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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Vu i,'— Date Received Date Issued: ' I PORTANT: Applicant must complete. all items on this page LOCATION S ! fro 5.S A Print PROPERTY OWNER 57r API,,-yi /`r%pq q is 4 Unit# Print MAP NO: PARCEL: T ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure y 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 EllSeptic ElWell ❑Floodplain ❑Wetlands D Watershed District Water%Sewer DESCRIPTION OF WORK TO BE PERFORMED: F}�1'5eg1;viA F ::PrSul4 >i0t1 io n>j/fi/AiAtr� (Identification Please Type or Print Clearly) OWNER: Name: S7 r P� e►^ �A r r -7 o n Phone: !��-� � Address: S� 176 f 6 Cf o 5S P, el CONTRACTOR Name: Peter Leblanc Phone: q?-F- I/a)- 263 6 /W fast Pine Stree �, T Address: "' ' 1 Supervisor's Construction License: /V&®I Exp. Date: Home Improvement License: f®1`�a G Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ L/°®®. ® c7 FEE: $ zK___ 11�Z, 01Check No.: Recei . NOTE: Persons contracting with unregistered contractors do not have acc s to the guaranty fund . _....... Signature'of Agent/Owner Signature of contractor F NORTH town of2 ®ver ® ® ..., _ hA ver Mass, 50 Zi 1 T O LAKE COCKICHEWICK A°Rnreo PP�`,��(5 S U BOARD OF HEALTH Food/Kitchen ,7 E RM-IT T aw Septic System THIS CERTIFIES THAT .......... .. .... ...... . ........... ....... .... ....... . ........ ...................................... BUILDING INSPECTOR has permission to erect ..... buildings Foundation .................... ... .... ...................... ............ .............' ® o Rough to be occupied as ... ... . ..... ..........®........ .... ... .. . .. ............................. Chimney provided that the person accepting this per hall in every respect conform to the terms of the 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMITI IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS TI �S" Rough Service ................ . . �UILD&iN�6 . ................ Final INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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. _ Federal ro0Q6oa066Y8 RUE Engineering NA eft I"M A div6tao of TLldseb fittgtnaring RISNG GOb`dawmutL'�Stt►�,Cea�ou,t�1A+7202: CONTRACT FAX 3n4W-6345 Page 2 PROGRAM rpoecrrissorst�ana�+a�tams a®saatrsoBnan eVacu R vriaee aAtc cuarre waitltoROBt Stephen Harrington (978)692-8917 03!10/2016 431832 00003 aaN=en w r COLM sIRW 59 North Crass Road 59 North Cross Road =V=arv.sur&za mean aff. rt%ap North Andover,MA 01845 North Andover.MA 01845 JOB DESCRIPTION VFNHtATION:Provide tabor and t to imtan 0)fi5U d admit l=wit toof=mwd flapper van to e exisfg balbroom WS). s3s6as VDI IU ATtON:Ptwtde law sad trtetatait to iustQU vordl tion dwtes in(114)taller boys to mdnt&air Bow. >R28.00 COMMON WALSS:Ptovfde tabor and materials to WO r FSK fl W s=Mgtd 04sss board WwU tort to(Yi2)square fba of Damson watt wvx THIS DX'LUM THE SKY UGHT SHAFT 581200 E epp3y an mak.d tnoeniives to this eoaueot You wtll Doty be bW dwWd mnotmt.Cunetnly. tbrdigibtaocnams„Calzabiaftotllts7$%ta�not towwwdSt,000txtedenderyear.and an iuoemiveof IOW ft ft Air StaftinewtM ap to the fist 5680 and an wmitLym SM irswho ere justified by then anditor. For the safety and heatdt ofyotu homes ftsdoor e'tr quality,we will be oondnetiag a blower door diagttostia ofthe available e1r flow 10 your bonen both bdbm the wok is begun,told aft the aeatlmization work is oottgdeta.WD will dso oondw a full 609mum of the combosdon sft afyoar WOWS system cad water heater.7bis bas avaloo of 540 oud h at no cost m yea.Toni allowable weatttetaattca bteecstivo is$3,110. ss0.00 Total: 54,07772 Progfem Incentive: $3,110.00 CustaDrner Total: 5887'72 the t vtor��tt -c0MPtatetn ttsrt AMESa an0MFORTItttntstor= '*'tine Hundred 3lxty4wen&72MOO Dollars $87.72 otaveeTloa�Na�a.aremaAaffA��am GUAWWWANUM OF o�artsAatoeROUNIMM DD WT8KW 7108 CoN7RACr tFTMW ARf:ANY B 7 SPACBB stcru ass¢sayoaaav nasmtsose�rraaereswaa�avtts�wsrtoo3angeraama eAraaaAccrsrrAswt <..7t/ft��/C� ACCQPMdCa oa eeem�er.rem Asova Rneas�aasev+urrots Aero eamtreoem Ana earn. Assea,taoeAe Asea aurrmoovr�rant Federal[DO 00405M RISE Engineering w Contractor Rogtah'ation No 8168 RENG tNA Cortractor Regtafratlon No 120878A dkvWon of Thlelseh EaglmeeriagINFERINr- 60 Shawr ut.Ifni;42,Caawn.MA 0202: CONTRACT 339-SOb6335 FAX3BSO2.6345 Page 1 ( PROGRAM trescomwarmerimmWroaertfi mraaa CKA-HESOESMISSM a coatwmc�a y core=st j Roan Dare Cu=xro womcoaaM Stephen Harrington � ' (978)682-8917 03/10/2016 431832 00003 ea+vMarr i oainro u:e emfsr 59 North Cross Road 59 North Cross Road SaMlee Crrv.ararazm aeras Cnr.WAie.MP North Andover,MA 01845 i North Andover,MA 01845 JOB DESCRIPTION i PHASE ONE-Proposal for this calendar year. $0.00 HAZARD BARRIER:We have identified that there are recessed tights present in your home.unless the recessed hebts ate certified as IC-mtd(Insulation Contact Rated)we will create a 3"cleamoc 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 AUL SEALING:Provide labor and materials to seal arms of your home against wasteful,excess air lealkage.This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will he left with a healthful levet of air exchange and indoor air quality.Materials to be used to seal yaw home can include caulks,foams and other products. Primary areas for scaling include air teakage to attics,baseaterus,attached garages and other unhealed areas(windows are not generally addressed.) This will require(12)working tours.A reduction in cubic feet per minute(efin)of alr infiltrniioa will oouw,but the actual number of cfm is not guaranteed. At the completion of the weatherizalion wort:,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety of the indoor air quality. 51,020,00 AIR SEALING:Provide labor and materials to seal arras ofyour tome against wasteful,excess air leakage This work will be performed in concert with the use ofspecial tools and diagnostic tests to ass<ue that your home will be left with a healthful level of oir 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,bascmcnts,attachd garages and other unheated areas(windows arc not generally addressed)This will require(4)working hours.A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the wearimrizaiion work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of tho indoor air quality. 5340.00 AIR SEALING ADDER (1)working hours $85.00 ATTIC FLAT:Provide labor and materials to install a 6"layer of 2l Class l Cellulose added (756)square feet of open attic it space.THIS iS THE SECTION OVER MASTER BEDROOM $95256 STORAGE BARRIER:Homeowner is responsible for the removal of Iter stored items blocking the installation of weatheriration work in the attic. Removal must occur prior to the scheduled work start $O.00 ATTIC ACCESS:Provide tabor and materials to insulate(2)back orthc kncewaU hatch with 2"rigid Thcro=board,and seal the edge of the hatch with weathusnipping $120.00 ATTIC ACCESS:Provide labor and materials to insulate the back of the attic door with 2"rigid Thermax beard end seal the doa>'s edge with wcelhm-Dipping to restrict air Ioakago 37391 RISE {` 60 Shawmut Road,Unit 2 1 Canton,MA 02021 (339.502.6335 ENGINEERING www.RISEenofneering.com OWNER AUTHORIZATION FORM I, ate f°h&14 (Owner's Name) owner of the property located at sib Al! Gy �� Aa ' (Property Address) /J* " (Property Add ss) 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. QW s Sign to Date The Commonwealth of Massachusetts Department of Industrial Accidents I ConB cess.Street, .Smite 100 Boston, IIIA 02114-2017 wwn.maass.bovIdia `Vorkers' Compensation Insul•ance Affidavit: Builders/C'onti-actors/Electricians/Plumbers. 'I-()tat: FILED WITH THE PERMITTING Al'TIlORt7'1'. �iptllicant Information TO Print Leeihh Name (Business/Or2annation/indn'idual):_�b �G r h eA r T7nSV A,'Ae N Address: P.