Loading...
HomeMy WebLinkAboutBuilding Permit # 3/30/2016 NORTH BUILDING PERMIT 0. �YLEo ,6 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION •�, Z _ yy J � Z ® moi Permit NO: � Date Received sgcNusE��y Date Issued:`` I ORTANT:Applicant must complete all items on this page LOCATION A� PA PR®PERTYOWNER sC ` �^ MAP NO PARCEL _ ,ZONING DISTRICT Historic District yes no Machine`:Sho Villa' a es n.o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units:" ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other ❑Septic` :01Nell D_Floodplain 0.Wetlynd5 ❑ Watershed District - .❑_Vllater/Sewer ._:. .. - � - - - DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: (,av S;t VfVx 5 Phone: 'PE Fo -0103 Address: Peter Phone ?�`;`tD,-7fa3 'CONTRACTOR Name =_ Address1��® - - �n 71 ra R d, Spervisor's,Construetion License y� d.J _.:. Exp Date Exp Date -�/G Home lmpreygment_License - ARCHITECT/ENGINEER Phone: Address: Reg, No. FEE SCHEDULE:BULDING PERMIT.'$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: FEE: $ Check No.: / r Receipt No.: NO'T'E: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatureof Agent/Owner Signature of contraeter _ . NOown ofR4P-o Andover 2 _ �' 0 IR No. 4A( AxJA 30, - h , ver, ass, ��pA coc"Ic"awlCK 1' S U BOARD OF HEALTH Food/Kitchen MEMEL Septic System 3 BUILDING INSPECTOR THIS CERTIFIES THAT .....r 'ERMIT .. ... .. .....t �r�.................................................... Foundation .. re has permission to erect............... .......... build' son .... ............ ... ... Rough to be occupied as . �......... .... ... *1 ....�...... ....... .... Chimney provided that the person accepting this ermit shall in every respect conform to terms o the applicatio Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Insnectior6AIttgration and PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. - Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ELECTRICAL INSPECTOR PERMI EXPIRES ® T S UNLESS CONSTRUCTION STARTS Rough 1�4.4 Service .................... .. Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit.Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Federal ID 1105-0405629 MS EI Ellgillect-ing RI Contractor Registration No 8106 0 MA Contractor Reffistrarlon No 120979 RISE A division of"I'llic1sch I-Algincering ENGINEERING* 60 Sharivintit Unit 02,Cantorr,MA 021121 CONTRACT 339.502-6335 FAX 339-502-6315 Page PROGRAM THIS CONTRACT 15 ENTERED INTO BETWEEN RISE CMA-11ES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT 0 WORKORDER Laurie Stevens (978)807-0103 03/21J2016 432236 00002 SERVICE 5 T HE ET BI4L1140 STREET 9 I 10 Farnum Street 110 Farrium Street ...................... 7 SERVICE CITY.STATE,ZJP BILLING CIMSTATE,21P North Andover,MA 01845 North Andover, NIA 011345 .1013 DESCRIPTION HAZARD BARRIER:We haveidentifiedthat there arc recessed lights present ill your home,unless the recessed lights are ctild-Eir—'- as 112-rated(Insulation Contact Rate([)we will create it 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,No insulation will be installed across file top and closed cavities which contain recessed lights will not be insulated. $0.00 AIR SEALING:Provide labor and materials to seal areas ol'your home against wasteful,excess air leakage. This work will be perlbrined in concert with the use of'special tools and diagnostic tests to assure that your home will be tell with;I licalflifid level of air exchange and indoor air quality.Materials to lie used to seal your home can include caulks,foams and Other products. Primary