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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 NORTH BUILDING PERMIT o��1LEo ,baa TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION Permit No#: I ' 1 Date Received CRATED PPP .t5 9SSgct+us�c Date Issued: 1 IMPORTANT: Applicant must complete all items on this page LOCATION Prmf PROPERTY OWNER bF / ��?:h r ,-.' <; nnf 100 Year Sfructure yes no P MAP PARCEL ZONING(DISTRICTHIStoric Distract yes no Maetiine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial 11 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg W Others: ❑ Demolition ❑ Other 14 /IV U, Septic D Well �`❑ Floodplain ;=0 Wetlands' ❑ INatershedDistrict 1Nater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ICY NC ri0 r- 141*// :y��u A An e-e Identification- Please Type or Print Clearly OWNER: Name: r\,"t f Mee 41--rk y Phone: Address: �telC' a allC. Contractor Name ° 1� tet Address Supennsor's Construction License � ,��� Exp Date ��� r ..Honig Improvement License >/��7�G, , Exp, ,,Date, ; .�/�/ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS TL ASED ON$925.00 PER S.F. J Total Project Cost: $ 3 e a • 0e, FEE: $ ` 6 Check No.: z® Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor � NORTH -% dover Town of An 0 0 a ® Fj - ?, h ver, Mass, COCNIC HI WICw � A�RATEO S U BOARD OF HEALTH Food/Kitchen P �E R T T Septic System THIS CERTIFIES THATAfj..4.. ............... BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on ... .... .. ..... .... ... . ................ Rough to be occupied as ..Etirm!..t... .. .. ...... . .. ". - . .... ". c. Chimney provided that the person accepting this permit shall in every respect confor�to the terms of the aation 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough Service ................. ........�U............................................. 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. Federal ID#05.0406629 RISE Engineering RI Contractor Registration No 6186 NIA Contractor Registration No 120979 A division of Thielsch Engineering ENGINEERING' 60 Sbawmut Unit#2,Canton,MA 02021 339-502-6'336 FAX 339 03.6345 CONTRACT Page 1 PROGRAM THIS CONINTO TRACT ENEERINGNHECUSMEROWRKKAS DESCRIBED BBMW CUSTOMMS PHONE DATE Cupmo WORK ORDER Daniel Mccarthy (978)886-0862 03/03/2016 406372 00006 SWTVICE WREST ---- —.-- —-— ... BRUNG STREET ..—_-- 1145 Osgood Street 1145 Osgood Street SUFMCe C .STATS.ZIP ---� -.- _ _atlUNO Crry STATE,ZIP •-- ` North,Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PHASE TWO- FOR EXAMPLE ONLY: Proposal is for 2nd phase of weatherizadon project,which cannot proceed until 12 months after the Ist phase of the project. Prices and program incentives not guaranteed. Please contact your Energy Specialist,to issue you a current proposal. $0.00 BARRIER:A Blower Door Test will not be conducted at your home,due to the ptesense of asbestos. $0.00 WALLS:Provide labor and materials to install blown in Class Cellulose to(1305)square feet of asbestos-sided exterior walls. Touch- up painting,if needed,will be the customer's responsibility. Invoicing will occur upon coinpletion of installation. Subsequent to your payment,as an added service,RISE Engineering will return when weather permits to check for any voids with an infrared scanner. Any major voids that maybe found will be filled at nn additional cast. $2,414.25 BASEMENT CEILING:Provide labor and materials to install(94)linear feet of R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $147.00 GARAGE CEILING:Provide labor and materials to install 10"R-35 Class 1 