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HomeMy WebLinkAboutBuilding Permit # 3/11/2015 NORTH BUILDING 1 IT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ROo o p` Permit iVo#: � """'" Date Received � RATED PP R5 s 'SACHl1s Date Issued: IMPORTANT:Applicant must complete all items on this page r 1011,�r 1/Jf �/ l.�rr//�l/o//�r�/�,!r r�///,/.rif/�l„/r�i/�t//////,/,l,�/llrr�//r/Z/./.r�r//�/i//O✓/��/�/�/�//r/N/�/r//�r�/r,/�r///,I/,/,/,/,Nf.r,r/,,,rr.���i�G,,//rii/,///a,-,�,/Dr.P,,/r/r�/�,r,/r,�,r/�S,/�n/n/�i,,�„.r/,/l>trir,rr/�/r rrr/r,ce f>rlf//,r//�,,�r.///,:,%I�r ,�/r/„�/I �//r�/�.Ot.i/0111r, �/ TYPE ,,/1,,/.///e1 If,✓,=;/.r,O/r,//rI.ia�,i/C/,n�rir r,r/„ei,,//1e//,//r„,S,Di/r/r,//,/t.l.S,lr/,/rrmsG.Lutr,�,,,h rt.c,//ror/r � , /.` . r /,. i/ , ,., ,,. OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building V,6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r rr,r ✓ r,,�% /ii%//ra.,l✓r, rii/,„ , /i, :/�/ ✓i // .r” r, „ilii,, r, :;n0/ ,a,,%r.. //r, i..✓,/ , ,- /,r , , ,fi/ i,,,/a ., r,, l ✓ r f ,i i>r✓�/ /' /' // ,r, ❑,Se fc/,C�,Wellr, //,� ' � �//, // ❑,Flood lawn// , ❑Wetlands.,,,, /�/,, � , ,❑ Watershed D.istnct r / ! r y 1 r r / r /�/,.,i,,, ate%,u�WG'C/i./r,r///iJ,i/�i%/�/r,,. , ,r,�,li�/iGi//rr�c,,./..,,,,✓�,,, //�.,//rrr!/,,,//Ii/�/�. .�/,,,/�,.��%��//„/,//,,,,/„///„ // r- DESCRIPTaON WQEZK TQ BE PERFORM D: 45 I entif cation- Please Ty e or Print Clearly ,77, OWNER: Name: D!' v�� �-� C ® - Phone:c?-1 P Address: IR rr r r r,/ /// / / r, / i,. iii r, � ✓ r / r r r ,/ /, rrrr„ r�.. r, r /.. /r,i.,.r/,.. ,,,,/ /. v., r / ✓/ ,/ / o � / r/ / r/ /r ,/r, /A. ,���„ S../G//1/,���+�, //�rt��, ,,.�Fi",1 ,,.,; i /rr,////,c ,iUML�////,��/i ,r.�.,. !V!'�.,r,.. a, r ,��G r/c,a/ r,,,i/���%l✓ . i,�,�//��///�//�%/i//,.,,,r,/Ur. r. l / / r I f/ f I r/ / ����� ✓r, /i � r ,, .,/////i r//r/✓„ iii/,// �,i /,,�� ✓ /< ./ ,// ,, I/ , /rr/,r /,,. ,, Hom Lm n I n 1,/,r> //� ,.„r�,riiiii�� ��//,�i��/�/��%✓iii/,i/� � / �/ ��i/r�,,�ri��/� / /�i,,,, ARCHITECT/ENGINEER 4� de OgCXe.n Phone:__q Address �Yt�yiA _ oc!3 on R. f t 37 Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost; $ FEE: $ „ Check No.: Receipt No.: . NOTE: Persons contractink with unregistered contr s d npt have access to the guaranty fund 9 Signature of Agent/Owner i tore of contractor F77 Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSA Public Sewer Tanning/Massage/Body Art ❑ Swmm�ing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc, ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ' 4�1 Reviewed On � Signature_ COMMENTS CONSERVATION Reviewed on Si nature c COMMENTS (� �- t �'C'J ✓� ter -' �� Cx. �') 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/Si nature& Da i Drive)AtaV Permit Town Engineer: Signature: f> p lir � 1 Lo ted84 ca 3sgood Street " ,r e..,.�1-, ��:;�,�7,r �r fr � � ,y _:..� .ra ,�,& c nObY�* .?� r" .'�r� xr lr �z/t.✓sr � j '`, t .,ryf�;.. a -a e� ;- ,,, � .,('_:, ,r'.. I �c; .�'�r t+slit",r�^/ �``"r'r:�'''�c'�� �'.,�f��, 71r'rt• x'�,l fi � r.. x ,r` ,c':: ,�.,r..p rw �:�:�"1�� 1 ,r� 2 �2 ai ,_, „ r.,;� � fir' ✓„ si ;.7�/yc� 1,: ��� '. ��alb�,,�tl � s�'-'f r� J3� Jfr F, r.�'� �r�ay�" y '.