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HomeMy WebLinkAboutBuilding Permit # 5/27/2016 BUILDING PERMIT0.1 �aoRrN TOWN OF NORTH ANDOVER � ® APPLICATION FOR PLAN EXAMINATION Permit No#: + Date Received ATEo�PPP"�5 cs�us�c Date Issued:— IMPORTANT: ssued: IM ORTANT: Applicant must complete all items on this page LOCATION ucIcf'tly 9pii d Print PROPERTY OWNER G►grd o Ca rot 0 Print 100 Year Structure yesOno MAP e _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 k Others: ❑ Demolition ❑ Other ,�/ ! 1 '�✓,r!. r L. rJ-,! '/ l.Am" 9 JY,/.rr /® 9Ytn;,✓� ,�! � ds�ryU f r'���❑ Watershed rr istnct �/, ! � �,,-.. �t Well x � ❑ FCood Iain r� ,.�Q Wet�a� ;,,,T ��� �_ r I�Se tiC ❑ m! `4 r t '� � �, r!� � � � r!r<v� � f ry rid 3�J „<....o-...P, .. �,r e.-: _r „�'.. r r. .l, M .„ ✓. t- t r�s'�".. �f^, w,,'x`�'',c.„ t f.'+.""^'rrr � y e �: �S ..rr;+'f`rr`: r., r:�s' U Y .!.. ,.., „v �rt'lH,NY I- S /T E',,:�, r, RrI.: ,✓N ,�.h C ..mf r. ,r.,� '��✓""r'r�i.,ru/ ..�,,. �':� ,.:.N f ,.,r,�s.. ww�� r,,, �"�s', ,; ,. .;. ��r i.. ,..� z. 3y� �,�x,.,.,rr„ ��,:N- r r .-...t r t:rilz� �'r�`.!,..-✓f 1r. 5�'. .r,.. ,, .l.S'r' rF' .�:�' /�rr{i.,r� r f` Y '�,.r;:.,.. DESCRIPTION OF WORK TO BE PERFORMED: 1 (,)0// Tp,5v Pa&1 C)evrSe pclCIC,-0( BSc glwolrhum 15;-d4 Identification- Please Type or Print Clearly OWNER: Name: 5 A®,co v\ �'Cx FO Vx Phone: � 51 J Yob Address: ->X AJCt t'n9li ,ptl f4 Contractor Name: ?r r r l C. I 0�v�C Phone: Email: Address: &957- �;,n -e 5 i P/0 -5 7-0 Supervisor's Construction License: Z 6 ®I Exp. Date: L/Id F11 Home Improvement License: !®d- 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: $ �- J Do. 0 a FEE: $ � Check No.: , Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acc to the guaranty fund .....__........... t4ORTH Town of Andover C, ver, ass, a ® � 1. COC MIC c"M$WICX � ,®A04ATE® p.4a�,`� S U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ................... PERMIT, . .. . ..... . . .... . . .... Foundation has permission to erect ...... ................... buildings on . .L.... 4Rough. to be occupied as .... .... ... .... ....... . . .. . . ... ..... .. . .... . Chimney provided that the person accepting this permit shall in every respect conform to the terms of the a plication Final on file in this office, and to the provisions of the Codes and By-Laws relating to the InspectionIte tion and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S S Rough Service ........................................... ..... ......... .................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy By Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r all OBe Done FIRE DEPARTMENT Until Inspeca rove the Building Inspector° Burner Street No. Smoke Det. Federal 10#06-0405629 RI Contractor Registration No$106 RISE Engineeiing NLA Contractor Registration No 120919 A division 01*1111cisch Engineering RISE (,onipany Address,Cilv,INLk 00000 CONTRACT ENGINEERING' 401-123-1234 FAX 401-123-1234 Page i PIS. ORAM jNe;CONTRAC119 EMEREDIN10GETNEEN RISE C NIA-I I ES ENGCRIBEDREERINGANDIHE cePijj?XN FOR WORK AS DESBELOW PHONE UAIF CUEBTO wonKORDER CU310MRIli/12/2016 422289 00004 Sharon Coran j9 Ll.9 01-1 alUjW SMEET SERVICE STREET 22 Buckingham Road 22 Buckingham Road 91WRO CITY,SV4,m,2jp SERVICE COY'SWIE.ZIP North Andover,MA 01845 North Andover,MA 01845 JOB I)ESCRUMON *clinjose to(1008)squarc feet of ill Lail inum-sided exterior Nvalls. WALLS:provide latIor and materials to install NO-)in Cl,responsibility,I joincomaer I)us received a copy of file EPA's Renovate Rigill ,f0t)cjj-IIp painting„if needed.will be 01c costorlices respOns -to be Lead-Sore inl'orillation 61lide explaining the potential risk of the lead hazard exposure from the NWRIlleriMl ion wN-L performed.Your sitpunure is YOUr Ucknowtilicnicin orreccipt and agrecincla to proceed. $2,016.00 RIK Engineering will apply all app Ical C, liol)Ic incentives to ihiscontracf. You NO,only IK:INIlcd IIle Net loontint. Currently, for cliot Ae measures,C(dand)in(,,asofrers 75%incentive,Not to exceed 52,000 per calendar year,kind air incentive of for tile Air Scaling measures tip to the first$680 and km additional$340 jf.,;Svioj;7,are justified fly tile atulitOr. For the satiety And licalth of your hollies Indoor air tImflity,We%%ill I\'-Conducting,,Mom tk)or diagnostic of the available air flow ill 1111crizat jon xwrk is Complete,We%%ill al duct-I full IISSCS."Sment Of your froole I-wh before the w)rk is m,and after lite ua you Total allowt-Able file c0DdNLqi(Nj safety Lfy0jr 11milingsystem