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41 HARBOR ST - BUILDING INSPECTION / The Commonwealth of Massachusetts' r/.11 i:,• I,W Department of Public Safety :\1.1 ss.11 husrtls"late Bu lldml;Code(i 811 C%I R) dd Building Permit Application for any Building other than done-or'Two-Family Dwelling (Thin Sk•dion For Official Use Only) - Building Permit Number: Uale Applied: ._ __ I Building Official: SECr10N 1. LOCATION(I'lease indicate Block #and Lot#for locations'for which a street addieas is not available) o No.end Street _ City/'town Zip Code Name of Building(if applicable) - SECTION 2:PROPOSED WORK _ Fditiun of MA Slate Code used If New Construction check here.❑or check all that apply in the two nncn helow , Existing Building❑ 'ReF+air Alteration ❑ 1 Addition O Demolition 0 (Please Till ntit an.l subnut i(ii•niIisI) ' Change of Use . ❑ Change of Occu�,,mcy . ❑ Other ❑ Specify: Are building plans and/or colnstrllChUn dMUIVIClhtl being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Fnginecrin' Peer Review required? Yes ❑ Nu Brief Description of proposed K'urk:_-RemA1Fe/"-t�-,�Q(,�rtf+_A+,,F„--t�—�Z _— -r--• — uror SECTION 3:COMPLE'rE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVA'rlON,ADDITION,OR CHANGE IN USE OR OCCUPANCY ' Check here if an Existing Building Investigation and Evaluation is enclosed(Sec 7&)CN,IR 34).,❑ Existing Use Group(s): __. Proposed Use Gniup(s): SECTION 4: BUILDING MIGHT AND AREA Existing Proposed No.of Flool:s/Stories(include basement levels)Br Area Per Flour(sq. ft.) Total Alva(sq. ft.)and Total Height(k). SECriON 3:USE GROUP(Check as a licable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-3❑ 1 B: Business O F: Educational ❑ F: Fade F-1 ❑ F2 O 1 H: Ili h Hazard H-1 ❑ _H-2❑ 11-1 ❑ 11-4❑ 11-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ NI: i•lercantile O R: Rcsidenttal R-1❑ It 2❑ R-1❑ It-4 O S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use _.. SECr10N 6:CONSTRUCrION"IYIIE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑t I IV ❑ 1 VA ❑ VB ❑ SECITON 7:SITE INFORMA rION(refer to 780 CMR 111.11 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: 17ench Permit Debris Removal: Public Cl Check if oul.side Flood Zone❑ Indicate municipel❑ A trench trill not be Licensed Dispus,ll Site❑ Priva •te 0 ,-;,or.indentiln' Lune: nr nn life system O required O or trench or.pecifv: y d --_—_— permit isonclu,ed ❑ Railroad right-of-way: Hazards to Air:Navigation: Not:\pl+lical+r❑ Is tilructure+e ilhin airport ipprnuc llow,l' Is their rev w%% completed'h, or Gulsenl to Mold enc loved❑ - l us O•or No e' to,O \o 0 .. SECT ION a:c'ON I I:N"r OF c'IarrlrlcArE Or•OCCUPANCY I!dition nl Code: ._ ._. ._ L'se Grnnp(n): _ _ . . I%rvol C'lm,lrmIwn: lh++up,un Load per I tenor: I+or, the Imilding cwilain in sprinkler Sh,lour _ tipcc1,11 Shpnlatirnu: . .. SE(`I'ION 9: PROPERTY OWNLR AUl'IIOI(IZA'1 ION \.uuc mtd Address of Property Otaner — - — -- __�-ian4_�lr 2rpan _-411- WaLr6ar 5}• 5giem --- -- ----- 0�97° INanIC(Print) No.and Street City/Town Zip PropertV Owner Contact Information: ©wn•�!- 91Y- 515-- L!23 I itle relephone No. (business) Telephone No. (cull) a-mail address r If applicable, the property owner hereby authorizes 1.� Ric6rd C.6,10ne- _I TV rn^1-��{ �1 573'rl f0 h Al it 0177a Name Street Address City/Town IState Zip to act on the property irwner's-beh;df; in.all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 1f building is less than 33,00)cu.ft.of enclosed s+ace and or not under Construction Control then check here D and skip Section Ill.l It).1 Registered Professional Responsible for Construction Control Longo Mare -Vnpra ove 6Il 351-,,?0 Nance(Registrant) t6 �6hQephone No. a-mail address Registration Number t3G Tlrinpnke Qd, 56ji-Wobralk 4Qf _Ot�7a /O /� / Street Address City/Town State Zip Discipline Expirahun Date 10.2 General Contractor Lowey uomf- 3:"p, r.rni- MD CanS+r,;Jiah company Name /"Mch 41e/1-4 1 1°/3 /13 Name of Person Responsible for Construction License No. and Type if Applicable Xz 2r,K441 t& Sales-, / 0/ 976 Street Address City/Town State Zip Wrq 77—spy Tale,hone No. business Telephone No. cell c-nail address SECTION 11:tut.Il F l t , t-t_Mi t\::v ON l tr1_11 stun M.G.L.c.152.