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Home My WebLink AboutMiscellaneous - 50 SANDRA LANE 4/30/2018 50 SANDRA LANE 210/098.A-0071-0000.0 ,r Date..../.... `.... a. ... �aOR7M 4,6 TOWN OF NORTH ANDOVER '+ PERMIT FOR WIRING SS�CMUS� R)i /Phis certifies that .,.>.........1�22?....�.�.-r-....�.�.�:........................................ _ .�� has permission to perform .,.R...... - .....:................... wiring in the building of:......I '",." ...................:.............:.............. at : -;t...�' ...................... .North Andover,Mass. iFee:...............:... Lic.No. 9-7Yy ....................................................... - f ELECTRICAL INSPECTOR fi Check # o' 8119 Commonwealth of Massachusetts officialO 1� Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 C 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: y � g City or Town of. NORTH ANDOVER To the inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)_ 50 Owner or Tenant ( SCD S Telephone No Owner's Address R367=I" _1 � Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 1 Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and A rapacity i Location and Nature of Proposed Electrical Work: ' Dpi6Q lie �- V v ` Completion of the followin ble may a waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceih-Susp addle -Fans No.- Total No.of Luminaire Outlets Transformers KVA No.of Hot Tubs Gene KV Generators A No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rad. rnd.• Batte Units No.of Receptacle Outlets No. of Oil Burn ers FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.o Detection and InitiatinTo Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers P Heat Pum Number Tons KW No.of Self-Contained . Totals: -_...__..__....__...__. .._. _._._. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection other No.of Dryers Heating Appliances KW Security Systems:* No.of Water ' o:of No.of No.of Devices or Equivalent HeatersData Wiring: Signs Ballasts. No.of Devices or E uivalent No.Hydromassage Bathtubs No. of Motors Total gp Telecommunications iring: No.of Devices or Equivalent 4 OTHER: t Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: .(When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such cove ge is in force,and has exhibited proof of same to the permit issuing office.. CHECK ONE: INSURANCE Z BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information o .this application is true and complete. ME FIRM NA : !x LIC.NO.: So' 4-q Licensee: Signature �:NO.: (If applicable, enter "` mat"in the license n�'mber'line.) ' Address: , O r _ Bus.Tel.No.: I 05 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below;I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$- L L I r w /av, t -Z2 The Commonwealth of Massachusetts k� ! Department of Industrial Accidents , s Office of Investigations 600 Washington Street la�� It Boston, MA 02111 www.nxass govIdia . Workers' Compensation Inmetrance Affidavit: Builders/Contractors/Eiectricians/Plumbers A Iicant Information Please Print Legibly .l Name(Business/Orgatiiration/individttal);_ AC' trG�.��it M Address: City/State/Zip: Phone ##: Are you an employer?Check the appropriate box: I.❑ I am a employer with 4, ❑ I am a general contractor and I Type of project(required): ' 6. ®New construction r/ P1oY (full an part-time).' have hired the sub-contractors 2. I am:asole proprietor.or partner- listed on the attached sheet.3 7. gRemodeiing - <, ship and have no employees These sui:i-contractors have S. ❑Demolition' working for me.in any capacity, workers' comp.insurance. g ❑Building addition [No workers'comp.insurance 5. ❑ 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 I I.❑ 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' comp. insurance required.] I3•[].Other ;Any applicant that checks bo)t#1 must also fill out the section below showing their workers'oompensation poi 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. ;Conttactors that check this box must attached an additional shestshowing.the mune tithe sub-contractors and tlrir work='comp.policy infrmation. I am an employer that.is proWing:workers'compensation insurance for nr employees: Below a the policy and job site information. Insurance Company Name: Policy#or Self--ins. Lie.#: Expiration Date: Job Site Address: City/Stats/Zip:�L. 0" tr MCC j 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 verification. I da hereby certify under the pains and penalties of perjury that the information provided above is true and correct a, Si orate: Date: q- 2� -C. Phone FBoardof only. Do not write in this area,to be completed by city or town official Town: Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4. Electrical inspector 5. Plumbing inspector son: Phone#: i 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 rl applicant who has not produced acceptable evidence.of compliance with the insurance'coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonweah`.h 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 k° Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if jnecessary, 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 r, 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, i 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.am required to obtain a workers' compensation policy,please call the Department at the numberlisted 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 permitAicense 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 bum 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 42111 Tel. 9 617-7274900 ext 406 or 1-8.77-MASSAFE Fax 4 617-727-7744 Revised 5-26-QS www.mass,gov/dia Date. . . ��.. . NORTH, ,<��,;..•"�o TOWN OF NORTH ANDOVER o ?� PERMIT FOR PLUMBING �,SSACNUSE� �� This certifies that . ... . . . . . . . has permission to perform,..,--' r plumbing in the buildings of . . . . . . �.�"c�-*�-'. . . . . . . . . . . . . . . . .'. at. . . . . . . . . . . ... . . . . . .. North Andover, Mass. Fee. 7�. . . . .Lica No.;--A�. . PLU BI,G INSPECTOR Check # 9 d/ 7712 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS +f -- i Date Building Location , LO-"-Q— Owners Name �i V-1 o f O 0 A.) Permit Amount -V/, 6V Type of Occupancy New �' Renovation Replacement "� Plans Submitted Yes No ❑ FIXTURES CC H rA 0 rA x C) U cc H y � Z - � O ern Ftp 3MFLOCIR 4]HRD 6MbIfM - 7M)EIaR s Flr�o R I (Print or type) Check one: Certificate Installing Company Name t.✓ - El Corp. i �'"Address t7x Partner. Business Telephone C1 ayirm/Co. e Name of Licensed Plumber: b L Insurance Coverage: Indicate the , e of insurance coverage by�he g the appropriate box: Liability insurance policy Other type of indemnity rl Bond Insurance Waiver. I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent F1g I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State;Oiumbing Code and Chapter 142 of the General Laws. By: e o ense mer Title Type of Plum mg License City/Town 1cense INUMDer Master Journeyman APPROVED(OFFICE USE ONLY Date..q.....f. ?. �10RT►, TOWN OF NORTH ANDOVER PERMIT FOR`(WIRING This certifies that ....01....f .....(?,', ................................... has permission to perform ..T!6.m.�. ... ..! e: ��'��' ..� ��C.�• wrong in the building of C--M.I!.to-. ..... . �.III4K......................................... z. at ""' �. !?�. ._ ..... !� ............ .North Andover,Mass. Llc. ELECTRICAL INE e. •� Check it 6,574 Commonwealth of Massachusetts -11lit NO, Department of Fire Services OCCLIpano:N and Fce Cliccked BOARD OF FIRE PREVENTION REGULATIONS [Rev, 9 051 1 lQa\e 1*ink) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All .%ork to he 1,.ertloniied in accordance with the \l:1SSQCl1L1SCttS [IIC06C,11(Akie(\11'.0. )52- AIR 1"00 i1'LL(SEPRLNT1A_1A:K0R 'PE ILIVINF0101.I TI ),V) Date: F1 Citv or Town of: To the 17NK*clor o/ fvil-cy.- Is Ivrice I 16-ill the electrical work descrihed Clow BY this ;Ipplication the undersign-MYN�,, t, '�.-�or her intention i tention to pet Location (Street& Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts Overhead❑ Undgrd No of Meters ' - I Number of Feeders and Ampacity AIdAlV\lAlt' Location and Nature of Proposed Eleqtrical Work:% I _W), AA k- No.of Recessed Luminaires 90-of Ceill.-Susp. Po�leilans No.of Tutal / Transformers KVA No.of Luminaire Outlets Vo.of Hot Tubs-*' KVA No.of Ltiminai Swimmin s�rboye Emergency Lighting ,%-Kool , El rnd. Baotle ry (,'nits . _[No.of Zones F*ALARMS No.of Rece le Opts No PP(C O)tf(e 00iI Burne No. of Sw/hes of Gas BUners ZLNo.of Detection and / Initiating Devices No.of ang No.ofAir Gond. i Z Mal Tons Tonsi No.of Ale, De ices I-leat iN qm b rons K No.oWelf-Con!uibed rL No. (&rste Disposers Y . is: De I.Ktion/Alerfirilk Devices No.of Dishwashers Space/Area He/ing KW local 0 Muni- pa Oth Conn ction No. of Dryers Fiea ing Ap/iances KW-� Security S t S:* No. of Water No.of 6�11vi es ox-C-quivalent KW No/of No.of Data Wiring: Heaters '-�- ns Ballasts No.of Devices or Equivalent No. Hydromassage Bathtub-s No,of M-.Motors Total tip I clecommunications Wiring: No.of Devices or Equivalent OTHER: F�Ainlated V�iluc 'tlCVjCaj AV01*k: (1-k lien rQquired h1v municipal pulic,,.) 1&orktoMai,t: I W� inspections to be requested in accordance�0h \IEC RUIC 10, and LIPO"C0111PICtiOn. INSLRANCE cMEVACE: (..nlcss �vakL�d by the oevnvr. no permit tbr the Perl'ormanct:of electrical work ma) 1'.AIC tilt: licensee provides proof Of li�lhility ill.'A11-;111CQ operation"coveraue ),, its �J&�Lllltidl �Altliv;1101t. III.- In lt)rcc. ;Illkl has C-Alihitc-LI proof ct!:J1"lC f(I HIC J�(:rlllit i-:.,uin- officc. 1-_': 1 6 1 X(,1--*, ❑ 11 1 1 k R -tt—,57 6 76 .6�, :0 vrrqj,, dl der he iw';A�•-fill/P11.17 ill(,, 1*,()11rjlll-1% Yfle�;tifim,ilafiwl"n. lis i Devi es "Itiull 'Jwe frod 0; �!P. RNI NAME: Wt V (0 "Ac. kiq� Address: 3us. TO. No.. Security Sy-,tcm Contractor k,io:vw;c I_CLlL11R;d for this,,,,urk. it applicablc,enter the license HLIMIXI-11%1V OWNER'S INSLAANCE AAIVER: I ;inl mv:lrc that Ili,., J(:--no/havc the liability instirtno-, I C(lUired by law. By ill) :::gnaturL below, I 11VNhy thil; 1-cquiro:111"'It. I ;ml the(chuck ono 0 nvnur 0 Otier_ Owner,'Acrent The Commonwealth of Massachusetts Department of Industrial.4ccidents Office of Investigations 600 Washington Street Boston, :VLt 02111 ,„i .,.;.� {VWW.maSS.�OvIllta Workers' Compensation Insurance ,affidavit: [Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ll3usincss.l)rganiratiun;lndividuall: Address: ------- — City.State;Zip: Phone #: :l re you an employer?Check the appropriate box: Type of project(required): I,❑ I can a employer with 4. ❑ 1 am a general contractor and 1 6 E] New construction employees(full andior part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ` ❑ Remodeling ship and have pr 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 10.E] Electrical repairs or additions required.] officers have exercised their right of exemption per MGL I I.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work g p myself.[No workers' comp. c. 152, }1(4),and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' 13.0 Other__ ___ - comp. insurance required.] — any applicant that checks box:+I mutit also till out the section below >ho\ving their workers cuay;ensalion I;r;licy iiiti r nation. L ing they arc doing all work and then hire outside contractors must xthmit a su new allidavil indicating ch. Homeowners who subnut this affidavit indicat Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and(heir workers'comp.policy information. I an;nn employer lhat is providing workers'c•onrpensation insurance fi r my employees. Below is the policy and job.site information. insurance Company Name:-- ------------_—..-- —.--------------- ----------- Policy 'i or Self-ins. Lic. #:_ __—__ _-_ _ Expiration Job Site Address: City;State/Zip:_______ _— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to jecure coverage as required!coder Section 25A of 11GL 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 tine Of up to 5250.00 a clay 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. I do hereby certify under the pains and penalties of petjar{,that the inforrnation provided above is true and correct. Date: -- OjJieial use only. Do not write in this arca,io i:e coenpletrrl try�i!{ ��i'tutvn official. City or Town: _ —11'i.rmit/License 4 -- Issuing Authority(circle one): 1. Board of 1-lealth 2. Building Department 3.City/Tomlin Clerk 4. Electrical inspector 5, plurrtl in» ln.;pcctor 6.Other Contact Person: Phone 9: ,4CORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD005 11/23/2005 PRODUCER FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DeAngelis Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 283 Merrimack Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Methuen, MA 01844 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED James & Patrica Gallagher INSURERA: National Grange Mutual Ins Co 42 Jim Gallagher Construction INSURER B: Atlantic Charter 352 Howe Street INSURER C: Methuen, MA 01844 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR CTI IER DOCUw.Cv'T 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSLTR VDDN' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY MPI45232 06/10/2005 06/10/2006 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500'000 CLAIMS MADE OCCUR 2SEMlqrq(Fa nm _MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000.000 POLICY JECT JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F]CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND CE TIFICATE TO BE ISSUED 05/17/2005 05/17/2006WC STATU- OTH- EMPLOYERS'LIABILITY DIRECTLY BY CARRIER. —1 TORY LIMITS_ B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? CERTIFICATE TO FOLLOW If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ertificate is issued in the interest of the named insured and Certificate holder listed below. ertificate is subject to company conditions and exclusions. ;ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of Salisbury 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn: Building Department BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Town Hall OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salisbury, MA AUTHORIZED REPRESENTATIVE Zza�p-/, 11/23/2005 11:43 FAX 617 488 6501 x y palm, ylRACORD T.1i , u I 11/23/2005 ..� t41 t� w:ic�.yci'#',Lo.�aidrJt❑y>. 'w.?c.tki�t4 u:....rxus w r_",. *..m"�'-iin •_r - .w 't qi&f .:i. �., L. PRODUCER ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFIC DeAngelis:Insurance Agency ATE HOLDER: THIS CERTIFICATE DOES NOT AMEND,EXTEND 283 Merrimack Street ALTER OR THE COVERAGE AFFORDED BY THE POLICIES BELOW. Methuen,MA 01844 INSURERS AFFORDING COVERAGE —COMPA A INSURED Atlantic Charter Insurance Company VDAC Tames Gallagher B 352 Howe Street COMPANY � Methuen,MA 01844COMPANY D A Y THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IND I' '� CATED.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..AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEp BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER O PLICY EFFECTIVE POLICY EXPIRATION LTR LIMITS DATE(MMrODIM DATE(MM/DD/YY) (In Thousands). GENERAL LIABILITY CCOILY;PefURY 'y COMPREHENSIVE FORM OCC PREMISES/OPERATIONS BODILY INJURY AGG $ UNDERGROUND PROPERTY DAMAGE OCC S PROPERTY DAMAGE AGG S EXPLOSION&COLLAPSE FIA2.ARD BI 8 PO COMBINED OCC $ PRODUCTS/COMPLETED OPER BI&PD COMBINED AGG $ CONTRACTUAL INDEPENDENT CONTRACTORS PERSONAL INJURY AGG S � - BROAD FORM PROPERTY DAMAGE PF_RSONALINJURY AUTOMOBILE LIABILITY BODILY INJURY ANY AUTO (Per person,) $ ALL OWNED AUTOS(Private Pass) BODILY INJURY ALL OWNED AUTOS (Per accident) $ (Other than Private Passenger) HIREDAUTOS NON-OWNED AUTOSPROPERTY DAMAGE $ GARAGE LIABILITY BODILY INJURY& PROPERTY DAMAGE COMBINED $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM OTHER THAN UMBRELLA FORM AGGREGATE $ $ WORKERS COMPENSATION AND X I STATUTORY LIMITS A EMPLOYERVLIABILITY WCV00131904 5/17/2005 5/17/2006 EACH ACCIDENT $ 100,000 DISEASE-POLICY LIMB Is 500.000 DISEASE-EACH EMPLOYEE S 100,000 OTHER .DESCRIPTION OF OPERATIONSILOCATIONSA/EHICLES/SPECIAL ITEMS - a SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWn Of Salisbury EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town Hall 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFF. Salisbury,MA 01952 BUT FAILURE TO DOS SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON T INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTAI&E CERTIFICATE HOLDER COPY