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HomeMy WebLinkAboutBuilding Permit #277 - 7 FULLER MEADOW ROAD 10/6/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: �� 6 IMPORTANT:Applicant must complete all items on this page LOCATION PROPERTY OWNER \ 1QJ Print4 Print MAP NO: 100 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 PERFORMED: �lr-vc-.-r- Identification Please Type or Print Clearly) OWNER: Name: Phone Address: v� CONTRACTOR Name: � C ;v �d C Sa/r-1 Phone: S 5- C) 9 S 0 Address: q�a c '�- I" Y Supervisor's Construction License: S C Exp. Date: C?/g-1 t U Home Improvement License: f Exp. Date:_ /C)q11 t 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: $ _ ��, (� � FEE: $ (D _ ao Check No.: ur3 Receipt No.: 2-562 NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund signature of Agent/Owner_ re '✓ _Signature"of contractor's Plans Submitted Plans Waived Certified Plot Plan Stamped Plans Location '7 (/` �f G��c t, No. Date �� 6 X,3 NORTH TOWN OF NORTH ANDOVER 3? i • O ' Certificate of Occupancy $ �'�s''••°''<� Building/Frame Permit Fee $ 336 J�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # 2L %'-dU � Building Inspector TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 4 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 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 i 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 a 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 L3 Certified Surveyed Plot Plan ❑ Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses o 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 Li 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) o Copy of Contract o Mass check Energy Compliance Report o 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 ,tAO R TH ® of R over No. a 77 dower, Mass., /0A-za T 0LAKE �• COCMICMEWICK V ADRATE D `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �j BUILDING INSPECTOR THIS CERTIFIES THAT .6 � �/ax( ,� Foundation •• ............... d ' �///�/' �F4� has permission to erect........................................ buildings on ..7.. .............................................................................. Rough to be occupied as .a.L.... ,�(/ /.. YOGvs 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 CONSTRUCTION ST.6RTS Rough 9 OF ............................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. 03/22/2006 18:26 9782785010 JOHN BEAVER PAGE 04/04 Renewal g RENEW�,L BY .A.NDERSEN MA HIC License Fed rol T x ID#os 1/24A101 Pectoral Tax IDir 83-0404201 byAndersen. wiueew ggn,NCEMENT ,�.,..,,..e�t.•v OF GREATER MAS5AG1iU',RT"l,S AND N..rw HAMPSHIRE, 104 Otis Street•Northborough,MA 01532 Phone 508.919.0900•Fax 508.9.19.0903 CUSTOM WINDOW AND DOOR REMOD.ETANG AGREEMENT Buyeris Name Dole of Apreemont �L) 04 aes 9- 2� - 0� Buyer(s)5trent Address,City,,State,and Zip Code / t� Vlkn ea�U1AI~ �r7"A C•Mail Address Home Tele hone Number Werk TAlephone Numbcr LNC N 19 7 21-x,92 2,3(�S BiryTr(s)hcrehy,joimly and severally agrees to purchase the products mid/or services of',J&T.Window::,Inc.dha.Rencwsri by Andersen of Grea.ter Massachusetts and New T-L nipshire("Contractor"),in accordance Widi IhS'wrnu and conditions dcsmhed on the front.and the.reverse of this aprecrncnt ruzd on the attached specirimtion ghcet(.ti)(collectively,this`A,grertnen.t").Buycr(s)hcirby agrees to sign a cnmpletinn certificate after Contractor has r-rnnplenpd all work under this Agxccr.octtt. ��'77 Method of Pymni: Cash 0 Check Mastercard ❑VIS Total Job Amount.OC b�� Estimated Starring D te: r_1Cl Q Discover O Financed,Applt: �9� 33(a 0 g-aa �Je s Deposit Received(33%):__9 00...,.r._—.___-.. .--- - Name on Credit Card: Balance at Start of Job(33%): 9000 FArnatod Com lotion Date: Credit Card#: Balance on Substantial 9 (oG T —5 �/ Completio %)_ ( --—" CC Exp,Date: CC Security Code: Tiy .i:i)int here,yeti ackngwledgc thatthc Valance ar.Start.of tub and the Ba.lancc un Substantial.Completion Buyer Ini'a1s of Job cannot be made by crcclit cat-and hoist be made by personal rhec'.k,beuik check,or cash. Buyer(s) agrees a.nd 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 deviadon from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor.Buyers)hereby acknowledges that Buyer(t) 1) bar 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. Rcnew } rsen of Greater MA and NH Bu cr(s) Buyer(s) By: _ S r attire f 1 oduct Manager Sig utturt Signature JD t 4 Print Name oC Product Manager Print Namc 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,SFE TIME ATTACHED NOTICE OF CANCELLATION FORMS FOR AN&XPLANATION OF THIS RIGHT. - - — — — — — — — — — — — —$<- — — — — — — — — — — -- — — •�<— — - - - - - - - — - — - -� NOTICE OF CANCELLATION K NOTICE O�GANCELLATION Date of Transaction You may concel I Date of Transaction -2_4Q-0 .You may cancel this transaction,without any pens ty or obligation,within I this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you undert e I property traded in,any payments mode 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 Seller of your cancellation notice,and any security I by fhe 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 Coatrvct or Sale-or you may,ify u wish,comply with the I Contract or Sale,or you may,if you wish,comply with the insfruct'rons of#{te S&Lr r+egat "y**returnt.�Kppm-w octions of the Seller regarding the return shipment of the goods at the Seller's expense and risk.if you do A riFctl! * the goods tit-ft'Selfet's expense end,risk.if do make the goods available to the Seller and the Seller does not the goods available to the Seller and the Se -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 of Cancellation,you may retain or dispose of the.goods without any Further obligation. If you fail to make the I without any further obligation. 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,thenyou remain liable I goods to the Seller and fail to do so,then u 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 1 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 I notice, or send a telegram to Renewal by Andersen of Greater Massachusetts and New Hampshire, 104 1 of Greater Massachusetts and New Hampshire, 104 Otis Street,Nor�gbo ough, A 01532,NOT LATER THAN I Otis Street,No�rhborough, 01532,NOT LATER THAN MIDNIGHT OF `7- -O .(Date) MIDNIGHT OF Y-Z w O ,(pate) I HEREBY CANCEL THIS TRANSACTION. x I HEREBY CANCEL THIS TRANSACTION. I Censumor''s Signature Date I Caneumer's Signature Date RbA Copy- White Cu'doinel:Copy-Yellow Customer Copy-Pin], 03/22/2006 18:26 9782785010 JOHN BEAVER PAGE 03/04 Renewal RENEWAL BY ANDERSEN MA 141C Licenac#149601(expiras 1/24/10) Andersen. REATi R MASSA Federal Tax mot $3-0404201 OF G woow arse Mn •..'��coma�y CHUSETTS AND NEW HAMPSHIRE 103 Otis Street•Northborough,Massachusetts 01532 Phone 508.919,0900•Fax 508.914.0903 Buyer(s)Name SPECIFICATION SHEEP Date of Agreement t_uc _ '7-(,- a'. The Buyer(s)listed above hereby jointly and severally agree 10 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 ACRFFMENT of which this Specification Sheet is a part, WINDOW DETAIIS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) [VEqual sash D Cottage sash(T./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 Cf Metro handle Double Casement(CDW) ❑ Standard handle ❑Metro handle Casement/Picture/Casement(CFM ❑ 1:1:1 or❑ 1:2:1 ❑ Standard handle(] Metro handle 2 Life Gliding Window(GM Glider/PictureGilder(GP�1) ❑ 1,I:1 or❑ 1:2:1 Awning Window (AW) Picture Window(FW) 14av or Bow WindowCr— Patio Doors(sec separate Door Specification Sheet) 11J N r 1 6 2• Yes EJlyo Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes No Qty of Sills to be replaced by Contractor: 4. ❑ Yes ,h No Qty of Windows to be New Construction Full frame(includes new interior&exterior,casings) Exterior cast s: ❑ Pine Ll Maintenance-free material❑ Factory applied 908 Fibrex brickmold 5, Glazing to be: I•IP Low-Fp SmartSunTM (TaxC?e tL%rbJe) ❑ Other If other,please specify: 