25 ROSLYN ST - BUILDING INSPECTION (2) � The Commonwezhh of Massachusetts FOR
a Board of Building Regulations and Standards
Massachusetts State Building Code,790 CMR, 7 s edition MUNI JSEITY
Building Permit Application.To Construct,Repair,Renovate Or Demolish a Revfsed January
One-or Two-Famfly Dwelling . 1, 2008
This Section For Ofvcial Use onlyLa4.
1� Build ng Permif Numbe . I Vza
Date Applied: z—
Signature
Building mmissiontn/Inspector of Buildings,
SECTION 1:SITE III' ORMATION
1.1 Property Address: 11.2 Assessors Map 8 Parcel Numbers
State T 01n 1 t
1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards - - Rear Yard '
Required Provided - Required - Provided Requind Provided
1.6 water Supply: (M.G.L C.40, g 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System.
Zone: Outside Flood Zone?.
Public❑' - Private❑ — Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 YA Owner'of Record•TT �J C 1
dthS ^� S nn.Frf SCh\c& d5 QOS\UUt lrt. Or\' l 6 c CAIA1. IYtCt
Name(Print) Address for Servie_:
Signature - - Telephone
SECTION 3:.DESCRIPTION OF PROPOSED WORKZ,(chcck all that apply)
1Je.: Ccns[ru^tiC:: ❑ 1 Exis "p116' i^❑ On':^r'Cccupi d ❑ P.epahs(s) ❑ ^ t .(s) ^ i, ^ ❑
Demolition ❑ x\ccessnrvBld_o. ❑ ITJumberofllnits__- IOtlier J sprxift:_,_, .�' � .
Brief Description of Proposed Vdorl•'-- r 0..
o Srr � Sul CL.hNL P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
L Building SoI ef.)ij 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'' (item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) I S List
5.Mechanical (Fire S
Suppression) Total All Fees: S
`' Check No. Check Amount: Cash Amount:
6,Total Project Cost: S y 3 b .&) ❑Paid in Full ❑ Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES 1 i
5.1 Licensed Construction Supervisor(CSL) ,b`Q5a
aJGL)�t� dGil�e!'o� - License Number Expiration Date.
Name of CSL-Holder .
Kik-
List CSL Type(s b ]ow)
� ss T e `:_ D sm son
0 j U Unrestricted(Up to 35,00 Cu.Ft.)
gnature��tu--ddr��e°��c R Restricted 1&2 Family Dwellin
&OZ-9ka _ CACIa M. Masonry Only
RC Residential Roofing-Covering - _
Telephone. - WS Residential Window and Sidin
SF Residential Solid Fuel BurningAo liance Installation
D Residential Demolition
5 21 Registered Moe hnpFoveglent Contractor(HIC) 1��6o1
el�t .�ak t P7_G1✓
H1CCom n NameorHC a istrant a Registration Number
�fMs�"��A��, ss n -
t 111 1 I V �� -C1101— 0 1Expiration Date
S ature 1 Telephone
SECTION 6:WORIMRS' COMPENSATION INSURANCE 6.FP'ID 4VIT(h7.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 permit
Signed Afn""davit Attached? Yes ........ No...........❑
SECTION 7a:,0WINrER kU.THORTZATION T.O BE GO IPLETEB:5=I I'. .'
ONVNTER'S:AGENT DR CONTRA6TOR APPLIES FORBLZLD NG:PERl\'IIT .
1, as Owner of the subject property hereby .
authorize �r.��l y_N to act on my behalf,in all matters
relative to work authorized by this building permit app ication. .
Signature of Owner Date
SECTION 7b .OWnTERt OR AUTc'IOR'IZEr3 A EIe£I? LAT`ATIOI�T
\ n T
- ,z�nwner nr Ailfhonz.d At eft 9l re¢v rt rllre
that Che StatClnent5 Ind 1P_1JR3]aTlq!1 Qll fl]e i];CgD1P. nppll�aL1U1]al etrLLe a11d aCClll'ate LD Ll].best Of my LI10'I].dge elld
belia( R
.'Print iJ : . . . .