��r r{�✓��rr� -;,,,. T��r 'sr r' � ' 'rr" ,v5 -,,-t„', ,.,,y r .r a -; ✓ ,....' " i �',�,.,, .;,� �. '�� "�,'�' ,, �`.� rz��r'�r-f�..�� �.Jt�",;�1 aY ,,F�` 1 � „��'•,P'. Via.-,�s��.r�'�5�� �-.r,,�,: NORTH own OfE. ... p nctover 0 15 , ax y h ver Mass, COCKICKEWICN V BOARD OF HEALTH Pr. R �M� IT T Lu Food/Kitchen Septic System addL THIS CERTIFIES THAT ..,N. .Q.& .... J � �C...... :...... .......... .................... BUILDING INSPECTOR has permission to erect ...... buildin s on M01. .. .—=T1!W AV.& Foundation i� Rough to be occupied as .. , � .. ..�! ..... Chimney provided that the person accepting this permit shall i every respect conform to the terms of the application Final on file in this office, and to the provisions of the Co s 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 lab k PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T Rough Service ............... ... .... ...... ........................ Final am BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay 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. Certificate Registry ID Home Energy Rating Rating Number EH0561 NAND L-16 Mollytowne Certified Energy Rater Ian Rex L-16 Mollytowne Rd Rating Date 01/17/2015 x North Andover, MA 01845 Rating Ordered For North Andover RE Corp. rv_ 'Estimated Annual Energy Cost Use MMBtu Cost Percent 5 Stars Plus Heating 106.7 $2117 46% Projected Rating HERS Index: 56 Cooling 4.0 $211 5% Hot Water 19.7 $368 8% Projected Rating: Based on fan .. Field Conflirmation Required. Lights/Appliances 34.0 $1679 37% General Information Photovoltaics 0.0 $ 0 0% Conditioned Area 4819 sq. ft. House Type Single-family detached Service Charges $1 4% Conditioned Volume 43344 cubic ft. Foundation Unconditioned basement Total 164.4 $45655 100% Bedrooms 4 Criteria Mechanical Systems Features+ This home meets or exceeds the minimum criteria for the following: 2009 International Energy Conservation Code Heating: Fuel-fired air distribution, Natural gas, 92.0 AFUE. Cooling: Air conditioner, Electric, 13.0 SEER. Water Heating: Conventional, Natural gas, 0.67 EF,40.0 Gal. Duct Leakage to Outside 120.00 CFM25. Ventilation System Exhaust Only: 86 cfm, 8.6 watts. Programmable Thermostat Heat=Yes; Cool=Yes Building Shell Features Ceiling Flat R-37.4 Slab None Sealed Attic NA Exposed Floor R-30.0 Vaulted Ceiling NA Window Type U-Value: 0.300, SHGC: 0.300 Ian Rex Above Grade Walls R-21.0 Infiltration Rate Htg: 3.00 Clg: 3.00 ACH50 The Energy Hound Foundation Walls R-0.0 Method Blower door test 11 Broadway, Suite 3 MA Lights and Appliance Features Beverly,233 14 1433 01915 978 Percent Interior Lighting 94.00 Range/Oven Fuel Natural gas www.TheEnergyHound.com Percent Exterior Lighting 8.00 Clothes Dryer Fuel Electric Refrigerator(kWh/yr) 500.00 Clothes Dryer EF 3.01 Dishwasher Energy Factor 0.00 Ceiling Fan (cfm/Watt) 0.00 Certified Energy Rater: REM/Pate- Residential Energy Analysis and Rating Software v14.5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. The Home Energy Rating Standard Disclosure for this home is available from the rating provider. Energy Code Inspection Checklist Property Organization