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HomeMy WebLinkAboutBuilding Permit #178 - 80 OSGOOD STREET 9/4/2007 W.— BUILDING PERMIT 6 4, TOWN OF NORTH ANDOVER ?M1� op APPLICATION FOR PLAN EXAMINATION * ,� Permit NO: �l—�//1 Date Received �°ssgc►+usE��� Date Issued: ` U IMPORTANT: Applicant must complete all items on this page �,03xa 3 ` TL L`t3C�1TION � , k h . * - PEROWIER t 9 x aa " a rp4 � f �.011,11 sk , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial 12-Alteration No. of units: ❑ Commercial impair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �� od lain CtUr/et fan', n © WatershedDtstrtt ❑ e'3t�G t E , m „`'` .e-1111T: ` c s a x: S. a ' ;` ,..... .x_' � - (�ES IPTIO OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: r S Phone: - Address: cuS ('7 V�2 n CC3NTfiACTR Napo r. " Phone "u ` _ 21 �uperv�sorQsaCorisf tion Lieelnse aExp Dace � y r Ione Irrfprovermertt license r � Exp ` Date 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: $ ys� FEE: $ 72,00 Check No.: �j 31 v Receipt No.: 0207/(04 NOTE: Persons contracti Will unrre 's eyed contractors do not have access o tl e aranty fund Signature c�f,AgentTOwner t; Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &-DEVELOPMENT ❑ ❑ COMMENTS 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 Conn eCtlOn/Si nature $ Date Located at 384 Osgood Street Dnveway Permit FIRE DEPARTMENT _,"Tem Dempster on site es Lobated at 124 Main :Street..,: � z n n•r �_F , Fire ©epartment signature/de 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 ............................ ......................................._.................................___............................................._............................_.... 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 ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 r Location So OT-<w S No. 1 Date �oRTM TOWN OF NORTH ANDOVER .�? � - - • OCL t p Certificate of Occupancy $ CH Building/Frame Permit Fee $ s� us Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� 205v �; Building Inspector Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. ## 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia i F' The Commonwealth of Massachusetts 7; Department of Industrial Accidents 1. Office of Investigations P `' / 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 073A S N�. 2op��w c, L(- C Address: '2 10 o 0 - City/State/Zip: Q�pr���jc�, S!� 0- / Phone #: Are you an employer?Check the appropriate box: Type of project(required): am 1.0- a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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.❑ Other comp. insurance required.] *Any applicant that checks boz#l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,4n"ec-riCutrk Ise0-wiIA a Ai.\Le&cA4 OA5\JAL} Policy#or Self-ins. Lic.