc. INSURER B: Nautilus 104 OtIS 5t , INSURER C: Northborough,MA. 01532 INSURER D: INSURER E: 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. INER ADO'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPE OF INSURANnF POLICY NUMBER UMRS B GENERAL LIABILITY N0958461 10/01/2010 10/0112011 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY A A PREMISES Me omurence - $ 100,000 CLAIMS MADE =OCCUR MED EXP(Any one parson) i 5,000. PERSONAL&ADV INJURY i 1,000,000 GENERAL AGGREGATE i 2.000.000 GEN'L AGGREGATE LIMIT APPLES PER: PRODUCTS-COMP/OP AGG i 2,000.010100 POLICY PRO- LOC A AUTOMOBILE 35MCC XD 6390 10/01/2010 10/01/2011 coMBINEDSINGLE LIMIT ANY AUTO (Eaaeddenp i 1,000,000 311 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per panxn) HIRED AUTOS BODILY INJURY. 0 NOI\LOWNED AUTOS (Par accident . PROPERTY DAMAGE s - (Paracddent) GARAGE.UABILrtY •• i rAUTO ONLY-EA ACCIDENT i . ANY AUTO EA ACC i ' OTHER THAN AUTO ONLY: AM i EXCESS/UMBRELLA LIABILITY - EACH OCCURRENCE 5 OCCUR CLAIMS MADE AGGREGATE • S DEDUCTIBLE S I RETENTION S s A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/201'1 WRYLIMFATMS U• I OR EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNERIEXECUTNE E.L.EACH ACCIDENT S 5010,000 OFFICER/MEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 1: 500,000 It yea,describe under' SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s 5010 OOD OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 101 DAYS WRITTEN NOTICE TO THE.CERTJMCATE HOLDER NAMED TO THE LEF,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ' AUT}IORGED REPRESENfATNE ACORD 25(2001/06) ®ACORD CORPORATION 19BB t •r � • ewal M.. • n & m ti rn i�m[w=r> ete it : '• ' • • • ! tD0-DDmbia Hmat P.E • • . • ' ►. D414�DD7 MUCE Ru • ��Oir(u.5�/i-�' SDZ3f�'=3f C3}Il G`Q�IIIGE=-,tZt' -• •' • V¢i6t3 Tragi:: :�1�_ ' .. s..tr�tr.w r'••�n�arr���'Pea+4Cla+�•4�-1t=�ea j €'ISRIS�TFR: 1�n I Im6ntelllt 1nc� aumbib mamma kLto . • i 91* IN IS .r IE�wF76E�E'2f _ . j Weir®-i•I e---wlti.EL�rtAk•J�'®�-' _ _e e�..eTeat.asede r Location 6 -7 1-6/L/< No. y/2 Date NORTI, TOWN OF NORTH ANDOVER AL O 10 s 9 L ; . Certificate of Occupancy $ Building/Frame Permit Fee $ s^cMU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23696 Building Inspector