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HomeMy WebLinkAboutBuilding Permit # 5/10/2016 taoaara1, BUILDING PERMIT ,-TLZD ,6 TOWN OF NORTHANDOVER ® - APPLICATION FOR PLAN EXAMINATION ORA coc.i:ew:cn�'t 0y Permit No#: L> Date Received gg �SSacHus�� Date Issued: 1 IMPORTANT: Applicant must complete all items on this page LOCATION 11,6 /12q rb/Ce T d S 7- Print Print PROPERTY OWNER_ kev;yj w r ) (®e Print 100 Year Structure yes 0( no 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 yY1Sv/Ci?j`O14 4.0"a rF� / ,� �� � � a►n [ :Wetlands ��.,�❑ Wafiershed Distncf�� r -.t' �-'. �'.`.r-r,�/.,r,.�.✓��+ nr rfi`� ..r F �r., ,:� r:.: p^r,�i.»a.'x� r :;l`3 t �:��f�zr- T� .:...:; x. ..r, a f ;� e � ,. ,. � fry nn� r � ..r�F�..�.l.s �,,,f y-�. rf.�r rte' ,r ./ .r .,,.,a ^!f �/F l'.:..! .�...,1 ,•,f...,r'w s-?NA ,��7 „_r ..�J x r ! ,.,<:.. ,. ,, a• x r` Hrr."rs� '"`f""Y -, Sr. .r'l„/G,+'q �'�..:,.r. #i l,�N U :� J f �.r.�. /...mt'1 �:.. 1, ,,,vµ.� i.:..,G1�� � .y x ^„ � ,,. ;; .>N�,�'`�/, ,1 .�. 1rt�.�.✓,ri„�..rr c^ .,-;�'. �vr`..err .r,nl.,r '�.T ::r'” G:.%' H �-,rx. r.: .,.k.- trn §.,.1 r ;:.: ,� l ,.a /,`�7 .,x G� v, ?. :J.�'$ .ra r .r<�. �` ^ ,� .,.,u �/ .+ ,, .,.. r r,{...% �' ,f 1. �. � G. .., ;� l.. ...,%.'� .�� ,���/'✓`/fir.. r r' '.;,r. �"�:� z;',"'{ ^r .<.r I, , ,.,.,�,'. ,r I �.� c r.. r11} •'irk--r, f�^ c,��r-. ,- ::r. .Y ,. l A ,% t Y/� 'J.l .?'. :f� .h,. nY.�✓J' f f3.' l y,-0'`.. r -lk�.,,:}'+l rn` s ❑ v ter Sewe � �. b �.>- � ����' t s ry1� ����� � � � � �.. �: DESCRIPTION OF WORK TO BE PERFORMED: 1,4' See,11'eq ,, A`rT�L 1�Sv��r1'oa� 7-0 �'y�r' Lien>�147-/� 0 Identification- Please Type or Print Clearly OWNER: Name: ,_eyi✓i w ,'Iloe Phone: ���-s7aa73r3 Address: 1/G vInA f ble �eotd S F Peter Contractor Name: 2 Ems Phone: Email: Address: Plaistow,, N.H. 03865 978-407-7638 Supervisor's Construction License: 1 dfob I Exp. Date Nome Improvement License: 10,)->X6 Exp. Date: /� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ °®- a a FEE: $ �-� ,n Check No.: Receipt No.: 1 NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund r N t%ORTH Town �� - . ` t' • � L Andover No. ® L T• _ _ h ver, ass, O". L. q4 16# 2-b( COCNICMEWICK �.95 RArED "V 11 BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT . .... 4........0` Q BUILDING INSPECTOR ............PERRTTT, ....... ...... ............. .... has permission to erect ...... buildings Foundation .................... .... .... ...... . . . ... ...... Rough to be occupied as ... .. MV ....�.�► �r .... ... .... Chimney provided that the person accepting this p r t shall in every respect conform to the erms of tle 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 UNLESS CONSTRUCTION §3ARTS Rough Service .................................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy hermit Required to Occupy Building- Rough Islay 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. IS RISEEngineering FederaliD#05.0405029 1 division arrhicisch Engineering RI contractor Registration No 8188 ENGING' MA Contractor-Registration No 120979 CO Sbawmu[droit N2,Canton,3LA CT contractor Registration No (401)784.3700 FAX(4011784-3710 CONTUCT PROGRAM Page 1 CVS — _..---.-- _ ChfA-HES Titf3 CaUTRAC713 E1lrHRED DrtOaETWEEURrsa 06¢R - -- --- EUOalFERtNo AND TRE 0U3—FOR Wale,AS Kevinwi)ioe --•--• -• --• -•--..