areas for sealing include air leakage to allies,basements,allached gari-cs and other unheated areas(windows are not generally addressed.) This will require(8)working hours.A reduction in cubic lect per mirmle(efin)ol'air infiltration will occur,but the actual number orclim is not guarainced. At the coropleliou ol'the Nveartherization Work,laid at no additional Cost to the homeowner,It final blower door and/or combustion salify analysis will lie conducted by file sub-contractor to Ensure file safely ol'thc indoor air quality. $680.00 -T)AMMINU Provide labor Had materials to install a 12"laver of'R-38 unfitced fiberginss batts to(40)square feet for damming purposes. $82.00 Chess I Cellulose added to(984)Square 1�ct ol'opellattic AITIC FLAT:provide labor and materials III install all 8"I.Yeror S1,348.08 ArriC ACCESS:Provide labor and materials to insulate file back ol'(1)attic hatch with 2"rigid Thermax board.Weatherstrip the perimeter. $60.00 M-11C ACCESS:Provide labor and materials In insulate(1) back orthe kneOwall hatch With 2"rigid Thermax board,aand seal file edge of the hatch with weatherstripping, SWOO V i?,rnl.ATl0N:Provide labor and materials to install(1'4 I)insulated exhaust hose to existing bathroom 11111(s). 550.00 Vl.3N"l*ll..A,ri0N:Provide labor and materials,to install ventilation choics in(40)rafter bays to maintain)airflow. 580.00 LLS:provide labor and materials to install 2"FSK Inced semi-rigid fiberglass board insolation to(18)square lcct of common wall area. $63.00 OVE-*R1 lANG:provide labor and materials to install 8"R-28 densely packed Class I(!ellolose insulation to(30)square flect of* exterior overhang located below a hemed floor area,by drilling boles in the Overhang Croill below. I toles drilled will lie plugged. Plugs will be scaled with exterior grade spackle and[ell in n relatively solooth condition.Finish sanding and tolich-up priming/painting ivill be the customer's responsibility. S117.90 Federal ID A 050405629 IZISE Engineering RI Contractor Registration No 0186 MA Contractor Registration No 120979 RISE A division ofThielseli Engineering ENGINEERING' 60 Shownuit Unit t12,CuRion,NIA 02021 CONTRACT 339.502-6335 FAX 339-502.6345 Page 2 I%OGRAM 71:13 CotOTRACT 15 ENTERED INTO BETINCEU fast CNIA-IIES V GINEERING AUDDIE,CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE RATE CLEOTH WORK ORDER Laurie Stevens (978)807-0103 03/21/2016 432236 00002 SERVICE STREET BILLING STREET 110 Farman Street 110 Fftrnuni Street SERVICE CRY,STATF,ZIP BILLING C17Y.STA-Ir-,ZIP Norili Andover,MA 018445 North Andover,MA 018 45 ,JOB DESCRIPTION GARAGECHILING:Provide labor still materials to install 8"It-2S(tensely packed Class I Cellulose insulation to(517)squaw feet of garage ceiling located below a basted floor luea,by drilling holes in the Ceding front below, doles drilled will be plugged. Plugs will be spickled and left ina relatively Smooth condition,finish sandhog and touch-up priming/painting will be tile custouters responsibility. S1,023,66 RISE linginecring will apply all applicable,eligible incentives to this contract. You will only he billed the Net amount. Currently, for eligible measures,Columbia bas offers 75%incentive,not to exceed 52,000 per calendar year,and an incentive oft 00%for the Air Scaling nicasurcs tip to the first$680 and all additional$340 if savings atejustilled by the auditor. For the safety and health of your home's indoorair qualRy,Nve will bt!conducting ,a blower door diagnostic ol'the available air(low in )our home both