HomeMy WebLinkAboutMiscellaneous - 27 BACON AVENUE 4/30/2018 (2)p m
Location
No. Date
Check#
26589
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 41� A-- 13
IMPORTANT: Applicant must complete all items on this page
LOCATION)
I?R.QPERTY,'QWNEfR4
a- dStwoure� no,;
lnnt, 1.00 -ye r,, -1 yes,
MAPINO:;V0 PARCEL,: CY, ZbNING,0.I$TRIQT.-' Hittbric District, yes, n0l
IVIa.c.hinq,.8'hQpYillage yes, n o,
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
El New Building
0 One family
0 Addition
0 Two or more family
11 Industrial
El Alteration
No. of units:
0 Commercial
El Repair, replacement
El Assessory Bldg
El Others:
El Demolition
0 Other
0 !�eptic, D,Well-
'D FlOodplaim Ed Wetlaridi
S
-0 WatershediDistridt',
11 Water/Sewer,
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please viDe or Pirint Clearly)
i2��
� 661
OWNER: Name:. .4W (2 'A e ZZ, 5 VVY Phone: --'�7k
Address:
G 0 N T RA C TOR N a In o,:, 7r��,WC X97
P h o n e
Address:
St4pervisor,&'Gonstruction LiGensez'
-Oat
Home lmprove�menfticenge:� _10?;7357 Ekp,. Date:- 7/7 he�'
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDINGPERWT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
.4 0 Z)
Total Project Cost: $ FEE: $
Check No.:. S�4 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
til, "n_a_tUt6'ofA'dent/OWner4
g _.Igj�tre,'Lotconftattor,
7_57166E
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
Plans Submitted 0 Plans Waived 11 Certified Plot Plan Stamped Plans F1
TY �EOF S�FWER�AGE DJ�SpOSA�L
Public Sewer
TanningrMassage/Body Art F]
Swimming Pools
well
Tobacco Sales . 11
Food Packaging/Sales [I
Private (septic tank, etc.
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT El Fl -
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Con nection/sig nature & Date Driveway Permit
DPW Towi-, Engineer: Signature: .
Located good Street
'F.I RE 110t P- ARTMENT -.Temp Dumpster on site yes
rip
Lo.catedbt-124,Main-'strdet.
Fire- Ddpiiii*
, ure a e
MOM-919ha"
COMM ENITSi'
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[Me (Business/Organization/Individual):
ldress:_11'�
/State/Zip: , /A/d )�-,AILWM,
/'7 -V -_Phone#:
you an employer? Check the a ropriate box:
I am a employer with �77 4. F1 I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the . attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
I am a homeowner doing all work
myself [No workers' comp.
insurance required.] T
employees and have workers'
comp. insurance.1
5. [:] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
ernplo yees. [No workers'
comp. insurance reauired.1
Type of project (required):
6. E] New construction
7. El Remodeling
8. F] Demolition
9. E] Building addition
10. El Electrical repairs or additions
I I - El Plumbing repairs or additions
12-�oof repairs
13.0 Other
7-
)plicant that checks box #1 must also fill out the section below showing their-work-ers' compensation policy information.
owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ctors that check this box must attached an additional sheet showing the name of the sub-contractors'and staitewhether or not those entities have
-es. If the sub -contractors have employees, they must provide their workers' comP. Policy number.
w employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
iation.
nce Company Name
IQ
V
or Self -ins. Lie. 4: .7a Expiration Date:--- //kX
Address: 2-
0 /1 / S/ City/State/Zip: 11145VV1400-'I-� /%V --
i a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a
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
o $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
gations of the DIA for insurance coverage verification.
weby certify under tZ ains andpenalties of -perjury that the information provided above is true and correct.
10
#:-,* _Y_M__6Je ---c VV - - '.- � � � - . - - - - - I - - - - - - -
Wal use only. Do not write in this area, to he completed by city or town official
i or Town:
Permit/License #
iing Authority (circle one):
;oard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
0er
itnet Pprgan- phnne. #-
Department of Industrial A ccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb . ers
)121icant Information
A Please Print Legibly
[Me (Business/Organization/Individual):
ldress:_11'�
/State/Zip: , /A/d )�-,AILWM,
/'7 -V -_Phone#:
you an employer? Check the a ropriate box:
I am a employer with �77 4. F1 I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the . attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
I am a homeowner doing all work
myself [No workers' comp.