------_-• DE3cRtaEDaE>.mv DNOUE ____ (617)510-7313 -OATS •____ -�EHitl__ _ __ .7 BE WV STREET-------------- _ _- ----•-_.—____ (617)510-73 13 04/04/2016 ' WORK ORDER i - ------- - ----- 4-9179 116 Marblehead Street Ma' ste eluruo smEeT ---__._ 00003 - ---- . - -- -------------- --------- 116 Marblehead Street Maste - SERvtCEgT$eiAT4rm North Andover,MA 01845 -- -- - '--ML&O CITy,STATE•TjP _- North Andover,MA 01845 •i®B H)ESCRIPTli®N - - lef Seed in pmvidc talar and materials to seal areas of)roar home a•i perfamted in mnnrt with the use afspccial tools and diagnostic tests to assure tint}our home TTill be icR with a healthfid level n[' air exchange snit indoor air nst wasteful.cxass air leRkage. T1tis work will be quality.fvinterinls to be used to serol yY1ur hone can in caulks,foams and other products, Primary at areas,jed.)thr-scoling include airleakuge toaaics,b,''wemonis,0l Ile * addcssed.)This no, require(8)working hours.:\rcductiun in c broafeel par mf uic�c fi,p ai;fir iron.1ltratiun will occur,but Ihz actual aamberol'c T is not_equirezed. healed areas(whidowFs arc not antern)h- At the aunpktioil he c uctuherizaitun work.and W ria additional cosi to the hotteoTrocr,a final bin[ver door mtd(or comhu.' sa1My;wtdysis"ill ftc ennduelcd by 01c soh-atntmctor to ensure of titz indoor uir(finallualk. uun urpow ses.INCi:Provide I;thur and ntatcriuis W install a purpo12"lnlvr ol'R-38 unlhced ftltemjuss bars to(74)square feet for damming S690.00 Al flC PLKC:Provide latxr and materials to tnslnll a 13"Inver aflt 454" space Class I Ccllulost:added(0096)square feet orupca tutie S I SL7t1 A171C ACCESS:provide labor and nt•r leak to insulate the bac!of tlic attic door will[2"rigid Thertna�board unit scat d>L door s �Mpc with uratht••ntrippinl;to restrict air teak $1,297.48 age. �-" —�� 1TON Provide hseas. 'Me suppl dincirclelor)block,hrattat gay mill finish. eiamatc llmushroom"n73.91 arecnt(s)to incrcace ventilation in attic $ existing b4thron,Prut•tdc loner Wait ntatcrinls to instal((1)insulated exhaust hose Tvith roof muunied Rapper ver[to cxlmu t existing bnthroum Eros{s). $337.30 VL•NTlI.A'I'ION:Provide labor and materials to insildl ventilation chutes in(60)reRer buys to maintnin air flu".. S 118.75 13ASEMCNTscme CEILING:Pr0lfic labor ad materials to install(Myl linear Cczt of R-19 unftced lihwginss insulauiou to the of the hmement ceiling at the house sill. St 10.00 perimeter RiSE 6nginucasar sill nppi}all applicable.eligible inantivcs u1[his cctnvact. Yua tvi1)only be billed the Non nuuumt. Gurrcutly, Ibr cligihtc ntcasures-Columbia Lias offer:75V5 incentive,nut to exa:rd$2,p00 per calendar $2h0.75 AlrScaling mensul"N up at the first 5680 one a1)ndditiona13340 it-N"cu year,mud rot incentive of 10045 far the [ bv For the safety toll hcahh ufyour home:indoor air qualiuy,at will be conducting nblq ver door diagnostic 01-the available air tlrnv In Your flume both before the work is begun.and ager the tvcathcrtzallot,work is compiue.We will also conduct 111.1111 assessment of too combustion snCety of}our irenline systen[and water heater.'itis has n smile ufS90 and is at no cost to)vu, Toual allowable Tw uthcrizotiun incentive is 53,110, SOII.UU ���� RISE Engineering Federal 1D#08.04D8829 A dR•isinn or 1111CIach Eng(uccring RI Contractor RegtstraUoR No 8186 ENGINEERING' MA cono-actor Registration No 120978 605hairmut Cntt#Z,Gunton,liA cTcontractor Registration No (401)7N4-3700 BAX(4(11)784-3710 CONTRACT PROGRAM Page 2 - -- - CA'IA-HES E. CONTRACT RI EgrsRED 7YTO EETVfE@JR4Sfi CUSTOMER •- _ ___...