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Home My WebLink AboutBuilding Permit #219 - 89 BEVERLY STREET 9/19/2012 BUILDING PERMIT 0 NORTff q tSL6C 6 �� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION • b T Permit N0: \ / Date Received �gSsq�H�SE��h Date Issued: Y IMPORTANT:Applicant must complete all items on this page LOCATT IONl Pri t PROPERTY OWNER 5-c6-4s FJ gy �� S�TL Hint -MAP NO: d� PARCEL: 00 ' 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: Ti- Commercial Repair, replacement v Assessory Bldg Others: Demolition Other Septic Well Floodplain. Wetlands Watershed'District Water/Sewer DESCRIPTION OF WORK TO BE P EFORMED: G U/� /�t✓��D�/�� -- /��- Identification Please Type or Print Clearly) OWNER: Name: Se U- A-s7/�N al �,g�v� Phone: OP-- Address: P'Address: CONTRACTOR Name: Phone: �j'7��-- �--�Z37 Address: Supervisor's Construction License: L21 Exp. Date: P p /J/ � Home Improvement License: - � � Ex . .Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING P-E�MIT.$12.00 PER$10000.00 OF THE TOTAL ESTIMATED COST BA ED ON$125.00 PER S.F. fc Total Project Cost: $ J, f1 00 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acJers to the guaranty fund Signature of Agent/-Owner Signature of contractor W /. I Location U No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ "� Other Permit Fee $— TOTAL $ Check#1wn(,g 25725 k Building 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 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 84 O ood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located;at 124.Main Street ' Fire`Depaftment'signatureldate: 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 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 o 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 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 ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 2.2008 t%ORTH Town of _ t E : ., Andover o _ No. '-T I � z � , h ver, Mass COC "i "a WICu y1' ASR^TED 0"f' �y S V BOARD OF HEALTH PER Food/Kitchen 1--T T LD Septic System • i THIS CERTIFIES THAT ........ . ..... .. .�,. .. ... .......................... BUILDING INSPECTOR has permission to erect ... ... buildings on . 4 :`..C7... Foundation Rough JOS to be occupied as .. ... ..:. � ...................... Chimney ......... ...... ......... ........... f�0 ......................... provided that the person accepting is permit shall in respect conf to the terms of the application Final on file in 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 Gr NTHS ELECTRICAL INSPECTOR y UNLESS CONSTRUCT O T Rough Service ................ .. ...... ............................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE NORTH Town of : _EAndover p 0 No. I Z • • I h ver Mass � COCHICHR-1 S U BOARD OF HEALTH PER I--T T LD Food/Kitchen Septic System THIS CERTIFIES THAT ........ . ..... .. ► i'�':.1. .:.!....... ,. �.. .. .......................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .... �:'!... 2......... ••••.••••••• ..,. .. .....s .. .. .. ...... ....... Rough to be occupied as ......... :.: ........ .. .: ....... .............. ........ Chimney provided that the person accepting is permit shall in-every respect conf to the terms of the application Final on file in 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 � LATHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT 0 T Rough r-� Service ................ ._. ...... ............................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. IF SEE REVERSE SIDE Propoal tam # of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or } 55 Pleasant Street 1-866-AJWALSH .North Andover, MA 01845 Proposal SubmittedTo- � SPb s t�y� n� Job NameJob# Address �(�'t'►a , � Job Loca� Date q1J Date of Plans tFax Phone# �1,j� �i �cc� # / Architect We hereby submit specifications and estimates for. �L =•�-C,� c��i /Z 0*dIac�(_1 'ham �v Adv .�- � i Nv c r.CC'�✓tc, rr' Jinn/ ,f�tiuci AGS c.�✓ /Lri �� a a C �. ,�. _- � PVIQ V -- -- V - 40� eA v -- J We propose hereby to fur nish material and labor—complete in accordance with the above specifications for the sum of: Dollars V with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs wilt be Respectfully executed only upon written order, and will become an extra charge over andL " submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. NN Date of Acceptance Signature The Commonwealth ofMassachusetts Department oflndushiglAccidents Office of Investigations qu 600 Washington Street Boston,MA 02111 www.massgov/d'ia Workers' Compensation Insurance Affidavit:BuUd'ers/Contiactor6/Electricians/Plumbers .Applicant Information Please Print Le;sibXy Name(Business/Organization/Individual): GIl "�- Address: - City/State/Zip: )V b 19f/J--)0&4eiZ /MW Phone 0: 97F-`(a W -ro 137 Are yo employer?Check the appropriate box: Type of proj ect(required): l. I am a employer with 4. ❑ I am a general contractor and I 6. []New construction employees(full andlorpait time)* have hired the sub-contractors 2.F1 am a sole proprietor or partner- listed on the attached sheet x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. F1 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 l 1.❑Plumbing repairs or additions myself.[No workers'comp. c.1.52,§1(4),and wehave no 12, oofrepairs insurance required.]t employees.[No workers' comp,insurance required.] 13.❑Other "Any applicant That checks box#1 must also fill outthe section bel6w showingtheir workers'compensationpolicy information. T Homeowners who submitthis affidavit indicatingthey ere doing all work and then hire outside contractors must submit anew affidavitindicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is,providing workers'compensation insurance formy employees: Below is thepolicy and job site information. f� _ Insurance Company Name:. !`� Policy#or S elf-ins,Lic.#: B.no 0/2 Expiration Date: Job Site Address: �` q3 B cde 9 ity/State/Zip: lyd ,�,4j& e14 Ajet Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 STOI?WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert! der t epains and,penalties ofperjury that the informationprovidedabove is true andcorrect. - Si ature: (;� ` /��"� Date: Phone#: 9-7 73 7 LOther only. Do not write in this area,to be completed by city or town official. n:. Permit/License# hority(circle one): Health 2.$uiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.J?lumbinglnspector son: Phone#: Massachusetts - Department of PjolFc Sa'ety Board of Building Regulations and Standards (")mtructilln SuperN k,lr _icense. CS-022680 ARTHUR J WALSHJR . 159A WAVERLY�RD N ANDOVER MA 01845 ,c j 'at o rmmtiss a e 06/09/2014 'c`6rrwlfi�r Office of Consumer Affairs&Busifiess Regulation - #dOME IMPROVEMENT CONTRACTOR ( _ Registration: 103358 •.:Expiration: 7/7/2014 Private Corporatic• A.J.WALSH&SONS,INC. Arthur Walsh,Jr. 55 Pleasant St N Andover, MA 01845 4 �- —z Undersecretary MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satisfies-all basicr"ttiremepts of the state's Home Improvement Contractor Law(MGL chapter 142A),but doei not include standard language to proteethomeowners. Seek legal advice if necessary. Any petsonplamung home oprovements should first obfain a copy of ra Massachusetts.consumerguide to home-improvementr before spacing to any work on your residence.you may obtains free co py office of Consu tcr:Afrairs and Business Regulation's Consumer Information Hotline at-617-9734. 787 or 1#88W83-3751. by balling the ' Homeowner Informationontactor Information Name . J b i PmY sine'_ Street Address(do not use.a Post Office Boxaaddress) tractor/S espesOw>t ,Name q/Y3 ,r�t✓v ��, est l�/ Cityrrown State Zip Code lusiness Address(must include a street addresg) / S� Daytime Phone EveningPhone ity?own State Zip Code Mailing Address(It different from above) ausiness Phone ederal Emptoyer lDor S.S.Ntunbe r.wrettdtnwutagq NO care 1CusnearaealV®6tr Bsprarimdre pmvmm cam=exec. {� ^J ou y . The Contractor agrees to do the following work for the Home o tree. (liescrine in Specifying me type; RequireelTermits-The-following building permits are rcquited Proposed Start anti Completlon Schednte The fdllowiiig schedule will and will besecured.fiy the contractor as the'homeowner's agent; be adhered to uriless circumstances beyond die contractors control arise (Owners who:secure their own permits will be q exclnded<from the•Guaranty Fund'provisions of �/ �Dt when aoiitraetorwilI begin contracted work MGL chapter 142A.) ,Date when contracted .work will be substodafly completed Total Contract Price and Payment Schedule a c+ 1 The Contractor.agrees to perform the work,finniah'the material and tabor specified abovefor the total sum of. 1.q1.q11)00. . O + Payments will be made according to the following schedule: i uponsigning contract(not:tb exceed 1/3 of the total.eontract price.gt the cost;of special order items,whichever isgreater) $ by or/ or upon completion of a by_/_� or upon completion of /),�L G(✓ S ��aD'y upon completion of the contract (I nw forbids demanding full payment�!"• yment until.contract is completed to both parry's.satisfaction) Ile following matmiavequipment must be special S __JA4 paid for ordered before the contracted workbegins in order -$— to be paid for to meet the completion sehedula(••) NOTES:(•)Including all finance charges(••)Law requires that any deposit or down-payment required by the contractor before work begins m not exceed the greater of(a)one-third of the total contract price or(b)the actual con of any >ry which must be special ordered in advance to meet the completion schedule. Y special equipment er custom made mateial Express Warranty-Is an expres warranter hero¢nrovtded by xt.r• tM '011 of the wamnry rt ti std ed to the ontr,eri SubcoThe contractor agrees to be solely responsible for completion of the work described regardless of the actions oftny tliiid Parry subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under.law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest)ras been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into sighing the contract Take time to end'aad fully understand it.'Ask'questions ifsoaiething is unclear. • Make surd the contractor has a valid Home Imarovement ontrac?or Reaisnar;nn The h&;requires most bome improvement contractors and. Subcontractors to be registered with the Director ofHonie Improvement Contractor Registration. You may inquire about.contractor registration by writing to the Director at:One Ashburton Place,Room 1301,Boston,•MA 02108 orby calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurarice? Check to see that your'contractor is properly insured. • Know your rights and responsibilities. Read the Important Information on the ieveraeside of this form and get'a*copy of the Consumer Guide to the Home Idlprovement Contractor law. You may cancel this agreement if it has been signed at a place other than the contractm s'normal place of business,provided you notify the contractor in writing at his/her 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.Sec the.attached notice of cancellation form for an explanation ofthis right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPAC'ESM 'two idmtinlcopies ofthe cw11 ctmust beemVieredsnds*oed poepyyahoatdsomaehomawae.Tiwothc .. . WPY shmld be lupi by the wptrauta. . �� Ll HomeownXer's Signature Coatracbes—Sig-tum Date J�r ,i>err i y Contractor Arbitraon . The Home Improvement Contractor Law:provides homeowners with:tlte:righttoinitiatean arbitration action(as an altematrve to court ac6 if.they;have alspute with.abontractor. Tate same:rightis 6f automatically afforded to"a contractor,.how.ever.-:.The contractor-would have-tp resolve any dispute hdshe.has.with a homeowner in court unless both parties agree to,the optional clause provided below..This clause wouldgive'the.contractor the same.right to arbitration as is afforded to the•homeowner.by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a.private arbitration firm which has:.been.approved by the Secretary of the Executive Office of Consumet Affairs and Business Regulation andthe consumer shall be required to submit to such arbitration as provided In-Massachusetts General Laws,7ha 142A. Homeowner's Sipliture Contractor's Signature NOTICE:,The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.:.Tbe homeowner.may initiate alternative dispute resolution even where this section is not separately signWty the pgMese- Homeowner's Rights A homeowner's rights undtfth-e Home1nprovement Contractor Law(MGL chapter142A)and other consumer protection laws(i.e.MGL chapte`93A)may not be waived in any way,even by agreement: However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. -The-contractor is responsible-for completing the work as described,in a timely andmorkmanlikemanner. Homeowners.may be entitled to.other specific legal:right&if the contractor guarantees. or provides.an.express warranty for..workmanship of materials. In addition to.guarantees-or.* es provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability:and frtness.for:a particular purpose. An enumeration of other matters on whichthe homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in d—u-Rlica a and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by.the contractor. Anymodification.to the gnginal•contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired. Accelerated Payments A contractor mgy not demand payments in.advance.of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances wherea contractor deems him/herself to be financially insecure,the contractor may require that the.balance of funds not yet due be placed in a joint escrow account as a prerequisite to.continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or.need.additionai information about the Home Improvement-Contractor Law or other consumer Q*.pi,if.you wish to..obtaut a free.6py of"A Consumer Guide to the Home.Improvement Contractor Law,"•contact Cgnsirmer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)283.3757 If you want to verify the registration of a contractor or if you have questions or need,additional information sliecifid y about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 t (617)727-3200 ort-800-223-0933 For assistance with informal rtretiiauon oral's"putes or to register formal complaints against a-businetsit9li., ConsnmerCbmpisint`Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 CERTIFICATE OF LIABILITY INSURANCE DATE`2/12/2011 - 1"2/12/2011 THISCERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Durso & Jankowski Insurance NAME: PHONE IncAX Agency nc (A/C. No. Ext): (A/C. No): E-MAIL 198 Mass Ave Suite 101B ADDRESS: PRODUCER North Andover, MA 01845 CUSTOMER IDA. INSURED INSUREDS) AFFORDING COVERAGE MAIC 9 _ Arthur Walsh INSURER A: A.I.M. Mutual Insurance Co 33758 dba A J Walsh & Sons INSURER B: INSURER C; 55 Pleasant Street INSURER D: North Andover, MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. nor Lt` TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS (x/DD/YYrY) (x4/DD/YYYY1 GENERAL LIABILITY EACH OCCURANCE $ COMhSERCIAL GENERAL LIABILITY DAMAGE TO RENTED ❑CLAIMS)woe ❑OCCUR PREMISES(Ea.occurrence) $ F] MED EXP (Any one person) $ ❑ PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES ER: GENERAL AGGREGATE $ ❑POLICY []PROJECT ❑LOC PRODUCTS -COMP/OP AGC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (ea accident) $ n-L OWNED AUTOS BODILY INJURY (per person) $ ❑SCHEDULED AUTOS BODILY INJURY(per accident) $ ❑HIRED AUTOS PROPERTY DAMAGE (per accident) $ ❑NON-OA�NED AUTOS � $ $ 11UMBRELL4 LIAR ❑ OCCUR EACH OCCURRENCE $ ❑EY.CESS LIAB ❑ CLAIMS 11DE AGGREGATE $ FJDEOUCTIBLE ❑RETENTION $ _ $ WORKERS COMPENSATION xc AND EMPLOYEES LIABILITY ® xORYsrLaxu-IMITS oxx- ER THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS ARE E.L. EACH ACCIDENT $ 100,000 F1 incl ® eXCl 7014648012011 11/14/2011 11/14/2012 E.L. DISEASE -POLICY LIMIT $ 500,000 E.L. DISEASE-EA EMPLOYEE $ 100,000 COMMENTS /DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. I CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1600 OSGOOD STREET EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVEG? — —\