andwater beater.'I'llishas a value ofS90 and Is" 00A mcatherization incentive is S3,1 In. 000110 $900) 00 qs '04011,00� 0,� 10000""00 '00 0,00� 00 010 olo, Tota 1: $2,106.00 Program Incentive: $1,602.00 Customer Total: $504.00 WE AGREE HEREBY TO FURNISH SERVICES.COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Five Hundred Four&001100 Dollars $504.00 4 FUU-WIERESTOF V/6 WILLISE CHARCED WOHLY ON ANY UPONFINALII PECT DAPPOVALOY I apoin-MA dUARARIEMIUMOSOFRECISM, UNPAID SALA 9 DAYS.RSFEREVER FOR"MOM"TrIGN THIS CONTRACT IF THERE ARE MY BLANK SPACES ONO AUlH ME IGNAIUAG DAVE 01ACCfP1ANCE ricre:IHM CON'SACTIAkY BE VNIHORAWN By USIPROTEXECUICI)WIVIIN ACCEPTANCE OF CON RACT-IM ABOVE PRICES SPECtFICAZONS AND CONINVONS ARE SA'OSFACMY M US AND ARE NCAEBY ACCEPkD.YOU ARE AUVIORIZED M DO IUE WORK 30 VAYS. AS SPECIFIED�PAYNERTWILLUE"ABE AS OUILINED ABOVE RISE 60 Shawrnut Road, Unit 21 Canton, M,A,020211339-502-6335 ENGINEERING" www.RISEengineering.com OWNER AUTHORIZATION 1, cel Ct. ' v , (Owner's Name) owner of the property located at; (Prop Address) (Property Address) hereby authorize (q '�✓ d/ �� °""" � (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. Owner's Signature Date The Commonwealth ofMassachusetts .Department oflndustria[Accidents Office of Investigations' 600 Washington Street .Boston,MA.02111 www,massgopl.4ja Workers' Compensation Insurance Affidavit:Builders/Contractors&lectricians/Plumbers Applicant Iuforznation �.'Iease Print Le�bly Name(Business/Organization/Individual): Address: PO BOX 958 City/State/Zip: Phone#: 17/�79 Ayou an employer?Check the appropriate box: FElectrical 1. I am a em 10 er with4. project(required): P Y ❑I am,a general contractor and I employees(full and/or part time).* have hiredthe sub-contractorsew construction2. I am a sole proprietor or partner- listed on the attached sheemodelingship and have no employees These sub-contractors havemolitionworking for mein any capacity. workers'comp.insurance. [No workers com .insurance 5. ilding addition' p ❑ We aie a corporation and itsrequired.] .officers have exercised their ectrical repairs oradditions 3.❑I am a homeowner doing all work tight of exemption per MC-Lmbing repairs or additions myself.[No workers' comp. c.152, §1(4),and we have noofrepairsinsurance required•]t employees.[No workers'comp,insurance required.] er Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submitthis affidavit indiQatingthey are doing all work and then 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,policy information. I am an employer that is providing workers'compensation insuYance foz my eyn information. ployees Below is tlzepolicy and job site Insurance Company Name Policy#or Self-ins.Lic. l Expiration Date:_ .e 1 h r% Job Site Address:_ _'21-k- tl) e</t,'��jagLAI City/State/Zip: /J_ ,4►1,1pve; 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 canlead 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 WORK ORDER and a fine 0-FU p 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 DTA,for insurance coverage verification. I'do hereby ce 'y nder thepains andpenalties ofperjury tlzatthe infolnzatdonprovidedabove is true and correct. Si ature: I Date: S® d ?hone#:FF Official use only. Do not iprite in this area,to be completed by city or town official. City or Town: Permit2icense# Issuing Authority(circle one): I-Board of Health 2.Building Department 3.Qty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC"R®® /�B p��+ p/�p�/� DATE(MWDD/YYYY) CERTIFICATE 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(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 endorsements). PRODUCER CONTACT Linda BO danowicZ NAME: g Insurance Solutions CorporationPHONE (603)382-4600 IFAX NO:(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A: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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH 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 DDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DQ1YYY MWDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAA CLAIMS-MADE ❑R OCCUR PREMISES TORErr 100,000 PREMISES Ea occurrence $ R NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 -PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY El ECT 1:1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 % OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident $ XUMBRELLA LIAB 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 I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ EACH ACCIDENT E.L.E $ OFFICER/MEMBER EXCLUDED? N/A (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,may be attached If more space Is required) Thielsch Engineering is named as Additonal Insured on a Primary and Non-contributory basis on the Liability policy as per written contract for work performed on their behalf by the insured for insulation work-mineral. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis 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 INS025(9014011 POLABEA-01 JONEILL DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY ONSURAMCE F116/201 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 FAX 11 Saunders Street NC N1�_(978)688 700D _ (a<p Ne;() 978)_688-7001 North Andover, MA 01845 EMAIL — — ADDRESS: _ INSURERS)AFFORDING COVERAGE ; NAIC# ___ INSURER A:Nautilus Insurance Co. _ 177370 INSURER B:Safet — rrvsuREo y Insurance Company— 33618 Polar Bear Insulation Co.Inc. INSURER C: -- - - — --: Peter Leblanc&Steven Leblanc — --- ------------ -- 1 P O Box 958 INSURER D_ Andover,MA 01810 INSURER E: _ I 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRi TYPE 'ADDL�SUBR; POLICYEFF POLICYEXP -- LTR; ':INSD VND s POLICYNUMBER MPNDD MMMD LIMITS A COMMERCIAL GENERAL LIABILITY ; ,EACH OCCURRENCE S - GAMAGE TO RENTED- - ---' CLAIMS-MADEOCCUR PREMISES(Ea occurrence) MED EXP(Any one person) S PERSONAL&ADV INJURY i S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i S )r POLICY` JEGT LOC --- i - _. -PRODUCTS-COMPIOPAGG S OTHER: AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT ;S 1,000,000 i Ea accidenll__ _ 13 ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Perperson) i S ALL OWNED SCHEDULED BODILY INJURY(Peraccidenq S -_ AUTOS _ ;AUTOS ; i x : itNON-OWNED ; i 1 ;PROPERTY DAMAGE----- ------- - '— HIRED AUTOS _AUTOS i(Peraccidgnt_ _ _.— S.- — UMBRELLA LIAR OCCUR :EACH OCCURRENCES ) A —EXGE33 LIAD - CLAIMS-MADE: i ) AGGREGATE _ _ S DEO RETENTIONS 5 WORKERS COMPENSATIOt! ! PER OTH- AND EMPLOYERS'LIABILITY YIN : STATUTE i_ +ER. :ANY PROPRIETORIPAP.TNERIEXECUTIVE r�: `E.L EACH ACCIDENT S OFFICERMiElABER EXCLUDED? u1 N/A - - — --- ; f Mandato to NH i If yes,describe ibe under ( ) �.L DISEASE-EA EA1PLOYEE S - i ---—— —" "- - -- - -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT:!S 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 hielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN T hiFrancis Ave ACCORDANCE WITH THE POLICY PROVISIONS- 195 Cranston,RI 02910 AUTHORIZED REPRESENTATIVE j n 1000 4111111 Amnon rnoonoA•rtnnt All_...e,c....,,,,,, _4 1/4/2016 Preview:Certificates of Insurance ACOR®® CERTIFICATE OF LIABILITY INSURANCE DATE / 01110 04 4122 0 1 016 Y) 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(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: PHONE Automatic Data Processing Insurance Agency,Inc. A/c No Ext): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC q INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: 429691 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 AUDI.5UHK1 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM1DD/YYYY MM/DD/YWY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMSMADEOCCUR PREh1u ES(E.occurrence) S MED EXP(Any one parson) $ PERSONAL 8 ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S - POLICY❑)ECPROT r I LOC PRODUCTS-COI:It'!OP AGG S OTHER: S AUTOMOBILE LIABILITY LOIABINED SINGLEI I S (Ea accidenq ANY AUTO BODILY INJURY(Per parson) $ ALL OWNED SCTOS HEDULED BODILY INJURY(Per xcidera) S AUTOS AU NON-OWNED (Pv accident) S HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S DEU I I RETENTIONS $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'LIABILITY YIN -- A ANY O FI ERLE BER EXCLUDED? NIA Y❑NIA N POWC772258 01/01/2016 01/01/2017 ELEACH ACCIDENT $ 1,000,000 '....., (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 1!•/es.describe under 1,000,000 DESCRIPTION OF OPERATIONS blow E.L.DISEASE-POUCY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached d mor.spat¢is required) '.. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACTION INC ACCORDANCE WITH THE POLICY PROVISIONS. 47 WASHINGTON STREET Gloucester,MA 01930 AUTHORIZED REPRESENTATIVE 1 1 A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0172 a� pE'SSd3flIl � �€r � yrs aid - 70 o Farb?l=a- 02116 -ft=ovement cog _ Reijts�ratint� '�Q2T26 TyPec- DQR Ti*# - -_-_ ExpTca6on 7=01 POLAR BEAR I S LpT10M Co- Vinnt LeBlanc P_0.BOX 958 ANDOVER= MA 4i8ifl aPdaftAddrm and nwmcBn 1 t LOAC&d t Address Renewal J .2812418 =i`'°. �`•l:�Wit_:moi a_SI:,�`::z,..r?�_ _� ti glaistn�i�Q3o� _