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HomeMy WebLinkAboutBuilding Permit # 5/10/2016 BUILDING PERMIT �%OR q� TOWN OF NORTH E �? y 6 APPLICATION FOR PLAN EXAMINATION nO Permit No#: s C�'�� Date Received AT.D PPa`�5 �SsgCwus�� Date Issued: 16 I PORTANT: Applicant must complete all items on this page LOCATION �� �������ct 50 Print PROPERTY OWNER Pe 7-,- ✓',.'dt e Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 7'1 ✓��i"i a 9J;'?fr%xrr ` Waters ed . �� See ttc ❑Well�. � r= �� D Flood lam , ❑Wef�ands� �� , � ..y hD ft:. ,...o �.� ,,/r,>i" �`�,✓....,,, l ,r.�` .7' ..c. � a'. /�,�. rt" -;i '�z`I...�,r� _„:;r- r-3 � s .- ,f 7 ..r>f. pl' ./I, f`. � , �a+' ..?�. ...,,.5 �o ,?,.. ,r '7 ,.Awr- . ro � .H,..£�,4�77.� ,�t`rr .r .,s* F.Fr �r r}„.rc�- ,,.: �`” ,. �` 1, r•:�- .x,v�lr�I .,,,,, ��� �,M r` r✓% s ,.. � ... > r G' T a/ r f�hr ( ��s . .,�.€�x, s'., .,rri r`. r rs� k' r�, � -, y � r,%: ;, N._ r .�.�Z�.�ta7l��,..� r�„F sa' ..,:r .c::, r... v”. ,,./�r..F1 f .� r .�,,r r,.. ,.r,.Ir ,.,✓. x� :.ss��.. r �fr}C 1 DESCRIPTION OF WORK TO BE PERFORMED: �'6'St g/�h �' rr� �� �'k?z°P i O V` G✓�i// Sv/�j'ias� e Aeh, V✓;i!.. to//�//aS� Identification- Please Type or Print Clearly OWNER: Name: 7;=, ?? r' �5 (�;�� Phone: Address: 77 r he d rN1`rk 67 Peter Leblanc Contractor Name: ast Phone: Email: Address: Plaistow, . 4`31. 03805 3F/5-41117-7638 Supervisor's Construction License: 10 U161 `1 Exp. Date: C/ Home Improvement License: Exp. Date: / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unrdgistered contractors do not have accep to the guaranty fund r ttoRTH Town oftAnclover L_ 'M No. 1161 ,20,1 "' ver, h , QA o Mass, c oc NlC..!wic K ADRATED P �y i! S U BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THAT7A BUILDING INSPECTOR .......... . . ..... ............................�:4� ................................. '. .. . . Foundation has permission to erect ........................... buildings on ..... ... ...... . . !I/!�.1. ® ` Rough to be occupied as ... .. .. ....... . . . /�........L 1Re Am.. Chimney provided that the person accepting this per it 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 UNLESS CONSTRUCTI TARTS Rough Service ...... ..... . t 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 10#05-0405629 RISE Enginceiing Fit Contractor Registration No 8186 MAContractor Registration No 120979 A division of"Ibicisch blgilleerhlf,' RISE60 Shimmut Unit 612,Carlon,MA 02021 ENGINEERING' CONTRACT 339-502-6335 FAX339-502-0345 Page PROGRAM '"s C0NMCT is ENV REO INVO DEVEEN RISE CNIMIES ENG)ISCRINGAItOlHgCUSIOWnFCRWCRKAS DESCRISED BELON CUSIMER PHONE DAIE CUENTO WORKORDER Peter Farina (617)939-8729 04/2612016 426743 (0011 SERVICE S"MEET IMLL040 SIREET 77 Chadwick Street 77 Chadwick Street SERVICE CRT.SWM,71P rawna CITY,Svvw,MP North Andover,NIA 01845 North Andover,NIA 01845 3OB DESCRIMION AIR SEALING:Provide labor and materials to seal areas Irl`your home a+ wasteful,excess air leakage. This%%ork will be performed in concert Will(lie use ot*special tools and diagjioslic tests to assure that your home will IV lef"t with a healthrul level of air exchange and ind�orair quality. Materials to Iv uwd to,seal your home can incltd.-caulu,foams,and other products, primary areas liar sealing include air leakage to;title,;,baseloclus,attached garates and other unheated areas(mindIms are not generally addressed.) This will require(3)%wrlk-iag hours.A red action in cubic feet per minute(efrin)ol'air infillralion will occur,but the actual Nualber ofsluris not guaranteed. At the completion of the%Watherization work,and at no additional cost to the homeowner,a final blomr door andlor comb uslion safety analysis will be conducted by the sub-contractor to ensure the sarety ol'the in(k)or air quality, $255.00 WALLS:Furnish and install blowl in Cljejs I Cellulose to(1192)square feet ot'vinyl-sided exterior walls,Honicomner hit%received a copy ofthe EPA's Renovate Right Leadsafeinformation guide explaining ll,pubaltial risk(11,tile lead hazard exposure Crum the matherizatiou work to be performed Your signature is your acknoNNOgenient of receipt and agreement to proceed. $2,205.20 RI SF Frigincering will apply all applicable,eligible incentives to this contract. You will only he tilled the Net amount. Currently, ror eligible measures,Columbia Gas offers 73%incentive,not It)exceed$2,000 per calcrukir year,and all incentive(if 100%for the Air Sailing measures up to the first$680 and an additional$340 it'saving i nrejuslified by the auditor. For the sallely and health of Your ilumes indoor air titeflily.we will be conducting it blower door diagnostic of the available air flow in y0tw houle both before the work is began,and after the kveatherization work is c(unplete.We will also conduct it fall assessment of the colubtlit jull safety ofyour heatimg system and water llcatel%This,has a value of S90 and is at No Cost III you Total allowable mitherization incentive is$3,1 10. $90.00 RISJ:1:11gulecring will apply a credit of$100 towald";this contract,in acknowledgement theflicposil you made it)Next-'�cp Living towards your original vwallierization Contract.'1*1 IFIN:ARE ISI'.1:1-WALLS LEMSIDE S0.00 16E=* Federal ID#OSM06629 RISE Engineering R1 Contractor Registration NO 8186 MAContractor Registration No 120979 R ISEING INEER ' CONTRACT 339-502-6335 FekX339-502.6345 Page 2 PROGRAM CNIA-11B Cuoromn PHONE WE CLIENTA W_oi(ORD­ER Peter I-`arina (617)939-9729 04/20/2016 426743 000411 SERVICE STREET UIWNO STREET 77 Chadwick Street 77 0HRINvick Street SERVICE CtTY,G1%T:,nP rowna CITY'Swc-,ZIP Norill Andover,MA 01845 North Andover,NIA 018,45 ,JOB DESCRIF11ON Tota 1: $2,550.20 Program incentive: $1,998.90 Customer Total: $551.30 W E AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCOROANCE W ITH ABOVE SPECIFICATIONS,FOR THESUFA OF *'*Five Hundred Fifty-One &30/100 Dollars $651,30 UPON FINAL INSPECWI ABU APPROVAL BY NSE ERGINEEHIRM CUSMRAGREES X)REWAVOUNTOU9 INFULL LWERESTOF W.WILL13E CHARGEONCtMLYWANY UNPAWBALAKEAPER 30 GAYS,SEE REVERSE FCR GUARAhr_!!S,RIWITS OFRECISION,ECHE Wt a,AND CONTRACTOR REGM-RATON. DO NOT SIGN THIS CONTRACT IF THERE MEANY LANK AN S P 7)c�S N. Hulk WeE16SI 77, SR E1VImehq—_ p NOV.:1413 CCiK'T�ACTNIAY BE WIMORAWN BY US WNWEXECUIEDWTHIN DATE OF ACCEPWICE ACCEPTANCE Or CCHSACT-1HE ABVJ9 PIRCES,SP ECIFICATCM AND CONNIONS ARE 30DAY8. AS SAISFACICRY 10 US AND VIARE BE RE n EBY AS ACCEP FO,0 AUOVC YOU ARE AUVICRIZEU TO DOHE WCAX S PECIFIED. AND IMOF OtHLINE 2 p RISE 60 Shawmut Road, Unit 21 Canton, MA 02021 339-502-6335 ENGINEERING" www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: (Property Address) (Property/address) hereby authorize PblarAekr TyL/far," (Subcontractor) a iEE, an authorized subcontractor for RISE Engineering, to act on my behalf permit and to perform work on my property. This form is only valid with a "g� d cgntract. t Owner's Signature Date The Commonwealth ofMassachusetts bepartment of IndustriarAccidents Office ofInvestigationg 600 Washington Street Boston,Mist 02111 www mass.govl.414 Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant IMformation Mase Print Legibly Name(Business/Organization/lndividual): MM A Address: PO BOX M .City/State/Zip.- Phone#: FEII n employer?Check the appropriate box: Type of project(required): a employer with� 4. ❑I am a general contractor and Iloyees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction a sole proprietor or partner- listed oa the attached sheget.t 7• ❑Remodeling and have no employees These sub-contractors have 8. [1 IDemblitioning fox'me in any capacity. workers'comp.insurance. g, Bg addition workers'comp.insurance 5. ❑ We are a corporation and its red.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing allwork right of exemption per MGL 11.❑Plumbingrepairs or additions lf.[No workers' comp. c.152, §1(4),andwehave no 12.❑Roofrepairs ance required.]t employees.[No workers' 1311 Other comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policyinformation. lam an employer that it providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (-/�-r a t ok Policy#or Self-ins.Lic. > � Expiration Date: Job Site Address:_ /e City/State/Zip: -A- /���dr.e r` Attach a copy of the workers' compensation policy declaration page(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 civil penalties in the form of a STOP WORK 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 under thepains andpenalties ofperjury that the informationprovided above is true and correct. Si ature: Date: /(r ?hone#: 9 >�' ya,--' only. Do not writein this area,to be completedby city or tofvn official.City or Town• Permit/License# [0ifjjJ77'c1a1use ssuing It (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person Phone#: DATE(MWDDNYYY) ACCOR®® CERTIFICATE F LIABILITY INSURANCE3/23/2016 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 SO9daIIOW].C2 PRODUCER NAME: Insurance Solutions Corporation PHONE (603)382-4600 FAX (603)382-2039 c No: E-MAIL lindab@isc-insurance.com 6D Westville Rd ADDRESS: — INSURER(S) AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A',Western World INSUREDINSURER B N,aut1lus 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. ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR I TYPE OF INSURANCE POLICY NUMBER MM/DDI MM/DDlYYYY - LTR 1,000,000 g COMMERCIAL GENERAL LIABILITY EACAM H OCCURRENCE 5 DAGETORENTED S 100,000 A CLAIMS-MADE a OCCUR PREMISES Ea occurrence NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS-COMP/OPAGG S 2,000r00O % POLICY❑JECT LOC S OTHER: COMBINED SINGLE LIMIT S AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) S ANY AUTO ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS S $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE S 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 B 2016 3/24/2017 DED RETENTIONS AN026107 3/24/ S _ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT S ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N/A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE S (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addttlonai Remarks Schedule,maybe attached If more space is required) CERTIFICATE HOLDER CANCELLATION LAGCOLFRDANCE LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas ION DATE THEREOF, NOTICE WILL BE DELIVERED IN WITH THE POLICYPROVISIONS. 195 Francis Ave Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA ©1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I N S025 r9n 1401 i 1/4/2016 Preview:Certificates of Insurance CEERTIEICATE OF LIABILITY IPdSURAiNii 01/009/2412 0116 E DaTE16 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 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 PRODUCER NAME- PHONE A.l" Automatic Data Processing insurance Agency,Inc. rHI-E.U' Itis.Hot A:cV•U I Adp Boulevard ALORE55: Roseland,NJ 07068 IIISURERIS)AFFOP,DIIIG COVERAGE I FIAICX 11111SURER A: NorGUARD Insurance Company I 31470 INSURED RISURER B: POLAR BEAR INSULATION CO INC INSURER C: I PO BOX 958 Andover,MA 01810 wsuRER o: INSURER E: IHSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL:C:ES OF HISuIRANCE LISTED SELO.;HAVE BEEN ISSUED TO THE If•ISURED FIA14ED ArO E FOR THE FOUCY PERIOD II•IDiCATED Ido i%:ITHSTA(-IDIi-IG ANY REOUEREt::EFiT.TERI:OR CONDIT[ON OF ANY COFITPACT OR OTHER DOCUI:CI IT 1,7;TH RESPECT TO AIHICH THIS CE1R T?F:C—TE t;;.\'GE ISSUED OR L':.Y PERT:.;fd.THE;NSURANCE AFFORDED We THE POL!OCS DESCR:'QED HEREIN:S SUBJECT TO ALL THE TERLiS. EXCLUSION--AND CONDIT:Or?S OF SUCH POLICIES LIMITS SHO1:i1I WAYHAVE ETCH REDUCED BY PATO CLAS:s ADD[" PULICY PULICT tJ(i• i INSH LL`�1T5 LTR- T'(PE OFItISURAt)CE -DSD VNO POLICY tiU.1dBER )IC.LSDD.YYYY) IAB�7]D:VWYjI 'C0'.17.lERCIALGEIIERAL UASILITY 16.,t}CUJIIa:N.Lt CIIilLIS(.I:•, 1 IPi;EIJI_' i,�. .. LIEU!,:4;:r.: ,;:•c;c: GEI:Lr:GG1iEG%•IcLL'.Iil%117`LIES 1'EIC. I rscHEFAL GGIa!=:IE i'LUC� uror.:oaaElJaeulTv :-:.mI:.LL•aR:LLEu:Ju I Ulu I ECCIL' If:JI_I:=:1 ptlsm,: LL:::L'cU FEPtLEU I j ECL'IL':ILD=1i ,14- :a_ziJE .!-IC4 CIC_ It 1•IrGi-Ila"U:.t.,;l�� 1^_ 1 tai._:+'•L_U 1 UAL 1:'. PI I� P.ELL1ALh1O 1 rL.F I ! _::i:!•:::�'_CI-^Ei.LE EXCESS LIAB !'LAILt57.i%,L•L: I :CGI:EI_-.1E I I DLL• ( RL•iEGI¢]LS I ''... ORKERS COMPENSATION IID EMPLOYERS'LIARILITY I I '):ltt it I IE1c r; (1'::::=la:crrl n.1a >a'_<lic:;+_Lu'.- FV-111'11A N POIAIC772258 01l 1,004,006 C212016 021022027 EL •C •I.LIUELI I: IFF:Eiii.:c1.1EEfi E:�.LLLEv' i - 1,000,000 (.�ndMary in tip.) E L.L•ioc.,oc E:,ELU1:J`'EE v c6s'<-l:Irilci:cFcl•t1s:.na_n-:,:- I f t:..u1�t:•st rcU'ul.ul 1,000,040 I I I i I DESCRIPTIOU OF OPERATIONS;LOCATIONS VEHICLES(ACORD 101.AdW110nM R—V: Sel,bui..m Jbc mnchcd it"10. is rcq,:iitd) 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 AUTHORUED REPRESEUTATIVE I A91988-2014 ACORD CORPORATION.All rights reserved. ACO RD 25(2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DAT11612 DnYYY)—� 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,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 _�97f3 688-7000 68 OOD r ac No (878 8.7001 11 Saunders Street ac N _._ i.._..__I_�. �....—.. North Andover,MA 01845 E-MAIL ADDRESS: ..-- - i INSURER(S)AFFORDING COVERAGE I NAIC 3 _ gSURERA:NautilusInsurance Co. 117370 INSURED INSURER B:Safety Insurance Company_ 133618 Polar Bear Insulation Co.Inc. INSURER c; Peter Leblanc&Steven Leblanc INSURER D c P O Box 958 — _ — - — i --- — Andover,MA 01810 INSURERE_-__ 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)S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSRi -- TYPE INSURANCE -- --'ADDI.ISUBR; P011CYEFF ( Llhlri5 — LTR !INSD;VA/D POLICY NUMBER I MMmD ! MM/DD VVV p 'COh1MERCIAL GENERAL LIABILITY 1 ,EACH OCCURRENCE S I ----— -� - DAMAGE TO RENTED-.. .---- CLAIMS-MADE ! OCCUR 1 hREMISE�E; occurrence) .$ i ;MED EXP(Any one person) S -- _ ---_------ -_ - PERSONAL&ADV INJURY ;S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S K POLICY' JECLOC OPROD -COMPIOP AGG S OTHER: �.. -- - --- S AUTOh10HILE LIABILITY I !COMBINED SINGLE LIMIT ;S 1,000,000 i(Ea accident),— ___ -- U ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) S ALL OWNED x_ SCHEDULED BODILY INJURY(Per accident)!S AUTOS !AUTOS - NON-OWNED i ;PROPERTY DAMAGE-_- HIRED AUTOS •AUTOS — S UMBRELLA LIAB :EACH OCCURRENCE :S ) OCCUR — — i AGGREGATE is A EXCESS LIAB CLAIMS-MADE; i OED RETENTION S OTH_ WORKERS COMPENSATION •PERER :AND EMPLOYERS'LIABILITY STATUTE t_ iA1JY PROPRIETORIPARTNERIEXECUTIVE Y/N' _ ----: - I----�� I E.L.EACH ACCIDENT :S ;OFFICERI7;,EM8EREXCLUOED7 IN/A! — (Mandatory in NH) _ :E-L DISEASE-EA EMPLOYEE.S If ves•describe under DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT i S i l � 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 IFICA T E HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 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 ?i n imo,nni n Ar�llO[l r%r1r nr10ATlf%t%l An�...cs................a Affairs office of CO � -and 10 Pia-Ste €➢2 1 ® t� 2sac � 5170 gs ion.Re ou Improvement TVPw- DSA T* 2MM - BEAR ttst� � t�t� CO- POLA Vincent LeBlanc p_C)-BOX 958 Am)OVER= MA 0� 1{} _- - -~ up add r andYebur¢�a 1 ent Lsdc&d OP8-CA1 ct$U 'tz1d127e - --- J3 _ _ _a�'_�'!3��Z_;gin ai515=�'�•'«- `_ `i� � '.. ALER C _