63 VALIANT WAY - BUILDING INSPECTION t4 The Commonwealth of Massachusetts
t Board of Building Regulations and Standards CITY OF
�f Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Fancily Dwelling
This Section For Official Use Only
Building Permit Number: Q Date—Applied:
BL]ilding Official (Print Name) Signat Date
SECTION 1: SITE INFORMAT
LI Propety Addres ( 1.2 Assessors Ma & arcel Numbers
If'-�-OWy
L 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 ft) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal [IOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O per'of Recur
fl liQY� �ou�thlih l o1916
Name(Print) City. State,ZIP
63 VGLIM4 Woq 4/3-2g-6313
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTIO COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building s 2qn I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical g ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S �. 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire i
S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ZIP i ❑ Paid in Full ❑ Outstanding Balance Due:
_ i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�/ I 9 91"ID 12�z� !z
lllhcen{ KI W(A) License Number Expiration ate
Name of CSL Holder
List CSI..Type(see below)
Atibu�r c9urf No. and Street Type Description
SlIys , �� D�y0� U Unrestricted(Buildin s u to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Cit)/'FON State,LlP M Masoni
RC Coveing
Window
r
WS Window and Siding
SF Solid Fuel Burning Appliances
70g l" 233—olot I Insulation
Telephone Email address D Demolition
5.2 Registered
1 'Home Improvement Contractor(HIC) q� f6 t7
/13
�W�S NounES C2"' HIC Registration Number Expirat on Date
HIC Colo an Nan? or H Re gistrant
No. re Email address
mush, mlll 0177.2 617-359-04
City/Town,State,zip Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE 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 permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES
�1FOR BUILDING PERMIT
I,as Owner of the subject property, hereby authorize Itl j)W acj. 0O'1Q
to act on my behalf 't al matter relative to work authorized by this building permit application.
11�i��iam /Y►C� oh�ih
I run wncr tmc(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain id 1 thi ppli do is true and accurate to the best of my knowledge and understanding.
I�Jnlxr� U)alono to Isd a
Print O%f ner, or th rized Agent's Name(Electronic Signature) Date
NOTES:
I. 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(HIC) 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 can be found at
www.mass.gov;oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•,q `M s v,^+#
" ",. `� CONTRACT ht
�R t 3P+t "�a''i}t v y -ay �.ki„'$ =� ta.` �`*# a,,.M'��y,Tv..��„.c`�*n. 3T ��v,`�i �'S+ � ��t :y. "A e'k' v •s � ctL�
Al
SOLUTIONS INSTALLED SAL'ES'CONTRACfi k
� �MASSA�HUSET'fS EXTERIORS gI
� �,'-..
"('�`,;j, INSTALLED SALES SPECIALIST f1 NUMBER -� • CUSTOMER
f�.'<
xT = STORE NO✓_µ, J ,STREET ADDRESS t{ C �� 'G6e$`+�11
STREET ADDRESS
.
•race. , .' s^....
u 1. CITY �� 'STATE ZIP •, °. ,� CITY STATE'r 'ZIP
K{ i TELEPHONE TELEPHONE
t , DATE f T. � CAH J cnRD LCCLOWE S HOME CENTERS INC SMA HIC NO 14868 ' cHARc
P°
FEIN 56-0748358 .
ttS°45x+ t €e x=. a , . } *�•'-w` "r'43 .—R ,$r u. t ;tom tG eUpB e f
rne"a 4 %as '. •" t ,! ui '# '.,a i�„1„ '"+ '��' - ..,t}" nos x.. . �r
s onNagl!gte for the merchandise antl serrates pnntetl 6eWe% hsbecomes ah agreement eport payment Upon paymen4 Me,enbre agreement, ndud'mg thespepfically eomd�ed Pages of Ehrs,x„�
I ft h dowmen4 tl e T®msre M Contl,hons m utled x H thfatlwomenra d any g her adCentla'ran a achrt en Ae eto shall'be refe eC o perem ash Cgri a h s""A +�ayT
ak`PLEASE,READLLJfERMS AND+GONOfT{pNS ON THE REVERSE 310E DF TFiIPAGE AND KO!{OwiNGPRGES BEFORE SIGNING ^6`
a: INSTALLATION STREET ADDRESS / , '.` - - CITVr 'STATE ZIP
m. i j
1-4 4
( . ._`�_ )0 6J.
1 1
., 30 a
t ,� �x '%, t a.b. "`"•;" T ,. � '� by - r f£
•
iT kf ^mi 4axu, 4, vr.'gym', �(.,r",�'f�a 5.�0� # T/;t �%�w •t' t..r 31"¢} �_ �� tly+'T k"
r^ : s:$
y Contract Totals=
Are permds•requlred for this installation?: [ ]Yes [ :.] No, 'applicable tax included ¢k 7 ] l;
!NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet Renovate Right Important Lead Hazard information forFamil-
+d x (es;Chdd Care°Providers and Schools.By signing.this:Contract-Customer acknowledges having recefved a copy of this pamphlet before work'liegan,<
informing Customer of the potential risk of the lead haiard exposure from-renovation activity to tie performed in Customer s dwelling unit
Work is to�. oT,"nae upon reasonable availability of Contractor and/or availability of any spe al rder or custom made,Goods which is ai�hcipated'
to_be !C. -[fill m 2 in d date].' Estimated completion date is - i [fill ate]/
Said estimated substantial oompleton date is not {of the essence.,Contingencies that may materially change said esti 9mated completion date follow c'
)-(if applicable.insert a statement of such'contingences)
4 IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. ' r`* A t
i CpMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL�EXCEEDS$1,000.00:,p�, n.t.
Customer to Pay in Full, OR t ?' [ ]Customer to use the following payment schedule.
fa (1)-De6osit $ a + to be paid upon siging contract.Deposit should be 1/3 the total contract price;.ana d '
i fY (2):Payment of$ s T ® " to be paid anytime after this Contract is signed and before commencement of installation 1/1Ne authorize Lowe s
I} to do one of the fur ollowing(check appropnate box below): 5 ;1 t, t.,t"+1 ?w a
[ ]'Charge my/o credit card for the,amount of the payment'indicated above anytime after the date this Contract is Signed;
;! Or. `@ e r ;fit .: ' a P= 5 ` ,� "`•« F t i y t F ,_ .a {
[ ]Deposit my/our check for,the amount of the payment indicated above anytime after the date this Contract is signed and( , tY:.,
(3)5nal payment of$100 00 to be paldupon.completion of the installation and both parties satisfaction F t'• 1.a-[ t, .; n •'� t,
i NOTICE REGARDING ARBITRATION AGREEMENT FORS v 41M COVERED BY M G L c 142A ,.; c Y s -s 1a� ,f, t,a4 yt3:,,,,y S`; >t ,i
LOWE S AND O,WNERWEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HASH DISPUTE.GONCERNING THIS CONTRACT,�THAT
LOWE B MAY SUBMIT SUCF99ISP//UTEtTO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF?HE EXECUT
` i ( IVE OFFICE qE-GONSUJNR AF�F-AIRS.AND BUISNESS REGULATIONS AND THE OWNER SHALL BEREQUIRED.TO SUBMIT TO SUCH ARBITRATION'
# 't'` 'A PROVI ED'IN3'k ` i ' • _. I p' x • "^!+xu tt,, ,s- ' E
, + 1
—�—rr' Date�� / �( s aC T '+M v'"
^`I Lowe omdleen fs Ince s a , ` - ' ,,
`yrp t f !'J IY a f } /° 0 �. �5+
�
% hrzi. .r_..rze....e.m.wawe.�7ae..,af..sxn�.w..:e r..,v. _..aaa+,.a.a. s •Y'.r. =...mina<..a =v.�+e.�naa ma.s - ",Y A "r ' 4: 1
.._ f-�,�
Contract Total 4 0
I At tax included d/0 z
Are permits required for this installation.: [ ]Yes [ ] No 7 v
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pampiet Renovate Right.Important Lead Hazard Information for Famil- #
les, Child Care Providers and Schools.By signing this Contract,Customer acknowledges having receivede copy of this pamphlet before work began
.informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit
Work is to commence upon reasonable availability of Contractor and/or availability of any special.�rder or custom,made Goods which is anticipated
to be +�/-r>i: / [fill in date]..Estimated completion date is J2;f�1 y •- [fill in date]. %J•;
Said estimated substantial completion date is not of the essence. Contingencies that may materially change said estimated"completion date follow:
(If applicable,insert a statement of such contingencies).'.
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. .. -
COMPLETE THIS SECTION.ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: '}:r y ••,+
[ ]customer to Pay in Full; OR ' [ ].Customer to use the following payment schedule'
(1)Deposit $ - ` .to be paid upon siging contract.Deposit should be 1/3 the total contract price;and
(2)Payment of$ - `%to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's
to 0o one of the following(check appropriate box below): .
"[ )Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed,
[ •]Deposit my our check for the amount of the payment indicated above anytime after the date this Contract is signed;and r _
(3)_Final payment of$100 00 to be paid upon completion of the installation and both parties'satisfaction.
- ; .
+ .NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142A '
LOWE SA ND,OWNER HEREBY MUTUALLY AGREE.IN ADVANCE THAT IN THE EVENT LOWE'S HASfA DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S MAY SUBMIT SUCH`DISPUTE TO PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY.THE.SECRETARY.OF THE EXECUT-
IVE:OFFICE. F.-CONSUNIER AFFAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PROVIfSED IN M G L c 2Af ,
��' ir�i" i l •s Date/a d�z�,O r a"
�.
22` + .L owe'
�s, onla'2' n/tefs Ina'/
o d By. `h' �.e6,� �.I/ iSd " 57ke,•ri+2si . ;t 4 Date,;./s` /sl t �e
i is Owner gnature t-#4ae.';df i, �P}
THE'SIGNATURES Or,THE PARTIES ABOVEAPPLY ONLY TO THE AGREEMENT OF THE PARTIESTOALTERNATIVE DISPUTE RESOLUTION INITIATED "�li
BY LOWE'S,PURSUANTTO M.G.L.c.142A.THE OWNER MAYBE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE"THE'""
SECTION ABOVE IS N07=SEPERATELY SIGNED BY.THE PARTIES.
DO NOT'SIGN THIS CONTRACTiF THERE ARE•ANY BLANK SPACES AND UNTIL YOU HAVE READ-THE TERMS AND
CONDITIQNS-CONTAINED OWTHE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS,CONTRACT
'BY SIGNING,BELOW;YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND ANDAGREE;TO THE .`,
< TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF.THIS
` CONTRACT YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. a
ut WITNESSOURHANDT§St AND SEAL(S)'BELOWTHIS .er . DAY OF ���t /`- '•' >; GIf
Lo
so- +r i
we s Horn ers fnc
i
�at° i�. �i"?-i .,� # 7,.? `* i'; �„' ���i�!< •. i�` ��'x"c r t � � +� t � ; "
S ec-i"list or Atitiv� r tr - r t
+. .., P r„ Spouse:Yt ez- r z
s Customer acknowledges receipt of a true`copy of this contract which was completely:filled in prior to Customers execution hereof;You tfie-buyer,"may
a 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•t
i form_for an explanahon of this right. Z
"A" E4 "s ! •r c F k' 7 ..x i2064 owe the
¢ @ t z p02004 by�owe's®Loaves and F.Corple design
tion.
+ �3 EXTERIOR SOLUTION GENERIC Rev'12/09 FILE COPY rg, isye �e tF corrorenon ,.
( ) S`�F
_ The Commonwealth of Alassachusetts
Department of Industrial Accidents
Office of Investigations
i-t-{ 600 lVashington Street
$oslon, 41A 02111
www.mass.go)ddia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plumbers
Applicant Information Please Print Leaiblv
Name(Business`Organization%Individual):
Address: y
city/slate/zip: �c �.- b' i Ea 7 ' ?
_. - -��, ._— 4-- - 1 hone - �-
Are you an employer'.'Check the appropriate box: Type of project(required):
I 1.❑ I :nn a employer tritlt 4• ❑ I am a general contractor and I
employees(till)andior pan-timer have hired the sub-contractors 6. ❑ New,construction
� _ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ g Remodelin
ship and have no employees These sub-contractors have y
8. ❑ Demolition
working for me in any capacity. employees and have corkers'
I No workers' comp, insurance comp.insurance.' 9. ❑ Building addition
required.1 `- ❑ We are a corporation and its 10.❑ Electrical repairs or additions
J.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself: INo workers comp, right of exemption per MGI.
insurance required.I c. I i2.§1(4),and tte have no 1_.❑ Roof repair.,
employees.I No workers' I;.❑Other——_--_-- ---_
comp. insurance required.)
':1m :q+pfrm!:hat check,M+,�:I must:dw!Iili om d::section hclue.,hna in_their ttorl:nd annpa!eatwn Ixdiq inli+rmation.