§ ZSC 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial o th•issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yeg No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT fEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)�S_ I. Building S 76 Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical 5 i appropriate municipal factor) -$ 3. Plumbing, 5 �. \lah•mical (I-fVAC) S Note: Minimum fee'S (iontact municipality) 3. Mechanical Other $ (1� ,�j.lj. F.nac chock payable to ` `S e 6.Total ,�i Cult S �..Q� (contact num - iiipality)and write check number hef-vn -----_—___ SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Ilv entering my name below. I hereby a0e.st under the pains and penalties of perjury that all of the information contained in this applii,Ition is the and aiaur.du to the b st of illy k i vlrJ};e and undrretanding. ---- ------ - Plt Ise print anJ sr•n moor Di 1 ille It hone Nu. Date l'v6 -TVfnQt RQ.. . . . -- f`�'`'M�r°��11 d1 4 U! 7 �Ireet Address Cit%,rot,it --- State %huaieipal Inspector to fill out this section upon application approval: / �- _ — — _ --Name -- -- Irate_-- CtTY OF S'UZN(, NEUSACHUSETTS t3t.u.ocvc DEptA'n�vt I'0 W,UH[VGTON Sr"JIT, Jw FtOOR rtL (973) 74S.9591 KIMBERf Y ORMOLL F.Vt(978) 740-9846 .titAYOR rROMU ST.PMM4 Dfxscrclt OP PLOUC PIIOPlR7'Y/9t:M.00JO COSCkfIssjONEx Construction Debris DIIPO531 Affidavit (required for aU demolition and renovation work) In accaniance with the sixth edition Debris, of the State Building Cade, 730 CMR section I and the provisions of MOL a 40, S 54; Building Permit a is fro issued with the condition that the debris resulting m this work shell be disposed of in a properly I 11, S I JOA. licecsed waste disposal racility as defined by,bICL c The debris will be transported by; 04me of hauler) Tha debris will ba disposed of in t&. V', (name Offacilify , w to lV ll/reur c(� lS3 �1a� SI Daxtvef� Wdrtir fn�N�aufpermitiPPl` I"nt— -- CONIDOAM%UIMPERMISSION iLM FOR BUILDING PERNIIT We; 6� STS Ti3Y1 /a'J�Q 0 2zj d [Name of condo association o4ffafiagerftent.corfipan address being the duly authorized representatives of �xlie ODE gain e of condo association have reviewed the plans and specifications for improvements to y f '11 r ber e,!4 . kddress and number of condo unit owned by ! ' !u Name of condo owners Revm��/replace Oew�+rn�r �r The condo associ Lion or management company agree that the above owners.have permission to k permits and o carry out the proposed work. Qimwvr6orcond6idbMtionr resentltive and Ode Print Name . (In lieu of this form,a letter,stating the same'.purpose is above,.on the,condomin um or management company stationary,-may be submitted.) U t Z lOZ-LO-£0 60 S5 41 NOIS3M N30018 Sb19-9L£-L29 STORE COPY INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR LOWE'S OF DANVERS, MA., STORE# 1094 STORE PHONE: (978)646-9099 153 ANDOVER STREET SALESPERSON' EDWIN VELAZQUEZ DANVERS, MA 01923 SALESPERSON ID: 794346 Document Print Date : 02/28/2012 This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree- ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any other addenda or attachments hereto, shall be referred to herein as this"Contract." PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING. Lowe's Registration or Contractor License Number/Lowe's Contractor Name Lowe's Home Centers, Inc.'s MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN: 56-0748358 Customer Name Home Phone S DIANE DEGUZMAN 978-595-6123 Customer Address Other Phone O 41 HABOR ST, UNIT 4 L City State/Province Zip/Postal Code D SALEM MA 01970 Installation Address r 41 HABOR ST UNIT 4 r1nstallation City Installation State/Province Installation Zip/Postal Code 0 ALEM MA 01970 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY 1046 : 87544 : STK : 1 X4X4 RED OAK BOARD : 1 X4X4 RED OAK BOARD : BABCOCK LUMBER - QTY 1 18302 : STK : PNE CASE 351 2-1/2X1 1/1 6X8' : PNE CASE 351 2-1/2X1 1/1 6X8' - QTY 3 131207 : 131207 : STK : 1X8X16 PRIMED FINGER JOINT : 1 X8X16 PRIMED FINGER JOINT : IRVING FOREST PRODUCTS (MAINE) - QTY 2 228473 : BMTTSFG1 130RBM : STK : 36" BMTT 6 PANEL FG SMOOTH RH : 36" BMTT 6 PANEL FG SMOOTH RH : TRU LOGISTICS INCORPORATED - QTY 1 Materials Price $ 279.82 Store. 1094 Prc:jeri No. 347E;36916 for DIANE DEGUZIVIAN Page 1 of 7 STORE COPY INSTALLATION DESCRIPTION Stock or SOS : Stock Door Type : Exterior Select Location : Front Door Select New Door : Single Pre-hung Number of Doors to Install : 1 Side Lights or Transoms : No Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : None Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No Install Storm Door : No Lead Safe Practices : No Total Linear Feet of Custom Trim to be Installed : 0 Deliver Door : Yes Customer Understands Scope of the Project : Yes Permit Required : No Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None Local Disposal Fee : Yes Describe Other Work Needed : b-out jamb.....[4th fir] all stairs Other Work Charge : Yes Comments : stock door fiberglass Labor Charges $517.00 Detail Deduction -$ 35.00 Additional Specifications: Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop- erty is governed by Historic District Regulations. Additional Specifications:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a 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. TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES 'where applicable SUB-TOTAL $761.8 'TAX $ 0.0 DELIVERY $ 0.0 ORDER TOTAL $761.8 BALANCE DUE Page 2 of 7 Store 10�34 Project ofect No. 34/636916 for DIANr_ DCGUZIUTAN STORE COPY Work is to commence upon reasonable availablity of Contractor which is anticipated to be [fill in date]. Estimated completion date is [fill in date]. NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom- er. IF T E CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full. ,COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1.000.00: JzJ Customer to Pay in Full; OR L] Customer to use the following payment schedule: (1) Deposit$ to be paid upon signing 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 do one of the following (check appropriate box below): [_J Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [_] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and (3) Final payment of $100.00 to be paid upon completion of the installation and both parties' satisfaction. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON- TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON- TRAC/ , THAT LOW``EyS MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET- MIRT f FSUCHA 131TTAT16�AS PROVIDED IN MEG.LFc.i 2A RS AND BU INES REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB- g �y< %l�f / f,L Date: — _� L7owe's Home Centers Inc i Store 1094 Project No. 347636916 for DIANE DEG UZMAN Page 3 of 7 STORE COPY y: 71t,. Date: / wner By: Date: Spouse THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT QIF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY I OWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. WITNESS OUR HAND(S) ANC SEAL(S) BELOW THIS - DAY OF Lowe's me Centers, Inc. i r ^—'� f By ��= 7i ----------------- (Seal) Print Name: -� / (Seal) Address / YJwner city State/Province Zip/Postal Code Print Name (Seal) Co-owner or Witness Print Name Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of this right. Store 1094 Project No. 347636916 for DIANE DEGUZMAN Page 4 of 7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass'.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N aloe l BtuinessiU1 gan i/aI it)Andic i(It al) :-_._�1�4�� Address: 5 tals-61 City/State/Zip: Wern , #14 Olf70 Phone#: 745 -534y Are you an employer?Check the appropriate box: Type of project(required): I. - I am an employer with_.. __ 4. ' 1 am a general contractor and 1 6. -1 New construction ��`111 employees(full and/or part time).* have hired the sub-contractors 2. y 1 am a sole proprietor or partner- listed on the attached sheet. 7 Remodeling / ship and have no eniplovees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. ' 9. ..1 Building addition requit-01 5. 1 We are a corporation and its 10. I Electrical repairs or additions 3. 1 ain a homeowner doing all work officers have exercised their myself [No workers' comp, right ofexeniption perm MGL 11. -1 Plumbing repairs or additions insurance required] I c. 152. § 1(4), and we have no 12. -1 Roof repairs employees. [no workers' comp. insurance required.] 13. -1 Other_ __ :\ny applicant that checks box AI must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this afftdmil indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box nest auacb an additional sheet showing the tame of the sub-contractors and state whether or not those entities have employees. If the sub-contractor s basic rmplovecs,Ibe,.oust provide their workers'comp police number. I urn an entplgver that is provident;workers'compensation insurancefor my empkgvees. Below is the policy and job site ill f n-Inatian, Insurance CompanyNanie:— p( l¢�h� r$nit?