© 90Y City/State/ZIP:_fihd0V-e J—, Mpq, 04/0 Phone #: �7 Are you an employer')Check thr appropriate box: Type of project (required) I ®1 am❑emploter with___emplo}'ees(full and/or part-times' 7. [J New construction 2®1 am a sole proprietor or partnership and have no employees working too me in 8 F] Remodeling an) capaciR [No workers'comp insurance required 1 9 Demolition 3®1 am a home(\Ni)ci doing all\cork myself [No%wrkers conip ntsurance required 1' 10 Building addition d ❑1 am a homeowner and will be hiring contractors to conduct all stork on m) propert) I will i i Electrical repairs or additions ensure that all contractors rather hate workers'compensation insurance or are sole proprietors with no emplotces 12 F1 Plumbing repairs or additions i I am a general contractor and I hate hired the sub-conlraclors listed on the attached sheet 13.n Roof repairs 'Ihese sub-contractors hate emplos ces and bane workers'comp insurance Iii []Other ii We are a corporation and its officers have exercised their right of esempnrm per Mt;L c 152,:IM-and we hate no employees [No workers'comp insurance required 1 *AnV applicant that checks box 41 must also fill out the section below shoscing their workers-compensation policy information lionncoxcners%Nho submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a nese aftidacrt indicating such 'Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state ichether or not those entities have cmplu)ccs If the sub-contractors hate emplocees,the).must provide their woikers'comp pope) number ant an enlplo)'er that is provitllnh workers'compensation insurance for 1111'enlplo;'ees. Beloit'is the policy and job site information, insurance Company Name.—IO-0-6 Policy or Self-Ins Lic Expiration Date �I di��t917 Job Site Address 5—C? VI b If �CFy5 S City/State/Zip ✓� r icv declaration page(sltosving tine police number and expiration date). Attach a copy' of the workers' compensation pol Failure to secure coverage as required under MGL c 15_ §25A is a criminal violation punishable by a tine up to $[,500 00 and/or one-year imprisonment, as X%-ell as ci\,il penalties in the form of a STOP WORK ORDER and a fuze of up to $250 00 a day against the violator A copy'of this statement may be torxvarded to the Office oi'lm�estigations of the DIA for insurance coverage verification. 1 do hereky certtfj'tin tier tit e pains and penalties of perjun'that the iltfortltation prorided above is trite and correct. Date 3 Sir�nature t�„�--Vv9 - -- Phone Official use only Do not write in this arett, to be completed hr cith or town official. City oi-Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. tither Contact Person: Phone 9: POLASEA-01 JONEILL CERTIFICATE OF LIABILITY IN URANIGE DATE(fdMIDDNYYY) 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 FAX — Durso&Jankowski Insurance Agency PHONE 978 688-7000 _! (ac NoZ(978)688-7001 11 Saunders Street A/c No,_�_� )_. —--- -----—- North Andover,MA 01845 EMAIL INSURER(S)AFFORDING CO_V_ERAGE i NAIL# _ INSURER A.Nautilus Insurance Co. — 117370 INSURED INSURER B:Safety Insurance Company_-_ 33618 Polar Bear Insulation Co.Inc. INSURERC-.__ Peter Leblanc&Steven Leblanc P O Box 958 INSURER D_ __— t Andover,MA 01810 INSURERE_ 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. INSR; TYPE OF INSURANCE 'ADOL SiUBR; POLICY EFF j-POLICY EXP -- LIMITS PO LTR .INSD WVD POLICY NUMBER MMIDD /> COMMERCIAL GENERAL LIABILITY I ,EACH OCCURRENCE S —_ --- I ' -! DAMAGE T(5-RENTED - CLAIMS-MADEOCCUR PREMISE�Ea occurrence) S MED EXP(Any one person) S ' PERSONAL&ADV INJURY 1S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is i r ) PRO- I { PRODUCTS-COMPIOPAGG S �� POLICY JECT LOC S -— OTHER: l AUTOMOBILE LIABILITY j ! COMBINED SINGLE LIMIT S 1,000,000 � a accident-_ _ 13 ANY AUTO 2100926 01/04/2016 01/04/2017' BODILY INJURY(Per person) S ALL DiNIJED �( SCHEDULED BODILY INJURY(Per accident)j S -_!AUTOS _ ;AUTOS OPE — -- — x NON-OWNED 1 i •PR RTY DAMAGE--.S - - --- — HIRED AUTOS �� AUTOS f r.(Peraccident) $ i _ UMBRELLA LIAB OCCUR _ EACH OCCURRENCE _:S _ J i A EXCESS LIAR CLAIMS MADE j i �! AGGREGATE S f—=-- - - -----'--- - --i S DED RETENTION S WORKERS COMPENSATION PER �l STATUTE � ERER AND EMPLOYERS'LIABILITY Y/N ' .ANY PROPRIETORIPARTNERIEXECUTIVE r--� i E.L.EEACH ACCIDENT OFFICERIMEIABER EXCLUDED? i Ii N/A i (Mandatory in NH) L� E.L DISEASE-EA EMPLOYEE!S If yes,describe under i I E. DISEASE-POLICY LIMIT;S DESCRIPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 CERTIFICATE 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 n Amo nn-1, n(+noc�nnuonoA�rtnrnr An�...tis...............i 1/4/2016 Preview:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCc DATE(fdtaDDYYYY) 01/04!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 NA!.1E: Automatic Data Processing insurance Agency,Inc. ac ti.Ene INC.No). 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERS)AFFORDING COVERAGE HAICd INSURER A: NorGUARD Insurance Company I 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: I PO BOX 958 Andover,IVIA 01810 INSURER o: INSURER E: NSURER F: COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLLC:ES OF iNSURArtCE LISTED BELO d HAVE BEEN 15SLIED TO THE INSURED NAt.tED ABOVE FOR THE POLICY PERIOD INDICATED.NOTI:VITHSTANDING ANY REOUREUENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT i'.':TH RESPECT TO•VHiCH THIS CERTi F:CATE MAY CE iSSUEO OR I.A.PERTAi(-L THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN:5 SUBJECT TO ALL THE TERLIS. EXCLUSIONS AND COND)T;OA:S OF SUCH POLICIES LIMITS SH01:4J NAY HAVE BEEN REDUCED BY PAID CLAMS INSR DLS P LTTE{- P LILY P I LILIITS LTR TYPE OF ItISURAfiCE ItlSD VNp POLICY NUMBER (LAFDD.YYYY) (Lff.FOlYYYYYi COMMERCIAL GEUERAL LIABILITY Eat:F UC::LJ.F:Ef.CE CL:AIS LI•;UE �CCCL ii P(tEL115ES IE.'..+:-r"cr..c: LIEU E:•.f°� - '. GECL i.Ctr•.EG%•IE 111.111 APPLIES I'EI:_ BEtcEFAL AC-ChEC-Alt - I'C:LIv- JE.f � 1'IiCC1'C i 8-CCaJP:::P•:GG J I FEIi: _ AUTOMDRILE LIABILITY :d,-ALARi ALLt';;dEL' SCFELILLEU I BCU1L':IkJI_Ii`.iP��.-.ecU2 S AU I:;S A CS 1'14=1'tH '=C'.V.LII•E FII:Eu%.Cres nL-(cs I' 1.11411RELLALIAL.F EACi I C4L'I2iEt.C'E .:.L EXCESS UAB CLAIMS0AVE: .ICGr EG:.IE DEC' I;L-1EMICI.S WORKERS COMPENSATION Sl:.il lE Eli AND EMPLOYERS*LIABILITY Y:tl 1,000,000 MEUB_I:PAIal.eisztLutls y !IA N POIIVC?72258 01!01.12016 01/01;201? "t";F;•cctc•Ef,t A HCEIid:ELBFJi E titGC•EGl olmdanny in NH) tL.L4Sv1SE E:.Er.0+Lc�'Ee > 1,000,000 IDES:_lill'IICI:''P CI'EIi:,:ICf.S Ups•: t.L.L`I_E,;SE 1'L:Ui;'Ui.11l I DESCRIPTION OF OPERATIONS;LOCATIONS f VEHICLES(ACORD 101.Additi—I RCma+kS Sch,-dtde.mai be atbehed it more sP.-is n,q.in 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 AUTHORIZED REPRESEHTATiVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD DATE(MWDD/YYYY) 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(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). PRODUCER CONTACT Linda BO danowicz NAME: g Insurance Solutions Corporation , (603)382-4600 FNC PHONE No-(603)382-2034 60 Westville Rd E-MAIL ADDRESS: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 LTR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER POLICY EFF MM%DnfYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE W OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ NPP8274967 3/24/2016 3/24/2017 M ED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 % POLICY❑JECT D LOC PRODUCTS-COMP/OP AGO $ 2,000,000 '.. OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODI LY INJURY(Per pe rson) S ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ '.. HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ IAN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER0TH- ANDEMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPMETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it 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 r9mann P 7/�+`O' s ; - office of CO � to 5170 10 �1 02116 Bostol),mass=4 tion. Imprgv Ccr�._._'ctc�r VOLBEAR INSULPITt C+1 O- P►.R 'Vincent LeBlancWb*yearn for Cbm'. p_o.BOX 95B AmDoV , MAOi$1{} _- 'jjpd8ftAddressandreWmca_-'01ployment LostCjed Address L_1 Renewal ass-c�,. �sau�.a�ma-�►o�is -°M LL i e� 041 Q1v