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HomeMy WebLinkAboutBuilding Permit # 4/25/2016 BUILDING PE �aomaTy IT o� TED ,b TO F NORTH DOVE p6 o APPLICATION FOR PLAN EXAMINATION ® _ Permit No#: 70I®� Date Received QDRgTED PPp`�y SSACHU`S Date Issued: I P®RTANT: Applicant must complete all items on this page LOCATION Acklebbeefy Ggoe Pr nt PROPERTY OWNER I-�Gy (� �2ee— Print 100 Year Structure yesOno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 „/q 1'1® ,=r4 sem, ,figs X ^,,r}l�Ir,;��r s � "''"' r},9�d ,r' i/9r,: F.c z ,r�vr�, ;,fie ✓;`rr,r� add � �'r,...✓��� r r"� ':!J ,h ,i i e f ❑f loud lay;>{ r {❑Wetlands 1 f; ❑JJ Watershecf1Distr�ct � Sep ❑�W I I �, / +� F � � � rr w,� ,� Jf ..... r.,. � r I.., rY ,,..,. / p 8 .:.f � x+r�;.„r. ,r Y c.: F' ✓{ t. n,zu �r � [.t.., „r. aP`",x� .: ,�7' �ur'1 �,„.,s 4 ..s. .,✓�'f:: J� �:, ks"r?c'.:,vii- .rsf+' >f.Ux .� �.. ?i�' ..,r'h d'c'n/. �✓� .r<' 't, �,..„f .�fi.�” r �f... r ,..,. �. � .,k'+.:�'.., � uz ..,r,� +" a-„� ,,,C�:i'f� n'.:r�F- s 5 .� r"7Y' 7�?r.,,,�; ✓7,,l�l� f.�✓r`�.,�;*'Jz� 6 ��s %``r ,;+.. i „r x f� /.;". s ,� w�btz�t,Y�`�^�� � � a �kr .,�w.;.✓ r��. r� h zk,.. ,�+ �,. r� ,,+r�..,., ✓7 s..4 r"i.� f. `.�Ya �1' ,s 5: s, DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: L a C y � -e s k e r Phone: 6 In - ®V-?o9-5— Address: -err y Contractor NarnePeter Leblanc Phone: Email: 2 East Address: PlaistoW9 978-407-7638' Su ervisors Construction License: /(q Cy®17 Exp. Date: �� �� I _ P 1 Home Improvement License: 1 ® G Exp. Date: 7 41 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3 j®® -® a FEE: $ 0 Check No.: __� Receipt No.: x)71 NOTE: Persons contracting with unregistered contractors do not have access to the guarant' - - F NORTH V V An GOver O .� - to No. IL Is o1 1 L^Ka -4 �l VL'I'' c1SS, COCNICKCWICK �1. �•9 A°RAreo PIS S U BOARD OF HEALTH Food/Kitchen rERMIT T L mumns" Septic System THIS CERTIFIES THAT ....... ............. BUILDING INSPECTOR . ... .. .... . .... ..... .. ... . ......... ... .. ... .............. has permission to erect g Foundation .......................... buildin s n .... ... ..... ... �A�.e....... �. .. ................. 444 Rough to be occupied as .... • ...... ..... ... .... .•lt.� ........ ... chimney provided that the person accepting this mit 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN.6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STARTS 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. ' r Fodoral tow 0 06.04015428 RISE Engineering Rt Contractor Registration No 8180 AAA Contractor Registration No 120979 RISE "` A division of"fbieisch Engineering ENGINEETRING7 np Sha Icon MA 02021 rt but Unit N2 Union, T CONTRAC 339.50335 FAX 39-502-6345 9 _ I Pape 1 �� PROGRAM ,... nos COMACT is ERTEI+za acro BETWEEN WU CMA-HES E roMo AvuacusvoarEwFOR WORK ae ascrmrEo orxow Clk9TTJttiEli a" 1 FI ME DATE CUEWT9 w09rfteRDER Lacy ender (610)304-8085 03/03/2016 431461 000102 SaMce aTREET 041JW STREET 79 Huckleberry Laneins �� rR � 79 Huckleberry Lane SERVICE CRY.STATE,ZEG.... r """.. "A."C".bTATE.PSP North Andover,MA 018 _ North Andover,MA 01845 _._._._.. 1 _.. . ._._ _._ ... 308 DESCRIPTION HAZARD BARRiER:We have identified that there arc recesscd lights present in your home.unless the recessed lights are certified as iC-rated(insulation Contact Rated)we will create a 3'clearance space around the fixturc 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. 