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HomeMy WebLinkAboutBuilding Permit - 55 MILK STREET 4/26/2016 (2) BUILDING PERMIT ORT#7' TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 0 permit No#: Date Received CHUS Date Issued: ik&IMORTANT: Applicant must complete all items on this page LOCATION y I t5;; Print 5;; Print PROPERTY OWNER IC-ri 7k-,er i't,e- eco J'q Print 100 Year Structure yes no MAP PARCEL:k3'7 ZONING DISTRICT: Historic District yes no Z67- 7 Machine Shop Village ye yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building U One family 0 Addition [I Two or more family 0 Industrial 11 Alteration No. of units: [I Commercial 11 Repair, replacement Li Assessory Bldg ZL Others: Li Demolition 11 Other DESCRIPTION OF WORK TO BE PERFORMED: 0 A17 $ /0 Ae 5 TI, r in / " ;-A 'r/'Plle7X irl �dL )Ovl Identification- Please Type or Print Clearly OWNER: Name: Le-&L 7 Im-e 11%vk-e- Cbr Q Phone: q>?-5F6-L/ 35-T-- Address: 6-5— M0 IC Peter Leblanc Y 0 Contractor Name: Phone: i�T_ Email: LEasir rine Street Address: NJI. 03865 Supervisor's Construction License- /v (0 0 1 ? —Exp. Date: Home Improvement License: —Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINGPERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3 `�ov_ bo -FEE: $ Check No.: Receipt No.: 3 62-_15 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I.......... g Td VW %A R TH Town of ndover ® ® + sAP "h ver, Mass, PA) COCMICM@WICK AoRATED re�`�.(5 S U BOARD OF HEALTH PERMIT LD Food/Kitchen Septic System THIS CERTIFIES THAT ........... ........... o BUILDING INSPECTOR ............... ........ .................... . ................... Foundation C�A has permission to erect .......................... buildings on .. .. ...... .................. ® T Rough to be occupied as .......... ..... ... .. .. .. .. .. .... ....... .•a,y chimney provided that the person accepting this permit shall 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT ELECTRICAL INSPECTOR UNLESS .N STARTS Rough XService ............r:../,; ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BuRough 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. Pei Federal 10 0 054405M RISE Engineering FU Contractor Registration No 8186 NIA Cordroctor Registration No 120979 A dlvhlon ol"I'filetsch Engineering 60 Shawrout Unit W,Conlon,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page I PROGRAM 1149 CONTRACTISERNAED WO 8MWM11VS9 CMA-HES EXONEERM A"'nm CUSTOMER FOR WORX AS DESCAMED BMAW OUR— Catherine Cora (978)886-4355 12/17/2015 402433 00003 fi5 Milk Street 55 Milk Street North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PHXgP.ONE-Proposal for this calendar year. 50.00 HEALTH&SAFETY: Have your heeling system tuned up and retested to be woe that the undiluted flue gasses do not exceed 100 part(�cr million(ppm)carbon monoxide.Weatherization work cannot proceed until this is fixed, SO.00 ,I)AlfRIER.,The following contract is not valid unless accompanied by the Pre-Weathcrization Barrier Incentive form,signed by Your licensed electrician.Work will not proceed with this work until we receive a copy of the form. S0.00 -XIRUALING:Provide labor and materials to seal areas ofyour home against wastorul,excess air leakage.This work will be P9 rlb est 'imed in concert with the use of tools and diagnostic texas to assure that your home will be left with a healthful level of pir exchange and indoor air quality.Materials to be used to seat your home can include caulks,foams and other products. Primary p,real for scaling include air leakage to attics,basements,attached garages and other unheated arm(windows am not generally llocir(tssod.) This will require(8)working hours.A reduction in cubic feet per minute(elm)of air intiltration will occur,but the actual p1lurbcr of elm is not guaranteed. At the completion of the weadicrization work,and at no additional cast to the homeowner,a fuel blower door and/or combustion wirer analysis Will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 41111iEALING ADDER: (2)working hours. S170.00 TT C FLAT:Provr`da dnbor and materials to install a 12"layer of It-42 Class 1 so added to(123)square tect oropen attic spncq. CONTRACTOR DISCRETION AS TO WHETHER OR NOT TO BLOW INSULATION UP THERE $196.80 S(OVES:Provide labor and materials to install a&*layer of R-21 Class I Cellulose added to(224)squaw feet of slope area. Whatever possible baffles will be installed to the entire length oreach bay to maintain ventilation space. CONTRACTOR DISCRETION AS TO WE EIER THIS CAN BE PROPERLY DENSE PACKED 5416.64 $NFFWALL SLOPE:Provide to install R-19 unraced fiberglass to(497)square feet of wall. Then install l" . - jgj4 board Insulation. Seal all scams with FSK tbpc, PLEASE INSULATE GABLE END KNEEWALLS UNDER THIS MEASURE AS WELL(SQUARE,FOOTAGE INCLUDED) $2,037.70 6TTAOE BARRIER:Homeowncrisre*onsible for the removal of the stated items blocking the instalintionotweatherizafion In the kneewall areas. Removal must occur prior to the scheduled work slut. $0.00 Federal 10 0 05-040509 RISE Engineering III Contractor Registration No 8106 MA Contractor Rogistratlon No 120979 A division ofThieftch Engineering 60 Shawmut Unit 02,Canton,MA 02021 CONTRACT 339-5026335 FAX 339-502-6345 Page 2 PROGRAM TWO CONTRACT 18 ENTERED are BETINCEN IUSIS CNA-HES EN(UNSERWO NO TH 0 CUSTOMER FOR WORN AS DESCRIBED BELOW Katherine Cora (978)886-4355 12/17/2015 402433 00003 55 Milk Street 55 Milk Street Ooqh Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Sting bathroom fouls). $50.00 V( `fILATtOIV:Provide tabor and materials W install vOntiladon chutBa in(4S)TaReT bays to maintain air flow. $90.00 '01SEngineering will apply all applicable,eligible Incentives to this contract, You will only be billed the Net amount. Currently, (fir eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Scaling measures up to the first$680 and an additional 5340 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 �nur lunne both before the work is begun,and after the weatherization work Is complete,We will also conduct a Nil assessment of Illy combustion safety of your heating system and water heater.This has a value of$90 and is,at no cost to you.TOW allowable )4atileri2ation incentive is$3,110. $90.00 Total: $3,731.14 Program Incentive: $2,940.00 Customer Total: $791.14 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR 7146 SUM OF ***Seven Hundred Ninety-One&141100 Dollars $791.14 tIPDN FINALURIPCOTION ANDAPPROVAL.BYRISe ENGINEERING.CUSPOWERAGAM TO MrrAMOUNT DUE IN FULL INTEREST OF 1%KILL BE CHARGED MONTHLY ON ANY D BALANCE DAYS.SM ROVEJUM FOR IMPORTANT INFORMATION ON GUARAWMMMORMOFRrzCtSlOKOCREDUUROAKDCOWMCTORREM$tRAT40N, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-Bol ABOVE PDXES.SPECIFICATIONS AND CONDITIONS ABU 30 DAYB. SATISFACTORY TO US AND ARE u2MY AccevrED.YOU Ana Auraomee To DO THE WORK AS SPECKED.PAYMENT WILL BE MADE AS OUTLINED ABOVE OWNER AUTHORIZATION FORM (Owner's Name) , owner of the property located at I k (Property Address) (Property Address) hereby authorize 4 k ct c J" ri u 1 C. �,0 (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. I i I) kOwne—eSignature ®ate 1 i i The Commonwealth of Alassachusetts Department of Industrial Accidents I Con gressStreet, .Smite 100 Boston, IVA 02114-2017 �1 ,l 41"'tt HUISS.aoVIdata Workers' compensation Insurance Affidavit: Builders/C'onti-actors/Electrici ins/F'lumbers. TO BE. FILED WITH THE Pt?Iii4 ITTING AI•TIInRITY. Applicant Information p Please Print Legibly N1111e �V Address: P©. 90Y (?s7k Citv/State/7-.jp: f� Jgtl-erg wtl Dido Phone #: .kre you an employer'. Check the appropriate box: 'I'ype of project (required) 1 ®1 ani a en t-dice ietth rniplutiees(full and•ur part-time)` 7. ❑ New construction '_❑1 ani a sole proprietor or partnership and hate no emplmees i+ork;ng lir me ui S ❑ Remodeling ane capacrh lido i,curkers'comp insurance required J 9 ❑ Demolition ❑I am a homeoxsner doing all stork nreself lNu s;orkers'comp insurance required j 10 F-1 Building addition 1❑I am a homeowner and hill he hiring contractors to conduct all%cork on ms property I sti'tll ensure that all contractors either hate n'orkers'compensation Insurance of are sole I I ❑ Electrical repairs or additions proprietors with no emplmecs 12 ❑Plumbing repairs or additions 5❑I ani a_eneral contractor and I has e lured the sub-contractors listed on the attached sheet 13 ❑Roof repairs I hese suo-contrrraors hate employ ees and hate\iorkers'comp insurance 14 ❑Other i,❑\1=e arc a cnrporauun:rod its ulTircrs bare exercised thea nghl ul'exrmptian per AtG[.c - 1�'_. Itdi.and ire hate no cmpkn ccs lNu icorkcrs comp insurance required] ':\m applicant that cher}.s box 1 must also lila out the SCC tion belt\\sho"ing their isorkers cunipensatit)n pohc} uilornratiom i lonreowners k\lit)submit this aftidivit Indicating then are doinu all\N'ork and then hit outside contractors must submit a nese atlidai it Indicting such 'Contractors chat check this bob must atiaclied on additional sheet shoxiing the name of the sub-contactors and-;tate WICOter or nut those emetics have employees 11-111c sub-ernuractras haVc crnpiocecs.the\ must pro\ide their v.oikers'comp puha number f an;an enlpltlyer!ball is providing workers'compensation lnsill-allce for nit,en7ph1 vees. Below is the policy and jolt sale information. Insurance C'ompanv Name__J__ p C 9 v V, Policy or Self-ins Lic Y 0 1.rJ_ C 7, a� �� Expiration Date d! vi/�r�)� .lob Site Address �` � /I/I��JG �7— City/State/Zip: Attach a copy of the workers' compensatioll polio'declaration page(sboNving the polio' number and expiration (late). Failure to secure coverage as required under NIGL c 152, §25A is a criminal violation punishable by a tine up to$1,500 00 and./M one-year iinnprisonnnent-as vveil as civil penalties in the firm of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator ;A cope of this statement mav he torwarded to the Office of 1i'vestigations of the DIA for insurance coverage verification. I do hereby certify wider the pahm olid penalties of perjwy that the inforluotioo prorided above is true and correct. Signature. l 0 _ Date Phone r: Official use only. Do not write in this arett. to be completed fit•c•iti•or/own official City or Town: Permit/License 4' Issuing Authority (circle one): 1. Board of Health 2. Building Department a. City/Town C'lerh 4. Electrical inspector 5. Phirribing inspector fi. Other Contact Person: Phone#: DATE(MM/DD/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(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 daaowicz NAME: g Insurance Solutions Corporation PHCNo (603)382-4600 A No:(603)382-2034 60 Westville Rd E-MAIL ADDRESS:liadab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC N Plaistow NH 03865 INSURER A:Western World INSURED INSURER B j'tautilus 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 5 BR POLICY EFF POLICY EXP LIMITS LT POLICY NUMBER MWDD/YYY MM/DD/YYY R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED 100 000 A CLAIMS-MADE $ OCCUR PREMISES Ea occurrence $ , NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 R POLICY❑PECOT- []LOC PRODUCTS-COMP/OP AGG $ 2,OOO,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccid ent $ X UMBRELLA LIAR 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 ER ANY PROPRIETOR/PARTNEREXECUTIVE ❑ 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 1$ 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 INS025/9014011 POLASEA-01 JONEILL FDATE(MMDDYYY)CERTIFICATE OF LIABILITY INSURA C 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,subjectto 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 - 978 658-700D j FAX No: 97$ 688-7001 11 Saunders Street ac No.( .--)-- (..__Z }. North Andover, MA 01845 E MAIL — ADDRESS: INSURER(S)AFFORDING COVERAGE j NAIC& _ INSURER A.Nautilus Insurance CO. 117370 INSURED INSURER B:Safety Insurance Company_ 33618 Polar Bear Insulation Co.Inc. INSURERe:____- 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- _ INSR! — TYPE INSURANCE — —ADDL�SUBR; POLICY EFF POLICY EXP -LIMnS LTR{ !INSD WVD! POLICY NUMBER MM/DD AMOR A COMMERCIAL GENERAL LIABILITY ; ! ,EACH OCCURRENCE S TED CLAIMS MADE OCCUR !PREMISES(Ea DAMAGE TC1RENoccurrence) S ' - —--- - MED EXP(Any one person) PERSONAL BADV INJURY ;S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is xPOLICY ^PE OC i ! PRODUCTS-COMPIOP AGG !S - OTHER. — l _ S !AUTOMOBILE LIABILITY j !COMBINED SINGLE LIMIT I g[ Ea 1,OD0,000 -- accident-—.---- _ -- '.. F3ANY AUTO 2100926 01/04/2016'01/04/2017 BODILY INJURY(Per person) i S ALL OWNEDSCHEDULED !AUTOS ?� 'AUTOS ' j ;BODILY INJURY(Per accident)!S X — 'NON-OWNED 1 f 1 PROPERTY DAMAGE ` HIRED AUTOS �� AUTOS 1.(Peraccidenl S.. � S i UMBRELLA LIABOCCUR !EACH OCCURRENCE S i - — A _EXCESS LIABCLA_IMS-MADE; j AGGREGATE S OED RETENTIONS WORKERS COMPENSATION 'PER OTH- :AND EMPLOYERS'LIABIL)TY STATUTE _ :ER Y/N ;ANY PROPRIETORIPARTNERIEXECUTIVEi I E-L EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? D!N/A• i (Mandatory in NH) ! E.L DISEASE-EA EMPLOYEE'S Ifes.describ=under DESCRIPTION OF OPERATIONS be!ot:, ! E.L.DISEASE-POLICY LIMIT;S i I ! j i f t 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 CER T IFICA 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 9 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n-1000 nn-r11 Af%f%MM oonon-rrnnt An....t.c,..,,,,.,,.,,,,,� 1/4/2016 -- ----_ -------- plytie))':Cil ca[t oflnsulancc THIS C «ft ER71FICgTE fS ISSUED qS A ���� �� LIABILITY CERTIFICATE DOES NOT AFF MATTER OF I L�Va��i BELOW.T ���-1l�frVC HIS CERTIFICAT IRpAATIVELY OR NE FORMATION O DAYS U.1hTDpp•YYY) REPRESEN7gTIVE ORP E OF INSURANCE❑p GATIVELY AMENDY AMD CONFERS NO RIG IMPO PRODUCER AND 7 ES NO EXTEND O HTS UPON THE CERTIFICATE HOLDER.4/ 76 RTANT:If the c HE CERTIFICATE CONSTITUTE A CONTRACT ALTER THE CpVERgG ele ter ertificate holder is, E HOLDER RACE BETW E AFFORDED BY THIS ms and conditions of the 3n ADDITIO EEN 7ME ISSUINGTHE PO certificate holder in lieu policy NAL INSURED•the INSURERS, POLICIES Y certafn policies Poficy(ies ( 1 AUTHORIZED PRoouc R Df such endorsements}. may leyuiII an I mustbe entlorsetl.!f SUBRO endorsement A statement on this c UBR ADtDn,at;c GgTioN IS WAIVED Data ProcPssin ate does not confer :Subject tD 1 AdP Baule 9 this A canrncr Roseland, va 7 Agency.Inc tw.tE: rights to NJ 07068 PHO:lE the I C.It,Ex11: 1,115URE0 ADORE ss: A. fA+C,f7o1 POLAR wSURER _ No! IrISURERIS)gFFOP,DIl7G COVE BEAR INSULATION CO INC GUARD I RAGE PO BOX 958 IrlsuneR a, Insure Company A ndover, I+Ate x MA '"SURER C: '-'-------__ I 37470 111sURER D: COVERAGES IrlSURER E: I «,OI�%.`TEe ER,iFr Tri�T THE FDL CERTIFICATE NUMB "IsuRER I= I PIOT,t`ITHr_ ER: 429703 cERrr-rc T_ F.ar:D:WG ht;r OF INSUR nCE usTED B cxCLUSIDtlS,;P;D CGe FsSt G REOUtRE;;rtti.-.. ELOv, ,, O%IsA PE, . i cRt t OR CDP/ Hn G�-'^:i$SUEO u+sR OND:TtD:.Jgr'rF.�.rr CgT,;t,•a. THEIr,? DIF/O/•tOF;,P:Y " - LTR I CH POUT:- SLFP-NC- CONTRACp TNc ttt.9UR VISION N rrrEDFNlsuR CS L?t.'. >Fr0RD^ OR DTH- `D rt^LIE MBER� VFCE !S=HOId`i•.L'q)' t_ ED C•i THG FQL' r. ER DDCULiEidT,C 'O:'E Fp THC TOO I CO:a'IERCL'tL GENE Ins Hnt c BEL'P1 R- , C'..S DE,CRtGED T`I R-coEC - cDJC' C5'��RIDD R,11 LIA91CITY D IA`0 POLICY? e0 G)'PAI HERE:F::3 ti RICHT T CLaltr .Era P(I F L CLAtt— S'`R ,-I TO_LLT HIS L_ C si:L1: 11�.1,:'OD.YYYYI U.t�L[CY P I'c +CRL;$- 'D0 YYi Llii1IS El C, Gct,L,iCGttEG%•tc tL'.ti/A I -...•,mer `.�. '.,. AUT I`!'LIE$I'Eli. re�e Jrvt-n:e: . ILVLAeIL17Y [-II:EU AL t_y +'It.5 ' •'Jt.l_+•EL•Sir: � I LC .='c:4EU � tt_:::-:c.❑ CCE ULbf UaUE::r•�b:rrarz _ +UR3RECLA LLtU ECUIL II.JLYi�,t°_':-`-•` E:CESS -L -P ,•F:`r " _u: .i uoax "'PIiEti=r:uCL$ i< aRD ERS COEUSATFO;t EriPLOYERS'LIARF 1 •. ,-•�t,l�I. t-l,,.lJ_,i 1ry . E,:LEfdSEf. L'U•_E b„andalor%:n lin)E"'tL tit;+ .y (J.IIA N PSI"C77225a X t`ti: - It'�I'CI°kti:•[ICl.g a.>.. r Si:I LIE I iii 11 07/C1/2Q76' 077 EL c:•c!.:r_.Fc t.r 1.000.000 OEsc I=L.t1:E.,. D0,000 RIP irOtiOF O PERAT'OIIS:LOCi,nort 1.000,000 s�VEHICLES(ACORD 10 t-r+Edi,ion:J Remur•„Sehwn4. n'T1 bC tibef:ctl if ran:Csp��e L;xeRuir j CERTIFICATE HOLDER CANCELLATION Theflsch En9lneering,Inc. T 95 Frances Ave THE SHOULD NY OF THE ABOVE DESCRIBED Cranston,RI 02910 ACCORDANCE 1I�I1THEP��HERFEOF, NO ICE Wt��sANCELLEDBEFORE ROVISIONS. E DELIVERED IN I AU7RDRlED REPRESENTATIVE '. ACORD25 (2014/01) Tile ACORD ACORD name and IDJ A�7988- gD are registeredmarks Z014 ACORD CO of ACORD RPORATfON.All rights resented• t Of are of consumer 1� p1 a_ Smote,51° 0 - - Rene -lo2-126 - Tvpe: DBS irdlz�r 712016ION CO. pOLALR BEAR --- Vilicent LeBlancp_0.BOX 958 ANC OVER= MA 0 :- --�':=�p ,� and arae P14�e n Lost oird Address Itmewa apscAt � ��o �s a tz IpBTERALEBLAW 7 _