Honwoans>ttho>uhmil i§i,aliidm it indicative that are doing ail ttork and Own hire tnn.cide conlractors nmst uhmh a nett aftidutit indicating.such.
Contractor•thin sleek this ho+ nn!et ahadled=additional.h,ci.honims nw name of Ole wh-com:aetun and>4na tthether or not Chow eatitic>halo
emplo}cc+. If tiw:uh-en...'"or,hoe employee..dtcy n;:m nrmidc their %corker;romp.polio numhv:.
I am an employer that is providing workers'compenwtion insurance for iqv empigrees. Below is the police and joh site
infornradorn.
InsltranceCompam Name:
J -
Policy or Sdf=ins. Lic. ::_ =�1 ' __.. - Expiration etc:_
,lob Site Address; �' Vlt I I sun'{ City/State/li a i 916
_. -- _ _... . p:---------x —-
Attach a copy of the workers'compensation policy declaration age(showing the policy number and aspiration date).
Failure to secure coverage as required under Section 25A of MGI.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 Iinm of a STOP WORK ORDER and a tine
of up to$250.00 a day against the violator. Be advised that a cop)of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereh)•cerrify under the pains and penalties of perjure•that the information pruvided above is true and correct .r
Signature: .-.. r:�._>. .. F _ _ Date: _
Phone--.__ ( I :r Gt•G -
Official use only. Do not write in this area,to he completed br city or town nffnc•ial
City or Town: Permit/i,iccnse#
Issuing Authorih'(circle one): ,
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#•
ohs f^[.nxm,Gscner,�f4 , l�ii: rl,.[..rl2t
- Board of Building Regulationsf and Standards t
� License or registration valid for:rt.is tdul use on
lyC HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
tz' Registration: 163105 Board of Building Regulations and Standards
.Expiration: ,577 V2011 Trp 2846442 Boston,Ma.02108
One Ashburton Place Rm 1301
Type: Prvate Corpc nratlo
WINDOW CHOICES INC
'VINCENT KI.ROW '
'. AUBUNN CT. e..'yy,,,,�
SAUGUS. MA 01906 Adminisrratnr Not valid s%ithout.signature
' 't rrnt+=nt F Public' -tii•ts �} , ° ��.—�`
R;.'tu! rr1 &uildin� Rt ul ttiure. -tn11 Ji'atf„Ct1Ur U PCf' $n. C ii,.invurds
trense: ^S SL 99770 - cer,se
Rest-Med to: RF,Wg :
1 'aJ 7
VINCENT KILROW
1 AUBURN �ur 4 COURT
SAUGUS, MA 019t)r ' � �,(i14 12-2
s
—�- n:
$�1i.aay 5 q
_—�'-- ' Expiratio 12/27/2012
t ,nmrn�u.n..r 0t9962198' .,,: .
Tr 99170 ro-v'7in
F
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massa*setts 02116
Home Improvement Q Wtor Registration
Registration: 163105
e Type: Private Corporation
WINDOW CHOICES INC " Exfliration: 5/1 112 013 TrN 217575
VINCENT KILROW
1 AUBURN CT. ---
SAUGUS, MA 01906
Update Address and return card.Mork reason for change.
oPS-0At 0 iou. J Address '-! Renewal [ Employment _ Lost Card
�L\ Ortice of�onaomer Tfave'&��eioesa� Ili License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Ragrstration 163105 Type; Office of Consumer Affairs and Business Regulation
Expiration _V1112013 Private Corporation 10 Park Plaza-Sutte 5170
W CHOICES Boston,MA 02116
17dtr :,.::.
VINCENT KILROW
AUBURN
S 019m
AUGVS,MAA 01906
Uaderaecrelary Not valid without signature
• 05/17/2011 11: 57 7813958083 INSURANCE:AGENCIES PAGE 01
CERTIFICATE OF LIABILITY INSURANCE I naval mccm'Y"
04/19/2011
THIS CERTIFICATE IS +ISS AS. A,- MATTER_OF I R NATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES ,NOT, CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE C11"FICATE'HOLOER,_
IMP c Date aR UREO, the cy must be Hiclowised. If SUBROGATION , subject l0
the (alma and condbbna of the policy, certain pollcin may require an endorLemem. A maburo d on this csrtXkate doe, rmt confer right, To the
certBcete holder In IISM of such mclorsement(s).
