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2 NAPLES RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts a ° 2 Board of Building Regulations and Standards FOR m MUNICIPALITY Massachusetts State Building Code,780 CMR, 7 edition USE Building Permit Application,To Construct, Repair,Renovate Or Demolish a RevfsedJanuory One-or Two-Family Dwelling . 1, 2008 This Section For Official Use Only j BuildingPermitNu r:// Date Applied: ` 'J Signature: C/�d� b ,z, Building Commissioner/ spectorofBuildings Date SECTION 1:SITE INFORMATION 1.1 Pro erty.4ddress: 1.2 Assessors Map &Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoninglnformation: 1.4 Property Dimensions: - Zoning District . Proposed Use Lot Area(sq ft) Frontage fl - 1.S.Build iri;Setbachs (ft) - - - - - Front Yard { Side Yards - -Rear Yard - Required Provided - Rcquircd = Provided I Required Provided - 1.6 Water Supply: (M.G.L c.40,g.54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑' P.ivate•O Zone: _ Outside Flood Zone? I Check if yes❑ Municipal❑ On site disposal system ❑ S; CTION2: PROPERTY OVBI'\rVP=' . 2.`�Owner'of R ord: YJnr\vv {�u4,n\w ' aA-\, c Name(Print) _ 11• ` Address for Service:: A scC SlG n� C` AI \(`\ nC4' (917 —IobS'• I 0 d E Signature �- Telephone - - SECTIOI1 3--DESCRIPTION OF PROPOSED V1ORK'`(cheek all that apply)' t i ❑ Orr„"' L'ccu^a Demolition ❑ 'Accessory Bltlo. ❑ Number of Units Ofh r - S,j,cufv: � • Grief Description of Proposed TNorl:': S \ i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only ].Building $ 5 �� 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electr cal $ ❑Standard City/Town Application Fee O Total Project Costa (Item t]x multiplier x 3.Plumbing S. 2. Other Fees: $ 4.Mechanical (HVAC) I S List 5.Mechanical (Fire S Suppression) Total All Fees: $ CheckNo. Check Amount: Cash Amount: 6:Total Project Cost: IS SU`�o2.U� j ❑Paid in Full ❑ OutstandingBalanc Due: SECTIONS- CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) ,b`Cl c l;l _i License Number Expiration`�Date. Name ofCSL-Holdert,. 1 1 Lrt'CSLTyp (s ebelow) Y� j� SRNI F\� t �)tn l4tvutiVll�r T e D-522 lion s .._ . .. U Unrestricted to 35,000 Cu.Ft Si tore - R I Restricted 1&2 Farm] Dwellin SD�"�lGC1 �ri4� M. I Masonry Only RC Residential Roofing Covering - Telephone. - WS Residential Window and Siding - SF I Residential Solid Fuel Burning Appliance Installation D. Residential Demolition 5- Ree stered Home`I—mprove ent Contractor(Inc) ,y a 0` GY\•P�Ir V� e,rC A HIC Comppst�yN_ame or HIC egistr nt N�nq \ Registration Number 1��1 Uri S ST �1 Jl �l In bofZ) �k cwS;t Adds�ss . t 1 LIJlnn� �Lo �} I`/'UrI 1 Expi ationDate SI ature Telephone SECTION 6:W.ORKERSI COIvirENSAi ioN INTSU�1..4NCE AFFIDAVIT(M.G.L.c.152. § 25C(6)) 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 pemmt Signed Affidavit Attached? Yes .,.......c5e�. No...........❑ SECTION 7a.UYVER AITTTI OPJ—ZA.TION TO BE COMPLETED WHEN',..' O NTER'S9GENTOI:CONTRACTOR_APPLIESFORBIJFLDi1\TC=PEELIGUT I, _6((�� /f�� 11 6n, IA 00A-es as Owner of the subject property hereby au horize_�jl j L r\C l2f T to act on my behalf,in all matters reiative to work authorized by this building permit application. - S`et SlC V\C-s .AAU(1\ ZCAl., SignatureofOwner Date SECTI 7b E1 r NER'OR AUTrdORL ED 4 EIk E DT CLAFZATION ' Y"1Rlut �+ K✓\ Crts"F—'S ac-0nroer nr AfAl:liz d At cart it r by rf cl<ite that die aatcn Ptis and Infonr ahon m C 1_for geiue a pph shun are iN a ld ECCnl'ate,to lie best of m;l :now] db>and behalf. .Print i'. 1 4L2 7- Signal,ec of Owner Authorized Agent Date (Si eved under the painsan en so erju ) - NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Horne Improvement Contractor(HIC)Program),will not liave access to the arbitration programor guaranty fund under M_G.L:c. 142A Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790`CMR Regulations 110.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total noon area(Sq.Ft). (including garage,5mshed basement/attics, deck or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number ofhalf/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Souare Fooia&' may be substituted for"T otal Project Cost" 4 60 L DEBRIS FORM This form is to be subnai ted with building penait applications wfi ever there is debris to be disposed of. Prop.,rty Address: In aceordaaoo with the psrorisioas of MGL c.40, g54,:a condifon of the 3uildia;Pe�iit Number is that the d bris rcmEng from this work shall b�disposed of in a properly licensed solid wasts disposal facility as&5atd by MGL c. 111 §15D.k This debris iuill bs\disp=,d cf in (Location of Facility) / )A i u�f Tc, /lam! 5imatnreof Permit?.pplicant Date 104 On,St.,Norihbonngh,MA 01532 ,J&L WiNr10ws,IN'G,o/a/A MA Home Improvement Contraetor C08)919-0900•Fax:(774j 987-3013 Renewal License (Expires 1/24/2012) byAndersen. Federaall Tax a.ID z83-0404201 wt.aa., .r.r.rrn.a, .,....K..�n , CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buy,r s Ncme Data al A,reemenl Of�f�Dt �s�-1 3 svycrhl Street Address,Cit,,Sloe,and Zip Code a te C 01q-7 E.Mad Manic Homa Teh hone Number Work Telephone Number Buver(s) hereby jointly and severally agrees to purchase the products and/or services of j&L Windows,Inc.d/b/a Renewal by Andersen ("Contractor"),in accordance with the terms and conditions desetibcd on the front and the reverse of this agreement and on the unachcd specification shorts) (collectively,this"Agrwment").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under[his Agreement. r� Method of Pymnt: Cash �7 Check 7 Mastercard ❑VISA Total Job AmoonL 50-6a Esllmoted Staniag Date: I' ❑Discover inonced,App#: 3�5 Deposit Received(33%(:.Ffr-\C(y�si-- --(P � µ Name on Credit Card: eolonce at Start of Job(33%l: - Eli, C mplat an Data: Credit Card#: Balance on Substantial _ _ _ Completion of Job(33%I: -- - CC Exp,Date: CC Security Code: It,initialing here,you ackn.wledgr that the Iialnnec tit Start olInd and the Balance on Substantial Comptninn Buyer Initials of jOb cannot bc made by credit card and must be inrd,by personal check,hank dmck,or rnsh. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are an verb.[understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyers) l) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the rival attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. i&L W-4da-n,In d/b/a e y en ( ' ty r(s) WLtx Buyer(,) f9- Bv: Si'91 urea- and abfunagor Signature Siymnumc Print Name of Product Manager Print Name Pin,Name YOU, THE BUYERS), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE TIFIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. �_ _ _ _ _ _ _ _ _ _ _ .� _f NOTICE OF A CELLATION W NOTICE OF CANCELLATION Date of Transaction You miry cancel Date of Transaction . You may cancel this transaction,without penalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days From the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if you wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make Lou do make the goods available to the Seller and the the goods available to the Seller and the Seller does not Tier does not pick them up within 20 days of the date pick them ujp within 20 days of the date of your Notice of your Notice of Cancellation,you may retain or dispose of Cancellation,you may retain or dispose of the goods of the goods without any further obligation.If you fail to 'without any further obli ation. If you fail to make the make the goods available to the Seller, or if you agree goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so, then goods to the seller and fail to do so,then you remain liable you remain liable for performance of all obligations under ?:ads of all obligations under the Contract. the Contract. To cancel this transaction, mail or deliver a I To cancel this transaction, marl or deliver a signed and tied and doted copy of this cancellation notice or any I dated copy of this cancellation notice or any other written r written notice,or send a telegram to Contractor. J notice,or send a telegram to Contractor.d&L Windows, &L Windows,Inc.d/ /a fernewal by Andersen, 104 Otis Inc, d/b/a Renewal by Andersen, 104 Olis Street, Sheer, Northboroyg 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF Nam_.(Date) OF .(Date) 1 HEREBY CANCEL T IS NSACDON. I HEREBY CANCEL THIS TRANSACTION. Buyers Signora. Date I Buyers signorine, Crate RbA Copy- White Buyer Copy-lellow Buyer Copy-Fink I,•d Renewal RENEWAL by ANDERSEN NIA ttC LlLvnuN 141601 a=Fires vz,nm 'OAnder$en, FMaral'I:u 10� d3-Oae4T01 , ..�,, OfGREnTER MnssnCH[:SE1'Is nun New E-In.\-trsmRE 104 Otis Street•North balruuch.Massachusetts 01532 Phone 508.919.0900•Ft,508.919.0907 SPECIFICATION SHEET Isuyer(s)Nante Galen Ag,-cntent 9 10 'Die Buyers)listed above hereby ioi nfly and scvcnlly agree to pu atIasc the goods and/or smvices listed blow,in accordance with [he cIces nn1 tents described on the Specification cheer and the inntf and the reverse of the accompanying CUSTOM WINDOW AND DOOR KF.MODI:LINC AGRr..iAlENI' of w'hieh this SPeLitieatiou$heat iS a p•-1 WINDOW DETAILS I. Conlraclor will Install a total of 3 _windows in Owner's home,using file following individual quantities: 3 Double liuug(DB) N-Equal sash ❑ Collage sash(1/3 lop:2/3 botlon0 ❑ Oriel sash(2/3 top. 1/3 bottom) C:Ixentenl(CW) ❑ Hinge Iighl ❑ Hinge left lot viewed front exterior•): ❑ Standard handle ❑ Metro handle 001ble 0ifuiont(CDW) ❑ Standard handle ❑Aldhv luutdlc Gtscmm.l/Picture/Cawntcnt(CPN') ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Litc Gliding Window(GW) Glider/Picture/Glider(GIMI) ❑ 1:1:1 or ❑ 1-2:1 Awning Window(AW) Picture Window(FW) Bay or Be,,window ratio Doors(see separate Door Specification sl 2. Yes ❑ NO Q:) of Windows to be CItsforu Fit Replaccntc ll' Yes N No Qty of Sills to be replaced by Contractor: 4. ❑ 1'e32�—NoCIS of Windows to be New Construction Full E (Inoludcs new interior&exterior casings) Extm'ice casings: ❑ Fine❑ Alaintenance-free material ❑ Factory applied;)()S Flrrex brickniold 5. Gla'ringlobc: 0.11FLOW-E1Dsnuirain-6r (Tax CivQy}/Ug'y/e) ❑ Gillet Header,please specify: G- I;slcrior color to bc: V] White p Sand ❑ Canvas ❑'Ferratone ❑ Cocoa Bean 7. titlerior Color to ba JEn White ❑ Sand ❑ Canvas ❑Terralonc ❑ Fire ❑ A4aple❑ Oak Note: hlletior color enn only be white,wood or sane color as exterior, \VOai immix n=e I to finished by Owner s. liardwnrc: [I \Vltitc El Slone ❑ Canvas CR Brass Double HitsiCH',�C� /Ur t�je,I 9 ❑ Yes ® No Install Lifts with Double Hung Windows II, Scrams: windows to have ❑ Half .. Full screens screens to be)RJiGrglass ❑ Aluminum ❑Tru Scene GRILLE DETAILS 11,Windows hula;grilles: 9 Yet ❑ NO II toes EgGrille Iktween Glass Icaw❑ Removable Interior Wood asrrm❑ Full Divided Light ape Qry; 3 Qly: Qty: Qly: Qty- Qty: Qty'— J1 EID 71-IF to clae, �cwv or 4pav, Draw grille patterns rvbove •'[Ise additional shot if neeAcd Owner approved(initials):C ) ADDITIONAL WORK DETAIL 12.❑ Yes ® No Contractor will ieaove metal Games of windows. Qty of Units': 13.El Yes © No Contractor will install new paint-ready or stain-ready casings. Interior casing qly of openings: Ercleriol'ca,ing, gE;•of openings: ❑ Fine❑ M a int act tact is] 14.❑ Yes MI No Contractor will install new paint-mady or stain-ready inside or outside stops qty of openings: Interior sfopsgty of openings: Exterior stops gn•ofo(xniugs: ❑ Fire ❑Mainuilarec-free material 15. Owner is aware that Contractor does not do any painting. ( 1 Owner Initials [6.0 YC', ® No Contractor will wrap exterior casings with aluminum coil stock of colt'. Note: Wrapping nay be required with storm window'removal;tenoval of storm windows will leave screw holes in casing. 1 T M Yes ❑ Na Conhackli will insulate,caulk slid seal windows with 3-paint syste n to prevent water and air infiltration I S. YS Yes ❑ No A limiled watranly shall be issued to Owner upon completion of thejob and payment in fnlL 19.R Yes ❑ No Building,Permit--Conhactor will secure any mud all necessary permits The fee for the permit(,)is not included in the Contract Price and a separate check is acquired a1 Its time of sale for this lee. 10. Addilionatjobdch ls: 21. 5?Yes ❑ No Owner agrees to be present on 1ha Fine]day of installation for final inspection and to deliver final payment. No firwyen m[) eut.vlydl be demanded uNi/the contract m complete ef to ffie Faliseacl on oltUl Parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there ate no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terns modified or varied in any way unless such changes are in writing aund by both the Buyers)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Rune Arus If o MA 17 Buye (s) Buvm(s) Si yrLAVI'm er Signature Signature - I ) • r(e Print Name of Product Manager Print Name Print Name Rb.4 Copy- While Customer Copy-fellow E•d Renewal ;.. byAndersen® '= WINDOW REPLACEMENT anAndersenCompany A (00 PROPERTY OWNER MUST COMPLETE&t SIGN THIS SECTION IF USING A BUILDER I, 0�20aA l���e O��C�, as Owner of the subject property hereby authorize Renewal by Andersen (d.b.a. -J &s L Windows) to act on my behalf, in all matters relative to work authorized by this building permit application for: Address of job � 3 Homeowner Signature I bate OWNER OR BUILDER (AS AGENT OF OWNER) MUST COMPLETE &L SIGN THIS SECTION 3 pt`\cro ` _, as Owner :thhorized Agent hereby declare that the statements and information on the foregoing application for: Address of Job Sighed under the pains and penalties of perjury. ��P,^ cn+ �T Print Name Signature of Owner Agent Date 104 Otis Street Northborough,MA 01532 Phone: (508)919-0900 Fax: (508)919-0903 www.renewalbyandersen.co m 9 •d a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 660 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information a Please Print Le ig bly Name(Business/Orgmization/lndividual): J)en o r.l 04d e l:.S yl Address: 104 Qli \TYeg- City/State/ZipAladAbafoi. M Cdg — Phone#: C vS) gjy- O�OG Are you an employer?Check the appropriate box: Type of project (required): La am a employer with 0 O 4. ❑ I am a general contractor and 1 6. ❑New construction employees full and/or part-time).* have hired the sub-contractors ( P ) 7.tmodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 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 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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 box#1 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. tContractors that check this box must attached an additional sheet showing the narne of the subcontractors 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: J 1"^� J�l &oMe- 1 x Policy#or Self-ins.Lie.#: 3Ji ����' � Expiration Date: Job Site Address: klo n L �� City/State/Zip: 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 do hereby ce u ler the pains and penalties.of perjury that the information provided above is true and correct Signature i Date: Ll U Phone#: �U O 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#: Massachusetts- Department of Public Safetc" 7 Board of Buildin!- Regrulations and Standards Construction,Supervisor License License: CS 101952 Restricted to: 00' DAVID BANCROFT I1OHNSTON AVENUE WHITINSVILLE, MA 01588 Expiration: 3119/2012 <'unnnisviunrr Tr#: 101952 i ✓{u'(oarnmromweaLlk °�'✓l�la°°a`lwaet¢ Office of consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR t Registr3ti0n-149601 f Ezpirat�: �12 � (� S�errrDerit Card " RENEWAL BY_C.. � ; DAVE BANCROi�;{�1p;; �= - - 104OTISSTREEFt; NORTHBOROUGH,M�AiflJ.53'2 Undersecretary i, ACORD. CERTIFICATE OF LIABILITY INSURANCE °o2iiorZ0' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE en Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR JP MGKeone Insurance Agency,Cyr ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC 4 INSURED Renewal by Andersen INSURERA: He ord Insurance CQM12any J and L Windows,Inc. INSURERS: Nautilus 104 Otis St INSURER C: —— Northborough.MA 01532 INSURERD 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 OTHER DOCUMENT WITH RESPECT TO WHCH 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. __------- POLICY NUMBER POLICYEFFECTIVE POUCYEXPIRATION LIMITS g oENERALLUBIUTY NC958461 10/01/2009 10/01/2010 EACNOCCURRENCE =S2,000,0000 00 COMMEROIALGENERALLIABILITY PREMISES Eaoarenca00 CLAIMS MADE' 0 OCCUR MED EXP(MY erre PenanlPERSONALS AOV INJURY00 GENERAL AGGREGATE00 ,GEN�L AGGPEiLTE WHIT APPLIES PER: PRODUCTS•C°MPIJP AG 1 I POLICY. JECT PRO. LOC A I AUTOMOBILE LIASIUTY 35MCCXD6390 10101/2009 10/01/2010 COMBINED SINGLE LIMIT If 1,000,000 ANY AUTO (Eo ow3Rnq }( ALLOWNEDAUTOS INJ URY BODILY — (PorI SCHEOULEDAUTOS HIRED AUTOS BODILY INJURY S NON-0OMEO ALTOS _ (Pv oxaenq I PROPERTY DAMAGE S i I LPor=denq GARAGE LABILITY AUTO ONLY-EAACCIDENT f - OTH ANYAUTO it ER THAN EA ACC I f AUTO ONLY: AGO S --- EXCESSNMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE 13 3 3 DEDUCTIBLE S RETENTION 3- q woRKER9GETENTI AT ONA 35 WECPP 1444 /211112010 02117/2011 wcsruu orH. EMPLOYERS'LIABDdY E.L.EACH ACCIDENT s 500,000 ANY PROPRIETOWARTHERIFAEOVTNE E.L.DISEASE-EA EMPLOYEE S 500000 OFFICERMEMBER EXCLUDED? - NyyeAMomTPWfef E.L.DISEASE-POLICY LIMB S 500000 SPECIN.PROVISIONS"I— OTHER DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LNBUJTY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTAT111M AUTXORPED REPRESENTATIVE //Q n I `TQ ACORD`+CORPORATION 1968 ACORD 25(2001108) . i 1 r 1 1 ' 1 1 4 i F F 1 I Ff.0 c��7,F d ,rai''� &R�I Vf 'L��'I..ECqu 'fl0Y7 F A .pgSti rs Gxraq � .. h�FarJ c h lhbDdAlmy!CDMP_S11.,I kraon - j Doubl=Hung So!�rliset Gain Coefiician4 C - I�I:S(513 i ran>iT1Iu�lC? . 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