HomeMy WebLinkAboutBuilding Permit # 4/25/2016 IAI BUILDING PE LEU � IT O� 6�� �(Z TOWN OF NORTH ANDOVER �� ab APPLICATION FOR PLAN EXAMINATION ® p Permit No#:' 'z�L Date Received �, A—ArEr,pea �5 CHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /6 � nCey-e d— -->7- Print PROPERTY OWNER rof,041'r Print 100 Year Structure no MAP PARCEL e ZONING DISTRICT: Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other r❑rSe ttc=� �We[� Y� >' � r�, �rr�❑ [ od lain,� , O Weflartds f ��r�, f ❑,f�lNafiers edgD sfrtct� � a,'f ^,,l � rr / tL'. ;,r S rr�.... l lG -.:.. u` I f r,H. ..... R: .4 ,f�.:v..if✓/ .Xf :v ! !✓7F �. r,.. ,. ;,�. '�a r c yrf.,s .,,v r` v,-., rr. :+Y` � r r �s,;.if '�S� n�.�" N..�: "r"rr�r. � .r ��'.„�/� l';r✓✓l r :,.... .rsy yy.. �'�,Nfrrf. d"k�...��`" ` :..?„� h :rfy �. 5... ar. ,�./.. flr .✓ r ,,. .,rr'�,✓. � r ..,si��,,:,: -e.., r .;.. ..-,rtr e .� wr r ,� t<t, ,'. ., � � F y�r r„ �''� m � �jz' f,r r` �: .,: . �l'x'f✓.rr`' t �<,; DESCRIPTION OF WORK TO BE PERFORMED: Cy.-trt' l'or” Wil/ ihSv IA /'c7A D-eV15e Nrit rt`C,w 5NCr- in5o/r;O A Q,-Ig Tin,-VN / I1 Identification- Please Type or Print Clearly OWNER: Name: hc.w vl CO P wt/'r V- Phone: Address: (C IF 4 11)aVeV- 5.1 Contractor Name: 2 East Pine Street, Phone: Email: Plaistow. Address: 978-407-7638 Supervisor's Construction License: / b Go Exp. Dater bL A? i Home Improvement License: 10a-W-(a Exp. Date: 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: $ 3Foeo .00 FEE: $ 4u�, Check No.: -7 Receipt No.: ,,2-1 NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund ghw NORTH &-,&ver Town ot Andu O0% ® _ ® 76 's 6iN. Il Ver a.SS OLIw1t COC L111411"Ichawqcw v� IF �qS RATED UBOARD OF HEALTH PER &W1 Food/Kitchen Septic System 01T T L �D THIS CERTIFIES THAT FAIW. BUILDING INSPECTOR ............. .AJ6 ...... . Foundation has permission to erect.......................... buildings on ....IM..... .SI ........ p g Rough pAi to be occupied as . . . .. ..�1y. ..ii .... ... ^�. . . '�..� . . .. ...... ................ 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 relatpup to the Ins4g do Alteration and Construction of Buildings in the Town of North Andover. ej PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES I -,6MONTHS ELECTRICAL INSPECTOR LESSIO TARTS 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. redww to B 0510405= RISE En*eering Rlf:onir*WR*Wb8tbnK0tlt88 UA Contractor R08bft%n No 120818 A dhtfw of Indettsb Eagineaft f9S!?---=n!tints02,C-- ton,Kit^zoic CONTRACT 3394602.6335 FAX 339.502-6345 Page 2 PROGRAM enensasrt0WWM=9 TeascoxraAcrm CMA-HES M"McU$f0I=faareancAs Shawn Cormier (617)549-2616 03/14/2016 406563 00007 Own Ffm 169 Andover Street 169 Andover Street North Andover,MA 0184S North Andover,MA 01845 JOB DESCRIPTION Total: 4824.65 Program Incentive: $2,M.00 Customer Total: $1,734.65 WE AQM M My Te Fu mBH SERYICEB.COMPLEn:IN ACCMMCE WnM A60Y@ SPECEF=TWW MR THE Sup OP ***One Thousand Seven Hundred Thirty-Four&85/100 Dollars $1,734.65 �ae"_LR9VERBa S � P OP� BAtmv tiN CONTRA ARE ANY ei.ANKliPAtW 3/29/16 KCrBtTIf0007f1AACTifAY86 T/IrISCitAWN 6YC9 V f10Y$1><OCfJTeD1T[Tf671 CAMCFACCMAM WTRIACT� TTQ ACC®IkA