before the%%-ofk is b"wo,and after lite weatherization work is complete.We will also conduct If lull a."essruent of Ills CORI b list ion sal"cty of)'on r healing system in id water heater.'Phis hits if val tie of S90 and is at no cost to you. Total allowable weatherizalioll incentive is S3,1 10. $570.00 LE D V I E ............... Tota 1: $3,654.64 Program Incentive: $2,770.01 Customer Total: $884.63 WE AGREE HEREDYTO FURNISH SERVICES-COMPLETE 114 ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF '"Eight Hundred Eighty-Four&63/100 Dollars $884.63 UPON FOIAL VISPECTIM)AND APPROVAL BY RISE ENGR(ECRING,CUSTOMS AGREES TO REMIT AMOUNT Due vi FULL,INTEREST OF I%VPLLUE CHARGED NIOUTHLYONANY UNPAID BALANCE AFTER 30 DAYS.SEE RCV0311 Fort IMPORTAIIT ffIrOTUVATION ON GUARANTEES,NIGHTS OF DECISION,5CHEDULINO,AND C014TRAC toll REG 13TRANDI). DO NOT SIGN 71-IIS CONTRACT IF THERE RE ANY BLANK SPACES 2) " Uw4tZ. $10 TU-RE-RISEE, ..... cuTo at AzClC�C_RTI_ANLC\ED J, -?/a It NOTE: CONTRACT MAYBE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE 0 ACCEPTAfWr OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND COU01110un ARE 30 DAYS. SATISFACTORY TO US ADD ARE HEREBY ACCEPTED.YOU ARE AUDIORIZED TO 00 THE WORK AS SPECIFIED,PAYMENTWILL 019 MADEAS OUTLINED ABOVE RISE 60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING` www.RI$Eengineering.com AUTHORIZATIONOWNER I, e 457 'C3 t'- .n �....... (Owner's Name) f owner of the property located at: r //0 (Property Address) m (Property Address) hereby allthorize PC) f&J Gi (Subcontractor) an authorized subcontractor for 115E Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. 5 00 24 1�lb O er's ignature �, t'llpk 11", M -11 'o111. Date �� � �u The Commonwealth of Massachusetts Department qj lndustfial Accidents 1 Con-ress.Street, .Suite 100 Boston, 11YA 02114-2017 d .;1� it-r64'EtCi711l�S.a©i'�I�ItF Workers' Compensation Insurance Affidavit: Builders/(`ontractors/Electriciins/Plumbers. TO BI. FILED NVITIi"HIE Pl:.IZ.,M1"I TING.AVT110RIT1. Applicant Information � Please Print Levibly + Name (f3usiness'()rgani auon�lndnr(Iual): //b �Gr( �t°Gi r T711sy/A-Mo M C O> ID,C Address: P 0.1 90 x �S Cjty/State/Z.ip:_Ph do✓-er, moI , o4lo Phone 4: \rc}ouan emplo,er°('heel:the appropriate boat T1 pe of project (required) 1 t am a cmp1mci X\]III rmpio}res(tldi and'or part-time)' 7. Q Ne\V construction '_ 1 am a sole proprictot ur partnership and have no emplo\ces v cukmg lou mem S. FIRenlodelin an%capacit\ [No\\arkers'comp insurance required) 9 ❑ Demolition 1®i am a homeon\ner doing all\\-ork im self [Nu\\orkers'comp ursuranee required 1' ]O ❑ }3uildingaddI Ion d ❑t am a homeo\\net and\vdl tic hiring contractors to conduct all\cork on m_s property I-ll ensure that all contractors either have v.orkers'compcnsauon imurance orate sole I I Electrical repairs or additions piopnciors with no emplovccs 12 Plumbing repairs or additions I am a general contractor and I ha\e hired the sub-contractors listed on the attached sheet 13 F-1 Roof repairs l'hcse soh-contractors ha\e empio\ee:and hace\corkers'comp insurance 1-1Other i,❑WC arc a Corp,natron and its uliicers ha%C escrciscd their right of csenrption per NIGI c I j?.;II�'i.and\ce puce no cmplo\ccs 1Nu\corkers comp msurancc rcqutred 1 am :replicant that chccks hos�I must also fill out the section helo\\shoving their\\orkers cumpensatdnr pohc\ miixrnation ilonteou'ners\\Ilo submit this affidavit mdreaumz theN are dom-2 allwork and then hit outside conttactots must submit a ne\\aifhla\it indicating such =('ontracturs than checl:this bus must atI3ChVd an additional sheet sho\\in the n nx of the sui,-conuaciuts and.;talc\\tuthcr or nut those entities have emplu}'ccs II the sub-nrntracturs hace ernplo\ces,the\ must pro\ide their \\takers'comp pollcN number f 11))1 ail eny)10)-er thtit is p i-o v;dh ig wo i-k e i w'e o mJ)e nvitio 11 invirrance fo)•H11,eniplvl•ees. Be1ml,is the p0liel-andjoh site informatiom Insurance Company P(tlict # or Self-itis Lic 7 )D W Co 7, c�; Expiration Date hl d11Xe?0 7 Job Site Address City/State/Zip /1 , 1�h0►®✓�� Attach a cop) (ifill police declaration pake(sbow'ing the police number and expiration date). Failure to secure coverage as required under NVIGL c 1S'- §25A is a criminal Violation punishable by a fine up to $l,500 00 and./M one-year imprisonment-as well as civil penalties in the firm of a STOP kV0RK ORDER and a tine of up to S250 00 a day against the \ic)lator ;\ copy of thu statement mai he forwarded to the()Rice of investigations of the DIA for insurance coverage verification. !do herehl• c•ertifi'im(ler the pains anal penalties of perjug that the hiforinatlon provided abot'e is trice and correct. Date --- Phone r: Of ficial tese onh. Do not wrile in this area. to be comj)leted bi ciO•or to)t')1 Off cltll. Cit% orTown:own: Permit/License ti Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityffoifn Clerk 4. }Electricni inspector S. Plumbing inspector 6. Other Contact Pei-soil: Phone#: q ®® DATE(MhVDD/YYYY) 1 CERTIFICATE OF LIABILITY INSURANCE 3/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Linda BO danowicS NAME: - Insurance Solutions Corporation PHONE (603)382-4600 FAX No):(603)392-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A Mestern World INSURED INSURER B Naut1lus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1632326134 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMWWYYYF MMm�YYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE a OCCUR PREMSES(Eaou ante) $ 100,000 NPP8274967 3/24/2016 3/24/2017 M ED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JECT '.. X POLICY❑PRO-- E]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 '.. OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS '... NON-OWNED PROPERTY DAMAGE $ '.... HIRED AUTOS AUTOS Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 '... B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 '.. DED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- '.. AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ThielsCh Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/?01401) POLASEA-01 JONEILL CERTIFICATE KATE OF LIABILITY INSURANCE F. DATE(6120 6YY) 1/6!2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: _ _ Durso&Jankowski Insurance Agency PHONE /978 688-700D �FAx 978 _ 11 Saunders Street A/c NNoo_E�_\ .__) (ac,_No��)688 7001 North Andover, MA 01845 E-MAIL _ADDRESS: INSURER(S)AFFORDING COVERAGE _ I NAIC 9 _ INSURER A.-Nautilus Insurance Co. _ 117370 _ INSURED INSURER B:Wety Insurance Company— L33618 Polar Bear Insulation Co.Inc. INSURER C Peter Leblanc&Steven Leblanc — P O Box 958 INSURER D_ Andover,MA 01810 INSURER E_ _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CONTRACTOR 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — —AD�L'SUBR POLIdY EFF I POLICY EXP LTR I TYPE OF INSURANCE 'INSD WVD? POLICY NUMBER MM/DD ! MM/DD ! LIMITS A ;COMMERCIAL GENERAL LIABILITY ; i ,EACH OCCURRENCE S _ DAMAGE TO RENTED — CLAIMS-MADE OCCUR PREMISES�Ea occurrence) S MED EXP(Any one person) S _ - PERSONAL&ADV INJURY j S GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE (S - { AL A - K RO- POLICY r JECT _LOC PROOUGTS-COMPIOP AGG S i OTHER: ! � --:5 !AUTOMOBILE LIABILITY i I COMBINED SINGLE DMIT ;S 1,000,000 _ i�Ea accident--_---- - -- B ANY AUTO 2100926 01/04/2016'01/04/2017' BODILY INJURY(Per person) S AALL UTOS OWNED xi AUTOSULED ( BODILY INJURY(Per accident)!S NON-OWNED PROY DAMAGE PERT X `HIRED AUTOS AUTOS f t.(Per accident _. _.— �S.. I — S — i UMBRELLA LIAB - !EACH OCCURRENCE S OCCUR ) — A EXCESS LIAB CLAIMS MADE AGGREGATE f 5_ DED RETENTIONS i S WORKERS COMPENSATIONPER OTH- ;AND EMPLOYERS'LIABILITY STATUTE ER. Y/N ANY PROPRIETORIPARTNERIEXECUTIVEt ` E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? DIN/Al i(Mandatary in NH) ! E-L DISEASE-EA EA1PLOYEE S If yes•describe under l R DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT;S i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICA I E HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n Amo nn�n nnnr,n nnonnon rtnnr Aft IN/2016 Preview:Certificates of Insurance >l DATE(MMDD lfY YY) CERTIFICATE OF LIABDILiTY iPdSUR�aNCE 01/0412016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED.subject to the terms and conditions of the policy,certain policies may require an endorsement-A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COtrrACr IlAttE: PHO,'IE Ak Automatic Data Processing insurance Agency,Inc- IAtc_no-Evt Lvc.Na}. I Adp Boulevard ADDRF55: Roseland,NJ 07068 )ItsURERIS)AFFORD III COVERAGE NAIC7 INSURER A: NorGUARD Insurance Company ' 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLGES OF IHSJRAi10E LISTED BELO7>HAVE BEEF:ISSUED TO THE INSURED PIALIED ABO:'E FOR THE FOL.cY PERIOD INDICATED IO i f.ITHSTANDING AP:Y REOU:REMEfIT.TERM OR CONDIT,OPH OF ANY COPITRACT OR OTHER DOCUL;ENT.*:TH RESPECT TO:i`HICH THIS CERT'.F;CATE Lt:,Y BE iSSUEO OR LIAY PERTAIN.THE iNSORANCE AFFORDED BY THE FOL'•CiES DESCRIBED HEREtd:S SUBJECT TO ALL THE TERL:S. EXCLUSIONS AND COND;TiONS OF SUCH POLICIES LIMITS SHOkVN VAY HAVE BEE-11 REDUCED BY PAiD CLA9a!S INSH TYPE OF POLICY tt' POLICY I• 1 LI::ITS LTR 11150 t'ND POLICY 11UtdBER INL:CD.YYYY) ILtLt•DO YYYY}I ',. �CO'dt.IERCIAL GEUERAL LIABILITY t:.,a5 U1�Cl:1:HLr,CB c1dC-I�d.la0c 011 GtCL.?GGI:EG7Ic LIt.RI AFFLI65PEti. i:EKEF•�ILGGIstC.it - 1'li:� III AUTOR:OBILELIASIL1T1• '-LI'1:�L•.�.R:LLtLILIII - :'t dt?:J1I L; i B BUIL'IIUL I:'a^✓v_o'm: .-LLi%W.i:U ::LFcL-LLEU •-1 l:._ t-;1:;= � 1•I-.'•:I'tlti"l:J.IAt:E ' . i� UCJ3RELLALUIB 'Lk i:Ac-;::_ LH?aLt 7: EXCESS LIAB L'L:ai.IS�7.)AU6 •:GG1i�t:,it OLD litiEk 11Q6: WORKERS COMPENSATION X •tic 1' r I r Alto Et.7r.n PLOYERS'LIARILITY l It Ili 1,000,000 Ii:'.I%latll:l_t%•Ff1i�k ciN-L'I I'E E:CH:•t.Lllct.1 A Pl�ti:t:L16614E:.�LLt�i;t rv1"tA N POtNC772258 (101/Q712016 D1/Q112017 t! 1;.andalary:n NH) LJ I It L LasE.h -t:.60FLE—,: 1,000,ODO LrSrlcn•ncccrcl=Lr.:,ncl_:,_1:: (t.L.l`15E:.__ r�.u:�uun 1,000.000 DESCRIPT ION OF OPERATIONS;LOCATIONS i VEHICLES IACORO lel.Additional Remait,;Schedule.—1 be alatbed it more space is rCtluif W) '. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theitsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS, 195 Frances Ave Cranston,RI 02910 AUTHORLED REPRESEnTATIvE I , A?1988-2014 ACORD CORPORATION.All rights reserved- ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD gg, Of fice,of Consone 10 parkplaa 5170 o2i16 Improvement 06 _._- R �titi 102126 - - T1dPwD131. tri P AR INSU�`Ctt i�SCI-,Vincent LeBlancEE���Mork�Te�ru�lulr DOVER. 01 _ _- �po,,,AddrmandrmmcO �t �LOACeied _ 1 Address Renewal qi