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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued:--2. " ` . IMPORTANT: Applicant must complete all items on this page LOCATION live' leLe ;eery L►� Print PROPERTY OWNER Lq C v be h d e C Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yes no f 100 year-old structure yes no 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 D'Well ❑Floodplain ❑ Wetlands ❑ Watershed District' ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: A��S�g ,�9 �TTrC %hSulq �I'oyr r� Q - V/f LA- r 14 )-io61 (Identification Please Type or Print Clearly) OWNER: Name: LAC'Y en d -e J' Phone: 1,1 IPJ-319V-7®?3— Address: 2 Ilvertbe yj,-!Y'y bin e CONTRACTOR Name: Phone: 1(0,),63� Address: Plaistow T**T 14 03865 978-407 Supervisor's Construction Lice-use: -7638 e1-0b �I/F ��/°> Exp. Date: Home Improvement License: Exp. Date: b- /G ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST.BASED ON$925.00 PER S.F. Total Project Coat: $ 31�6o. a Q FEE: $ Check No.: 1,� Receipt No.: l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/OwnerSianafure.of.contractor. FirujownF NORTH 2nclover O •;-mow Y~ t+► ® b 12 b - h ver aSS 30Zal , LAKE � ' 1 C0C"1C"9WICK- 1 RATED �4 5 S U BOARD OF HEALTH Food/Kitchen R IT T Septic System THIS CERTIFIES THAT ep ♦ BUILDING INSPECTOR ....................... ................ . .................................................... ..................... . Foundation has permission to erect buildings on .. 00M r .... .. .......................... . . ...... ...... . ......... ....... ................. At- ® Rough to be occupied as .... ® .... ......... Chimney .......................... ..t...... . .... .... ... provided that the person accepting this pe it shall In every respect conform to the terms he application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT S ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S RTS Rough Service .................... ..... . .. .. ........ .................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. o �,,,..,.,, ............... ..... .... __ Fodorai 10 d 06.040 129 DISE Engineering M Contractor xtr r 8091 rat tion No 120 MA contractor RoglatTaOon No 1209"1'9 RISL Z- A division orT'bielsch Engineering, ENGINIERNG" 60 Sha rout llrut#z Canton CONTRACT NIA 02021 339-504.035 )� FAx 39-502.6315 Page 1 [,I F PROGRAM RAM 1141 COMACT u EXTYAW WTO oa»wew case CMA-TIES euaMOER040 PXD nra CUSTOMER FOR WO uc as CUSTOUER .... .,... r I rnWUE DATE CMUTE WORK ORDER Lacy Bender (610)304-8085 03/032016 431461 00002 SERVICE DTPUY DDAM STREET 79 Huckleberry Lane 79 Huckleberry/,Date `E�w� ►'fY .._.SL.WCE WY.STAM XIP . . .._.._ L..i � cxrv,ararE,za• Noah Andover,MA 018 North Andover,MA 01845 .m.w.... �IOB DESCRIPTION HAZARD HAIWER:We have idcnrified that them are recessed lights present in your home,unless the recessed lights are certified as IC-raled(Insulation Contact Rated)we will create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be Insulated. $0.00 AIR SEALING:Provide labor and materials to seat areas of your home against wasterul,excess air leakage. This work will be perforrncd in conccn with the use of special tools and diagnostic testa to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unhealed areas(windows am not generally addressed.) This will require(8)working hours.A reduction in cubic feet per minute(cfrn)of air infiltration will occur,but the actual number ofefm is not guaranteed. At the completion of die weathcrization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will he conducted by the subcontractor to ensure the safety of the indoor air quality. $680.00 DAhIM1NG:Provide labor and materials to install a 12"laycr of R-38 unlaced fiberglass baits to(196)square feet for damming purposes. $401.80 ATTIC F'LA'P:Provide labor and materials to install a 7"layer of R-25 Class I Cellulose added to(I 148)square feet of open attic space. $1,492.40 KNEEWALLS:Provide labor and materials to install 2" FSK faced scmi-rigid fttrcrglass board insulation to(40)square feet of knccwall are,. $140.00 ATTIC ACCESS:Provide labor and materials to make(1) access opening from one attic area to another by cutting a passage through sheathing, This items will be left open as it is between two common unheated non Rrewalled attic areas. 