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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 TOWN OF NORTHANDOVER APPLICATION FOR PLAN EXAMINATION r � Permit NO: I j`' Date Received Date Issued: ` r IM ORTANT:Applicant must complete all items on this page r Pnn ' Print 100 Year Old Strrlcfure yes no MAP NO ��PARCEL ��� ZONING DISTRICT Historic District yes no , ' Machirie'Sho"pUillage 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 Well O Floodplain ❑Wetlands = D Watershed Districf ❑Watet, ewer' DESCRIPTION OF WORK TO BE PERFORMED: AT i^Sv/4/Wo pj ib r-119Ayt�?f!e.?•'oot, Identification Please Type or Print Clearly) OWNER: Name: -JvI if yvie-{/ro v Phone: Address: .5_® Ton rNY ("Oe I.7,o e �. Pi1Cx' � 'lC , `CONTRACTORNarne *;fir e� :,..�. Phone; m ais ', Address. . _,.. Supervisor's Construction License: (d faa I Exp Date ti � /� ;Horne lmprovernent License;: /D�-`fit-L Ex ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ tJS--o® , a FEE: $ M d_ Check No.: +L Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracto Plans Submitted �.j- Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans NORTH own of2 1 nclover ® j%Zb- 2,ajy h ver, ass 2.6)o • LAN! � � � COC NICNl WICK CRATED S U BOARD OF HEALTH Food/Kitchen rvERM' IT T LU Septic System THIS CERTIFIES THAT ® BUILDING INSPECTOR ................... ..................................I... �. ........... ... ...... ............ �` ...... Foundation has permission to erect.................Ah......... buildings on .......!1�. .. .. .......... .. . .... ...... . Rough g tobe occupied as ........ ............................ .. ..... .................. ... .�. ...... ............................. chimney provided that the person accepting this pe 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA Rough Service - 9 ......................... ......... . ..... ............................ Final BUILDING 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. s i i R=> wlng atcetottsae Adhr6loaal7htetsch 1QACeatreatorRoeliot20i70 �0 udl0%�°°°`'�JAXOt6Jf3 CONTRACT ® PROGRAM Rage 4 lorcum Pima taliD mc*y (978)AMI97 10%16/2015 420781 00004 , 50 Johnqy Cabe Lane U SO Iolumy Calm Lsae r North Andowor,MA 01843- o Noah Andwiw MA 01845- �- j DESCREMON amasofy0�irome wa0a&d.m maim dVa.7E6aakwMbe pertonaed in eooa:t wiffi tho u3o ofapedei mots aed d saa a euune dmtyour hasaawiU bo hd;with a txatth8il feud of e[rmoetea�mdiadaorsFcgtmthy.i�tetaFeiem6etssedmsealyourts�oeaa6�a�tbaaneadott�rprOdvap.t�nsmy mea4 RrsmlhtgioctudoalrlealaSa mettles.6mmi,asgeeegmmdothertndmdmrae(wfadourm m0aotg�anitjr eddnessod.)7hbwttli+cgahe(8lwmlo�tmms.Aremoedaalaaddatbntpam{ams(ceu)afafr6v�aeaar.6utdmetiue! tmmberofo8a is sntgmtmiteed. AttbommO aofdwwaeftbW=%:kimdattaa&Wocslcost coftb=wwm.aiinelMom doa=dlorc=btW= aafd,Y eadyalswlU 6aaa¢�stodbytha�tboaaarcooetoansme tke�gaflbe htdaorairqunUy. (680.00 AtItBEA MADDFA:(4)woddegbotes. S3C0.00 DASdIi(Pitk PtovidaTe6�audasetaiafatotosSapa 11'taprerafiW8�fl6agtesabettrm(t48)agnece�ettbrdmm�g t 3303A0 A777C FIAT.havHotaboraad aero bbto ImW an V IaywofR.28 Chea 1 CeUWmaadded m(1072)sgam+e&et cfopwattla Vam XNERi1�368.64 /AC1S:Ao+ eadmdale tob*ts r FSKkWnmkfgld85a&�m6oe:dtos W=tD(214)swmetbdof IatoaomU am S749A0 AMCACCB8 Pmvldelabarandteb=t(I)emiVmovc0.bollsbacomibr mwlica mWAfnsw*.Am H Rot=fmofptywoodwlUbaaeaI wound