ACiMOR® �ICRK 30 "Ya A9 oiCCJt�PAYYSNTWtLL9aYACHAsoUItDCDAsoYa J � e�c 4 u ace 7'O 7U 00054 0M RISE Engineering al aoatraoW IFlegstration No 8188 MA contractor Regleb ffon No 120970 A division of Thlelseh Engineering 60 Sbarmu!Uslt A Cantor,M—A 01MI CONTRACT 339-5026335 FAX 339 5026345 pap 1 PROGRAM TrescormatortsaoeREDwrottanseettose CMA-HBSENIKKEENUM TMaouNattaaFOR MCI"ca Shawn Cormier (617)549-2616 03/14/2016 406563 00007 169 Andover Sheet 169 Andover Street North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PHASE TWO-FOR EXAMPLE ONLY:Proposal Is for 2nd phase of weatherizatian project,which cannot proceed until 12 months after the tat phase of the projeer Priem and program incentives not guaranteed. Please contact your Energy Specialist.to Issue you a eurreat proposal $0.00 BARRIER:A Blower Door Test will not be ooaductod at your home,due to the presmse ofasbestos. $0.00 WALLS:Provide labor and materials to Install blown to Class i Cellulose to(7S)sgwm feet of exterior walls through an interior surface drill and plug method. Plugs will be speckled and loft with a rough finish.Finish sanding and toucb-up priming/painting will be the custome's teepor>sibitity. Homeowner has received a Copy of the EPA's Renovate Right Load-Safe information guide explaining the potential risk of the laid humd exposure from the weatherization work to be performed.Your signature is your admowedgemeat of aeccipt and agreement to proceed. 5150.00 WALLS:Furnish and install blown In Class I Cellulose to(1305)square fon of shingle and/or clapboard exterior walls.The butt of the upper course of your wood siding Is cut to drill holes into the wall sheathing behind The holes are then plugged and the wood siding is reinstalled using stainless stoat finish nails.Touch-up painting,if neo ed,will be the customm's responsibility. Invoicing will , occur upon completion of installation.Homeowner has received a copy of the EPA's Renovate Right Lead—Sara information guide explaining the potedW risk of the lead hazard etpw=from the weatherization wont to be performed.Your signature is your admowodgement of receipt and agreement to proceed. $2,414.25 BASEMENT CEILING:Provide labor and materials to install(I74)linear foci of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $217.00 CRAWLSPAC&Provide labor and materials to install(140)square feet of R-19 unf§oed fiberglass Imulation to time crawhpaoe calling to be in txmorct with the subfkror and completely filling tha joist cavity to be flush with rho joist bottoms. Then Insall I" polyhoayanurato foam board Insulation.Scal all amps with FSK taps $539.00 CRAWLSPAC&Provide tabor sad materials to Install(112)square fat of R-10 rigid Than=Insulation to the cmwtspoe perimeter wall up to the sill and agaiaat the band joist $414.40 RISE Engineering will apply all applicable,eligible Incentives to this contract. You will only bo bided tiro Net amount Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per caleadar year,and an Incentive of 10046 for the Air Scaling measures up to the fast$680 and an additional$340 if savings ate justifiod by the auditor. For the safety and health