531.31 A'ffiC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover far the attic access folding stair. A small flat surface of plywood will lxc created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. $237.65 ATTIC ACCESS:Provide labor and materials to make(1) temporary access to an attic arca The opening will be closed with materials similar to those existing. f=inish sanding and painting is not included. 585.00 VENTILATION:Provide labor and materials to install(5)8"diameter roof vcnt(s)to increatsc ventilation in attic arcas. The vent can be supplied in(circle calor)black,brown,fly or milt finish. 5427.50 VENTILATION:Provide labor and materials to install(2)insulated exhaust hosc with gable wall mounted flapper vent to exhaust existing bathroom fan(s). 5237.50 •,P • Federal In00644"M RISE Engineering Caerarn�orReslabTdton��� tdA Comracfnr Ramon Ko 1f!0819 A division ofThlebub EogloeMngRISE 60$baKmpt fait bK,Oauiun.FTd 020I1 �� FA?f 339.so2634s CONTRACT Page 2 PROGRAM CMA-RES oaoo.otrraamrw°RDa�ro.woeane ovlseammTTemw aTsrarmt PH= DATA CURB• wo"ORM Lacy Bender (610)304-8085 03/032016 431461 00002 Aeavre eTaeraT CaOC wase. 79 Huckleberry Lane 79 Huckleberry Lane ABMGa er1Y,FTATe,IlP CLOW em,STATS.zw North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION VENTILATION:Provide Isbor and materials to install ventilation chums in(64)ratter bays to maintain air flow. 5128.00 RISE Engl ccring will apply all applicable,eligible Incentives to this scams _ You will only be billed the Nd nowunt. Currently. fbr eligible measures,Columbia Gas offers 75%incentim not to exceed 52,000 per calendar year,and an incentive of 1000A for the Air Sealing atm up to the flist 5680 and an additional 5340 if savings are justified by the sudhor. For the safety and haft of your home's indoor air quality.AT:will be conducing a blower door diagnostic of the available air flow in your bane both before the work is bqM and after the vmatberimdon work is complete.We will also con"a full asseamatt of the canbustion safety ofywa besting system and water heater.Ibis has a vale of S90 and is at no oast to you. Totel allowable weadnabalm incentive is 53.110. 590.00 Total: $3,861.16 Program Incentive: $2,770.00 Customer Total: $1,181.16 WHAaRU T OWN To FUIMM SERvtct s•CONK re w AcoORDRMM WTTN Aeove SPOM:rA=ft poR The also of ""One Thousand One Hundred fthtyOne&16H00 Dollars 51,181.16 UPON rNALOSP90TiDMANDAPPROVAt.MMtl16tlWIFeiD.CWTONeA AWttFF TOREMANWNTOUa TNFUU-e WAWOF TAWDJ.Sa CARGeRAOMMYONANY uJ AoMAN=AFTER30AV0.0E8aRMIRFCRWWTAMTWCWAWAOM OpAa1�N1134agfntioPREg610r4eCN�Ityl0.N000NraACSOARt TMf10N;....... _... - 00 KOT SOON TNS CONTRACT IF THM ARE ANY BLANK 9P saw NOM TMC UTW=MAYSa rOTIO NAWN en Us rFNOTOMOU DM"M OAfl OIAOCE"AMCa AOCWTAW20FOONIRACT•TNS ADOVO PRICrA,ePlV7tICAT1010 AND C.-Orms0 ARe 30 U a ATtWACTORYTousMmARSNFFSIVAtcunv&VCUAREAOnlOOMTOOOTM VIM AsaTsmTeavAYMTNTwns.eo NAoaADorTur®Aaava r 60 Shawmut Road,Unit 21 Canton,MA 020211339-502-6335 ENGINEERING` www.RISEengineering.com OWNER AUTHORIZATION FORM I, Z, c lqek'eie✓ , (Owner's Name) owner of the property located at: 7`/ leu C r L (Property Address) Al . ¢912-�-T,a.je, ---We =) (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE 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. r4--,., A4�4- 4 er's i atu 0� 6 Date The Commonwealth of'Alassachusetts Department of Industrial Accidents I Cono fess Street, Suite 100 c Boston, MA 02114-2017 Mass.CIO VIdia M AVorkers' Compensation insurance Affidavit: Builders/C'ontractors/Electricians/Plumbers. TO BE FILED NNT I TILE p1c,lzmI 1'TING AUTHORITY. Applicant information L Please Print Lc�ihle Name (Buamess/Organization/individual): //b �A r rJ roti lT U��P/�0 N ('d. ..T�►c . Address: P.® 90Y X 5 F City/State/Zip: }{neo✓-f —R }'t/I/9 o 4lo Phone #: �7 arc you an employer"Check the appropriate box: Type of project (required). 1 I ani a emplo\cr vvtlh cnmplo)'ees(full and/or part-time) 7. ❑ Nexv construction ®1 am a sole proprietor or partnership and have no emploN'ces working tirr time to 8 n Remodeling ane capacm. tNo vvorkers'comp insurance required l 9 El Demolition 3®1 am a horncowmcr doing all work myself tNo vvorkers'comp Insurance required]' 10 Building addition d 1 all,a honmcovvmer and will be hiring contractors to conduct all work on mN property I w'111 I I E]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employ ees 12 0 Plumbing repairs or additions S®I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13 ❑Roof rel)atrs 'I hese sub-contractors have enmplovees and have workers'comp insurance 14 ®Ocher_ i,®We are a corporation and its olticers have exercised their right of exemption per MGL c 152,§10).and we have no employ ccs INo vaorkers'Comp insurance regtttted l 'ane applicant that checks box 41 must also fill out the section below shinvine their workers'compensation polrc\ information Homeowners vvho submit this aflidavn rndicaune Ihcy are doing ail wort:and then titre outside contractors must submit a ncvv allidavtl mdmcaung such tConiraciors that check this box must attached an additional sheet showing the nano of the soh-contracumrs and state whether or not those entities have enmployees if the sub-contractors have employees.the) must provide their workers'Collip pope) number 1 tint til: elnploj'er that is pro vidill.-workers'compensation insurance for!!!t'en:pligees. Beloit,is the policy and job site itlfol-(nation. Insurance Companv Name Lo!! _q_�s=-C1l Ex)irationDate dI ei��d17 Policy i# or Self-ins Lic #a 0 t�1 I f Job Site Address 14 n<L City/State/Zip r ��' -'°r�y ,Attach a copy of the workers' compensation polio'declaration pale(Showing the policy number and expiration date). Failure to secure coverage as required under MGL c 152. §25A is a criminal violation punishable by a fine up to$1.500 00 s vicell as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a and!or()Ile-year imprisonment,a may be forwarded to the Oftice of Invests-atlolls of the DIA for insurance day against the violator A copy of this statement coverage verification. I do hercrht'certifj•render the ptlins'mud penalties of perjure'thtrt the ilifornultiun provider)ah01't:!s true and co!"rect. Signature: f� � Date. — — Phone h: � Official use vnit. Do not)tgite in this area, to be completed bj'city or town q�firrl. City or Town: Permit/License # Issuing Authority (circle one): it 3. C ity/I'o�an C'lerla . Electrical Inspector 5. Plumbing Inspector1. Board of Health 2. Building Departme 6. Cather Contact Person: Phone#: ® DATE(MM/DD/YY YY) AC40M IDO 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(iss) 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). CONT PRODUCER NAME:CT Linda BcgdanoWicz Insurance Solutions Corporation PHONE (603)382-4600 FAX No:(603)382-2034 60 Westville Rd E-MAILss:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A:Western World INSURED INSURER B Nautilus 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCEINSD WVD POLICY NUMBER MM/DD/YYY MM/DO/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE [i]OCCURPREMISES Ea occurrence $ NPP$274967 3/24/2016 3/24/2017 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY❑ JECT $ OTHER: AUTOMOBILE LIABILITY Ea acSINGLE LIMIT $ accideINED nt) BODILY INJURY(Per person) $ '.... ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ '.. X UMBRELLA LIAB OCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ PER OTH- WORKERS COMPENSATION STATUTE JER AND EMPLOYERS'LIABILITY y/N 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 ISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below E.L.. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 I NS025 x901 4011 POLABEA-01 JONEILL ® CERTIFICATE OF LIABILITY INSURANCE DATE 1/66/20120IYYYY) 16 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(les)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). CONTACT PRODUCER NAME__, Durso&Jankowski Insurance Agency PHONE97g 688-7000 _!