Signatu of Owner or u orize Agent Date r
(Si;nedunderthepains d enal 'esof 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 Home Improvement Contractor(H1C)Program), will not Have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.). (including garage,finished basemenUattics, decks 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 Square rootage" may be substituted for"Total Project Cost"
DEBRIS FORM
Tliis form is to be subnu+tted v�ith buildingpmniit applications whenever there is debris to be.
disposed o£
1
Property Address.' Q"\1 1 v� <SZ
In accordance with the pr. risiors of MGL cA0, §54,:a condition of the Building Permit
Number is that the debris rc u Ling from this work shall bi disposed of in a properly licensed .
solid waste disposal facility as L-fmzd fey MGL c. III § I5D k
This d bris grill be disposed of i=
(Location of Facility)
Sieuature of Permit Opp : ant
Date
FROM : KAOBLY FAX NO. : 6033629675 May. 09 2010 11:20PM P7
101 Onir-SI.. .orou;;h.MA 01,-,Cj .J I,}I Im i u,h, I,c_ Wig/, atn porno rnipn,rvmmmu r'nnn a,uor
fl}00% 19-W100. 1'ar. 771 !W7-:WI �enewa0 .`„'; tic url' 1FJ1 (l xph',s I/Z4i 201 Z)
dtiml I I¢IU H85 0u04-101
byAndersen. ;S
r CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
aoyegsl No x Dw.of Agreement
a,yers So-eet Address ry,5 k ALp Code
E-Mell Add zn one N mba N 4 rcicphono N ,nt-
iluver(s) hereby Jointly and severally aSre,,to purchase (he product,,and,/or services of)&L Window.,,Inc_d/b/a Rwvewal by Andersen
("Contractor"),Ire aetor<hnee WhIl the terms and evnditions described on the(runt and the reverse of IN, ASr'cement and on the allnched
spceificah it shecl(5) (c00a:tively,Ihie"Agrccnrcelt°).Buyer(s)herehy agrees to xi��n,t n contplellon certificate after Co ed Contractor has complet
all we,k under(his Agloenten=_.
Total Job E
Meod of Pymnt:IJ.Cosh a Check ❑Mastercard D VISA
Amown. �� s.rimed 5(��ti�g�D.I.a - th
t"lI 5 G U Dis<;nver psi te�i,Ate:/
Deposit Received 133%):-,- Nome on Credit Card:
Balance at.earl of Jah 13!/�:.�/ Eslrmored Compleon Dare:
J p Credit Card#:
balance on SDbstantiol / 7 r l l ._ -''—
Completion of Job 133%i: J _ {' D CC Exp.Date: CC security Code:
.ltyl r I l..rn,—
Buyer hdtials r 1 nuwled�c tiv t dw Rela.r Sr Y P Jnb a u1 du$altmtt on Suhsuv r I( yh*.don
„I I unnot he m ud L Y credrl eel Anil must br m tdt b croon IJ 1wok,ha nl rhr r nr rich
agrees aad understands that this Agreement constitutes the entire understanding between the parties,and that
there are me vcrhol and.rstaadings changing or modifying any of the terms of this Agreement.No alteration to or deviation
from this Agreement will be valid without the signed,mitten consent of both Buyer(s) and Contractor. Buycr(s) hereby
acknowledges that Buyer(.) 1) has read this Agreement, understands the t.rma of this Agreement, and has received a
completed,si mcd,and dated copy of thi.Agew..me.t,melding the mo attached Notices of Cancellation,on the data 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.
J&LWind Inc.d/hie Benewalby Anders.. $vye s) Buyer(s)
Sigt a" of Pro In anaerr tenteauc Silmatum
-"' �
Prhn.N..�m I rcxiunr.3l.auiyrr Pn;u Naxnr Feint Nacre Ii
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
x- _ - - NOTICE OF /�1CILLATION-- - - -�- - - - - - -NOTICE OF CANCELLATION
Date of Transaction -K 7C' 1 . You may camel DOM of Transaction _ {. _(�� You may cancel
this transaction,without a a oror obligation,within this transaction,withou t ny penaly or obligation,within
three business days from the above date.if you concel,any three business daysfromthe 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 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 t.ansoction will 1 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 camel;you must make available to the
Seller et your residence,in substantially as good condition Seller of 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 of.the Ballet's expense and risk. .1 the goods of the Seller's expense and risk.If you do.make
If you do make the goods available to the Seller and the the goods available to the Seller and the Seller does not
Seller does not pick them up within 20 days of the date I pick them up 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 ony further obliggation.If you fail ro without any further obligation. If you fail to make the
i make the goods available to the Seller, or if you agues 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 obligation under for performance of all obligations under the Contract.
the Contract.To cancel this transaction, mail or deliver a I To concel this irmisoNion, marl or deliver a signed and
signed and dated copy of this wmellaticen notice or any I dated copy of this cancellation notice or any other written
otter written notice, err send a telegram ro Contractor.J I notice,or send a telegram to Contractor.J Is L Windows,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/o Renewal by Andersen, 104 Otis Street
Street, Northboro 01532, BY NOT LATER THAN North h, 1532,BY NOT LATERTHAN MIDNIGHT
MIDNIGHT OF .(Date) OF EaV�.(Date)
I HEREBY CANCEL TH S NSACTION. I HER CFL THIS TRANSACTION.
Buyer's Signature Date- I Buyer's 5igrroture Date I.
R1,A Come- Whiter liuver C:wv Yellow lichee CoPv I`Ink
FROM : KIIABLY FRX NO. : 6033629675 May. 09 2010 11:25AM P1
).R t.windows,Inc,d/b/n 4'nC•Y
d1A leek 1r,l- _ev2a/Is)
10l Utl $IIC'I itallL.. u l AAA 015t" g _ I' 'll 1
r...n. Y .n . .x n.1,, I 117,311 r+ Renewal l'<,7"�� I'Cdn'xl'I'n 111p s,5-04py201
byAndersen.
W iN00w R I�OCMf Ni iAnlrnvil'.nI WY
Or GutwtYa rvussnauurrrS tiun Nl:w i InnuSatxa
WINDOW SPECIFICATION SHEET
Buyers)Nantc ,. Dale of Agrennenl
1'he Buyers)lured,thou. crcby jomuy and severally agree to purelmse the greeds sine/or services]sled below,to aacONnnce with the paces anA tkrnts
deacribtd on du S{xcifVcuKnn Sheet and the front and the reverse of the xcenmlmttyhtg CUSTOM WINDOW ANI1 DOOR REAdODEI.ING AGREEMENT,
of wh,,b this Specification$haN is apart.
WINDOW DETAILS
I. C [rnefor will Install a total of— windows in Owner's home,using the following individual quantities:
Double Hung(DB) "ual sash ❑ Cottage sash(1/3 top,2/3 Lx tt000 ❑ Oriel sash(2/3 top.1/3 bottom)
Casement(CW) ❑ Hinge right [] Ilinge,left(as viewed from exteflol): ❑ Standard handle ❑ Metro handle
Doublc Casement(CDW) ❑ Standard handle ❑ Metro handle
Casement/Tlcture/Casement(CPW) ❑ I:10 Or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window(GW)
Glider/Picture/Glider((;I'W) ❑ I:1:1 or ❑ 1:2:1
Awning Window(AW)
Picture Window(FW)
Bev or Bow Window
Patio Doors(see.separate'.Doter Sperifrcattoft Sheel) -
2'es ❑ No Qty of Windows to be Cuslom Fit Rcplaeetnenl:
3 ❑ Yes 2;1Qo Qty of Sills to be rplaced by Contractor:
4. ❑ Yes � Qty of Windows to lw New Gonstrncfall,Full frame(includes new interior fc cxtcrior casings)
Exterior casings: ❑ fine ❑ Maintenance-free material ❑ Factory appliu9908 Fibrex brickinold
5. Glazing to bc: -HF,`�L,orar-F,'x]smertSuxt (Tax Qrdit£G,�ble) ❑ Other If other,please specify:
g
6. Exterior rotor to be: 7<vhit. ❑ Sand ❑ Qmvru ❑ 'rerratonc ❑ Cocoa Scan
i. Interior color to last 7>1`mte ❑ Sand ❑ Canvas ❑ 7erratone ❑ Roc ❑ Maple ❑ Oak
Ne httc color can ecly bc.while,wood cr xmtt color as cxtcrior. Wood interiora(teed to finished by Owner.