-COYYI�g(1�t_-- - -- — Policy 14 or.Self-ins. Lic. 4:_.__VJrj 1 a7,316 Expiration Date: It/17 la _ .lob Site Address:--------��-- [�r�o( _ 1 City/State/Zip:__5%1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (date). failure to secure coverage as required wider Section 25a of MG 152 can lead to the imposition of criminal penalties of a tine Lip 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. l do hemp cert/iif/�/jr�undCr thins/and penalties of'perjury that the information provided above is true and correct Si ncrane: l - y s- Date: Prim Nuntc��Q e' }�1_>re l Il� _ Phone#, 17 Jt'" 7./5- S 3L y 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): I.Board of Heath 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone#: ftn,wd of 840(filly k "i'Lllllm' ,ji';) G1;imLAIA' WCHAEL'I DEMILLE 5 BRISTOLST SALEM, MA 01 97D OMW use or Lim registration valid for individal use only s-- .ZFlOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to. Registr&Wn: .162722 Type- OM"Of Consumer Affairs and Badness Regulation ...... ExPic3dom: 4WO13 Individual 10 Park Plaza-Suite!5170 MfdAAEL THOMAS DEMILLE Boston,MA 02116 WCHAEL DEWLE 5 BRISTOL ST SALEM,MA 01970 Not Valid without signature Office of Consumer Affairs&Bns'n OME IMPROVEMENT CONTRACTORType Registration 1gg666 Supplement EXpiratf" iotl8I2013 LOWE'S HOMES GENE IN G RICHARD CHALONE 136 TURNPIKE RD.WOE tflo. SOUTH BOROUGH.MA 01772 Unders ecretarY NHkkPITE IPl' URRI'•ICE Fax:9785315587 Jan 20 2012 17:29 P. 01 r From New England Excess Exchange 1.800.347.4935 Thu Jan 19 13:30:10 2012 MST Page 1 of 1- A4U � CERTIFICATE OF LIABILITY INSURANCE DATE(MKDDftYro o1/1912012 CERTIFICATE CERTIFICATE IS ISSUED IR A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS'UPON THE CERTIFICATE HOLDER. THIS THISCERTIFICATE ODES 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(S), AUTHORIZED REPRESENTATPJF OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the eertlficRR holler is an ADDITIONAL INSURED,the policy(ies)muss ne endorsed. If SUBROGATION IS WANED, subtoet ro the termS and conditions of the Policy,certain policies may require an endorsement. A statement on this certificate doss no[coMsr rights to the certificate holder In lieu of such endorsements). PRCDpLER COMA NAME New England Excess Exchange, Ltd. Not! PO Box 219 e.MAIL ADDRESS: Montpelier. VT G5601 PRODUCER -- INSURER "PURDINO F6"ETAGE ,^NAICE INSURED INSURER A:INORnianO InsuranCe LJO '24015 Mike DeMllle INSURERS: MD Construction INSURER C: 5 Bristol Road INSURER D: Salem, MA 01970 INSURER E: INSURER F: COVERAGE$ CERTIFICATE NUMBER! REVISION NUMBER: THIS IS TO CERTIFY THgT THE POLICIES . INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. MOTNITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BF ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Nafl. TYPE OF INSURANCE POUCTNUMeER POLICY EYFP MDRlOfVI EXP lJRllrS A GFrvERAILWbILITY WS127316 EACH OCCURRENCE $ 300,000 X COPMFRL`JYOENF_Pq U421LITY I 1t�17i11 11J17�12 E^ E, �R��e $ 50,000 X X CLAIMS_MADE �i VQcUR li MED ExP An alv�Demon) B 5,000 Ji PERSONAL&AM INJURY $ 300.000 -. GENERAL AGGREGATE $ BOO OnOnO � EEIV'L AGGREGATEUMII APPLIES?ER: PRODUCTS-COMP/GP AGE $ 600,000 X POLICY PP.OT LOC S AVTDIdCBIL°LIARIDIY OOMSINW SINGLE LIMIT ANYAUTO (EgacmgM) AUOWNfOAUTCS EODILY INJURY(Per pvrsan) $ SCHEGULEDAUTOS aLl'INJUNY(PRrygidmt) $ HIRED AUTOS 1 gr accidel%)AMA(3E S NON-OWNED AUTOS S I ' UMBRELLA LIAR CCOUR - EACH RiLT1RftENCE $ EXCESS LIAR CLA..LPMADE AGCREGATE - $ UEI1cCTIaLE s I RETENTION $ WORkEPLOYE LI AnON WCGTATU. OTH- AND EMPLOYERS'PARTNrTY E OFFICE PRIETORPARTNERIF.XE4U'flur YIx OFFI�C�EWM in NXR E\CLUDEDT xlAl EL.EACH ACCIDENT 5 Ma, Y I Ny.- d�aibe u��tlar E.L.DISEASE-EA EMPLOYE S DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S I DESCRIPTION OF OPERATIONS r LOCATIONS I VENICIFS (Aaech ACORD IOI,AddMong Remw'Im Schedule,if more spat!le requE I CERTIFICATE HOLDER CANCELLATION Town of Winchester 71 MOUnt Vernon St SHOULD ANYOF THE ABOVE DESCRIBED POUC(ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Winchester, MA 01890 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD