HomeMy WebLinkAboutBuilding Permit # 5/20/2016 BUILL� PER IT �,ED 1 q ��Rq TOWN F NORTH ANDOVER ..,.,, �4 APPLICATION FOR PLAN EXAMINATION PL'PBYIit No#; - Date Received "'" pip arao �S`''pCFIU��R Date :��Issued: 41ORTANT: Applicant must complete all items on this page LOCATION dC R 0 b! +n eov rT Print PROPERTY OWNER 5"e t evi Y X f u Print 100 Year Structure yes (noMAP _m PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes o 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 �t �/�+7 '� 61 DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please'Type or]Print Clearly OWNER: Name: 7cir,!rm=/ Phone: PP-6y1- 17 Address: b%viS"am Pv Contractor Name: Phone: Gly 7 !fad Email: Address: -0NX ,4,1dVe { Supervisor's Construction License: Exp. Date: Home Improvement License: I o,)- "?0)- Exp. Date: h-z/6 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: $ 0.- 0 0 FEE: $ �( Check Na.: Receipt Na.: NOTE: Persons contracting with unregistered contractors do not have access to theuaranty f inn ghat / r / ,,, "`%f of /lri / rr �i�nature of/A /Owner; "Signature o�cpfl . Town of Andover °' No. c2b. C' Mom ® .AKS ,� V�I°� SSS' COC MIC"t W°C O° FATE® BOARD OF HEALTH Food/Kitchen PERMIT 1 LD Septic System THIS CERTIFIES THAT .. .. ........ BUILDING INSPECTOR ............ . .. ...... . .. .. .................. .............................................. 4 has permission to erect .. buildings ® Foundation � � ® Rough to be occupied as .......... . . ... .... .. . .. . .. .. .. ................ ...gm.oj". .. .. chimney provided that the person accepting this per 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 CONSTR Rough Service ............... ...... ... .............................. Final BUIL ING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Federal ID#05-0405529 RUSE Exigincel-ing RI Contractor Registration No 8106 MA Contractor Registration No 120979 CT Contractor Registration No 620120 sinar 6'0 RISE ' ".1 vh 1 tirt' i , ('V''' 202"1 ENGINEERING7 CONTRACT 339-502-5197 FAX 339-502-6345 Page PROGRAM 'o 115 CONTRACT IS ENTERED INTODETW8FJJ RISE CNIA-HES ENGIREEMNO AND THE Comm Fort wonK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIE?ITO WORK ORDER Jeremy Kratise (978)641-1728 05/03/2016 434133 00002 SERIACE STREET BILLING STREET 14 ff:� 9 \V I I Robinson Cotirt h I I Robinson coln't C" SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP North Andover, MA 01845 North Atidover,MA 01845 .JOB DESCRIPTION AIR SEALING:Provide labor and materials to scid areas of your home against wastertil,excess air leakage, This work-^will be pZT concert with the use ofspcciul tools and diagnostic tests tow i ;sure that your home will be left with it lucalthfitil level of cxchange and indoor air quality.Materials to be Ivied to seal your]ionic can include caulks,foams and other products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed) 'This will require(8) working hours.A reduction in cubic ICCI per nanote(0,111)ofair infiltration will occur,but the actual number ot*cfni is jun guaranteed. At the completion orthe weatherization Work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-coiniaclor to ensure the safety or tie indoor air quality, $680.00 AIR SEALING ADDE'R: (2)working hours, $170.01) ATric Provide labor air()materials to instill it 10"layer orR-35 Class I Cellulose ridded to(522)square feet oropen attic spaec. S767.34 KNEEWALIS:Provide labor and materials in install R-13 Bleed fiberglass to(252)square Im ot'knemall. Then install 2"rigid board insulation.Scal all scams with FSK lupe. 5919.80 KNEEWALL.FLOOR:Provide labor and materials to install It 14"layer ol'R-49 Class I Cellulose added to(180)square fect ofopen kneeivall floor. $273.60 iV I'FIC ACUSS:Provide labor and materials to insulate lbe back-or(1)allic hatch with 2"rigid'I'liernim board,Wcatherstrip the Ixrlojctef. $60.00 ATTIC ACCESS:Provide labor and materials to install(1) new,finished plywood,kneewall space access hatch.'rhe hatch will be insulated with code compliant 2"rigid'I licimax board,weather-stripped,and held closed by eye hooks, (Wood Surfaces will he unfinished. Prime coat amt/or paint is not included) $120.00 ATI IC"ACCESS:Provide labor air(]Inatcrials to make(1) access opening froun one attic area to another by cutting a passage through Sheathing, This access will be left open It,it is between two common Indicated Ron firewalledattic areas. $31.31 VENTILATION:Provide labor and materials III install(1)insulated exhaust hose to existing bathroom flau(s). S50.00 Federal ID ft 05-0405629 RISE EngineeHng RI Contractor Registration No 81813 MA Contractor Registration No 120979 RISE 6"0 dii ii it i'rIvo 1 11 CT Contractor RegIstratlon No 620120 ENGINEERING' mut,Carnon,MA 02021 CONTRACT 339-502-55197 FAX 339-502-6345 Page 2 PROGRAM THIS CONTRACT'IS CUTERIEDINTO IJEWMEN RIDE CNIA-11ES EUGINEERINO AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW .......... CUSTOmen pflotlE DATE CLIEUT 0 WORH ORDER Jeremy Krause (978)641-1729 05/03/2016 434133 00002 ............. SERVICE STREET W1.1.010 STREET I I Robinson Court I I Robinson Court SERVICE CrTV,STATE,Z1;` BILLIbM CITY,STATE,ZIP North Andover, MA 0 1845 North Andover, MA 018,15 'J'013 DESCRIPTION VEN'ril-ATION:provide labor and materials to install Ventilation chides in(58)rafter bays to maintain air flow. S116.00 CONINION WALLS:Provide labor and materials to install blown in Class I Cellulose to(60)square feet ofd"common Wall through all interior surface drill and fling method. Plugs will be spickled Bud left ill It relatively smooth Condition.Finish sanding and touch-up priming/painting will be the customer's rest)onsibility.Ifunreowner has received a copy of the I-IA',s Renovate Right 1ad-Salc information guide explaining the potential risk-of the lead hazard exposure Rom the weatherization work to be performed.Your signature is your acknowctigement of receipt and agreement to proceed. 5111.00 You will only be billed the Net amount. Currently,tbr c I igible measti ircs,Col u rubia Gas avers 750/"10 incentive,not to exceed$2,000 per calendar year,and in incentive of 100"°"for Ill e Air Seal i rig measures till to the first$680 laid an additional$3,10 irsavings arejustified by the auditor. For the safety and health ofyour home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home hoth belbre file work is begun,and ahcr file weatheri7alion work is Complete.We will also conduct a full ivisessInent ofthe Combustion st6ty of your heating system and waler beater.This has it Value orS90 and is Ill no cost to you. 'fond allowable weallictization incentive is S3,11 10. SWOO Total: $3,389.05 Program Incentive: $2,776.79 CLIStOmar Total: $612,26 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "**Six Hundred Twelve& 26/100 Dollars $612.26 UPON FINAL UIS -CTION AND APPROVAL BY RISE EMOWEERUIG.CU57W.IER AGREES TO REMIT AMOUNT DUE In FULL.R"EREST OF 1%PALL 13L CHARGED MONTHLY Oil AnY UPlPAaD It" CT "11110 APPROVAL '0 BAY"*SEE REVERSE Fon HTS R Tv!taamrlorjorj GUARMItEES.RIG F RECISIOU,SCHEDULMO,Alto Ceti TRACTOR AFOI3;RA`GQN. DO NOT SIGN THIS CONTRACT IF THERE ANY IW90AC AUTribRd J�_I_A E.tlmwinqit A P AA IC IF NOT EXECUTED VAT1,1111 DATE OF ACCEPIAUCII ACCEPTANCE OF COMRACT-THEABOVE PfilCES,SPECIFICATIONS AtlDCO?4DlTlOt4S ARE 30 SATISFACTORY HEREDYACCEPIEM YOU ARE AUTHORIZED IODOTHE VIORK DAYS. AS SPECIFIED.PAYMENT WELL Br MADE AS OUTILNED ABOVE RISE60 Shawrnut Road,Unit 2([canton,MA 020211339-502-6336 ENGINEERING www.RISEenginearing.com OWNER AUTHORIZATION FORM Jeremy Krause (Owners Name) owner of the property located at: 11 Robinson Court, North Andover, MA (Property Address) (Property Address) hereby authorize (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. idkature Date ........... The Commonwealth ofMassachusetts bepartment of IndustrialAccidents Office oflnvestigations' 600 Washington&,eet .Boston,MA 02111 "` www massg0V1, a Workers' Compensation insurance Affidavit:Builders/Contractors/Elec>riicians/Plumbers Any icani Information 'lease Print Le bl Name(Business/Organization/Individual): Address: PO BOX%8 , MA 01810 City/State/Zip: Phone#: 17 79 Agou an employer?Check the appropriate box: _ 1. am a employer with 4. Type of project(required): � ❑I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 F1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached shRet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. [❑Demblition working for me in any capacity. workers'comp,insurance. [No workers comp..insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its required.] .officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per McL 11.❑Plumbing repairs or additions myself[No workers'comp. c.152, §1(4),andwe have no 12-El Roofrepairs insurance required•]t employees,[No workers' comp,insurance required.] 13.❑Other !Any applicant that checks box#1 must also fill outthe section #Contractors that check this box must attache below showing their workers'compensationpolicytnformation• T Homeowners who submit this affidavit indiFatingthey are doing all work and then hire outside contractors must submit anew affidavit indicating such. d an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: j Policy#or Self-ins.Lie.#:_ "7� - Expiration Date:_ Job Site Address: ( i h SO City/State/Zip n- /9 dU t/P d' 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 ofMGL 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 WORD ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ee y nder the pains and penalties ofperjury that the inforwzation provided above is true and correct. Si ature: Date: ?none#: 9 >F' go- ��3 FOifon1y. .Do not write in fliis area,to be completed by city or town official. Town: Permit/License# ority(circle one): 1.Board of$ealth 2.Building Department 3.City/T9"Clerk 4.EIectrical inspector 5.Plumbing Inspector 6.Other ContactPerson: Phone#• 0 DATE(MM/DD/YYYY) 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(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 Linda Bo danOWicz NAME: g Insurance Solutions Corporation PHONE (603)382-4600No:(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc—insurance.com INSURERS AFFORDING COVERAGE NAICR Plaistow NH 03865 INSURER A:Western World INSURED INSURER B NaUtIlUS Insurance Group Polar Bear Insulation Company Ina 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. NOTIMTHSTANDING 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. ?LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MNWdYYYFyMM%Ddl'EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR DPREMISEAMAGE TO RENTED 100 000 S Ea occurrence 5 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) 5 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE 5 2,000,000 X POLICY❑JECTPRO-- DLOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S '.. Ea accident ANY AUTO BODILY INJURY(Per person) S '.. ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident S X I UMBRELLA LIAB OCCUR EACH OCCURRENCE S 3_000,000 B `' EXCESS LIAB CLAIPAS-MADEI AGGREGATE S 1,000,000 DED I I RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION H AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT S D? OFFICER/MEMBER EXCLUDE (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 Franck Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA _. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS02519n14011 POLABEA-01 JONEILL / ®R® DATE(PdhVDDIYYYY) 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(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 -7000 FAX _ 11 Saunders Street Atc,_N�E�_(978.. )688 _!laic,-HoZ(978)688-7001 North Andover,MA 01845 ADoe ss: INSURERS)AFFORDING COVERAGE NAICI _ INSURER A:Nautilus Insurance CO. 17370 INSURED INSURER B:S3fetY Insurance Company__ _L33618 Polar Bear Insulation Co.Inc. INSURER C 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. — — - -- INSG - —AO�LISUBR; PO1DJr,_ ^ POLICYEXI' ' LTR i TYPE OF INSURANCE i INSD 1 VND? POLICY NUMBER MM/DD E MM/DD LIMITS A COMMERCIAL GENERAL LIABILITY ; ;EACH OCCURRENCE 5 --- 1 DAMAGE TO RENTED-_- - ----- CLAIMS- OCCUR OCCUR I PREMISEs_(Eaoccurrence) $ —--- -- 1 MED EXP(Any one person) S -- PERSONAL&ADV INJURY ;S GEN'L AGGREGATE LIMIT APPLIES PER: ; GENERAL AGGREGATE s t` +PRO- POLICY JEGT LOC PRODUCTS-COMPIOPAGG 5 OTHER: ! - -- --.5 f AUTOMOBILE LIABILITYi ! COMBINED SINGLE LIMIT ;S 1,000,000 I Ea accident-— --- - - _ .- EI ANY AUTO X2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) is ALL AUTOS OWNED :AUTOS SCHEDULED BODILY INJURY(per accident)'S �� i NON-OWNED i 4 ?PROPERTY DAMAGE X `HIRED AUTOS AUTOS !.(Peraccidenfl _ _. __S.. UMBRELLA LIAR OCCUR - !EACH OCCURRENCE-, -,_- S A i EXCESS LIAR j CLAIMS-MADE; AGGREGATE _ S ---DED RETENTIONS — WORKERS COMPENSATION !PEROTH- ;AND EA9PLOY6RS'L)ABILITY ._STATUTE _ ' ER ; Y/N i ANY PROPRIETORIPARTNERIEXECUTIVEE L EACH ACCIDENT ;S 'OFFICERIMEIABEREXCLUDED? �1N�A� t ` DISEASE-EA EMPLOYEE 3 i(Mandatoryin NH) E.L. If yes,describe under - I ---—— — ---- - - -- -- DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT;S i DESCRIPTION OF OPERATIONS/LOCATIONS I 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 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 g 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n 4000 nn4A A r�r%nm A If r...L.F..........'...�.F IW2016 Preview:Certificates of Insurance GATE 1.•%voDlfYYY) CERTIiF'UCATE OF LIABILITY is�iSURAIN c �- ovoarzDie 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 NAME, T :IArfE: PMO:IE A] Automatic Data Processing Insurance Agency,Inc IA:G no.Enu: �VC.tlol. I Adp Boulevard aoDREss: Roseland,NJ 07068 ItiSURERIS)AFFOP,DItIG COVERAGE I NAlC7 crsuRERA: NorGUARD Insurance Company I 3147D INSURED (USURER 8 POLAR BEAR INSULATION CO INC I P (USURER C: O BOX 956 Andover,MA 01810 INSURER D: INSURER E: ) INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE FOL:CiES OF IISUrRA110E LISTED BELOY:HA:'E SEECI;SSUCO TO THE INSURED NAL',ED ABO`=E FOR THE POLICY PERIOD INDICATED NO i::ITHSTANDING AN, REOUiREt:ENT-i EPL:OR COND:TIOF)OF ANY CONTRACT OR OTHER DOCU, Et1T•:RTH RESPECT TO NHICH THIS CERT'F:CATE f.i;.Y BE ISSUED OR L:AY PERTAiFI.THE:I-ISURANCE AFFORDED BY THE POL1CiES OESCmBED HERE:Pt:S SUBJECT TO ALL THE TERL:S. EXCLUSIOYS AND CONDITION'S OF SUCH POLICIES LIVi T S SHO1711 I.AY HAVE BEEN REDUCED BY PAID CLASL!S INSft TYPE OFItISURAitCE QL— •ULICr Y POLtL'Y EXI• t -- UL11TS LTR( IISD SND FOLICYRUSiBER If�GSCD.YYYY) I:AV,�D:YYYYiI CO:.ILIERCIALGENERAL LIAe1LITY I E•SCr;;:_"LI:kLt.Ct f—j. •waw c• _ :.L%•L'.t�.Li•�Ut t�_!j;�(:LI: I:i%Ef.INSeS Ie:�__.!•_n: I Gtt;L AGGREv%•itULIii AI9'LNtS IEI:. � r_cN:LFiL nGvht6•:It _ �r•Ii:J 1'LL tC'[_IJ'-I�I 1+L:;L: � I"r.'_l:t:i ;:�LII��1=•ILII. (= MAUT07.:00LE LABILITY "t.l'I.�L•_If;LLt U:Jit LLL=:LtU 1I1� F-cGLLEL 1 t:.UIL:' I-II':tD At Isn: DG9RclLA LN6 i..,..LF. 1 _;t!-CI„"LI•^Et.:L- EXCESSLIAS 1 CLAI IS LI-41--!z ( aCC1iE•_4tt RKEFrS COLIPENSATION 1 tl ^tIDEN,IPLOYERS'LIAe11lTY IX I Sl:.[L It Ili I Y i 72 �'::�I!'"I°Nii6I C1_}Anil�li c:<6:-Cu•:� f:L E•:CI-a1:�ICzN.I I i 7.000.000 IFfNCeii.t:ctlbLli E:.�tLDEL•� w—I INA N POI.A.IC772258 (01!07:2016 01101:207? (I.annatory m LIN) L--1 L-L.DIEL-s_-t--.tt.u� --l� E 5 1,000,000 DI Y:OJlarilcc cF cl•Ln:mmlcl= _ � � I I L_.Ice:. 1•cU�-ul.bl i,000A00 '.. I I I OESCRIPNIOU OF OPERATIONS;LOCATIO115 i VEHICLES(ACORO lel•Aumtf.-i Rem:Jiy SChbnie,m.Ti be axacbc l it motosrace Ns regoitw) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theiisch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS, 195 Frances Ave Cranston,RI 02910 AUTHORLED REPRESENTATIVE 1 , Ag 1988-2014 ACORD CORPORATION_All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Afion9 Al2- 0 ()MCC of consumer AN31s an'& 10'Fla- te 5 170 211 �tc�rti�x�. 14 �remet � ja2-726 Type:- DEA T4 252M 712aul6 - IONCO \1ncent LeBlancMork P-0.Box 958 ANDWER2 MA��$�� - = -~ g3pda#�A dr anda£ebaraca�' 1 ent LostCad -i Renewal �`alp� D Address y tt •�� — tic'_=_.._-`"'._ �=j .�-:S?`=_. !._�� =G NgTLBBLW ER g]�5{pg Wff aOMP&S _