HERS North Andover RE Corp. The Energy Hound Projected Rating L-16 Mollytowne Rd 978-233-1433 01/17/2015 ' North Andover,MA 01845 Ian Rex Rating No:EH0561 RaterID:1454792 Weather:North Andover, MA Builder Registry ID: NAND L-16 Mollytowne Carroll Construction Lot 12 Mollytowne-.big Windows and Skylights [ ] 5. Window: U:0.30, SHGC:0.30 1 (22 s.f., East), U-Value: 0.300, SHGC: 0.300 For windows without labeled U-factors, describe features: Name: Back-Fdw Orientation: East Comments/Location [ ] 6. Window: U:0.34, SHGC:0.30** (40 s.f., East), U-Value: 0.340, SHGC: 0.300 For windows without labeled U-factors, describe features: Name: Back-Fdw Slider Orientation: East Comments/Location [ ] 7. Window: U:0.30, SHGC:0.30 1 (11 s.f., South), U-Value: 0.300, SHGC: 0.300 For windows without labeled U-factors, describe features: Name: Right Orientation: South Comments/Location Doors [ ] 1. Door: R7 steel insul (20 s.f.), R-Value 7.0 Comments/Location [ ] 2. Door: R6.7 fiberglas insul(20 s.f.), R-Value 6.7 Comments/Location [ ] 3. Door: Steel-urethane foam(20 s.f.), R-Value 1.7 Comments/Location Frame Floors Floor: R30,FG2,X-16 (1502 s.f.), Between conditioned space and unconditioned basement R-0.0 continuous insulation, R-30.0 cavity insulation. Name: Floor> UncBsmt Insulation Grade: 1 II III Face / inset Comments/Location REM/hate- Residential Energy analysis and Rating Software v14,5,1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 3 of 6 Energy Code Inspection Checklist Property Organization HERS North Andover RE Corp. The Energy Hound Projected Rating L-16 Mollytowne Rd 978-233-1433 01/17/2015 North Andover,MA 01845 Ian Rex Rating No:EH0561 RaterID:1454792 Weather:North Andover,MA Builder Registry ID: NAND L-16 Mollytowne Carroll Construction Lot 12 Mollytowne-.big Frame Floors [ ] 2. Floor: R30,FG2,X-16(924 s.f.), Between conditioned space and garage R-0.0 continuous insulation, R-30.0 cavity insulation. Name: Floor> Garage Insulation Grade: 1 II III Face / inset Comments/Location Slab Floors N/A Foundation Walls [ ] 1. Wall: Uninsulated 10"(360 s.f.), Between unconditioned basement and ambient/ground R-0.0 interior continuous insulation, R-0.0 interior cavity insulation, R-0.0 exterior insulation. Name: UncBsmt>Exterior Insulation Grade: 1 II III Face / inset Comments/Location [ ] 2. Wall: Uninsulated 10"(736 s.f.), Between unconditioned basement and ambient/ground R-0.0 interior continuous insulation, R-0.0 interior cavity insulation, R-0.0 exterior insulation. Name: UncBsmt>Gnd Insulation Grade: 1 11 III Face / inset Comments/Location [ ] 3. Wall: Uninsulated 10" (272 s.f.), Between unconditioned basement and garage/ground R-0.0 interior continuous insulation, R-0.0 interior cavity insulation, R-0.0 exterior insulation. Name: UncBsmt>Garage Insulation Grade: 1 II III Face / Inset Comments/Location Rim and Band Joists [ ] 1. Joist: Band-Blockers(168 s.f.), Between conditioned space and ambient R-0.0 continuous insulation, R-21.0 cavity insulation. Name: Band-Blockers Insulation Grade: 1 II III Face / inset Comments/Location REM/Rate Residential Energy Analysis and Rating Software v14 