Cellulose insulation to(416)square feet of garage ceiling located below a heated floor area,by drilling holes in the ceiling from below. Holes drilled will be plugged. Plugs will be spackled and ` left in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the customer's responsibility. $673.92 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization Incentive is$3,110. $90.00 - 2016 1 Mph � Federal tD S 115-0405M RISE Engineering R1 Contractor Reglsbation No 6166 MA Contraeter'Regtstraffon No 120879 A divtsion of Thietseh EagtnDering 60 ShawTaut Unit N2,Canton,MA 02021 pA 339-502-6335 FAX 339-502-6345 CONTRACT Page 2 PROGRAM MCOMmacrlsENMWWMRMY&MRISE CMA HESOMOMM MCAs OSSORMamaw FMONE DA78 S Daniel MCCMAY (978)886-0862 02/04/2016 406372 00006 MMM ST T O 1145 Osgood Street 1145 Osgood Street A .STA North Andover,MA 01845 North Andovcr,MA 01845 .SOB DE+SCREMON Total: $3,325.17 Program incentive: $2,050.00 Customer Total: $1,235.17 WE AMES MERMY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE VM ABOVE SPECIFICATIONS.FOR TWO SUM OF ***One Thousand Two Hundred Thirty-Five&171100 Dollars $1,235.17 UPDHF[NAR.IR3PBCt{aNANDMPRav/LLHYRISeEnaatBHCKo.CU$ra34ERA6R2EST0pE{tffMdelfrRaseawtJ.D7TP bZoP1xtYf1r.SUCNARIMMOMUCHANY UItPAla HAt/ItiCEAFTEArODAYSSHTttflYBtQt FORtTBCRTATTTROa0RHA7tON CH 6GARANT Rt6FTT8 IIFR8�S1OH MIN WW.U.DC00RA0ORf9MW MML DO NOT 81t3N THIS CONTRACT IP TH EARS ANY BLANK SPACE8 Ox NOTE:THta COHntAETNAYRE t(H BY U9 tF NOT EI?CUTED w MN DATE Of ACCEPTANCS ACCEPTANCE OF C OMMACT.TNE ABOVE PRICES,a9ECIRCATtaHS AND COKOMONS ARa 34 DAYS SATISPACfORYTOU9ANDARBHEREBYACCFFrtAYOUAABAUiNDR1ZF�TOBOiT@WOHH AS SFECr.9 AO.URrWiLLBBMAaEAS C n ARWASM 1 OWNER AUTHORIZATION FORM (Owner's Name) ,owner of the properly located at (Property ddrew) 2 �vLk 4VOC3 verWtQ - C "Li- 6' (Property Addres) hereby authorize �® � q f��Ca (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. is Signature i Date The Commonwealth of Massachusetts Department of Industfial Accidents I Congress Street, .suite 100 Boston, 111A 02114-2017 �1y WHIM 11111ss.(OVIdia Workers' Compensation Insurance Affidavit: Builders/( ontractt)rs/Electricians/Plumbers. TO BI'. FILED WITH'I'llE PIr,RN-11I TING.AUTHORITV. Applicant Information Please Print L"ibly � i Name (t3usines ()r aniratilm�indn rcivat}: /✓t) �A r�7 r°�r T-ill%,t/At l40 cit Address: .P©. go X 9S City/State/Z.jp:_)9hdou-e P, Wj'9_ Dido Phone #: Are you an employer?('heel:the appropriate hoer Type of project (required) I 0 1 am:i cmplo%cr\e 1111 4_--employ ccs(fill!and;()[part-lime)` 7. Q New construction 1 am a stile proprietor lir partnership and hate no cmplm ecs v.oTkim_ lir me ini 1 Remodelilh ane eapacu\ [No%corkers'comp insurance required J 9 ❑ Demt)lition ®1 am a homeowner dein g all hurl.nnself [No�tiorlxr,'comp iusurancc rcgwrcd 1' 10 Fj Buildingaddition 4 F-1 I am a homeosi m and kill be hiring contractors to conduct all stork on m\ nroperh I s"dl ensure that all contractors either hast v:orl:ers'compensation insurance or arc stile I I M Electrical repairs or additions piopnctois with no emplos ccs 12 Fj Plumping repairs or additions 5 r7 I am a eeneral contractor and I hake hired the sub-contractors listed on the attached sheet 13 F—]Roof repairs 'I hese silo-contractors hate emplos ecs and hate tcorkcrs'comp insurance' i,❑WC arc a corpnrauon and us officers h:nr e�erctscd thea n0ht ul'rsenrpuror per MG[.c 14 F-1 Other I-Q' I0).and tie hacc no einplo\ccs [No rcorkers•comp insurance required J ',1m applicant that checks bos I must also till out the section IWIONC shusjin'!their%%orkers conipcnsation polies intiirrnation I lonicoscners::lin submit this aftidivrt indicatme the} are loin_all work and then hire outside contractors must submit:i ne:c aflidaru uidicatm_::ueh 'Contractors that check this box must attael,•ed:in additional sheet shoscin,-:the name of the sub-contraetots and.siatc sthcthet or not those entities have employees If the sub-contractors have cniplo\ccs.the\ must pros ide their nutkers'comp pulley number f am an eny)loyer that isprot,itfi)ig it'oi'/ieiS'coliipeilSYttioi)Ii1S11)7(il('e foi'till'enphc/ -ees. Below is the polity andjoh site 1nfol-matlon, Insurance Company Nante p G � Polies r or Self-ins Lic # p 1.J C" 7, ;k.. .-P Expiration Date 0/ Job Site Address oal '5 City/State/Zip p.i9/l dav'01 Attach a copy of the workers' coin ensation policy'declaration page(showing tie policy number and expiration date). Failure to secure ctts'eraUe as required under NIGL c 152_ §25A is a criminal violation punishable by a tine up to$1,500 00 and/or orle-_year itnprisonnlent-as well as civil penalties in the form of a STOP N1VORK ORDER and a fine of up to$250.00 a day against the x"it)lator ;1 cttff nfthis statement Ilia\" he ti)rwarded to the Office of Investigations of the DIA for insurance cmerage verification. I do hereby cei-tij'under thepains andpena/ties ofperjmy 1hut the(lifi)iili(itloiipr(i1'itied above is true and c'orrec't. Signature -- - Date ----- Phone Of ((se on1 r. t)iiol)vrite iii thi.v(ire(i. to be c'oiiiplete(I ki-city or lo)t,ii ocint C'it% or rot►n; Permit/Licertsc f' Issuing Authority (circle one): L Board of ficalth 2. Building Department a. Cityffine"n Clerk 4. Electrical Inspector 5. Plumbing Inspector (i. 01lier Contact Person: Phone Y: r . `off Regd -10 'F PI a 5170 . 02116 IDSMtis�xx -_ 'RI bplovemen Typec TMOO ,ON Co- \rjLs Cit LeBlanc AMDOVER. MAO .Address Dp;�CAt ca 54M•�A PETERALBRW4C DATE(MWDD/YYYY) A�" 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 Bogdanowicz Insurance Solutions Corporation PHONE . (603)382-4600 FIIXC NO:(603)382-2034 60 Westville Rd E-MAIL lindab@isc-insurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC d Plaistow NH 03865 INSURER A:Western World INSURED INSURER B.Nautilus Insurance (iron 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 I TYPE OF INSURANCE ADDL S BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MWDCVYYY MWDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE iOCCUR PREM ETORENTED 100 000 PREMISES Ea occurrence $ NPP8274967 3/24/2016 3/24/2017 M ED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 '.. X PRO- FILOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 1-1 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 Peraccident '.... $ 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- ANDEMPLOYERS'LIABILITY Y/N STATUTE I 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 $ 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 ]! - ✓(�j @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025tmia ti POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(PAMlDDIYtYY) 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(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 NAME- ___ Durso&Jankowski Insurance Agency PHONE 978 688 AY 700D _ I(A�c,NoZ(978}.688-7001 11 Saunders Street a/C No Ems_( ._ )._ North Andover,MA 01845 EMAIL — ADDRESS: INSURERS)AFFORDING COVERAGE I NAIC A INSURER A.Nautilus Insurance Co. -" 117370 — INSURED INSURER B:SafetY Insurance Company_ 133618 _ Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc a anc&Steven Leblanc INSURERD: � P O Box 958 — --- -- — - 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ._..- . LTR ADOL`SUBR� P011CYEFF POLICY EXP TYPEOFINSURANCE 1 I LIMITS _ -INSD WVD POLICYNUh1BER MM/DD MM/DD A ;COMMERCIAL GENERAL LIABILITY J I ' EACH OCCURRENCE S —_ -: CLAIMS-MADE :OCCUR DAMAGE TO RENTED I i PREMISE' occurrence) i MED EXP(Any one person) S -- _-_ PERSONAL&ADV INJURY i S GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE S _ _ POLICY? PES -LOC PRODUCTS-COMP/OPAGG S OTHER: - -.S AUTOMOBILE LIABILITYi ',C O aBI a�EDtSINGLE LIMIT S 1,000,000 B ANY AUTO 2100926 01/04!2016'01/04/2017 BODILY INJURY(per person) S _ AUTOS ALL �EO Xi AUTOSULED i 1 BODILY INJURY(Per accident) S X Y NON-OWNED i !PROPERTY DA MAGE-- '`S _ HIRED AUTOS ' AUTOS i,(Pei-acciden) i UMBRELLA LIAR OCCUR - EACH OCCURRENCE S ) EXCESS LIAR A I CLAIMS-MADE; AGGREGATE S DED RETENTIONS ; WORKERS COMPENSATION PER TH- D? STATUTE . :AND EA9PLOYERS'LIABILITY Y/N ^ E lANY PROPRIETORIPARTNERIEXECUTIVE R S OFFICERIME1ABER EXCLUDE . I(Mandatory in NH) iEL DISEASE-EA EMPLO_Y_E_E� $ If yes,describe under ( — — - DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT i S i � t t 1 I 1 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 CER T IFIGA T 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 ACCORDANCE WITH THE POLICY PROVISIONS_ 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE -1000 nn-411 Annon nnonnoA'rtnnt All 11412016 Preview:Certificates of Insurance DATE(dr.4ODYYYY)CErRTIr (✓`ATE OF LIABILITY 1 SURANCrE 0110412016 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 15 WAIVED,subject To — tile 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 CONfACi NAidE: Automatic Data Processing Insurance Agency,Inc- rPHONE No-Exn: Inlc.Noi. I Adp Boulevard E-14ac REss: Roseland,NJ 07068 171SURERIS)AFFORDUIG COVERAGE MAIC INSURER A: NOTGUARD Insurance Company 31470 INSURED INSURER B: ' POLAR BEAR INSULATION CO INC msURER c: I PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER'r_ COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL:CtES OF HISURANCE LISTED BELOV.HAVE BEEP!ISSUED TO THE 11-ISURED tIALIED ADOYE FOR THE POLICY PERIOD INDICATED NO'P:PTHSTAHDIHG AP!Y REOU;REL:EPIT.i ERIN OR COI.IDMON Or ANY CONTRACT OR OTHER DOCUMENT Yi;TH RESPECT TO Y,'HICH THIS CERT.FICATE MAY DE ISSUED OP.(.IAY PERTA:N.THE iNSUHAI.ICE AFFOROED BY THE POL`CiES DESC !BED HEREN:S SUBJECT TO.ALL THE TERL:S. EXCLUSIONS AND COt)DiT:OrdS OF SUCH POLICIES LIVITS SHO11,111 UAY HAVE BEEN REDUCED BY PATO CLAI::'S '. ICJSK T'JPE OF ItISURAHCE JAUDC— PULICY h POLICY txP t LTR I IVSD YND POLICY tR1R19ER (L5640D.YYYY} Ir,V.LUDYYYYi I LtL11TS CO..MMERCIAL GENERAL LIABILITY ._L:,ILr_f.6;UE Ok.:CL.i_ LIEU f;•.P _ Peke_'r.-,L r-AD:I:.JL1f,' GhCL AG+_GEC•;I E LUJI I AFI:LIh51°EE. r_EICEk4L AGC1,EG-:IE - ('i:UL: JE.1 AUTOL:ORILE LABILITY I : -t.l'1:...t-•SII:LLt LII.iI l .tN.�AU It= (i BUIL'=II:AIC_il�,v:o:an3 S'FEULLEU .;CI CS FI}.:EU AL 1.__ I.L'I._:•:.1 U 1•i•:�I'tt:i"'L•;r.L-,r_t ..__ UL[aRELLA LUIS -'-LF vii:F t:: CIC>;EI.:E EXCESS UAB IitL` liti tt:IlCi.> - t'fORKERS COMWENSATION AND ELIPLOYERS'L(ASILIrY -SI:,IL It Eli Y.II 7.000,000 !•1 1!:',PIa_Iraa':,I:ILtla..6r_UII•s .� {A T' POI:'C772258 t9 -r ht-t:.CF1:CCICcL1 A ::r reit-LyLlhhtSEr:CLtI• 101107,20.6 01107,_011 1,000,000 (ISandalory in NH) t L DI_b ASL_-to tGIPLtJ�'hE S '.. i (( D ESC RIP IOU OF OPERATIONSF LOCATIOIIS i VEHICLES(ACORO lel.Addiarm.l Remarks Sch-Wille.mrJ be alnchcd it more space Is required) 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 REPRESErITATIVE i AQ 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD