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HomeMy WebLinkAboutBuilding Permit #777-15 - 8 BUCKLIN ROAD 4/13/20154 1 t A �4 -, - A J- & 4 1 � 4 " '- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � r) Date Received 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 �� , �- � �,..�.-s - " � -:4f ❑Floodplain❑Wetlands -�--� ���� s❑ Watershed,Distnct -'4� P �{ Z j �. � i# �.�'� • i ,T`a fy � 'S..k� •'� ' C `-g =zOWwater/Sewer _, y� .., r, _ , OWNER: Nam UtsL;rur i iUN,Ul- wUKK 1 U BE PERFORMED: -: Please Type or Print Clearly 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: $"' 04 FEE: $ -3 J W-"" Check No.: NOTE: Persons contracting with Signature of Agent/Owner, Receipt No.: 2C3� I contractors do not have access to the a ad, Si nature ofLcontractor� �, . Www � � I� Location LI No.Date Check # `0 () A102 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ Building lngpd6tor FA . t i 1413 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 PLANNING & DEVELOPMENT Reviewed On Signature. 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: 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 NU I t5 and UA I A — Ivor department use ❑ Notified for pickup Call Ema Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract - ❑ Mass check Energy Compliance Report, ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 N CD 0 Z CD O Cr CL �. -a cc 0 O mv < CD0 C a� CD O �Wl 0 cn F 0 U) 0 CDO CD U• U) Z CD a O CD 0 n 0o� `DCL . n CD n 0 rL m o =r CD O_O rtQ W Fn --' CD D) "~ Cl) _ 0,0 y O cD. 2' CL as C CD D c:s n 'r n � ==r �� CD 0 <to on: �,_� Z CD 0, a D0=- ,• CL a oQ �� N o — < CD O O CD O C W� LA (D . N rt 0 O CD 3 CD :' N CD CD N C) o DCD CD -0 0 SUrt = _ O O O O Q . N Ln co Z A mm N A �� nrn Z T .� T ;orn O 0-- Z N -q Dl Z C y 3 C Z -O O rOr O �.. n 3 C 04 7 �*. Q Z . G7 z ti 0 o O 0o� `DCL . n CD n 0 rL m o =r CD O_O rtQ W Fn --' CD D) "~ Cl) _ 0,0 y O cD. 2' CL as C CD D c:s n 'r n � ==r �� CD 0 <to on: �,_� Z CD 0, a D0=- ,• CL a oQ �� N o — < CD O O CD O C W� LA (D . N rt 0 O CD 3 CD :' N CD CD N C) o DCD CD -0 0 SUrt = _ O O O O Q . N Ln co T A T N A T .� T O N C Dl D1 C y 3 C -O O rOr O �.. n 3 3' 04 7 �*. Q m o z m m N o • m o s T rW (Dm m C C 3 : W m N W G D H r n n p rn z m m O m m m Dm z ra next Step Living,,, home energy solutions This agreement is made by and among Saket Sankhla 8 Bucklin Rd North Andover, MA 01845 Site ID: 410132. Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866) 867-8729 19 -Dec -14 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the work in detail (the "Work") which are incorporated herein by reference: Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 4 $75.00 Hr $300.00 Work Location: Doors Door Weatherstripping w/ Sweep 2 $75.00 Each $150:00 Work Location: Attic Flat Attic Stair Cover Thermal Barrer with Carpentry 1 $237.65 Each $237.65 Damming 88 $2.05 Lnft $180.40 Vent bath fan to soffit exhaust 2 $118.75 Each $237.50 Propavent 2' or 4' 52 $2.00 Each $104.00 Attic Floor Open Blow Cellulose 9" 152 $1.36 sgft $206.72 Attic.Floor Enclosed Cellulose Dense Pack 6" 836 $1.78 sgft $1,488.08 100%Airsealing Incentive up to Program Max 75 % Weatherization incentive ul) to Proaram Max tsumareta Annual tnergy savings from the Above Improvements 2. PAYMENT CUSTOMER agrees to pay NSL for the work as follows: $450.00 1,840.76 $469.00 Payment #1: $100.00 -Credit Card or E -check deposit is due at the time the Work is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed 1/3 of the total retail costs. (Note: Mastercard, Visa, and Discover accepted) Additional Payments and Final Invoice: $513.59 -Additional Payments for the Work shall be due upon completion of the Work. GIG Ov�V�%` '4 �L�G 191h 2011 Custom Signa Date 19 Dec 2014 Willi Aquino N L Signature Date Name of NSL Representative A717269 The Terms of this Agreement are contained on both sides of this page Next Step Living " 21 Drydock Avenue a 2nd floor a Boston, MA 02210 0 (866) 867-8729 a Inquiry@nextsteplivinginc.com a www.nextstepliving.com TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.617.973.8700. 5. PERMITS NSL will obtain any necessary permits as the Customer's agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all partes. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save® Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customers request, any defects in workmanship and materials provided by NSL which appear up to (1) year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non -code construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not property protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terms other than as expressly contained herein. This Agreement supersedes aff prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. You may cancel this Agreement if it has been signed at a place other than the NSL's normal place of business, provided you notify NSL in writing at its main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agreement. See the attached notice of cancellation form for an explanation of this right. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Mass Save Planview Diagram if customer S&r-e-t So n0n(a. Advisor Name: Address i h =D Advisor Number: I !T Town N i&JOVICIVgS Any limitations to access by truck? Site ID q l 0 Iia I Mt NOT S Ogg inq-!},'G 4hrs// ©pgt WS 2 ✓/ 4 Vf.�r�'►- �� -tv Soft t -c xlnctuot L ✓ 0 �a�Ymrni�ng � $ ®pyo Pave.v�� 2 n r 4 52 001,,,D The in A *r, C. 1 SZ$ I® �411 DQC, in A* t T►'Do rt, Ss3la� v� -T1n�s had o, vj9 . A-ec-e,,� . ' OO 2� or PDS ® 22 Z �� 4 Office ®f Consumers Affair -Is and Business Regulation 10 Park Plaza o Suite 5170 Boston, Massachusetts 02116 Homme Improvement Contractors Registration ion :(; I-Tif f TTT uA' ii 10M 14,0.1 ,;1, 121- /11,> f n >r• ,.i�r..a , ..,(�/ ,� f�l.r,l�rrru ells Oaffase ou Consumer Affffhirs & Business ReguNtion "HOME IMPROVEMENT CONTRACTOR Registration: 162111 Type: E cpiratiosn: 1!1412017 Supplement Card NEXT STEP LIVING INC. ROGER OUELLETTE 21 DR`(DOCK AVE. 2TH FL— BOSTON. MA 02210 v¢+derseeretar5 Registration: 162111 Type: Supplement Card Expiration: 1/14/2017 Update Address and return card. Wii ark reason for change. E] Address F--] Renewal ❑ Employment F-] host Card License or registration valid for i ndividul use only before the e%piratioan dates 1(a found return to: Office of Consumer Affairs and Business Regulation 10 Park plaza - Suite 517D Boston, WwA 02pIl6. I valid without signature AMML Massachusetts Department f -)f Public Safety Board of Building Regulatio-s and Standards Construction Supen icor SpeciAN t- is e n s e C -SK -1028 1i 55`��0 RcM, demd To: CSS OCA - (Insu d an Contractor .xplratlon (MIX2®16 Befit re to podsLzss a current edrelon of tell@ Vvlassach us8ts R@ae Sufl ing C de is muse for revocaVan 0P this license. The Department q flAdastrial'A(ccidenis e r� Office of Anvessigaiions W A d _1 Cenvresv Street. Suite .1 Ddb .1 estan, MA 02114-21117 `1M 5V Workers' Compensation Insurance Affidavit: Builders/Contractors/EqEq lectricians/Plumbers Applicant Informationse Print Legibly Name (Busirtess/Organizatio,dladavidual);Neat Step Living Address: 21 Drydoek Ave Boston, MA 02210 Phone #: (856)057-8729 Are your an employer? Check the appropriate bozo 1.0 1 am a employer with 850 4. ® I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 1 am a sole proprietor or partner- artnership listed on the attached sheet. shipand have no employees 'These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.{ 5. We are a corporation and its required.] 3.E1 I am a homeowner doing all work officers have exercised their myself. (No workers' comp. right of exemption per 1MGI., insurance required.] t c. 152, § 1(4), and we have no employees. (10 workers' comp. insurance required.] Type of project (required): 6. D Mew construction 7. ® Remodeling 8. ® Demolition 9. ® wilding addition 10.Ej Electrical repairs or additions ILEI Plumbing repairs or additions 12.® hoof repairs 13.V other Insulation *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. .i Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aiiida, it indicating such. tContractors that c1heck this box must attached an additional sheet showing the name of the sub -contractors and state whether or rot tho se entities have employees. ff the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees Below is the policy andjob site information. Insurance Company Name: A.LM Mutual Insurance Company Policy # or Self -ins. lLic. #: AWC-400-7030025-2014A (Expiration bate: 9/30/15 .bob 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage VAgotion. Ido hereby certify under the pains anal pen e/ perjury that the informadon provided above is true and correct Signature: / Date: ! o / o Phone #1 -WI I� Official use only.Do not write in this area, to be completed by city or town official, City or Towne PermnatUcense. # Issuing Authority (circle one): bo Board of Health 2. wilding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6< Other Contact Person- Phone #- NEXTS-1 OP Ilse EL A �T CERTIFICATE OF LIABILITY INSURANCE DATE I14 °THIS CERTORCATE IS ISSUED AS A PW'TER OF INFORMNI'SON ONSy AND CQNfER$ RIS K01 Pj IJPo Tviiro��`3'I��t�� SOLDER. THIS CERTIFICATE DOES NUT AFFIIRMA 1VELe� OR NEGA'UVELY AMEND, E3G6'END OIR ASI -ER fHE 0YVERAOE AFFOR' 3ED BY 'I -HE POL6GIESL BELOW. THIS CERTIFICATE OF INSURANCE DOES NUT CONSTIT'I.I TE A CONTRA(? BETWEEN THE 98SUM0 INSURER($), AP.IT PROMP 119R PSENTATIVE OR PRODUCER, AND THE CERBTFICAT rE HOLDER. IMPORTANT: Bf the gerdficrate holder is a@n ADDITIONAL INSURED, the policy(les) must be andorsed. 9f SUBROGA: 'ION 0§ the terms and conditions of the policy, certain policies may/ require an endorsement, A statement on this certificate does not confer rights to *p certificate holder in lieu of such endl®rselTeentQs). PRODUCER 3cLaughlirl I ISG anco Ageacy Lyronfea ParkWpy Melrose, MA 02276 lJohn . MCLaUghlin Jr. ___ CONTAC3 NAME: Erin Lyons AX- PHONE 6 a�d:7SI IC No:78202328 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL iJ INSURER A; NalytllRaS Insurance 09/30/2024 INSURED 21 O Stop �9Q9ven Inc.e,INSURER �'I ®ry�l`�rk Aav�ml�I�, �rl� Ploor Boston, MA 02210 B:Commerce Insurance Company 34754 BNSURERC:A.I.M. Mutual Insurance Co. INSURERD:AXIS Insurance Company 115610 INSURER E: PRODUCTS -COMP/OPAGG $ $ INSURER F : AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS [��Ti�q�. 7_Teli� Nf�(rnllllyl[�H'_�ll �'c"h9liLnlf LI�f-„ .TI�!II��ICr� �,l 1 `. � P r ra THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYERII- INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICM T9i 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. IGYR TYPE OF INSURANCE I S BI$ POLICY NUMBER iVPiNO1@g1YM EFF MflONIDD EXP LIMITS A X COMMERCIAL GE6EFAL LIABILITY CLAIMS -MADE ® OCCUR 09/30/2024 09/30/2025 EACH OCCURRENCE $ �,®®®,000 PREMISES EaoccTuante $ 190,000 MED ECP (Any one person) $ 0,900 PERSONAL & ADV INJURY $ 11199119 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT F-� LOC OTHER: GENERAL AGGREGATE $ UP01446 PRODUCTS -COMP/OPAGG $ $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 2�M ��I 09/30/2024 09/30615 _ Ea accident) SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ Per accident $ ® UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE rE�U783547022024 09/30/2014 09/30/2016 EACH OCCURRENCE AGGREGATE DED RETENTION$_ C WORIKERS COMPENSATION AND EMPLOYERS' LIABILITY V I N ANY PROPRIETOR/PARTNER/EXECUTIVETO OFFICERIMEMBER EXCLUDED? F-] (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A DE ISSUED DY CARRIER -.-I,— 09/me/2014 -. B3W0012010 STATUTE .PRH E.L. EACH ACCIDENT $ 300,000 E.L. DISEASE - EA EMPLOYE $ 500,00 E.L. DISEASE -POLICY LIMIT $®®,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 901, Additional Rome ft, Schedule, may be attached if move space is nquirad) FOR %NFORWT%ON ONLY I I I I INFO -01 For lnformation Only SHOULD ANY Or THE ABOVE DESCRISE0 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORON. ARI ilgihts mz npearerl ACORD 25 (2024102) bhp AOQRP qomqce 190( �e 6��o ir r Fl>r AC®RIS,