of your homes indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your Memo both before the work is begun,and after the weatherhaWon work is complete.We will also ooaduct a tail ammunatt of tate combustion safety ofyour heating system and water tmater.This has a value of 590 and Is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 Z/aG SGS OWNER AUTHORIZATION FORS! � f I. —Shawn on vp III (Owners ane owner of the property located at 169 Andover Street Adm) hereby authorize 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. Owner's Signature o� ��, PLX The 'C'ommonwealth of Massachusetts Department of lndustrlal Accidents 1 Congress Street, Suite 100 Boston, IIIA 021]4-2017 11 Mflss.UOVIdia Workers' Compensation Insurance Affidavit: Builders/C'ontracttUrs/Electricians/Pluntnbers. TO III. PILED WITH TIIE PI?Rii91-I TING.-fit-THORITY. Applicant Information Please Print Leiaibh' Name f f3uslness'(ir ant�atton�lndt�t�uaf j:_ �b �G/ �>'A /4, /16 til Address: P 0. [150 X 95_F City/State/Zip: -er, yt/I..4, o 4lo Phone Are you an employer'('heel:the appropriatr box: }'pe of project (t'CilWred) 1 0 1 am a employer with rFIT10%ers(fuli and•ar pari-(inc)` 7. Q New COnSlruclil)Il '_❑I ant a sole proprietor or partnership and have na emploN res v.orkm, lire me In S Ej Remodeling ani capacih [No%wikers'camp insurance required J 9 ❑ Denu)liuon i®1 ant a hameox%ner drum,all\cark nt\self I?vu v orl.ers'comp Insurance rcqurrcd J' 10 ElBtiildinb addition -1 F1 ant a honteotsmer and will be lin ink contractors to conduct all[cork on m� property I r:ill ensure that all contractors either have tyorl:ers'cumpcnsauon insurance tit arc sole I 1 0 Electrical repairs or additions ploprtctors[velli no employees 12 F]Plumbing repairs or additions i 1 am a_eneral contractor and I have hired lite sub-autnaclors listed on the attached sheet 13 [:]Roo f re pa i rs I hese soh-cuntrtraors hate employees and have tvurkers-romp Insurance i,❑We arc a carporauun and its ulilccrs have exercised[lieu right of 14 no ther csrt»p[trnt per 1iG1-r - --- li],§It41.and rye Istcc no rmplo�crs INO tcorkrrscony[ msuranie rcyuurd J °an applicant that check box=I must also till Out the icCllail helon shatyHIL then tyorkers-crunpcnsauon paha trtfitrmau»n I luntcutrncrs.aha submit[lies attid ivn Indreatute they are doing all work and thee[hire outside contractors must submit a new affidavit utdtcaung ouch Contractors[lilt checl,ill Is b(A must attached an add)uonal sheet shoe in the name kit,tilesub-conttactots and.icor tthethet in nOl those enttucs hove emplu�ecs If the sulrumuactars have entpluyies-the\ must provide then norkers'comp pollr} number I trip on eny)hlyer that is providin workers'compensation instrroilc'e fpr)til'entphc l.-ees•. Belot'is the policy and job site information. Insurance Company Name n �J Puller # or Self-ins C.icp W C" 7 a;k' S—P Expiration Date 6// Job Site Address ��it�fl7t/�✓ S% CayfState/Zip' Attach a copy of the ir•orkers' compensation policy declaration page(shoNving the policy number and expiration date). Failure to secure coverage as required Under MGL c 152. §215A is a criminal violation punishable by a fine up to$1,500 Ot.f and./or one Fear imprisonment-as well as civil penalties in the firm ofa STOP�VORK ORDER and a fine of up to$250.00 a clay against the x folator A cope of this statement rimy lie f rwarded to the Office of Investigations of the DIA fOr insurance coverage verification. I do hereby certify ander the pitims and penalties o0erimy that the iitia)'))rtrtto))prt))'illetl abot'e is trite and correct. 51�'lltttule t7_ --- -- Date Of itse only. Da not write in this arca, to be co)apleted hl'city or town olftcial. C'itv or Town: Permit/License# Issuing Authority (circle one): 't. Board of health 2. Building Department ?. Ci!)-/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Cather Contact Person: Phone#: DATE(MM/DD/YYYY) A D® 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 ADD171ONAL 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 danowic2 NAME: g Insurance Solutions Corporation PHONE (603)382-4600 FAX No):(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC A Plaistow NS 03865 INSURERA:WeStern World INSURED INSURER B T7autiluS 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 EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DLVYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE ToREED A CLAIMS-MADE [A]OCCUR PREM SES Eaoccurrrence $ 100,000 NPPS274967 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 S 2,000,000 POLICY❑PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X 0 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 I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ 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,Addhlonal 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 INS025 onl4o11 POLABEA-01 JONEILL 14 ccm® CERTIFICATE OF LIABILITY INSURANCE FDATE(61rN2o0nNyy" v)/ 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). PRODUCER CONTACT NAME: _ _ Durso&Jankowski Insurance Agency PHONE 11 Saunders Street A/cN� (978� _ (688-7000 1 FAX,-Ro-(978 888-7001 ._ -- ac ). North Andover, MA 01845 E MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL _ INSURER A.Nautilus Insurance Co. _ 117370 _ INSURED INSURER B:Safety Insurance Company— [33618 Polar Bear Insulation CO.Inc. INSURER C: Peter Leblanc&Steven Leblanc INSURER D: I P O Box 958 — --- -- — --- Andover,.MA 01810 INSURER E_ 1 _ 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 ADDLISUBR; POLICY EFF i POLICY EXP i LIMITS LTR; 'INSD i W1/D; POLICY NUMBER i MM/DD MM/DD Q COMMERCIAL GENERAL LIABILITY l I , EACH OCCURRENCE 5 '. DAMAGE TO RENTED - - `- CLAIMS-MADE OCCUR I PREMISEoccurrence) S - —--- - MED EXP(Any one person) 3 _ _ • - ` PERSONAL 8 ADV INJURY S _ GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE (S 'POLICY PRO- i I X _JECT _LOC PRODUCTS-COMPIOP AGG S i OTHER: AUTOMOBILE LIABILITY i 1 COMBINED SINGLE LIMIT S 1,000,000 i Ea accident_— —___ _ B ANY AUTO 2100926 01/04/2016 01104120717!' BODILY INJURY(Per person) S ALL OW_ SCHED AUTOS�EO X i AUTOSULED i I BODILYINJURY(Peraccident)!S `NON-OWNED i i PROPERTY DAMAGE HIRED AUTOS Y AUTOS t ?.