(AAc,-NoL(978)688-7001_ 11 Saunders Street A/c No_�_( .. )._ �--- E MAIL North Andover,MA 01845 -- INSURER(S)AFFORDING CO_V_ERAGE_ — INSURERA:NaUtiluS Insurance Co. _ 117370 - -- -- - --- 33618 INSURED INSURER B:Safety Insurance Company— _ _ Polar Bear Insulation Co.Inc. INSURER C:__._____, ---- Peter Leblanc&Steven Leblanc INSURER D: P O Box 958 — — -- i Andover,MA 01810 INSURERS:-_. - 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 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. !N—SR—i— ADOLISUBR; POLICY EFF j POLICY EXP LIMtrS LTR TYPE OF INSURANCE '`INSD I WVD E POLICY NUMBER MM/DO ! MM/D0 A —"; COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S DAMAGE TO RENTED CLAIMS-MADE OCCUR 1 PREMISES occurrence) S MED EXP(Any one person) 5" — - —--- - - PERSONAL&ADV INJURY is GEN'LAGGREGATE LIMIT APPLIES PER: ? GENERALA6GREGATE (S i I PRO- i ! ! :PRODUCTS-GOMP/OPAGG !5 )( POLICY JECT LOC —� - - — — S OTHER: V=n 1S 1,000,000 AUTOMOBILE LIABILnY _B ANY AUTO 2100926 01/04/2016'01104/2017on) ;S ALL OWNED )( i SCHEDULED i BODILY INJURY(Peraccidenq S !AUTOS `NON OWNED i !PROPERTY DAMAGE 'S HIRED AUTOS �( 'AUTOS 1.(Peracciden� — — $ UMBRELLA LIABOCCUR 'EACH OCCURRENCE ;S ) — i i AGGREGATE _ _ S A EXCESS LIAB CLAIMS-MADE --DED RETENTIONS— I i$ ER WORKERS COMPENSATION _ SER TATUTE ER ;AND EMPLOYERS'LIABILITY Y/N i j ANY PROPRIETORIPARTNERIEXECUTIVE I ' ; i E L EACH ACCIDENT ;S OFFICER/MEMBER EXCLUDED? N/AE.LDISEASE- MPLOYEE S (Mandatory in NH) i EAE I ( I If yes.yes,describe under i E.L.DISEASE-POLICY LIMIT is DESCRIPTION OF OPERATIONS below ! i i ! 1 i 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 CERT IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE f �4000 1)(1411 Af%f%C3l�Mrl0A'r1ABi An_...�.a...............r 1/4/2016 Preview:Certificates of Insurance DATE(nmUDDYYYY) A4CCl`RV CERTIFICATE OF LIABILITY INSURANCE 01/041Z016 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ONT C PRODUCER ACT CONN PHONE AX Automatic Data Processing Insurance Agency,Inc. rA;c.Ho.Eru: Ia,C.tm). t•,I J 1 Adp Boulevard ADDRESS: Roseland,NJ 0706B I11SURER(5)AFFORDI14G COVERAGE HAIL d INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER 8: 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 POLICIES OF it ISURANCE LISTED BELO'd:'HAVE BEEN ISSUED TO THE IFISURED NALIED ABOVE FOR THE FOL:Cy PERIOD INDICATED.NOTIA1THSTANDING ANY REOUIREL!,EtNT.TERM OR COND:PON OF ANY CONTRACT OR OTHER DOCULIENT V';TH RESPECT TO'A`HiCH THIS CEPTIRCATE MAY CE ISSUED OR LIAY PERTAi!•I.THE INSURANCE AFFORDED BY THE POL'.CiES DESCRIBED HEREIN:S SUBJECT TO ALL THE TERIAS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN 1,.AY HAVE BE-EIJ REDUCED BY PAID CLA:LiS INSRP LILY F P LICY P i LVAITS LTR—Tl TYPE OF INSURANCE IVSD VNp POLICY 11WIBER trA?NDD,YYYY) 11,11.11DWYYYYi COMMERCIAL GENERAL LIABILITY 6nLH CC::LI=F:H.it CLAL'.16 Lb;Ut 0S;R LI: I'fiEL115tS IE.'..,cc:�•cr•: CELL i,GGIiEG%,I t LIt.111 FF1'D6S PEI:_ I GENERAL AUGhEC-A i t = I'I'- i HL:LIC �JECI �LC:; :J I FEIt: 3 AUTOLIOBILE LIABILITY -:-1.1'tI.E SII;It LIIIII '.,... E- AUIL', BCDIL`IGJLE :F•,1,,-1 ALL L`tEL L'CFEL%LLEU I B::UIL:'ll-Jlai�d°r=:a_clJd J AIJ 11:5 %,CICS 1::I.C:=:I;EIi 1'1 V:1'tl�l-: :.:LIRI•t 1 Ur.'BR'cLLA LNB Er1C}-CC::U±itt.Lt EXCESS UAB CLAIMSd.IAVE OEU H01ilzIIUL_. _ WORKERS COMPENSATION I IAI Nt DnEdaM.:_PPLlOaYtElRcSl_'LIABILITYr—) ELES,u1�,IL.:cItaDto-.I EI~ I s- 1,000,000 PARI Lers;tl_un. A :41- 1 Y.tu1A N POWC772258 01101,2016 01/01/2017X i 1.000,000 yin NH) ELUISEASt E:,tl.tl'U,`'Et > u s:•e,a•.,:�•' 1,000,000 CPEIil,HMS EL-DIiE:,SE I'COC'U(.111 DESCRIPTION OF OPERATIONS i LOCATIO14S T VEHICLES IACORO lot•Adddional P.-.k6 sehedute.m.Y be albched i1 more space is mQ.ili d) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORLED REPRESENTATIVE I s AC 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD #Usines,s alioll Consumer Aff*&and ()fftce,01 10 parkplaza 1&,5170 SL its Boston,Mosacbus � D1 . '0 _ R inn- 102726p - = nap, '6 -rte vao Vincent LeBlancp 0.Box 95a - AwoVER, NLA 018io _- ,j , AddrresRandMCO��pi��t � 1tostcdrd P ddress ar=s-cap �sann��a�a� - rnytii]' '.:7'"'„9_`I>t59.--''rf3i:��.wx_i �'__ �...� • pF, A LB L Iggsto it NEi