PRODUCER
RAJ-PH J. QUINN INSURANCE A(ENCY � NAME RALPE J. QUINN
jA/CNv.Evl: 781-395-8400 ,yG N,1781-395-8063
15 MAIN STREET ADORES,: RJQUINOWSURANCUNETSCAPE_NET
NEDF'ORD, MA 02155 'PROoucER __ ._....___._-- ___..... _--...—...__. ... ...._........
cusroM_Ert 1DR _ ----
_ ,^��. _ IN911RER(e1gROROwG CDVERAgE NyC•
WINDOW CROICES INC_
imstAERAFIRST_FINANCIAL. INSURANCE COMPANY
IwuRERBPLYNOOTR ROCK ASSURANCE CORPORATION
1 AUBURN COURT ---
IxEIIReRe
SAUGUS, NK 01906 INSURERo:
INSURER Es
PrSUAERC •.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO 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 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 CONDOIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS.
LTR TYPE OF IN,URANGE Wbi yWD P YNUMBER IMMOO/+YW) (NNIDNYYYYI LRMe
A GENERAL UAaurY 491FOO5623 04/27/10 04/27/12 EACH OCCURRENCE s_300,000DIatAGE TO _
X COMMERCIALGENERALLIAeILITY 491FOO6099 04/27/11 04/27/12 PIE.Ma) _
3100,000
CWMSMADE COCCUR MEDEXP(API'.W..) r �5,000
,,- PERSON Ala ADVINJtIRY 000,000
GENERAL AODREDATE s600,000
GEN'L AGGREGATE LIMIT APPLIES PER ppgpUCie-COMp,OF pGo 5600,000
X Pf Icy : TO-
JECT LOC S
A AUTOMOBILE UARILITY ,:OM&NEpaINaLE LIMIT
A.ALTO
'I LONNED AUTOS "LY IWURV LeerP n)) 100,000
1 eoaLV IRnIRr lPereccMam) s 300,000 ...�
B X SCHEDULEDAUTOS FMOOOOI163343 01/12/11 :01/12/12 P-OPWY—D"PE
A X HIREDAUTOS 491FOO562-1 04/27/10 104/27/11 IPma ww) s 100,000
A X NON-OWNED AUTOS 4917006095 !04/27/11 I04/27/12 5 300,000 _
AGGREGATE s 600,000�
uMaaeLLA Las a-cuR
EACH OCCURRENCE i
EXCESSUAB -•.CUIMGMADE AOOREO/,TE _ $y^•.
OEpUCT1,LL' E
RETENTION 5
9
ANDEM SCONw Uuu ION
AND EMPLDYERe uA TNER YIN -, TORV LIMITS ER
ANVPROPRIETORJ EXCLUDR.EXECUT)VE EL EACH ACCIDENT �s
(bo D nAEM MI EY.CLVDED? ❑ NIA
(MVMrb,y In NMI I El DISEASE-E4 EMPLOYEE IS
I Ey PI TIONOFQ
DESCRIPTION OF OPERATIONS I`Aldv E.L.DISEAeE-IA]LICV UMR 2
OEecRIPIION OF OPERATIOIre I LOCATIONeI YORDl15 IA(MP11 ACW W 181,AOGIeonY Re Mrte 6crodu4,d men yeee N roq WIT!)
LONB'S COMPANIES INC, AN) ANY AND ALL SUBSIDIARIES ARE NAMED AS ADDITIONAL INSURED
AS RESPECT TO aENFJ kL LIABILITY AND AUTO LIABILITY.
CERTIFICATE HOLDER CANCELLATION
LOWE'S COMPANIES INC.
ATTN: IS INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WALL HE DEUVERED IN
P. O. ROX 1111 ACCORDANCE MTN TN LICyPNOVISIONS-
WORTH wILEESBORO, ITC 28656
;AM�Dpcppc Af®t AC RD N. All rights reserve
ACORD 25(2008lOS) Tile ACORD name and logo aed marks of ADO
\ J1ee �o n...io�u+.ral!!c o�.��aaoar/u eecla
Office of Consumer Affairs&Business Regulation -
.OMEIMPROVEMENTCONTRACTOR
Registration 1,48688 Type
ExpiraE7gft 40/48/2013 Supplement
LOWE'S HOMES'GEiJ�-f INC,
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RICHARD CHALO„NE
136 TURNPIKE RD'.StJtfiE 100
SOUTH BOROUGH,MA-01772 -
Undersecretary
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