(Peracciden� S.. _ $ UMBRELLA LIAR OCCUR - I EACH OCCURRENCE — A EXCESS LIABCLAIMS-MADEi ? J AGGREGATE S DED RETENTIONS iS WORKERS COMPENSATION PER OTH- :AND EMPLOYERS'LIABILITY STATUTE `ER ! _ - Y/N; ?ANY PROPRIETORIPARTNERIEXECUTIVEi E L EACH ACCIDENT ;S 'OFFICERWEIABEREXCLUDED? DIN/A! t(MandatoryinNH) ? ; E_-L DISEASE-EA EMPLOYEE 5 If yes,describe under DESCRIPTION OF OPERATIONS below i E.L DISEASE-POLICY LIMIT;S i i ! I i 1 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(FICA 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 g 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE rl-4000 nn-4A AnnMn f1rl0n1lMAT1f%k1 All�...L.F..r....e.......1 IW2016 Preview:Certificates of Insurance DATE(t.it,1UDYY YY) OERTH ELATE OF LIABILITY INSURANCE- �- 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 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 CutIrACT NA1.tE: PHONE FA% Automatic Data Processing Insurance Agency Inc fA:C_No-Ext): (A%c.Not I Adp Boulevard ADDRESS: Roseland,NJ 07068 IIISURERIS)AFFOROIIIG COVERAGE HAIC7 INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER c: PO BOX 958 Andover,MA 01810 RiSURER D: INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THnT THE POLICIES OF INSURANCE LISTED BELO..HAVE BEEN t85VE0 TO THE;NSURED NAMED ABO`:E FOR THE POLICY PERIOD INDICATED NOTIANTHSTA(IDII-IG ANY REOU(REi.ENT_TEPIJ OR CONDIT!ON OF ANY CONTRACT OR OTHER DOCULIENT RESPECT TO:;RICH THIS CERTIFICATE LIAY BE ISSUED OF.i.!AY FERTA:(-L THE 7NSVRANCE AFFORDED BY THE FOLiCIES DESCRIBED HEREa•I:S SUBJECT TO ALL THE TERt.;S, EXCLUSIONS AND COND)T:Ot%!S OF SUCH POL.C-)ES L)LUTS SHOto4d&'AY HAVE BEE-IN REDUCED BY PA0 CLA9t.'.S ;NSR TYPE OFIt15URAttCE AIIQL� POLICY❑V!,18ER P LILY F POLICY P f LI;1175 LTR Inso VND (LILSDD.YYYYI t:.%vDn:YYYYi I 'CO.MMERCIAL GENERAL LIABILITY L:.,:F.dcLl:NIEr.C_ :=Lfiit.I5d.FVE � CLI; Pf%Ef.liSc:S lea ;;LGL kGCIE�f-A�I)LO•.111 I�I'UtS PLi;. i_tia_k•�L AGLIsEI Alt : 11-.; ILC: P[,LtC:LIL I JEt-I 1 , Pt::ti_i:iS t 1-+Ii. AUTOJ.'OBILELJABILITY :t.l"It�G�If;LL Le.ilf t.�:J�i:; BLL•IL''If:lLI:'::I�,i•:r.-�n: 5 r:LL:'.:t.EL• N-cL•LLEU .'1:1:: :.L'I CJ AL, `::Sf.L• I � I I•t•.'-:I'ttei" :.i.1:,UE y t-n:Eu:.Ll::s ,:OILS ' Is Ut.SRELLALIAB Lk a.:Cf-C-1 vClcitt:IL EXCESS LIA9 I L'LRI1.1g.l.K.L•t :,CCIiN_:,i L - ULL' HLIOi IICI— VJ RKERS COMIPENSATIOU X AND Et.1PLOYERS LIABSI 1IL ItILITY Y;ItI 1,DDO,OOD :•I. Ii:'.PIa6l-i 1 u r,E. _utct n1„Ja PI POl".'C772252 02!01;2016 0110?:2017 LLE:.ct-:.r-actt.t %a =FiLEit t.wLlbH:E::7LLL�i;� �i•• 1,OOD,000 (Yandalory in NH) L DI chi_ LA LLiPLt,`"LE a,_;.s_•s_ ._- 1.000,000 L"tS::}ili'lir,i:•_.t Ci'kli:.11Cl�•v:�:= lt.L.l`I�E:•5L {-..DL OI-111 I OE5CRIPuON OF OPERATIONS;LOCATIONS i VEMCLES(ACORO lel.Additional Refn31S55[hidulc,m.(be wfa.hed it--P.— CERTIFICATE spacrCERTIFICATE 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 A^'-,1988-2014 ACORD CORPORATION.All rights reserved. ACO RD 25(2014101) The ACORD name and logo are registered marks of ACORD f SSS-Regdeonof AEms _ - d 1 0parkploa. SIfIte 5170 �211� ,bilprovemen _,_. : '10272 ipOLJkR BEAR.ifi1V3 -flim Co- )jincent LeBlanc p_o_BOX 958 _ _ _ -- :_ a ox a� �+£ �(� �R� 0� io - y'_ ups Address dremmCA * �YanstfCarr3 Address �{6t2Y6 pP5-CA"t ca pj •C'6.dLiliEAltwW