insurance required.] T
employees and have workers'
comp. insurance.1
5. [:] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
ernplo yees. [No workers'
comp. insurance reauired.1
Type of project (required):
6. E] New construction
7. El Remodeling
8. F] Demolition
9. E] Building addition
10. El Electrical repairs or additions
I I - El Plumbing repairs or additions
12-�oof repairs
13.0 Other
7-
)plicant that checks box #1 must also fill out the section below showing their-work-ers' compensation policy information.
owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ctors that check this box must attached an additional sheet showing the name of the sub-contractors'and staitewhether or not those entities have
-es. If the sub -contractors have employees, they must provide their workers' comP. Policy number.
w employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
iation.
nce Company Name
IQ
V
or Self -ins. Lie. 4: .7a Expiration Date:--- //kX
Address: 2-
0 /1 / S/ City/State/Zip: 11145VV1400-'I-� /%V --
i a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a
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
o $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
gations of the DIA for insurance coverage verification.
weby certify under tZ ains andpenalties of -perjury that the information provided above is true and correct.
10
#:-,* _Y_M__6Je ---c VV - - '.- � � � - . - - - - - I - - - - - - -
Wal use only. Do not write in this area, to he completed by city or town official
i or Town:
Permit/License #
iing Authority (circle one):
;oard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
0er
itnet Pprgan- phnne. #-
CS # 022680
HIC# 103358
I-Fli[I]i I
A. J. Walsh & Sons
55 Pleasant Street
.North Andover, MA 01845
# Of
978-688-6737
or
1-866-AJWALSH
Proposal Submitted Job Na:y
Job #
Address Job Location j
Date
I Date of Plans
Phone # Architect
Fax#
�(We �hereby st, bmit specifications and estimates for.
nor
'-- -- 777,1,," �— L", — - R-- .#—, ,
A" 2� J/- 16&�4 4,on- e"
We propose hereby to furnish material and labor complete in accordance with the 'above specifications for the sum'of:
$ Dollars
with payments to be made as follows:,
L/
Any alteration or deviation from above specifications Involving extra costs will be Respectfully
executed only'upon written order, and voll become an extra charge over and su
likes, accidents, or delays
above the estimate. Allagreements contingent upon elf bmitted
beyond our cdhtrol. Note — this proposal may be withdrawn by us 9 not accepted within days.
Screptmut of prop ofol
The above prices, specifications and conditions are satisfactory and are 4,-�Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
noRtlr GF-KT11'- IGA 11: Ur LIAWLI I T INOUMAN%ot: 1 01/11/2013
,.HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
'ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND ExTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
)ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTFUTE A COhTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
IEPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
MPORTANT: If the certificate holder Is an ADDITIONAL INSURED. the policypes) must be endorsed, If SUBROGATION IS WAIVED. subject to
he terms and conditions of the policy, certain policies may require an andoriement. A statement an this certificate does not confer rights to the
.ertificate holder In lieu of such andorsement(s).
62AIACT
IDUCER 00775 - 001
2.1#0. Ext,; ttq,-, (910)794-1k313,
Arso & Jankowski Insurance FM -
18 Mass Ave Suite 1018
)rth Andover, MA 01846
!�.I.11�_(AR)Mut4�1 Insurance Company 33758
URED IKWRR&PU— - -- —. - - -- ... -
thurwalsh
i Walsh & Sons
I Pleasant Street . ... ...
arth Andover. MA 01845
OVERAGIES CERTIFICATE NUMBER: REVISION NUMBER!
I -His IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V41TH RESPECT TO WHICH THIS
THE TERMS,
,ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES� LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAJD CLAIMS.
LIMITS
TYP`9 OF INSURANCE Ila W POLICYN�MBER
EACH OCCURRENCE
GENERAL LIABILITY
DAM-A-ffErTURENTED
-.41COMMERCIAL GENERAL LIABILITY PREMI ES.(EAZZM3=)-..
CLAIMS.MAOF r7 OCCUR MED EXP (Any " Perg0n)
ENL AGGREGATE LIMIT APPLIES PER;
RO.
�ho�LIL MIT
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUYOS AUTOS
HIRED AUTOS NON -OWNED
R AUTOS
FUMBRELLA LIAO OCCUR
U 8 1
EXC as LIAO CLAIMS MADE
DE RETENTION
D
P�p
y
WCUTNE NIA AWC7014648012012
(Mand;dory In NH)
P
I,
PERSONAL & ADV INJURY
S
GENERAL AGGREGATE
PRODUC73 - COMPIOP AC30
OJ�
BODILY INJURY (Per perscn)
B DILY INJURY (Per acc4dGnt)
PROPERTY tTA-FAAGE-
I
3
3
EACH OCCURRENCE
AGGREGATE
$
6
I Q -T W, AIS- 0J
1111412012 11114/2013 F.L. EACH ACCIDENT __ 100,000
LL DISEASE -EAEMPLQYFE 5 100,000
"i.L 0�iASE-POUCYLVNIrr 6 600,00
OF OPERATIONS I LOUTIONS I VMICLES (Att..h ACORD 101, AddlU.rjei R..ft $dwdul., d more apnf IS f6CIUIr9d)
Town of North Andover
1$00 Osgood Street
North Andover, MA 01846
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DEUVEREO IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Au,FHbPA?90 ASPRESIiNTATIVE
ACORD 26 (201010S) The ACORD name and logo are registered marks of ACORD
'd �L�L 'ON 3DNVdnSNI fliVIDOM NdZl:� E10Z 1I 'NVP
iM Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super,% isor
License: CS -022680
ARTHUR J WAI,�O JR
159A WAVERLY�RD
N ANDOVER NIA 018_
Ex piration
Commissioner 06/09/2014
Office OfWnsumerAffai �e"'�ullatft)n
rs
MME IMPROVEMENT
us
CONTRACTOR
egiStration:
.103358
xpiration:
Type:
— -7/7/2014
Private Corporati(,
A. J. LSH & SONS'lNC.--'
Arthur Walsh,Jr.
55 Pleasant St
N Andover, MA 01845
Undersecretary
iM Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super,% isor
License: CS -022680
ARTHUR J WAI,�O JR
159A WAVERLY�RD
N ANDOVER NIA 018_
Ex piration
Commissioner 06/09/2014
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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
U Notified for pickup - Date
Doc.Building Pennit Revised 2010
Building Department
The fol�owing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Li 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
Lj 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
Li Certified Surveyed Plot Plan
Li Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
Lj Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
Li 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
Lj 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
Li Mass check Energy Compliance Report
Lj 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 app;�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm'Ated with the building application
Doe: Doc.Building Permit Revised 2012
S
P z --
Location
No. Date A51 -
A
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL s
Check #
15923
0�� uildi g Inspec6r
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERNUT NUMBER:
DATE ISSUED:
SIGNATURE:
Building Commissioner/InELwor of Buildings Date
SECTION I- SITE INFORMATION 1 -1
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
o
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning Mai ict Proposed Use
Lot Area (sf) Frontage (fl)
1.6 BUILDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
ReqLdred Provide
Required ProvidW
Reqiir6d Provided
I.Mater SuppplyM.G.L.C.40. 54)
1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private 0
Zone Outside Flood Zone . 0
Municipal 0 OnSiteDirposal System D
SECTION 2 - PROPERTY OWNFRS111P/AUTHORIZED AGENT
2.1 Owner of Record
CL LAA 67,.k
Name (Print)
Address for Service:
Signature
T41ephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
�VTereptt6ne
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor -
License Number
IP/
ress
C== -4C
Expiration Date
Signature
I elephone
3.2 Registered Home Improvement Contractor
Not Applicable 0
d, I —P,2-fJ62(�
Company Name
on Number
Expiration Date
r, g—n —at u, e - "4
Telephone
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NO
I SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building Unnit.
Signed affidavit Attached Yes ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 11
Repair(s) C�11_r
terations(s) 0
�ion
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
z
-SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estim�aled st (Dollar) to be
Complet6d by permit applicant
0 FFICIAL
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 6u, Z� r) /4", as Owner/Authorized Agent of subject property
d)w-auduaize to act on
Her R, r, ",-/ �;� I
(lay bel ' 'n a I rn d bf tTil-s building permit application—
_ - "V.? — 0 57-0 Z-
7�5jature of 57"1'1'77 Date
-SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I-9 1 L — as Owner/Authorized Agent of subject
property If
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
2 e I
- .'
-N
Print
Owner/A�enf-_ ' Date
ailr ;,0—
n
_95a, 5151Z
.3, 111170
NO. OF STORIES SIZE
-BASEN4ENT OR SLAB
-SIZE OF FLOOR TUVIBERS 2 ND 3RD
-SPAN
_DDAENSIONS OF S111S
DIMENSIONS OF POSTS
-DIMENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
MATERIAL OF CHDdNEY
FIS BUPLDIN ' ON SOIJD OR FILLED LAND
I IS BUILDING CONNECTED TO NATURAL GAS LINE
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SEF -UJ -02 TUE 03!18 PM UILL NHY ��LHK�) VHA NU. 01QUIU4LJJC i . VI/ V1
OP ID L
ACORA CERTIFICATE OF LIABILITY INSU RANC�ILRATT
DAT� (MMMDN-f)
108/27/02
PRODUCER
SCS Agency, Inc.
P,O, Box 220493
11 Grace Avenue - Suite 300
THIS CERTIFICATE IS ISSUED WA MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES 140T AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED eY THE POLICIES BELOW.
NOTWI1 HSTANOING
Great Neck NY 11022-0493
PhonasS16-466-6007 Fax:516-829-5957
INSURERS AFFORDING COVERAGE
INSURER A: Hermitage Insurance Company
!��LR 8: State Insurance Fund
INSURt-4)
Bil-Ray Aluminum Siding Corp.
0
A Sea�s nc.
,)�,,�ue,ens I
Home Central
40 t1inont Road
Elmont NY 11003
INSURER C: Scottsdale inaurance Company
INSURGIR D; Zurich -American Insurance Co.
IINSURERE; -.6-i-a-'r-eIndon National Ins CO
GUVLKAUL,i
—THE ISSUED TO THE INSURED NAMED ABOVE FORT111P POLICY PERIOD INDICATED.
NOTWI1 HSTANOING
F POLICIES OF INSURANCE LISTED D6LOW I IAVI7 BEEN
RACT OR OTHER DOCUMENT WITI I RESPECT TO WHICH THIS CERtIFICATE MAY BE ISSUPO OR
ANY REQUIREMENT. TERM OR CON017ION Of ANY CONI
MAY PCRTAIN. Tf ir IN,U RANCE krFORDI;U BY THE POLICIES 0CSC;ZIQ go 14RCIN IS SUBJECT I CALL THE TERMS, EXCLUSION 6 AND CONOMONS
OF SUCH
MUCIF.S. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
PZ9cVrFMTW-PZ)QdYtXPfRATI0N
LYR TYPE O*F INSURANCE POUCY NUMBER DATE jMM/DD1YY) DATF IMMID01YY)
LIMITS
EACH OCCURRENCE
5 1,000,000
GENERAL LIABIUTY
_x EGL431843 08/25/02 08/25/03
-
FIRE DAMAGE (Any one rha)
S 100,000
A
-
5 5,000
�COMMCRCLAI.GrNCRALLIADILITY
GLAIMS MADE Ir X71 OCCUR
MED GXP (Any Otte plasart)
---
rIRSONAL & ADV INJURY
S 1,000,000
GENERAL ACGREGATE
$2,000,000
PRODUCTS - COMPIOP AGG
1,000,000
GEN1 AGGREGATE LIMIT APPLIES PER:
POLICY F LOC
—] i I -
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Eo acciacni)
ANY ALI 0
ALL OWI,1�1) Al)TO!;
BODILY INJURY
(rer person)
SCHEDULrDAU10S
HIRFnAUTOS
BODILY INJURY
(Pcracadcnk)
NON-OWNEDAU'10S
PROPERTY DAMAGE
(Peracmdeno
AUTO ONLY - EA ACCIDENT
S
GARAGE LIABILITY
OTHER THAN �AC
ANY AUTO
I
s
AUTO ONLY: AGG
EACH OCCURRCNCr_
000,000
$2,000,000
A
GXCFSS LIABILITY CLAIMS MADE
OCCUR
XLS0009269
08/25/02
08/25/03
AGGREGATE
000,000
$2,000,000
DCDUCTIBLC
RETFNTION
WORKERS COMPENSATION AND
LxiT2,Ly, 0—Im"! i,
EMPLOYERS' LIABILITY
132329132 - NY
06119102
06/19/03
E.L. rACH ACCIPF,:NT
$500,000
,
I.L. DISEASE - CA E.MPLoyr-r
s500,000
B
E
OrHER
05/14/02
05/14/03
C.L. DISEASE - POLICY LIMIT
$500,000
BCTCCO12160101 -
01 * R
EHE
D Di2abi:ltiy Benefit
1) iS
1794038-001
10/01/01
1 0 1 0
Statutory
[SCRIPTION OF C)r'Er,;,TIO.NSILOCAT;ONSNEHICLEI-.'CXCLUI.:O','S A00GO sy F.\,DOP.SGMPNT1SPrr1AI_ PROVISIONS
D r "r,
BLAM- I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOt
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRITTEN
NOTICE TO T14S CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILrTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
111111EIT�TIVES.
PRESgNTATIVE
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