50.00 AIR SEALING:Providc labor and materials to sea)areas of your home against wasteful,excess uir leakage. Ibis work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a hcaithfui level of air 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,basements,attached garages and other unheated areas(windows aro not generally addressed.) This will require(8)working hours.A reduction in cubic feet per minute(cfr a)of air infiltration will occur,but the actual number orcrin is not gummitccd. At the completion of the weathcrization work,acid at no additional cost u1 the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contraclor to ensure the safety of the indoor air quality. SHUT) DAMMING:Provide labor and materials to install a 12"laycr or R•38 unfaccd fiberglass baits to(196)square fent rot damming purposes. $401,80 ATTIC FLAT:Provide labor and materials to install a 7"iuyer of R-25 Class i Cellulose added to(1148)square feet of open attic space. $1,492.40 KNEEWAL S:provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(40)square fect of knccivalI arca, $140.00 ATTiC ACCESS:Provide labor and materials to make(1) access opening from one attic area to another by cutting a passage through sheathing. This access will be left open as it is between two common unheated non firewailed attic areas. $31.31 ATTIC ACCESS vide labor and materials to install Ieasily moved,insulating cover for(he attic access folding stair. A small Oat surface of 1 rod will be created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. $237.65 ATTIC ACCESS:provide labor and materials to make(1) temporary access to an attic area. Tire opening will be closed with materials similar to those existing. Finish sanding and painting is not included, $85.00 VF.NTtt-ATION:provide labor and materials to install 15)8"diameter roof vents)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,brown,gray(rr mill finish. 5427.50 VENTILATiON:Provide labor and materials to install(2)insulated exhaust hose with gable wall mounted flapper vent to exhaust existing bathroom Tants). 5237.50 • Federal too Qty RISE Englnee6* RI Cot V=WRagWAW*n No 8180 RISEAK°' `ar `` NoI diviston of7'btetseb t,.ngimeeriag MM ENGINEERING 60 Stuwatat UW1 a2,Cautva,MA Omit CONTRACT 339302.6335 FAX 339-SH-6345 Pegs 2 PROGRAM CMA-RES BtOP{i3D0AMM0TMKCtiOTCIfEAi�e 69LOW cieareAaa} PVAMa CAM CUMA %DIaRM= Lacy Bender (610)3048085 03/032016 431461 00002 acRY+ee arRmr aK.rdeo aTReer 79 Huckleberry lane 79 Huckleberry lane • him aw.ffTATLZP .. 11"=MY.STAY&2la North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION VENTIbA7iON:provide labor and materials to install ventilation chutes in(64)rafter bays to maintain air flow. 5128.00 RISE Engl wdog will apply all applicaW eligible htoeadves to this contract.You will only be billed the Net amamt.Currently. fbr eligible measum Columbia Gas offers 7595 iaoentim not to exceM 52,000 per calendar ym and an inmtive of 1000A for the Air Sealing measures up to the ftrtt 5680 and an additional 5340 if saving;aro justified by the audhor. For the safety and heft of your homes indoor air quality,we will be conducting a blower door diagnostic of the availabto air Row in Your home both before the work is begun,and after rho weatherimdon work is complete.We will also conduct a full assessment of the combustion safety ofyour beating system aid water beaterno bas a value of S90 and is at no coat to you. Total allowable WeetbCFhMtiam inactive is 53,110. 