6. Exterior color to be: [lWhire❑ Sand Ll Canvas ElTcrral:one C] Cocoa Bean 7. Interior color to be: White ❑ Sand ❑ Canvas ❑Terratonc © Pine ❑ Maple❑ Oak Note: int •or color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. S. Hardware: White ❑ Stone LJCanvas ❑ Brass Double Hung: 9. ❑ Ycs No Install Lifts with❑ouble Hung Windows 10. Screens: windows to have: Qfi-la or ❑ Full screens Screens to be,: [ Fiberglass ❑ Aluminum Trltscene QRILL£DETAILS T 1.Windows,haavc grilles: Yes F] No If yes:E] Grille Behvecn Cass(GaG)El Removable Interior Wood aN m❑ Full Divided Light(rDi.) Qty:_ qty: Qty: Qty: Qtr- Qtr Qly: DH DH DH cW/Plofu4 Glklnr C Draw grille pal terns above, "Use additional sheet if needed Owner approved( ); ADDMONAL WORK DETAILS 12.❑ Yes Contractor will.remove metal frames of windows. Qty of Lrnits: 13.❑ Yes 4 No Contractor will install new paint-ready or stain-ready casings. Interio acing qty of openings: Exterior casings openings: ❑ Pine ❑ Maintenance-free material 14.❑ Yes [ZNo Contractor will install new paint.. ee�stain- outside stops qty of openings:—._... Interior stops qty of openings; F,xterior sl' Pine ❑ ❑Maintenance-free material 15. Owner is a e that Contractor does not do any pain er Initials 1 G.❑ Yes No Contractor will wrap exterior casings with oil stock of color. 17.dNote: Wrapping may be required with storm window removal;I moval of storm windows will]cave screw holes in casing. Yes ❑ No Contractor,will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. I8.[J� c ❑ No A limited warranty sha)1.be issued to Owner upon completion of the job and payment in full. i 9. Yes ❑ No Buildiltg permit—Contractor will secure any and all necessary perinifs. The fee for the permit(s)is not included in the Contract Price and a epa.ra.te ch is required pt triftbof sale for this 20. Addilional,iob details: Al 1'.3 D 671W Ly o_G,vs 1s 21, Ycs ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. to©.Fina/.pgyynent.,sh rtll�m dmrna 1;ded4.rn07-0ccontrectis completed to the satisfaction ofall parties. It is agreed and understood by and between tho parties that this Specification Sheet,along with the CUSMM WBVDOW AND DOOR REMODELING AGREEMENT,constitutes the entire undetatanding between the parties,and them are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its s modified or varied in any way unless such changes arc in writing and sighed by both the Buyers)and Contractor. Buycr(s by earn ledge that Buyers)has read this Specification Sheet. Renewal b An en f Greater MA and Su. Buyer(s) By. / S' tum oduct ManagerS ah Signature Print Name,of Product Manager Print Name Print Name RbA Copy- White Customer,Conv-Yellow The �C}Tf2f 0 )4'Cltltf2 Of��aSSaCl1lESettS e ' Department of Industn'al Accidents 1 / Office of r7wesziptions 600 'ashingtorz Street , 3oston,M 02111 wnw.znass.g ov1dia Workers' Ccmpensa>ionInsurance Arn-idavit: u iders/Coli Tactors/ iec.ricia s/gi tubers ADDlicant Informajon . Please Print Legibly -�TSi�e(Business/O::znizationlIndiridual): ,�t_?r��;,�y.� 7) 'Address: I D•y , ' City/S tate/Zip:—AI (lhyn Co ' I (�lJ F2. e'you?n employer?Check the approp�'ate bo;::. Type of �o ct re vired � 3P P" 1� ): I. 'Lam a employer with j D 4. []'1 am a general contractor and I employees(full and/or part-time).* have'tared the sub-contractors 6. New construction I am a sole proprietor orparter- listed on the attached sheet.± 7<C�;�'?,'model�g ship and have no employees Th°se sub-contractors have B. Jt]Demolition worl�ng forme in any capacity. workers'comp.insurance: 9 J]Building -No workers' comp.insurance �. ddition 1 0 Ire are a corporation and its required.) oFlicers have exercised their 10.11 Electrical repairs or additions 3.(^]I am a homeowner doing all work risk of exemption per I\,IGL 11.Q Plumbi c repairs or additions Myself [No workers, coma: c.152, 5.1(4),and we have no 12.7 Roof repazrs insurance required.]i employees.[No workers' eonp.insurance required.] ------------------------------ 13 ❑Other *Any appIicant that checls box ri mast ak till out the section below showing their worltirs'compensation policy inforxnarion. Homeowners who submit this affidavit indicating fney are doing all wort;and then hire outside co lConi actor mu t submit a rew a u3avi±indicating such aL�ctor that checl,this box.m=attached a,,additional sheet showing the n_,ne of the sub-contactors and their worker'comp.pc iicy information. -Tam an_ern to,o 9 P e n } r that is pror iding, it or l rs cotrpensadon insurance for ray employees 3elow.is the p��icy and,job site information. n / Insurance Company Npme:_ n Policy A,or Self-ins.—Tic._ Si Expiration Date: Job Site Address:_ / (J(��/l.. ,{ ,� t S ��'/.� /`/J� Ci /tate/lin zL Cli a Copy of the�'4rl ers"�CDTMpeMation polley.declarataan, page(sLton'rr a the pO is r LEIII}er creel eg / y pratlon dzte). t'ailZe to S-cure Coverage as required under Section 25-k of MGL c. 152 can lead to the Imposition of crimp inal 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 fore of up to$250.00 a day against the violator. Be advised hat a copy.of this statement may be forwarded to the Office of Investigations of the DLA,for insurance coverage ver fication. Ido hereby cel-,—i under the pains and penalties,of perju;y that the Information provided above is true and correct 5i Qnature: Dain: o �c�l Phone Official use only. Do not r rite in this area, to be eDtrDletea`by city or tow:° nr�iictal. CH, L 3r a To 17n- :11 ai " TSSTLILg,,_77�iY.E:�ori 1.�u<drd, OI IT' 2 - g.Di:1lr. ins Den Gr tzrt eat ✓<Q: Jnw_1 E °rl4.1 '..,... k S._1l tc 'Li g FspeC:or 1 Contact Person. P';one= - j i 'i_' -�-•.•-., +:7 Lfi�'-100971477A�1d:Y,, Lcra C�c./l 'lLG1o„�.i( t � � �=�.�-.a �': yos.doiiuildir.6Fe�uIaaons:�dStands;ds I f , 'Cansr;icticn.Supafi+,sor�ic ns_•, tea. Li - n's:, is , � .. c�nsz;, Lic 982 - - i =_- - ^' 0570 BRV lq 1)ENNI80N °� -Fj, 85 CREST CIRCL= WORCIE=FF'MA01503'J91 Commission r L I ' I Al.SY ANDE Ri=t�!LVVRSON BRIAN..DENI11SON' I OA O T:IS STRcl- f\iORTHSOROUGH, MA.01532 D?S-CA1 sa M420 Board { Board oi,uildine? ebulations and Standards tVr' HuBfiBIMR.KOVEMEN'TCOi\?T `COB _.7G 1 +12412010 { >jp l=-m.nt Card tv 'In BRIAN pBNNISO>!.-== `NORTH30ROUGH,i(Lri 07532 "dministrator / Y uma g %1 I 7�4ES 72 PS AS A' 0 7/2 o.cQ F I-Niz 11 R AND CONl7ERS Ho _Z P­%i 3ON U:' UFOil Tin'= -=Z; -1 _11 00=S POT AK:�_ ,TFC' ATZ= L - 1 , m _­1 ExML30 ,!f�p_g,GE ALFFORDED Eli BE A L Tvk- =x 333 tkirblor, Vjj 4o`­0e,_nrz-. ­­ j Fen_ 7 AG U.BIC bjy And_=rson INSup.sR A: a rL1, JjSUnS,- "Afuldows, Inc. a INSURER E: 04 . 0, c)ft o r cu a h, V,A 0 i 5-322 INSURER 0: C 0V Fr,A POLIci_--s GF:IJSUPANC LIS-12 D BELOW;-AV-= !t�SU 0 THE INSURED HAM ASOVE FOR,_11HE POLICY P=r I O_'I LAY P12QUIPEMENT TEIRM 3R COKNO�-,_m OF - L . V 10 ANY C^ CFOR OTHER. O0FjIV.E:'1JT' 77,H� RE_S== -10 WHICH THIS CER-is FICATE,A.Y 2 JAY PERTAM,THE if"SUPANCE AF=OPI:,-=;;By_j`,=POLICIES DESCFI--_��z SUED OF, POLICIES.AGGREGATE I !S SUSim T T 0 All T..E TE A N D C 0 H D I-j, -I m r s H o w N h1k y R R=- __ - ­ ,HE. -PMZ-,EXCLUSIONS s or,"LICH DUCED BY, CL�Alm:. p C Lj Cy yu Vz VI EFALILr_ HOP 50-7 404 II =MMERCIAL C-NMRAL LI-24LIrf u-S 10 7 122 0 10 EACH-,occUPPE.NcsO NTT Z 17X OCCUR I ME:)EXP(Any one Demcn) LpEPSO9kL.ADV iNjup, I_91-acc.000 = CE,;IL AG3Rs.:;AT=_LIMIT APPLIES PZP�:. I.G Ai_ I5 2.000,000 PRCOUZ-72-ComplOp AGO 2.000.00-- POLICY -71 LC--- 0/0 i!2,003p 11 SI ANY AUTO 1,zL—E ymIT t=s 8=.eril) — 1 3 1,0001.000 ALL OW_D AUTOS SCH.B.IDULED AC"OS (Per pecan) HIRE:-AUTOS SOCILY INJURY (Per z=.zant) CAMAGE ALTTO ALM 0 ONLY-EA A=IDENT OTHER TK4,v !A AC15 - AUTO ONLY: - A= a___uR CLAIM.S MAC= UPRENCE An TE GRt-:;Ajc Ia C'E:UC7IBLc 1 IS V"OFrIERS COMPENSATION AND t= vvi=v- I ZC S7ATU. 0,0 LL PP I-4� 4 iACI CCC FA STR E:;AT E I Ypp ANY PROP R_,-TC)R,7A7,TN:Rr s.L.F 48 ACCZZ?jT 500,1000 lives. Lc. =J.-D!-_-SASS EA EMPLOY=:- _;,pOV!SzIOK1Sbz!a• I R E L D!S A S -.. - 5 0 1).10 0 POLICLIMM L' 'M nIN aEOL11--,AW Or'7xv-ASOVS C-L= THE V z DAT E:H�BAVnR TD r ZF AP; e5 citiTs 4