-.__.._._ OrJEEM., TRE CUS701tEq FOR 1YORR AS ---' OEaeareEODELow CVl)t uJll10C PHoNE ... oarE---• _'---�•-'------•-.__-__.. _ _ 7)510-7313 ----•--•_ SeRME STREET X61- 04/04/_)016 ._w91 WORK ORDER 4_9)79 IlGMarblehead StreetMasre •""`-�- 00003 BLLL7HO eraEET --- ---•-- -•- SERIR --•-- -CE CITY,STAY-E.-- - -- ---1 1 G Marblehead Streer Mast,"'--•--- North Andover.MA 01845 --- - ----- &LLG+D CITY.sraTE.zm --"----- ----- -- North Andover,MA 01845 -- JOB(DESCRIPTION -- -- - - - - Total: $3,149.89 Program Incentive: $2,554.92 WE AGREE HEREBY TD FURNISH SERVICES.COMPLETE IN ACCORDANCE WITH ABOVESPEpFICATCustomer T :THE SUfO1taPl $594.97 'Five Hundred Ninety-Four&97/100 Dollars UPON FU7AL INSPECTION ANDAPPROVAL OY RISE ENOeIEERI p _ -UNPMD BALANCEAFTE_RJa OAVS•SEE REVERSE FOR D_VORTANr $594.97 •----. _ NO.CUgiDMER AOREES TD gETdIT ALWUNi DUE O1 FULL '• _MWOR!•UI7IOH OH OUAIUUJTeBS,R1GHTSOpRFULWNTOMST OF 1%VALL DE CHARGED UGHrHLY ON A/IY DO NOT SIGN THIS CONTRACT IF THERE _BCNEDULGIO,ANO CONiRACTORREGISTgAT10N. AREA Y BCA K SP ESQ- _ AUTHI.ORED SIGNATURE•ROE EM4Rnhq - -- - -- ___.,_ - ._._ _, +'C. �-_/a/.���-CA WSTON C , _. ANCE •- NOTE.-THtS CWJTry{�•T UAY ea VAM5YN 0Y US IF NOT E;ECU7E0 VA THIN S THO a DATE OP ACCEPTANCE �_�� !16 DAYS. ACCEPTANc _- SATISFACT RV CON1RACi.THEASOVEPRICES,SPECiF{C,LTHJNS AND COHGlTIOAg ARE Ag 3PEC1 ORY TO US AAW ARE I/EREBYACCEPTEO.YOU ARE AUTHORED ND TI FIEQ PAYME/JT PALL BE J•TAOE AS OUTLMW ABOVE THE WORN rrn �� �• V , °; pPR 2 � 2016 1 Ri-SE GO Shal-mut Road.Unit 21 Canton,?AA 02021 1339-502-633s EN G IN E=R I NIG 'WWWAISEengineering.com OWNER AUTHORIZATION FORM Kevin Willoe tFo w,n c r's N a m.e owner of thr,proporty IOCate-d at. 16 Marblehead Street North Andover, MA fp01845 '�p—eh�-X-d—dtasss) an authorized subcontractor for RISE Engineering.10 act on MY 00half to obtain a building ratmiir And in ni-Wnrai ivajk nnniv 01,mor's n0tUr Date The Commonwealth of Massachusetts Department oflndustrrza[Acddents ®ffice oflnvestigationg 600 Washington Street Boston,Mil 02111 www.ma_ssagov1d1a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers Applicant Information please Print LegibXy Name(Businessiorganizatio&Individual): .Address: PO BOX 958 ---AWEWER,MA 01810 .City/State/Zip: Phone#:-17 1 Ayou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. F1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑I am a solo proprietor or partner- listed on the attached shget.1 7. ❑Remodeling ship and have no employees These sub-contractors,have S. []Demolition working for mein any capacity. workers'comp.insurance, g. Building addition [No workers'comp.insurance 5. ❑ We aie a corporation and its required.] .officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am ahomeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.FJ Roof repairs insurance required.]i' employees.[No workers' comp,insurance required.] 1311 Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information. X am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site infopmation. Insurance Company Name:_ no crr-d t ok Policy#or Self-ins.Lic.#: �b tAl'C `7> � Expiration Date:_ Job Site Address:_ //(0 W-q i b&1 ee-d 5% City/State/Zip:- 4- aIs�rl Attach a copy of the workers' compensation policy declarationpage(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civilpenalties in the form of a STOP WORTS ORDER and a.fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D9 for insurance coverage verification. Ido hereby ce y "der the pains andpenalties ofperjuiy tliat the information pr ovided above is true a"d correct. Si ature: Date: ?hone 7�0 3 official use only. Do not write in this area,to he completed by city or town official. City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tpwn Clerk 4.EIectxicaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• DATE(MM/DD/YY Yy) AC40RE0 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). CONTACT Linda BOgdaIIOW1.C2 PRODUCER NAME, Insurance solutions Corporation PHONE (603)382-4600 NG No:(603)392-2039 E-MAIL lindab@isc-insurance.com 60 W6StVil1B Rd ADDRESS: --- INSURER(S)AFFORDING COVERAGE NAICH Plaistow NH 03865 INSURER A:Western World INSURED INSURER B Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERc: PO Box 9558 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. ADDL SUER POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYY MMlDD/YYYY LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000r000 g S DAMAGE TO RENTED 100,000 A CLAIMS-MADEo OCCUR PREMISES Eaoccunence S ` NPPS274967 3/24/2016 3/24/2017 MED EXP(Any one person) S 5,000 PERSONAL BADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG S 2r000r000 % POLICY 1-1PE° El LOC S OTHER: COMBINED SINGLE LIMIT S AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) S ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) 5 AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED per accident HIRED AUTOS AUTOS $ $ IUMBRELLA LIAB OCCUR EACH OCCURRENCE S 1 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 B 3/24/2016 3/24/2017 S DEO RETENTION S AN026107 PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT 5 ANY PROPRIETOR/PARTNEWEXECUTIVE ❑ N/A OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE S (Mandatory In NH) U yes,describe under E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OF OPERATIONS below 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 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave 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 rgntAm1 POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE TE(ffiMtDDjYYYY) P1161�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=7000 ;FAX Ne 978 688-7001 11 Saunders Street A/c N,�_�_� ._ )-. --(.. L-t 1. ---— North Andover, MA 01845 E-MAIL - INSURER(S)AFFORDING COVERAGE ; NAIC A _ iNsuRERA:Nautilus Insurance Co. _ 117370 _ ENSURED INSURER B:Safety Insurance Company_._ +33618 Polar Bear Insulation Co.Inc. INSURERC__:_ Peter Leblanc&Steven Leblanc 1 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSG i 7ypE OF ADOL�Sl1BR; POLICY l}F POLICYEXP ' LTR iINSD WUDs POLICYNUAIHER MM/D 1 MMlOD LIMITS A COMMERCIAL GENERAL LIA13ILnY ! I ,EACH OCCURRENCE S _ I --- GE CLAIMS-MADE OCCUR 'PREMA ISE_UEa occu r nce) S j f MED EXP(Any one person) S — - --- — -_ - PERSONAL&ADV INJURY GEN'L AGGREGATE LUAIT APPLIES PER: ! GENERAL AGGREGATEPRO- S POLICY' JECT , LOC PRODUCTS-COMP/OP AGG S — OTHER: AUTOMOBILE LIABILITYi !COMBINED SINGLE LIMITS 1,00D,000 � ! .. B ANY AUTO 2100926 O1/04/ZOl 6'Ol/04/2017'BODILY INJURY(Perpersan) S ALL OWNED SCHEDULED i I BODILY INJURY(per accidenl)!S AUTOS :AUTOS - ! i' ii NON-OWNED i [ ;PROPERTYDAMAGE --- - _S X `HIRED AUTOS AUTOS -(Peracciden] UMBRELLA LIAB F OCCUR EACH OCCURRENCE �S ) � ———- =---— - AGGREGATE ;S (> IXCESS LIAR CLAIMS-MADE; DED RETENTIONS WORKERS COMPENSATIONPER OTH :AND EP.IPLOYERS`LIABILITY —-$1'ATUTE !