g. Hord sac: While ❑ Stone ❑ Canvas ❑ BrTsss ❑ tstatcllardware: Style:
9- ❑ No Install Lifts with Double IIm g W' dawn
10. Scmens: windowstohavc: ❑ H.alf or P111Illsctcena Screenslo bc: fiberglass ❑ Altimmum ❑TrnSOene
Cain DETAILS
11.Windows Iewe,grllles: ❑ Yes r o If yes:❑ Grille Ilehveen Glass mats❑ Ranovablr.Interior Wood amwt❑ Full Divided Light(mu
t;ry: Qty: Qty: Qty: Qty: Qty: Qly:
on oa oe on cwr¢wre Olmer stun one
Draw grills patltrna above 'U.sa additional sheet if needed Owner approved(hart,
ADDITIONAL WORK DETAILS
12,❑ Yes o Contractor will remove insist frontca of winds ow. Qty of Units:
13.❑ �Yes FL%P'•'/Contras(Or wil l install new pain-ready or stflin-ready caeiogs.
]ntes.r�io�rcasing qty of Openiliys: Exieriorcasings qtv Ofopenings:_, ❑ pine ❑Maintenance-free material
14.❑ Yes K;T o Contractor will install new paint-ready or stain-rendv inside or outside slops qty ofopenhtgs:
Interior stops city of openings:_ Exterior stops c t - Pexit ❑ Pine ❑ Maintenance-free material
15. Owner is nav that Contractor don not do ally pain na Initials
I G.❑ Yes oContraeter will wrap exterior casings withe mr stock of color.
,�f/Note: Wrapping may be reciuired with storm window mmoval;removal Of storm windows will leave screw holes in casing.
17.L Yw ❑ NO COnl.ractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
1S.[�i�,'��d'as ❑ No A limited warranty shall be issued to Oamcr upon Conpiction of the lob and payment in full.
19.4�'cs ❑ No Emijefing Permit—Contractor will secure any and all necessary permits. Thn fee for the permit(s)is not
included In the Contract Price and a separate check Is requimd at the dole of sale for this fee.
20, Additional job detalls:
_ 1
_..2L... .Yes..❑.No—.Ow'ncr.avpccs.to be.pcesent gtLthofinel day of installation for final inspection and to deliver final payment. .
No film/p,tmucnt s'hallle denanded mnil McCO»G:ac1 le mmplcted to Nle M141faction ofellµir(ies.
If 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 bctwcen the parties,and there are no verbal understandings;changing or modifying any of the
terms. This Spcdficntion Shell may not be changed or its terms modified or vaned in any way wliws such changes arc in writing all signed by both
the Bayer(s)and Contractor. Buyer(s)hereby acknowledge t SuycMit)has read this Specification Sheet.
Renewal by ldersen of G ,e ter MA and h Buyer(s) _ nl Buyers)
P 4 C
By: i
Signature Of disc anager ,� igrmture Signature
Print Name 'duct Mana,GOr t Name Print Name
FROM 1CIMBLY FAX NO. 6033629675 May. 09 2010 11:26AM P3
Renewal
byAndersenta
WINDOW REPLACEMENT an Andersen Company
PROPERTY OWNER MUST COMPLETE&SIGN THIS SECTION IF USING A BUILDER
I• J '� r- ,as Owner of the subject property hereby authorize
Renewal b An rsen (d.b-a. -J &t L Windows) to act on my behalf, in all matters relative to
work aauthhoor zed b this building permit application for: 9 J
2nT
Address of job
Iio eownerSignature ate
OWNER OR BUILDER (As AGENT OF OWNER) MUST COMPLETE&SIGN THIS SECTION
I, .. ` s , as Owner /Authorized Agent hereby declare that
the statements and i.nfotm anon on the foregoing application for:
Uh \�T � Sn_�-c vim,
Address of Job
Signed under the pains and penalties of perjury-
Vav�� C' r'o�T
Print Name
Signature of Owner/Agent ate
104 Otis Street
Northborough,MA 01532
Phone: (508)919-0900
Fax: (508)919.0903
ww -renewalbyandersen,com
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office Of Investigations
600 Washington Street
Boston, AL4 02111
www.rnass gov/dia
Wpricers' Compensation Insurance Affidavit: Be€Fide>rs/Contractors/Electricians/Pdumbers
A D11eant Information Please Print Le�Fbly
Name(Business/Orgmimtion/Individual): en uI� ' �V Anrl ers eYl
Address: 104 S
City/State/Zip: lVorlh bo ro ,_ 1.5 I Phone#: C�08� l�lsn a 00
Are you an employer?Check the appropriate box: Type of project(required): .
i.E] l am a employer with �J D 4. ❑ I am a general contractor and I 6. ❑New construction
em to ees full and/orpart-time).* have hired the sub-contractors
p y ( 7, modeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet
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• ❑ We are a corporation and its 10.❑Electrical repairs or additions
requ red.] officers have exercised their
right of-exemption r MGL ILL]Plumbing repairs or additions
3.❑ I am a homeowner doing all workP pe
myself. [No workers' comp. c. 152,employees.
[ and or have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
-Any applicant that checks box Rl must also fill out the section below showing their wortom,comp,usation policy information.
t Homoovraers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContactors that check this box must attached an additional sheet showing the name 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.
Insuance Company Name: --
Policy#or Self-ins.Lic.#: �1 /n� L%($ j`f apiration Date 1 17��.,__
Job Site Address: S \Z6S\� to �2 v� l k _City/State/Zip: cZ:). tit,
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 car ultderlthe pains andpenaldes.ofperjury that the information provided above is true and correct
Signature: Il!'' -� l Date: lC I[4I(0
Phone ,L—��U /! D%aq
Of use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Perntit/Llcense#
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#:
f4.
+- Massachusetts- Department of Public Safety'
' Board of Buildin,, Re^ulations and Standards
Construction.Supervisor License
License: CS 101952
Restricted to: 00' -
DAVID BANCROFT -
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01588
—� s- Expiration: 3/19/2012
('nnmisniunc•r Tr:: 101952
d
✓fze foo�nmo�u�eaL!/i �i,,ss Regulation
b I
Office of Consumer Affairs&Bus Hess Regnla6on h
� HOfiflE IMPROVEMENT CONTRACTOR t
RecJistratiori;�4 601 1
ExPirait? ta 12;
Y
IT_;'F_ es•L,Ent Card
m 4"J
RENEWAL BY q f3E1 5�� � _
1 �.
DAVE BANCROt�j /r
104 OTIS STREE'1';�,W__>
NORTHBOROUGH, CD_1532 tluders -
g 66 o DATE(LIMM nY '
0211012010
PRODUCER
6NILYC ICATE is
ANDCONFERSSNo RIGHTS UPON THE FAC E
AT
Joseph McKeone HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND O
JP McKeone Insurance Agency, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. BOY 333 NAIL a
Ann Arbor, M1 48105-0333 INSURERS AFFORDING COVERAGE
' INSURER k -HaI't4ord Insurance Com an
INSURED Renewal by Andersen INSURERS: Nautilus
J and LndDWB,Inc. INSURER C. --
104 Otis St INSURER D:
Northborough,MA 01532 INSURERE:
COVERAGES
THE POLICIeS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAhS=D ABOVE FOR THE POLICY PERIOD R FICICATEO.NOTWITHSTANDING
ANY RE ICIE SOF IN, TERM OR CONDITION OF ANY CONTRACT OR OTHER DDCUFfENT WITH TO ALL T E WHICH THIS CER7IFICATE NDI,AY IO S OF S OR
POLICIES.AGGREGATE LRANCS AFFORDED BY THE HAVE BEEN REDUCED CRIBBEBy D CE.41RF15.16 SUBJECT TO ALL THE IERW�S,EXCLUSION$AND CONDITIONS OF SUCH -
WAY CLAIMS.
EFFECTiYE POFCY ELPIRATIDN LIMITS
I S D'L ee P ' N^� P0IJCYNUMSER EACHOCCURRENCE I S D000o0
T I NC95B451 10/01/2009 10/01/2010 P 1.
REMISES ESa�^ re 5 900000
B GEKERAL LIEBILRY
COMMERCIAL GENERAL LIABILITY Y=D E%P IAnr tm Pa' "a s 5,000
CLAIMS MADE 0OCCUR PERSONAL ADV INJURY 5 1DOO OOQ
GENERAL AGGREGATc S 2 000
PRODUCTS-COYPIDPAGO s 2OD00000
G=NL AC>".+PLiATE LIMIT APPLIES PER:
POLICY
n Pao- n L� LIMITI s 1,000,D00
I (Eaooaanq
Auro%DICE LIkBIIJFY. 35[rPICC XD 5390 16t61t2009 10/01l2010 eoMalgeED SINGLE
ANY AUTO BODILY INJURY S
ALL OWNED A'TDS (Parpar )
I SC-OULED AUTOS BODILY INJURY o�ina 5 —
HIRED AUTOS (PW nll
NONDwNEDAUTOS PROPERTY DAMAGE S
I HI
par anU
I AUTOONLY-EAACCIDENT 5
DARAGELIASILITY - OTH-RTHAN E4A� I�-�
I MY AUTO - AUSOONLY: AGGI5
I EACH=CURRENCE 5
EDr SWIUL°-RELLA °ILET'
AGOREGATE 5
CLAMS MADE - S
O CUR s
S
DEDUCTIBLE
VJC.STATU• OTH•
RETEnTON S" TOR Y Tc
35WECPP1444 02h7/2010 02P1Z(2011 E.L.EACHA� s 5DO,DDD
A tYDRY`RS CDxrxsA:sON um - I 500000
E6 LGYERS*L=!Urf E.L.OISEASE-EAEMPLOYEE S
I ANY PRWRIETDR?ARTNER)E.ECUT, E B.L.DISEASE-POLICYLIMIT S 500 ODD
0E- CEvAE,IScREACLUDEDT
If,,,:1 5 0 a W
SPECU PROVISIONS pelvis I
OTHER
pESCR,FTION OF OPERATONS f LO'.ATIOhS f L�KICLES 1 ESCLOSIDNS ADDED BY ENDORSENIEJSTP SPECIAL PROVISIONS
CANCELLATION
CERTIFICATE HOLDER SHOULD AIN OF THE ABOVE DESCRIBED POD ENDEAVOIES R
VOR 70 NAIL CANCELLED BEFORE10 DAYS WRITTEN
DLTE THEREOF, THE ISSUING INSURER WILL END
INSURED COPY NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILTY OF ANY ,,ND UPON THE INSURER ITS AGENTS OR
REPRESERTATMS.
AUTHORD=D REPRESENTATKE /j11�A (oJ/jA T ry
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