tba"wbgwtft*craft 7hfswMdtowdow. sb egsa wa a4tripp to tesI t .I rIealkw i23Z6S ATMACCES&FtarldaldmudtouWm(2)emtiposmyeamtoenatdcam 7mapaia3wMboclaadvfA mounts AnSar m ttmso mbtteg Fhtisb ssodlrtg and pshtthtg Is aot 6tettutod $170= VFNTM A7IMt PawWe hdtormd maflaistsm imtat{(2)lenulemdmdmost hasowabse�mouatedRappavemto motel 523730 VEWFMAWtFro*laboraadmao�alsmhtttaUveatUatioodmtwio(6D)atexrbiprstoaahmdaelrSoa► $1202 BASS WffCB=QFtovldelabasadmasidstobmU(98)tlox &datR-19wAxedSbagtanmthaperhtatet cf the basomtt affxS st the home sUL SIUSD > � luccatoaaao4o: e Ri a RegleLalthm Them IrA i me Ko1>! Fe A dlehtoo a!'rh�eb B�ivario5 CONTRACT 379d0>r6i94 FAX 3d pap 2 PROGRAM MA CSMA-HS as rvum°a0mt itpetw �$ vem RAW Julia Mcafmy (978 208-0197 101t6IZ015 420781 00004 lummm 501ohmw Cake L= 50 Johnay um Lana North Anwar,MA 01845- Notth Andover,MA 01845- JOB DESCRIPTION R38Enslnw gwRlq*ap blQ dlgibleiaoad mt*d&uxueet.Youwdlanly6ebiUodthotZet=wn Sam*, fitroHgihto Coltombtat?moifbs7995 4aottnetmeed52A�Pa Ieu.uedmthtuiot&eof10095forthe AitBeeltogtntes�auptotho6yti6�ead�tttdd&�a15340 Kmvteg4ttto jmtIBedby theend&ar. Fettlm aathtyr mtdhmhh ofyt�homda hMoorairgtmllry,we will Ee ooadUcdngebfowadoordteg�attcoltheavaiiebtaeuEtawfn your b=v bu&befin&o wwk b bqm sad aflcrtkd mdobWovok b oogi to.Wo wlll alto uottdtx a0 A zuessmwA of dnoombndelaat ftdyauthw tge%=andnwheor.Uhhoavaboaf990eadbetnoaoutoy=lWattowabk aoahtoadivebS3,i10. S90A0 Totah $4.66749 Program Inaan"n., $8.110.00 Cuettionw Total: =1,467.6 ataAG=KgtaevtvtottnMGHR=ca•uatwt MCMACCOF= sttantAMBGtBto TMMMRntaatwor "t0w Thousand Four Hundred Fllg 4Wm&69N00 Dollars 51,467.6 ami` n��a� itur�iii�at�r�n�i►u� atawwww A F.,AL� tsarseeoatmaartutrent tanavttortttmartmtateaa atrsarw dozmo '.f` 30 0Masaem►�tet � Doi �wsmt OWNER AUTHORE;ATION FORK! /i a l"c&1 VWX ca+�s owwoldeap boated at adder) 1V 1'Qo ' t�Imm fi ana motorIkeEngem.ftedonnVtndwffftobiseabuitft permit aid m peg M wG*Gn ny p up*. r The Commonwealth of Massachusetts Department of IndustTUTl Accidents I Congress Street, Smite 100 Boston, IVA 02114-2017 WWW MUSS.(YO I.(t Workers' Compensation insurance Affidavit: Builders/C'ontrnetttrs/Electricians/Plumbers. I Cs BE FILED 51'IT11 THE.PE,1UN f1 TING AUTHORITY. Applicant information Please Print L"HAN, Name tf3usiness'(irgattiiauon+'Indtvlduall: I/b 16iet 1/At Ae 0 ( O. rhe Address: .P®. 90Y CJS __ _ City/State/Z.1ip:_fi1ndo,)-ed', yt A odlo Phone #: Are you,n employer'Check the appropriate hoz: 1'ype of project (required) I 1 aim a enrpiirvcr \coli cmpluyres(full andxlr part-tune(` 7. Q New construction 2❑1 am a sole proprietor or partnership and have no cmplovecs\.cul.ing ilii me to 8 F-] Rernodehna any capacity I'No workers'camp insurance required J 9 ❑ Demolition I am a homco\vner doing all\curl.nn elf INn V,0rl:Cfi"comp nsurancc reyuncd]' 10 0 Building addition d 1 am a homeownet and wall be hiring contractors tri conduct all norl,on nix property I\vdi cnsttee that all contractors either have workers'compensation inwiance m arc soic I I F�Electrical repairs or additions propncto rs with no emplovices 12 ❑Plumbing repairs or additions s L_I I am a eencral contractor and I hay c heed the sub-contractors listed on the attached shed 13 E]Roof repairs These sub-contrttaors have empiocee;and have hese comp insurance, i,❑We arc:1 curporauur,and tt.uliicers have exercisedtheir right of rsrmptton per itdG[.c 14 FjOther 1 j?, If tl.and tic[rrcc no employ ees ]Nu\corkers rnntp insurance required] `An\ applicant ilia!checks bo-x 1 mut also till out the section below showing their workers cotnpensallon pohcv minrmation I lonicowners who sutxnn this aflidavri tndicatute[hey are lain_a!I nark and then hire outside conttacti,ts must submit a ncw-affidavit Indicating such 'Contractors that chccl,this box must attached an additional sheet,hove in the name of the sub-contiacturs and nate whether or not those enutics have employ etas If the sub-cunuactois havc cntpluyecs.[hey must provide their workers comp policy number f aril an emphtj,er that is•provitlin workers'compensation insurance for til,eniplt tvees. Below i.v the policl•and joh site information. lnSUratlCC C ompanv Name.__,0_0 Policy K or Self-ins Lic 4 p W 7, a;. .-P Expiration Date 611 Job Site Address Sy 10d1n`Z—e_q k t9n�L Cit-dState/zip /I/�i9 Attach a copy of the -workers, compensation police declaration page(showing the police number and expiration date). Failure to secure coverage as required under NIGL c 152, §25A is a criminal violation punishable by a fine up to$1,500 00 and/or one-year imprisonment.as well as civ I] penalties in the form of a STOP\1%0RK ORDER and a fine of up to S-250 00 a (]as against the violator ;\ co1e of this statement may be forwarded to the Office of]nvestigations cif the DIA for insurance coverage verification. 1 tit;herehr certify It Wer the pt ins titinpenaltie.S of perjury that the hilorlllotlon provitle(l above i.S trite and correct. h 1 Date 3 /� 9�•� Sit',nature e\1 ____l __ -- Phone r: �Z7E Y02 _ Of use on1r. Do not write in this area. to be completed lit'cio-or tortes offiviaL C itE or Town: Permit/License# Issuing Authority (circle one): 1. board of Health 2. Building Department ?. C ste•fi own Clerk !. (Electric:r) inspector 5. Plumbing inspector 6. Cather Contact Person: Phone': 1/4/2016 Preview:Certificates of Insurance Ac")?"® CERTIFICATE OF LIABILITY INSURANCE FDATE 011/MM/0412201016 Y) 6 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 NAME: PHONE AIC,No): Automatic Data Processing Insurance Agency,Inc. 0 No Ext): I 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC 4 INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURERC: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 429696 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYV (MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAVAS-LtADE D OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S PERS014AL&ADV INJURY S GENE AGGREGAT E LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PRO LOC PRODUCTS-COI.IPIOP AGG S JECT 5 OTHER: v y AUTOMOBILE LIABILITY (Ea accidern BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY tPer accident) S AUTOS AUTOS , G- S NON-OVINED (Per accident HIRED AUTOS AUTOS '. S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S 5 LIEU RETENTIONS _ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'UABILITY YIN 1,000,000 ANY PROPRIETOR'PARTNEREXECUTIVE NIA N POWC772258 01/01/2016 01/01/2017 E.L.EACH ACCIDENT S A OFFfCERJ.1EMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If -describe ands E.L.DISEASE�POUCY UMIT S 1+000,000 DESCRIPTION OF OPERATIONS bc.av+ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remark.Schedule,may be attached If—..pato I.required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CLEAResult,Eversourse,and National Grid ACCORDANCE WITH THE POLICY PROVISIONS. 50 Washington Street Westborough,MA 01581 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION.All rights reserved. ACO RD 25(2014/01) The ACORD name and logo are registered marks of ACORD ® DATE(MM/DD/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(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: Linda BOg daIIOWiCZ Insurance Solutions Corporation PHONo , (603)382-4600 FA No:(603)392-2034 60 Westville Rd ADDRESS:Iindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC N Plaistow NB 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 TYPE OF INSURANCE ADDL S BR POLICY NUMBER POLICY OLIO YYYF POLICY EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAAA CLAIMS-MADE ❑R 'REM REMM ETORENTED 100 000 PREMISES Ea occurrence $ 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 X POLICY❑PECOT- [::]LOC PRODUCTS-COMP/OP AGG $ 2,000 r 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 AND EMPLOYERS'LIABILITY STATH Y/ UTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑N 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 1901401) POLABEA-01 JONEILL ��®�® DATE(MPNDDNYYY) CERTIFICATE(FICA` E OF LIABILITY INSURANCE 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-T000 I axe No 978 688-7001 11 Saunders Street ac N,�_E�_l .- )-- _ --._- - (.._,_-1- �. North Andover, MA 01845 E-MAIL — ADDRESS: I INSURERS)AFFORDING COVERAGE _ i NAICS INSURER A:Nautilus Insurance CO. 17370 INSURED INSURER B.-SBfetY 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 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADSL SUBR - POLICY EFF POLICY EXP ` LTR I TYPE_ INSURANCE i INSD I WVD S POLICY NUMBER ! MM/OD I MWDD LIMITS A —;COMMERCIAL GENERAL LIABILITY ; ` ,EACH OCCURRENCE s I - DAMAGE TO-RENTED CLAIMS-MADE OCCUR I PREMISEsjEa occurrence) S ;MED EXP(Any one person) s PERSONAL&ADV INJURY 1S -" GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is r ' PRO- - �� ;POLICY I _JECT LOCPRODUCTg_r_.OMP/OP AGG 5 OTHER: i S AUTOMOBILE LIABILITY i I COMBINED SINGLE LIMIT i S 1,000,000 .._ i 1(Ea accident)._ —___- _ -- g _ ANY AUTO X2100926 0110412016 01/04/2017'BODILY INJURY(Per person) is ALL OWNED �SCHEDULED � -- AUTOS �� AUTOS BODILYINJURY(Peraccident);S X `HIRED AUTOS X ;NON-OWNED ! j ' i ;PROPERTY DAMAGE s AUTOS i,(Peraccidenl :UMBRELLA LIAR OCCUR - EACH OCCURRENCE :S EXCESS LIAB ;CLAIMS-MADE i J' AGGREGATE :S OED RETENTIONS i WORI(ERS COMPENSATION :PER 0TH- .AND EMPLOYERS'LIABILITY `:.STATUTE j ER Y/Nj i ANY PROPRIEFORJPARTNERIEXECUTIVEI EL EACH ACCIDENT !S OFFICERIMEIABER EXCLUDED? �1 N/A —— - iMandato ( ry in NH) :E.L.DISEASE-EA EMPLOYEES$ and If yes,describe under - I --'—— - "— DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT i S i i I 1 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 elsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thi ThiACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE i! rn-S000 IM-114 Af%r%MM9Nr10Df\i3ATI/1P1 An....�.f............,,..i cz of CoeI d 10 ? 8.�S 5170 02116 Reacs tsn 102-126 TVpw-. D13N pt�LAR BEAR.IN8IJ�Clt�l� - �incent LeBlanc ?.o.BOX 95$ _- �Itsr �torr cCsange. ANDOVER, MA 01$1t} CpdauA cIdrm and wwm c� t ❑LastCsrd y Address Renewal ppss,cm sz SUN G1d12i6 7 EAST PM SMET l,lwsw,v WK 4