_ ER iAIJY PROPRIETOR/PARTNERr IEXECUTIVE Y/Ni E.L.EACH ACCIDENT -- - _ r---�I ;5 ;OFFICERIMEMBEREXCLUDED? I N/A' ;(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE_s If yes,describe under - DESCRIPTION OF OPERATIONS below ! _ :E.L.DISEASE-POLICY LIMIT;S a 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 i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I!I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS, 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n 4000 nn4 n Anon nnonnn A'rtnnt All.....is..........�....a 1/4/2016 Preview:Certificates of Insurance G DATE Itdl.7DDYYYY) CERTIFICIATE Of LIABILITY` II SURAI CE: �. 01/04lZ016 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 CUNIACi IIA1.4E: PHo:IE A\ Automatic Data Processing Insurance Agency,Inc. IA:c Ito.E.11: I"C.140- 1 Adp Boulevard AUDneaS! Roseland,NJ 07068 IIISURERIS)AFFOROIIG COVERAGE I F)AICd INSURER A: NorGUARD Insurance Company 31470 INSURED RIBURER B' POLAR BEAR INSULATION CO INC ItISURER C: PO BOX 958 Andover,MA 01810 IRSURER o: RISURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429TO3 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL:CIES OF INSURANCE LISTED BELOY,HAVE BEEN ISSUED TO THE INSURED NnLiED AEO`.,E FOR THE FOUCY PERIOD IND%CATED NOP,1.9THSTAPIDING AN'i REOU;REt ENT.TEERL'OR CONMT101-1 OF AHY COPITRACT OR OTHER DOCUL ECIT'::ITH RESPECT TO*NHICH THIS CEP,T!FICATE LIAY GE ISSUED OF r.t;,v FEPTA-.N.THE;NSURANCE AFFORDED B'i THE POLICIES DESCRIBED HERE:1-1:S SUBjECT TO ALL THE TERL:S. EXCLUStON'S AND C0t1D:TIOP:S OF SUCH POL;C!ES L!f.!I TS SH01:4.1 I:'AY HAA c SEE-1)REDUCED BY PAID CLA!t'S Rase TYPE OFItISURAtICE c 'OL— POLICY rx1• LI`.SITS LTR IVSD VAID POLICY HUt.IBER U.TINDDRYYY) It1t."'MO:YYYYii C0.'..VdERCG&GEHE�tRl--L;;LIAB(LITY t�lJ 1—._t-�L I ......,tea n.:a .I c ::L,t C.I�LI�•VE CLI: I f:ilEJ.liSc tc.=�_.."_r::_�: 1 1 LI ED EXP'.r..:a. ;.:•:5a: I:- GEI:L RGGI:EL:%4E LC.IIt:d'1`U651'EIi. � Gd�F=.L:;LGIa=G�!t - 1'I:: ttt I:�LIti�❑J6:_I IiLU'Z c I rER. AUTOt"09ILE-111 Ln 1' I,I,� I 5CL'•IL'�1(:JLIi'.:P,;,_rnnF .ALL C:a.cD Lt-EDLLEU I .v_IC5 L'I CS etiU1L:'IIJI_I;`-iPr :�_:I.q U1:13P,ELLALLI6 I;_;!_L'F ) L!•C L!•7iti.:E EXCESSUAS 1 cL:,Lls.I:.L•E ( accr,Ec:.IE ULU I r.{EI:B t.> I IWOR ERs COMPENSATIOt1 X t'tl: AtIOE PLOYERS'LIASILITY I I "IAIL IE I ER YiN (:.I=�Iazl.rlaEu'Ic!=:.l:u_h E:;L:.cu•,~: N EL EACt-.a_LIL'£1_I 15 1.000.DOD rl::Ei:t.:c1.ItiEh E::::LLt•OU� fv1 ;t P0:^.'C772258 1 01/01.12016 C2f0'.pC17 (LSnndalary in tip.) 1-1 E L.UISE%'-=-E:.ELIPL!J?'Et 1,000,000 I I E s I i I DESCRIPTION OF OPERATIONS;LOCATIONS i VEHICLES(ACORO RUL AUdlU-1 R—r kCScb-,dw,maybe m=md it—c.Pace is rcqui,cd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theitsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORLFD REPRESE11TADVE I AS 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consmer AfB&s and� jo Fa& Sm 5170 Boston, 2116 -fly _ Ron_ X02726 Tt# 2MM Q-q BEAR p���[ tl tom yam■ \fie -- `, intent LeBlanc P-0.Box 958 Upds plonent n Lnstc&d Addeess I newm ��- OP-r-GAi u "tz1612i6 --- s7km glsistoFr Td�t.u�gw _ Q 19