#:_0 - kA ol-I -c9 b l Expiration Date: ®3-OZ-G gj Job Site Address: tO0540A ." City/State/Zip: pS_ AA& ,GSA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage7aed under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 art "or imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.0 �y agaiolator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of the DIA r insurance c verage verification. I do herebyrtify u der the ai ndpenalties of perjury that the information pro *d above is true and correct. Signature: Date:✓C 7`- a Phone# 4S�- 7 19l 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#: �,.. ri VA IN 211 Complete Home ImprovementSpecialtic.1111 gar xaa 290 Kelly Road Toll fret(877)266-2074 Office(M)473-2774 Northbridge,Ma 01534 Fax{508)234-0371 ??� ROOFING PROPOSAL 08/15/07 Andy Fergus 80 Osgood St. N. Andover, MA (617) 448-4007 • THE ENTIRE ROOF OF YOUR BARN TO BE STRIPPED OF EXISTING SHINGLES 1— 2 LAYERS • CTBA WILL EVALUATE THE CONDITION OF THE ROOF DECKING, IF NECESSARY A 1/2" CDX PLAYWOOD MAY NEED TO BE APPLIED OVER THE EXISTING DECKING NAILED RAFTER TO RAFTER AND WITH A 6 MAIL PER FOOT NAILING SCHEDULE. • CTBA WILL ADD 3' OF ICE AND WATER BARRIER ON THE EVES AND VALLIES THE REST OF THE ROOF DECKING WILL BE COVERED WITH A #15 FELT. THE LOW PITCH PORCH WILL BE COVERED 100% WITH THE ICE AND WATER BARRIER • CTBA WILL PLACE A TIMBERLINE 30 YEAR ARCHITECTURAL SHINGLE ON YOUR HOME (COLOR CHARCOAL) • A *WHITE* 4" DRIP EDGE WILL BE INSTALLED ON THE PERIMETER OF YOUR ROOF. • WE SHOULD COMPLETE THIS JOB IN 2 DAYS, TO YOUR UTMOST SATISFACTION, BY WORKING DAILY UNTIL COMPLETION; TAKING INTO ACCOUNT WEATHER OR UNFORSEEN PROBLEMS. • DUMPSTER AND MATERIALS WILL BE SUPPLIED BY CTBA SIDING AND ROOFING AND REMOVED WITHIN 24 HOURS OF JOB COMPLETION • CTBA WILL CLEAN ALL WORK AREAS, MAGNETICALLY SWEEP YOUR DRIVEWAYS, WALKWAYS AND LAWN FOR NAILS • All CTBA EMPLOYEES WILL CONDUCT THEMSELVES IN A PROFESSIONAL MANNER AND RESPECT THE HOME OWNERS PROPERTY. EXTRAS • IF THERE IS ANY UNSEEN DAMAGE TO THE ROOF DECKING OR FASCIA THERE WILL BE AN ADDITIONAL CHARGE OF $60.00 PER SHEET FOR 1/2CDX PLYWOOD, AND $4.75 PER LINEAR FOOT FOR REPLACEMENT PRE—PRIMED PINE FASCIA OR LEDGE BOARD • AFTER INSPECTION, IF CHIMNEY FLASHING NEEDS TO BE REPLACED, THERE WILL BE A $350.00 CHARGE PER CHIMNEY TO HAVE A 12" LEAD INSTALLED ON YOUR CHIMNEY. • CTBA WILL COMMENCE WORK ON OR BEFORE **DATE HERE** AND WILL COMPLETE THIS JOB TO YOUR'UTMOST SATISFACTION • 10— YEAR WARRANTY ON WORKMANSHIP TOTAL ROOFING COST WITH PLYWOOD I/2 BARN $5,045.00 OR $101.00 PER MONTH* *After the 12-month No Inter o Payment Program Homeowner Signature / Date7 CTBA Siding Et Roofing LLC Date "noor nn F+me w;H% m;nimn/ Mcrosm4nn" " Page 10 f 1 McEvoy, Jeannine From: Fergus, Katherine Y. [KYFergus@duanemords.comj Sent: Tuesday,August 28,20071:47 PM To: gschruender@carisonre.com Cc: Fergus,Andrew;steve.etba@yahoo.com Subject: Re:80 Osgood Street, North Andover Roofing Project Mr. Schruender, Thank you for providing us with your opinion that per Chapter 125, Section 125-6 of the North Andover Town by-laws, our proposed roofing project for our barn located on our property at 80 Osgood Street, North Andover, Massachusetts is exempt from the requirement that the historic commission provide its approval. As we discussed, where, as here, the proposed work is simply repairs and replacement of the roof without any change in design or materials such that the roof will look the same (shingles, etc.), the project is exempt from review or control by the North Andover Historic Commission. The roof will be repaired per the proposal of our contractor, Steve Hamer of CTBA Siding and Roofing. Per this e-mail, I am also letting Mr. Hamer know that if he has any problems with the permitting in this regard, he should contact you directly. Again, thank you for your assistance in this matter. Kate Fergus FJ Katherine Young Fergus Attomey at Law Duane Moms LLP 470 Atlantic Avenue,Suite 500 BIO Boston,MA 02210 P:857.488.4253 0 E-MAIL F:857.488.4201 0 WEB SITE C:617.875.9448 0 WARD Confidentiality Notice:This electronic mail transmission is privileged and confidential and is Intended only for the review of the party to whom it is addressed. If you have received this transmission in error, please immediately return it to the sender. Unintended transmission shall not constitute waiver of the attomey-client or any other privilege. 9/4/2007 «r Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 151030 Expiration: 5/12/2008 Type: LLC CTBA SIDING & ROOFING ANDERSON CASTRO 290 KELLY RD. NORTHBREAD, MA 01534 Deputy Administrator License or registration valid for individual use only Before the expiration date. if found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Bosto , . 02108 ,. Not Valid without signature ACOMA CERTIFICATE OF LIABILITY INSURANCE ceras 06/07/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION -ONLY AND HERS NO RIGHTS UPON THE CERTIFICATE Thos J Woods Insurance Agcy HOLDER.THIS CITE DOES NOT AMEND,EXTEND OR P-0. sox 2940 ALTER THE COVERAGE AFFORDED BY THE POLICIES I#EL.OW Worcester SLA 01613 Phone; S09-755-5944 'Fox:508-791-9841 INSURERS AFFORDING COVERAGE NAIC# D SRA. Connecticut Underwriter's .�. CTBA Si+ding & Roofing N,LSZARERC. Andlerson +C�is �5UR£fT e: tro DHA 294 rl Road u�,SIARERD: No�rt>tsbr we NA 01534-1137 COVERAGES THE POUCIES OF MISURANCE USTED 8EWW HAVE BEEN HUED TO THE*ftREO NA#iED ADDVE FOR THE POLICY%RiDD MCA TED tNOTwgHSTANDwG AWY RFOUIREMENT,TERM OR CON WWN OF ANT COWRACT OR OTHER DOMAR ENT W fill RESPECT TO WHICH TMtS CERT MATE WAY BE LSSUEO CM2 MRY PERTAK,THE pL5 gWrH E AFWRDBD SY THE POLrMS DESCRIBER HF.FWM IS SUFUEGT TO ALL THE TEAMS,EXCLUSKM AA?IO CONWTIONS OF SUCH FOLUCAES.AGGREGATE LOWTS SHO"MAY HAVE BEEN REDUCED BY PAC CL AWS- LTR TYPE OF kIxURANCE i'fALX Y 11MB OMTE DATES y Gow"L LiAmf" : i (EACH OCCURRENCE *2000000 A ( E c0% w Rc'ftm v-qy NPPI036764 06/07/07 F 06/07/08 PR�s(EsCtWrenm) is S0000 _- # S CLAM MADE ]C OCCUR { &*DEXP{AftMep&W) 1x5004 i PERSORk a AM IN uqy $1000000 I rm A%m"rE $2044004 GEM AWREGATE LWT APP.ti'S PERI I PROM=$•GC MMOPAGG $1000004 2 POLICY LOC - -AU`T;QkW"A.tA UM o t } j � � �(� Wer xwAM S ! Eft "11 ALL C3WHE0 AUTOS B0t31LY tNALlRY I x �---�SCHEOMEO WOS � � tP8*oe,s�n) ' ( 141RED AUTOS i a0D)LY)MURY ODN-OWNEO AUTOS ' tPe,stOO"..) x k1PF40PERV iDAMA(, x GAM"UMUTY t AUTO OWY-EA ACCIDENT S iAWAUTO { sAACC S i ! AUTO ONLY- E lQtCESS4 ELAA tAA0&" I EACH OCCURRENCE --�5— OCCUR CGtgR5WOE AGGRFC,A%E �S } E ; `s REtENTXN� ; �— x voomm cOMPF.R m)m Am TORY LtAaaTS ER _ fitiPi tAYER7F LT+OLM AW WAR WEXECUTM 751E NOTE BELOW � E.L.EACH ACCM00 _ S OFPI RREEY LUDE01 i {E.L. EA1EWL Sq DISEASE CA i �,�Y',a�s,�AR7RIDt 471M11� f I SPEt:IAL=Delow £A-DISEASE-POLMY LUT S 1 OTHFJt OE TION OF OPERATIONS A LOCATIM A VEMCM A MCCLUSOM ADDED By EMDORSAWNT I SPECLIL PRDVMNS WORKER$ COMPEN"TION CUVERAG8 TNVORKATION WILL SB PROVIDED UNDER SEPARATE COVER BY TRX ASSIGNED RISK CARRIER. CERTIFICATE HOLDER CANCELLATION SHOULO ANT Of TME ASOYE DESS POLIOMES SE CANCELLED BEFORE T!t EXMAIM CTBA OFFICE USE a+►r��s+�c�.THE,GsscuNG w� E,�Avoiz,arwL i0 0AYSMMEN FOR PRESENTATION USE ONLY MOMETO'tHECER3"CAT ORDEtDAWDTOM*LEMBUtFAriUMTO0050SHAM to WW ALO LDSLAGATM OA LtA nJ"OF ANY MW LAN THE NSURtER,Trs AWNTSOR REPREMWAnM, AtiiHon=FtEPREWWATM welter X. Conlin, Jr. CPCU ACORD 25(2001108) O ACORD CORPORATM 1'988 MMIL ,CERTI:FICA i E OF INSUi' ANCE DATE{AA�10DtYY) DUCER ONLY LAND CONFERS NO RIGHTS PROUPON THE I CERTIFICATE TIIOMA.`i .i WOODS INS AG HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED 811 TILE POLICIES 8ELOW. 20 PARK AVE PO BOX 2940 COMPANIES AFFORDING COVERAGE WORCESTER M.A. 016-.3 COMPANY A INSURED COMPANY CASTRO, ANDERSON a BSA C T B A SIDING S GUTTERS COaIPAa'v 290 KELLY ROAD O NORTHBRIDGE PIA 01534-1:23? COMPANY D THIS IS T4 CERTIFY THAT THE POLtCiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T41E INSURED NAMED ABOVE FM THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REEQUUIREMeNT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wnm RESPECT TO Ww-m THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. E)OCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- Co TYPE OF MISI)RANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXINRATION UMITS LTR DATE(WOMYT) DATEIMMODWY) GENERAL UAMUTY 0ENERAt A00REGATE COMMERCIAL.GENERAL LIABILITY PROCUCTS•COMAIOP AGG i CLAWS MADE�,XOJR s�fRSf11Wl R Ai7Y N+tJRY i OWNER'S 8 CONTRACTORS PROT EACH OCCURIMWE i LIKE DAMAGE(Any one tee) S MED EXPENSE{Roy on®person) S AUTowe?LE uAwuTY COMBINED SiNGtE _ ANY AU70 LI;IIT ALLOWNEDAlTOS BODILY WAY SCHEDULED AUTOS (Pet Porsw) t MWED AUTOS BODILY;wulf?Y i NON.OWNED AUTOS ;Per A-.deli} PROPERTY DAMAGE S GARAGE LIABILITY Ab•TO OILY EA ACCIDENT S ANY A47,0 07HER T14AN AUTO ONLY EACH ACCIDENT S AGGREGATE i EXCESS UAMUTV EACH OCCURRENCEF f UMBRELLA FORM AvGMF.GATE _ OTHER THAN UMORCLLA-R)F ? VM%ER'SOOMPENSATtON AND STA,tiTOPY LITS WA­ A " A EMPLOVER'SUASMITV (UB 848x701-1-061) 03-02-07 03-02-08 EACI,AGC"Jii>vr s TrE PROPRETOm h,.. DISEASE-?OtsCv LAT i ion FARTNERB?EXECUI WE OFFICERS ARE EIL'.L NSc1kSE—EA.^.N r LOPE: S 1 OTHER D TI RA OCATI N EHICL F E 0 AtITEMS' THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE -CENTFICATE WMERCANCtL LATKO SHOULD ANY OF THE ABOVE DESCRIBED POUCIES Or CANCELLED BEFORE THE EXPIRATM DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL CTBA OFFICE USE 30 "AYS WARTEN NOTICE TO THE CFFllFICATEHOLDER NAMED TOTHE FOR PRESENTATION ONLY LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBUGATION OR LIAAPUTY OF ANY OND UPON THE COMPANY,TTS AGENTS OR REPRESENTATIVES. AU(T040FAZED REPRESENTATIVE ACORD 2'54 t A� 993