5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 4 of 6 w Energy Code Inspection Checklist The Property Organization HERS w North Andover RE Corp. The Energy Hound Projected RatingEfi L-16 Mollytowne Rd 978-233-1433 01/17/2015 �ri< North Andover,MA 01845 Ian Rex Rating No:EH0561 RaterID:1454792 Weather:North Andover, MA Builder Registry ID: NAND L-16 Mollytowne Carroll Construction Lot 12 Mollytowne-.blg Rim and Band Joists [ ] 2. Joist: Band-Runners(68 s.f.), Between conditioned space and ambient R-21.0 continuous insulation, R-0.0 cavity insulation. Name: Band-Runners Insulation Grade: 1 II III Face / inset Comments/Location Mechanical Equipment [ ] 1. Heating: Fuel-fired air distribution, Natural gas, 92.0 AFUE. Make and Model Number [ ] 2. Cooling:Air conditioner, Electric, 13.0 SEER. Make and Model Number [ ] 3. Water Heating: Conventional, Natural gas, 0.67 EF,40.0 Gal. Make and Model Number Mechanical Ventilation System [ ] Mechanical ventilation system rated for, and capable of, providing continuous ventilation. System shall include automatic timing controls. System type: Exhaust Only, 86 cfm, 24.0 hrs/day, 8.6 watts. System description(make) Air Leakage Control [ ] Blower Door Test at Final [ ] House is air-sealed so as to achieve 3.00 ACH50 or less at final blower door test. (Max CFM50 is: 2167) [ ] Visual inspection at rough for mandatory code air barrier and insulation features. Infiltration Requirements for IECC 2009 IECC Infiltration limit for the design home is 7 ACH50. 2012 IECC Infiltration limit for the design home is 3 ACH50. Duct Leakage and Insulation [ ] Duct System 1 Leakage to Outside and Total Duct Leakage [ ] Duct System 1 Leakage to Outside is specified in REM/Rate at 120.000 CFM @ 25 Pascals REM/bate- residential Energy Analysis and Rating Software v14.5.1 This information does not constitute any warranty of energy cost or savings. 0 1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 5 of 6 Energy Code Inspection Checkl'st Property Organization HERS North Andover RE Corp. The Energy Hound Projected Rating ; L-16 Mollytowne Rd 978-233-1433 01/17/2015 WT North Andover,MA 01845 Ian Rex Rating No:EH0561 U Rater I D:1454792 �1 Weather:North Andover,MA Builder Registry ID: NAND L-16 Mollytowne Carroll Construction Lot 12 Mollytowne-.blg Duct Leakage and Insulation [ ] Duct System 1 Total Duct Leakage is specified in REM/Rate at 200.000 CFM @ 25 Pascals Duct Leakage Code Requirements for IECC 2009 IECC Postconstruction Leakage Test: Duct Leakage to Outdoors<=8 CFM25 / 100 sq ft CFA. 2009 IECC Rough in Test with AHU: Total Duct Leakage<=6 CFM25 / 100 sq ft CFA. 2009 IECC Rough in Test without AHU: Total Duct Leakage<=4 CFM25 / 100 sq ft CFA. 2012 IECC Postconstruction Leakage Test:Total Duct Leakage<=4 CFM25 / 100 sq ft CFA. 2012 IECC Rough in Test with AHU:Total Duct Leakage<=4 CFM25 / 100 sq ft CFA. 2012 IECC Rough in Test without AHU: Total Duct Leakage<=3 CFM25 / 100 sq ft CFA. Notes REM/Rate- Residential Energy Analysis and Rating Software 04.5.1 This information does not constitute any warranty of energy cost or savings. ©1985-2014 Architectural Energy Corporation, Boulder, Colorado. Page 6 of 6 0nstr11torr S aper:iso;; CS-063503 JAMES V CARROLL 21 JOHNSON CIRCLE j North Andover M- 01545 JJ , 07/19/2015 I I Office of Consumer.Affairs&Business Regulation �-----=HOME IMPROVEMENT CONTRACTOR tegistration: 171245 Type: ration: 3/1/2016 Individual CARROLL V.JAMES CARROLL JAMES 21 JOHNSON CIRCLE NO.ANDOVER, MA 01845 Undersecretary I The commonw?aNz of.Massachusefts -• 7�epa�t�nen�o,f X�c�ust�inr.A.ccz�'enfs Q face of.Investigations 600 Washington Street Boston,NA 021.11 vww.mass gov/ciia Workex$l Compensatxonymsiffance Affidadt:BuRderslConlxactoxs/Elecixicl um� ZpleasPrint b Xzeant�n£oxmation Name(Business/Organizationll'ndvidual.): Address: k v1 I cityf8teemp: P0r A,r'e ax an employer?Clreekthe appropriate box: Type of project(required): F 4. ❑ I am a general,contractor and I 6. j'ew construction m. 1. aa employer with_ — have Nixed the sub-contractors employees(fall and/or part fig). listed on the atEached sheet. '7. []Remodeling 2.[( I am.a solo proprietor or partner "' These sub-contractors have S. [[Demolition Ship an.d'have no employees -workers'comp.insurance. 9. U Building addition working forme iu any capacity. �I'o workers' comp.insurance 5. [�We are a corpoxatiox<audits 10.[(Electxicalxepairs or additions required.]workers' officers have exexeisedtheir right of exemption par MGL 11.[j Pluml7ing repairs or additions 3.❑ I am.a homeowner doing all work c.152,§1(�),andwe have na 12.[]Roofrepairs myself o r workers comp. employees.Lao workers' m El Other insurance required.]i comp.insurance required. .Any applicant that checks box#i mustalso fill outthe section below showingthdr workers'compemationpolicy information. .Homeowners who submit this affidavit lndicatiugthey Rr doing aliworMand then hire outside contractors must submit a new afffdavit indicating such. Ii-romeown thatho submit Boy must attacfied m additional sheet shoving the name of the sub-contractors andtheir workers'comp.policy information. orX�ers'camperasation insurancefor my employees; Below is tltepolicy and,�o/i,site X am cin employer,that isprovicling w information. C l�Z b� f Insurance Company Name:. W G� 3 �0 ( Dxpixation Data: Policy#or Self ins.Liv.#1: ' Iola Site Address: T L (� `(yb lt5y-f Qcvlle �C� City/StatOMP. 0 aj-o Qez bl t �J Attach a copy of the workers'compensation-policy declaration page(showing the policy number and e)ipiratlon date). 5A of of crhninal penalties of a kaGL 0.152 can lead to ilure to secure coverage as requiredundar Se ent as wellasSc civil penalties in the forme oa STOP WORK ORDER,and a hue aim up to$1,500.00 and/or one-year amp , of-up to$250.00 a day against the violator: Be advised that a copy of this statement may be forwardedto the Office of Investigations of the DIA for insuxatace coverage vexifroation. ^ X da liere7a cert ztrlde tlieprrins andpenalties ofperjury that Me in ormadon provider:above tate and correct Date' 3Al Si afore: ' Phone �r Official use only. Do not write in this area,to Ire completed�y city or tower official. City or Town: Permit/License# Xssuing.A uthoxity(circle one): xtnaent 3.CitylTow�.Clerk d.Electrical Inspector 5.Plumbing Tnspecto X.Board of HeaIth -2-Building Depax° 6.Other - Phone M. PAGE 01101 OG/09/2014 09:36 9786833147 DATE(MMIDDfrYYY) p / �y +/� �° INSURANCE 6/9/2014 A ✓ i�� CERTIFICATE O LIABILI A RIGHTSS NO CERTIFICATE ATE W4LOER. THIS THIS CERTIFICATE I$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERTHE CERTIFICATE DOES NOT AFFIRMATIVELYONOES NOT CONSTITUTE AEXTEGONND TRACTTBErNEEN HER SSUINGFIN9 RER(% AUTHORI EtI BELOW, THIS CERTIFICATE OF INSURANCEAND THE CERTIFICATE HOLDER. REPRESENTATIVE OR PRODUCER, subj re ulre an ondon3ement A statement on trill tertlflcete daee not confer rights to tris IMPORTANT: If tris C9Rlflceta!Holder Is$n ApCITIONAL INSURED,tris pollrryWes)must be pntlersed- If SUBROGATION I$WAIVED,ghts t a the terms and condlllons of the polley,certain polldle&may q Carlotta}folder In IISjA of such endorsoment(e, NAME- PRODUCER AME PRODUCER P E , (978)683-8073 A1C No:� M P ROBERTS INS AGCY INC A1c sandi@ robartsinsuranoe•Com 1060 Osgood Street ADDRESS: NaiCtl NMSUREA AFFORDING tOVERAaEY North Andover, MA 01845 INS CO tN$uRER A;AS S00ITED �,11IpL4YERS V INSURED NORTH ANDOVER REALTY CORP. INSURER B ; 66 SPIiIRG HILL RINSURER G ROAD INSURER r 14ORTH ANDOVER, MA 0184.5 INSURER E INSURER F: }Z�vISION NUMBER: COVE ES C>=�tTiFICATE NUMBER: THIS THIS IS TO CERTIFY-THAT THE .:14y IRECIUIREMEI�NSUN�T RM OR CONI]ITION OF ANY CONTRACT i 4S OTHER DESCRIBED CUMENT N ISPOLICY PERIOD BSUBJECT TOE FOR EALD BELO�'UII�VjE BEEN ISSUEw WITH RESPECT TO LVTHEHTERMS, INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE: ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T LIMITS EXCLI,ISIONS AND C01401TIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE SEEN REDUCED By PAID CL41MS' POLICY NUMBER MM/DDmv1' M IDDfYYYY MR TYPE OF NSURANGE mad EACH OCCURRENCE S LTR cOMM91tclA4 oENIERAL LIABILITY PREMISES Ee ou 'm3nto S _— CLAIMS-MAnE 0 OCCUR MPD EXP Airy One Parr•6A) $ PERSONAL&ADV INJURY $ — GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-GOMPIOp AG Q $ PRD- LOC POLICY E pi o- g OTHER: E&e�AidtfAt AUTOMOBILE LIABILITY BODILY INJURY(Par Person) ANYAUTO BODILY INJURY(Par Accident) $ AAUTOS NFD SCHEDULED g AUTOfi Por eccldent N014 01NNED g HIRFD AUTOS AUTOS EACH OCCURRENCE S UMBRELLA LIAE OCCUR AGGREGAtE S EXCESS LIAS CLAIMS-MADE S DED RETENTIONA STATUTE ER WORKERSCOMPENSATION 03/13/14 03/1,S/15 E.L.EACH ACCIDENT $ 50Q r� � AND EMFLOYERS'LIABILITY YIN WCC5010734012014 ANY PRQPRIEtORIPAd#T4fa]EIECfTiVE NIA E.L.DISEASE-EA EMPLOYE S 500,000 A OFFpERMEMSER EXCLMED7 b(�U Q00 lMundetoy In 191-11E,L,DISEASE-POLICY LIMIT $ if describe describe under DESCRIPTION OF OPERATIONS halOw DESCRIFT(ON OF OPERATIONS 1 LOCATIONS I VEHICLES (AGOno 101,AdONOAd Remerka Schedule,may 6a ottaoltied If more spam Is required) FAX! 978--655-4760 CANCELLATION CERTIFICATE HOLGIER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEkr=OF, NOTICF WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH TME POLICY PROVISIONS. 1600 OSGOOD S'HEE'T AUTHORIZED RF,PR $E TATNE NORTH ANl?C,IRTER, MA 01845 0 ( 1988.2014 ACCJRO CORPORATION, All fights fe$Orved ACORD25(2014!01) The ACORD nSMP-snd logo are registered marks of ACORD