590.00 Total: $3,951.16 Program Incentive: $2,770.00 Customer Total: $1,181.16 WE AGM MOW TOFORMMatRVIM•COMM 0ACCORVANCBWITH AME SPECIFICATION&POR"MSWIOF *"One Thousand One Hundred Eighty-One 8161100 Dollars $1,181.16 UP"SUL ertPECI HAND APPROVAL err;=10=0a%tM CU910eR AURM to RaWTAMMWOW 00 ML WW"T or t%V"0 CWxaftRItWMVON AMI/ U7mAPDOAtANeaAPT01mWYaamRmRRaeroRYtPORMMr00'ORAIAt10Mg1 OUANXIM LROMOPRNUMaatECtMiMO,AMDooMrRAeTeRwalnRAttDM. iD0 NOT StON Tl{t8 CONtRAC'r tF TH�iE ARE ANY BiANK SP ..---. MCTat Tian count CT my as vnnarAm m era er war exiewworm MTeorACCFP7AM1 ACCWTAMea OPCCUMACT•nmADove PR10El►aDaQi1CAY10/OAMD COID)ItID1O ARK 30 ogre. gAnWACIMYTOLOAWAR8WMBYAOefPMVOUARLAtmMIMMTODCflffitMORK Aa WICOMPAYU MV"NUADEAaoU1YM®AOM r R� � .. 60 Sbawmut Road,Unit 2 1 Canton,RAA 02821 j 339-502.6335 ENGINEERING www.RISEenginearing.com OWNER AUTHORIZATION FORM I, Lf� c 1.3et,�,ei- c,rl- , (Owner's Name) owner of the property located at: (Property Address) (Property Address) hereby authorize_- P0 (Cr(,-,J (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. O er's i atur Date The Commonwealth of MassflChusefts Department of IndustHal Aecidents 1 Congress.Street, .Shite 100 Boston, 111A 02114-1017 v 9Uit'IfCnulss.g®I''Mia Workers' Compensation Insurance Affidavit: Builders/('ontractors/Electricians/Plmnbers. TO BE TILED W11*fi"I'llE PER?49I"I-f-t;`+C:.-'tt"THORITI. Applicant Information Please Print Legibly NanneV���/i9 Address: P©. 90Y City/State/Zip: R n d ou-er, m,;4, o4la Phone #: .kre you an employer"Cherk thr appropriate hos: Type of project (required) 1 ®1 am a cmplincr aerie�emphr\rrs(fuli andiur pari-miner` 7. Q Nell'construction 2®1 am a sole proprietor or partnership and have no cmplo\ccs\\arking lire mem R Remodel Ing an}capaciiv [No aorkets'comp insurance required J 1) El Dernol I tioll i®I am a homeomier dour_all lurk m\self INu anrt:cn romp insurance required]' 10E] Building addition d❑1 am a homeowner and arll be hiring contractors to conduct all\cork on m\ property I\vett ensure that all contractors either have\corkers'compensation insurance or are sole I I EJ Electrical repairs or additions propnciurs with no etnplu\ees � j 1_ �Plumbing.repairs or additions 1 and a_eneral contractor and I have hired the sub-contractors listed on the attached sheet 13 Roof repairs I hese sub-contractors bare emj\lo\'ecs and have\curkers'aanp insurance*, i,❑We are a co;poranorr and its ol}icrrs have exercised thou fight ufexrmpunn per i\4(.[.c 14 nother Ij�.;11'1.and at hetet no rmplO\cis INu\corkers'comp insurance rrganed J :\n\ applicant That cher!.;tux 1 nnut also 1-111 Out the section belo\v sho\cing their\corkers'aanprnsation poic\ mlormahon I Imuco\vncrs aho sabnut this aitida\rt indicating the\are doing all\\'ort;and then hire ouis;dc conliactnrs must submn a ne\v affidavit indicating such =[ontractors that Chea;this box must attached an additional sheet shu\ciug the name of the sub-conniclors and a;ur attether or nor those chimes have employees if the sol?-corttracnrrs have cnifilm ccs.the\ must pro%Ide their \\urkers"comp polic\ nuurbcr f tim an em1)10}-er that is provitling workers'conilmnsatlon Ii2S111itl2ce for n2l,emphorees. Below is the policf'alidjoh SINN ',...... 1llforlllatl oll. Insurance Companv Name G v Policy r or Self-ins Lic # p W l0 77 a;I• Expiration Date d� d"w4dl7 Job Site Address � /4 l te-�r Pry it q- e- City/State/Zip r A- B Attach a cop), of the %vorkers' compensation policy declaration page(sbosi•ing the policy number and expiration date). Failure to secure coverage as required under NMGL c 15_. §25A is a criminal Vio)ation punishable b), a tine up to $1,500 O(t and/or one-year imprisonment,as well as civil penalties in the tbnm of a STOP X1%ORk ORDER and a fine Of up to S250 00 a dav against the violator t1 copy of this statement mai he tOryvarded to the Office of Investigations tri the DIA for insurance covera:.,e verification. I do hereby certify wider the pains!11111 peltalties of peijmy that the ilifoi'2Ntltioti proi-itled aboi-e IS true and correct. Signature 1 — Date Thune r: Oficial use onlf% Do!lot write in this area. to be completed lit'city or toren offtchll. CitE or Town: Permit/License# Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk A. I. lectricnI inspector -5. Plumbing Inspector 6. OfheI- Contact Pei-son: Phone#: DATE(MWDD/YYYY) A�E® CERTIFICATE F 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(iss) 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 endorsements. PRODUCER CONTACT NAME: Linda BOg danoWicz Insurance Solutions CorporationPHON o (603)382-4600 F� No:(603)382-2034 60 Westville Rd E-MAIL lindab@isc-insurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERA: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. NOTVVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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 S BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYY MM/DD/YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE R OCCUR PREMISES Ea occurrence $ NPP8274967 3/24/2016 3/24/2017 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PET 11 LOC PRODUCTS-COMP/OP AGG 5 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ '.. Ea accident ANY AUTO BODILY INJURY(Per person) S '.. ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS L AUTOS Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 '.. OED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVEF-1 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,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 t9riunn 1/4/2016 Preview:Certificates of Insurance 3 DATE IMM-DWYYYY) CERTIFICATE OF LIABILITY INSURANCIE 0110 412 01 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 C IMI— NAME: PHOIIE A\ Automatic Data Processing Insurance Agency,Inc. rA;C.Nu.E:n- IAtc.No)_ I Adp Boulevard aooakss: Roseland.NJ 07068 UISURERIS)AFFORDING COVERAGE I NAICq INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER o: INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOY:HAVE BEEN ISSUED TO THE UNSURED PIANILD ABOVE FOR THE FOL CY PERIOD IP101CATED NOT'>:ITHSTANDING AN'i REOUIREL:ENT.TEPL'.OR CO(-ID)T!OPl OF ANY CONTRACT OR OTHER DOCUI"ENT METH RESPECT TO'r7HICH THIS CERTi F:CATE MAY BE iSSLIED OR L.AY FERTAzi-l.THE T-ISURAI.ICE AFFORDED B'i THE POL!CiES DESCRIBED HEREIN::S SUBJECT TO.:LL THE TERLIS. EXCLUSIO.IS AND CONDiT;ON'S OF SUCH POLICIES LIMITS SHOt.'H LA)'HAVE SEE).)REDUCED BY PAID CLA1IdS L)ULIN5R TYPE OF c KI P UCY t POLICY I' 1 LIMITS LTR RL.D V,Vp POLICY NU1dBER ILtL:OD,YYYY) R,V.UDD YYYYjI I CO.MMERCIALGEIIERAL LIABILITY b"Ut-CC"'LI.KHA:L ::L".U.I�LI:.(it � (:1.1: Ii+tl.11Sca lctJ-�!•d:',.: '. LIEUti.P. r... ItCL%:CGIiEG%.MIME'....FI'RLit'd l'EI;. � t_tI:EPo+LAGUrtI•UE 5 PCLIC'( 9AUTOV,111111-F LIABILnY : "f.i It�tl'Slt;t.L Ll:.ill I.�AU1_; B-L'•IC°IY.JLE.:I�✓P.cmli L'I�S H`*�f. 1-.0-U-1.):.LII:A: 1 CIi UL'SRELLA LUIS C•t1.Lt EXCESS LIAB CL;,ILIgt.S•L'E Aucf-*Lr--'dE - INFO IiL-!tt:l ivt.: WORKERS COMMENSATiON X AND EI.IPLOYERTUABILITY SI.IL It Ef: Y.tN I; 1,000,ODO %•1.' H:'_IId�Il.i.i•:.i:ll_I:E.:Er.LII':E EL E%.Cf:•I'LIC£t.i A i prlLEi:l:aabtltE'.°:�:LLtt1;, " IN to N POt:rC772258 1011011?016 02/0?:2017 - (7.andatory:n faI) I t Lt-.ELu!Lcvtt 1.000,000 ;:usr ccs:_I:u•n�ccFcrtr,:alcl:_:,_,:: � �E.L.DISE:•5t 1•�.UCAOLIII � 1,000,000 ( DESCRIP11101:OF OPERATMUS F LOCATIOIIS,VEHICLES(ACORO 101.Additional R—kS SCMWIHc.m J bCW=be dit—.—p—i5 .Iui,ed) 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,R102910 AUTHORIZED REPRESEIITATIVE I , A^1988-2014 ACORD CORPORATION.All rights reserved. ACO RD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLASEA-01 JONEILL DATE(rdM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F1/6/2016 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 i FAX 11 Saunders Street A/c N��_(978)688 7004 _ !(ac,No)_(978)688-7007 North Andover, MA 01845 ADDRESS: INSURER(S)AFFORDING COVERAGE ; NAIC4 _ INSURER a:Nautilus Insurance Co. _ 117370 _ INSURED INSURER B:Safety Insurance Company—_ L33618 Polar Bear Insulation Co.Inc. INSURER C:_ — -- - — Peter Leblanc&Steven Leblanc INSURER D: E P 0 Box 958 — - -- — -- — i --- — Andover,MA 01810 _INSURER E_ _ INSURER F: COVERAGES - 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 7VPEOFINSURANCE — —fADOLSUBR - POLICY EFF j PDLICYEXP — LIMITS LTR I _ .INSD VIVD: POLICY NUMBER j MM/DD MMIDD A COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE S —_ DAMAGE TO RENTED' CLAIMS MADE OCCUR I 1 PREMISE�Ea occurrence) S MED EXP(Any one person) S PERSONAL&ADV INJURY is GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL_AGGREGATE !s POLICY! JE PRODUCTS LOC j _ _ CTS COMP/OP AGG S _ OTHER: -- !AUTOMOBILE LIABILITY j I COMBINED SINGLE LIMIT S 1,000,000 _ i(Ea accident)_— ---- . BANY AUTO 2100926 01/04/2016 01/04/2017 1 BODILY INJURY(Per person) j S ALL OWNED SCHEDULED AUTOS X AUTOS1 ! BODILY INJURY(Per accident)!S Y NON-OWNED ! j F ! PROPERTYDAMAGE X -HIRED AUTOS X AUTOS i Per accidento - S .(-_. — '---- -. i UMBRELLA LIAB OCCUR I EACH OCCURRENCE S ) Q, _EXCESS LIAR _ CLAIMS-MADE; AGGREGATE _ S DED RETENTION S--- - A - — S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LABILITY STATUTE ER. YIN +ANY PROPRIETOR/PARTNERIEXECUTIVE • SE OFFICER/1,4EIADER EXCLUDN/A! i (Mandatory in NH) I i E.L.DISEASE-EA EMPLOYEE S If yes•describe under DESCRIPTION OF OPERATIONS below ! ? E.L DISEASE-POLICY LIMIT I S i i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACO RD 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 CERTIFICA 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 r n-f000reninnr�nonn�oononrrnnt nrt�...cs.�...,.....,...i w , ,/r mss. �� - Cl consumer s and 10 Sliltc 5170 0*2116 ._ `o" ,Ome bxvovemeu - = _ - VPPZ DEN 16 � 'fig - 7=0 ION CO. ,pOLALR BEAR viticent LeBlanc w --,' ��o Akno ER, UP0mPLostc4ri p P ddeess 7�e�ewa3 ops cfa amt® 7C rd dq�yq,7g�$�ks2SL`�4+