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HomeMy WebLinkAboutBuilding Permit # 5/27/2016 1111®DI PE IT �aoRrH o� �t,eo ,6 14o TOWN OF NORTH ANDOVER ® APPLICATION FOR PLAN EXAMINATION Permit No#: i Date Received �SS�cwuS�R Date Issued: �'�� I PORTANT: Applicant must complete all items on this page LOCATION/ am 5 ®`1 � ���'� Print PROPS TY OWNER d,��► Print vi 7 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 [I One family [I Addition [I Two or more family [I Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Zr Others: ❑ Demolition ❑ Other %3-../. ✓r>,�G„Yi,�r.,k�,..�,,•.E�g....�.�.�., ,.:r t`❑rst�F z,�rCG"d,.•ro.:;.:rd prF�5l'a�n�^"f FEX'v'I�rt�r�4."�....,..,Dr,��W/�f er,tlanrds r rr'l.r,r.fY✓r(n,-rfr�.sur:P.:.:"d5 t,..rf'r���:F,GV.l'.so.r,❑Nw.'Wr,'G"'.'�r r1'r,Nr�,�-a!➢.,rt..9.ed.rr.(,:r:r./.s,:(,hr.t"rGiea-.fd^z,rr`D.�lr.,�t;.<s:,<d trna.ciWr ,tJnrr= � r,. r a. (�....2'�:" c� .::� I 1 �..„ ,„,..gin' r'�.. ...,<, � n .�."•,x .� .,,:;,. ..!„ :,.,r,�.,.. � rz., rr.. A .t,.,,, n sl ��rr �".rr.,�• .W ,� r�' r � ,.�� ,?..� �:t1.�"f Y~r`.", r i ,- �7 s. ;.->��' r�" ,^r.s l t u. rJ..✓rr (.� .r. ,.� ��� sC F. �+Y ..�c •t'z r, -.'� - ,, '., rr ya ;'h✓r...T �� ..9:,.,. (.. ;, r.7 rx ,?£� e' la. y ? rf� a.�"f4�.�iN �'F r I X59 %' r�. lr:-, ,. �"d✓r^S�uSWater/S,,eu�ers%�,�.�r�:( ,5?� �'•I,;.✓d'�. ?���(' ,/,ah��3f(fsrrir/lig!�eIl,�,ra�� :.;�``„YwrN.�✓�'r:,,���:f..,�'1/�l,�w f; fjr;'�f�.,,�,r��:.,S1if y4r.�.:"�, r?.:. ;�'� rr 1' DESCRIPTION OF WORK TO BE PERFORMED: ee,li✓lu t9Ty i C i v111614 Ta - t/f, 4j?1101 lGi/®tj Identification- Please Type or Print Clearly OWNER: Name: J)t a kc, v1 ne-r I rro o Phone: Address: 3 y �'� S /-1 '49r el®L/- Contractor Name: 7e-t of I r Phone: Email Address: �- r-g57- P, o e ,5 1191 0 Supervisor's Construction License: /C;( 0 t Exp. Date: L/ /fi g/ ' Home Improvement License: Exp. Date: 7 �6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 3cg®v ® iD FEE: $ Check No.: '1 , Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 5 r,r t%OR ray Town ol4 � � ��' Andover No. ® s �O LAME W e , Mass, COC NIC N@WIC O[ ��� x.95 RATED U BOARD OF HEALTH PER k a LD Food/Kitchen 4 Septic System THIS CERTIFIES THAT BUILDING INSPECTOR AN has permission to erect g Foundation ........................ buildings ...... 31� ....... .. . ........... ....... ... ..... . ® ® Rough to he occupied as ...... .. .. ......... . .. .. . ..... .. ..... . . . .... .. ... .. ...... ... chimney provided that the person accepting this permits 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ............ Service ..................... ..... 1..� .. .. .°.................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. •e _ /lit Id t O T2007, Federal I0#054405624 RISE Engineering RI Contractor Registration No 8188 MA Contractor Registration No 120974 K"""ISE A division orniclsch Engineering ENGINEERING 60 Sh2wroLt Unit1rry Cantcn,MA 0_021 339502.6335 FAC 339502-6345 CONTRACT . , r------ 'Page 1 PROGRAM Erin! CMA-HES ro TM COMM =r M eon A3 unrorrfsr ; �U� recon oa' _ etm+ro — VIMORDER Meghan Nettleton (978)655-3193 03/25/27016 431843 00003 _ w soavxe Sr,"T 34 Elm Street 2 rte,. C=-.0 34 Elm Street 2 aallrta CnY.STATEIID Notch Andover.MA 01845 1 North Andover,MA 01845 ]DESCRIPTION PHASE ONE-Proposal for this calendar year. so.o0 BARRIER:A Blowcr Door Test will not be conducted at your home,due to the prrseasc ofasbcstos. 'Y- $0.00 HAZARD BARRIER:We have identified that these are uncovered electrical junction boxes present in)vur home.These nest to be covered prior to the sten ofyour bomals weatheriznuon work,and are the respansiil"lity of the homeowner. 50.00 AiR SEALING:Provide labor and materials to seal areas oryour home against wasicrul.excess airleakoge.This wort:gill be perrorrtncdin concert ttiiih the use ofspccial.tonts and dispiastic tests to assure that your home%"It be icR with a healthful 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 rot sealing include air leakage to aeries,bm=cn s,attndred garages and other unheated areas(windows are not generally addressed.)This will require(8)working hours.A redaction in cubic feet per minute(cfm)of air infiltration will occur.but thcacuml number ofcfm is not guamatmA s At the completion of the mnatheriration wed:,and at no additional cost to the homeowner.a final blotter door"or combustion surely analysis will be conducted by the sub-conductor to ensure the sorely of the indoor air quality. WORD ATTIC FLAT:Provide labor and materials to install a 6"layer of R 21 Cierra I Cdlutose added to(630)square Cat of floored attic space. i 51.121.40 DAMMING:.Provide labor and materials to install a I r layer of R 38 unraced pber8tass hap to(40)squaw foci for damming Purposes ,_ S82.Q0 ATTIC FLAT:Provide labor and materials to Install a iV toyer of R 35 Class 1 Cellulose added to(336)squaw fed ofolim nntc space. 5493.92 STORAGE BARRIER:Homeowner is responsible for the removal of tho stated items blocking the installation ofwcatherimttorr work in the attic. Removal must occur prior to the scheduled work star. $0.00 ATTIC ACCESS:Provide labor and materials to insulate the back of the attic door with 2"rigid Thermax board and seal dee dooes - edge with%%vadierstripping to restrict adr lcakago. 573.91 VEN'TI ATION:Provide labor and mmcrials to install ventilation drutcs in(48)rafter bays to maintain air flow. S96.OD VENTILATION:Provide labor and materials to install(10)4"X 16"rectangular aluminum soffit vents to increase ventilation in attic areas.Specify color.White or Gray. 5250.011 Federal t0#05-0405629 RISE Engineering RI Contractor Registrat on No 8180 RISEA division oflbiclsch Engineering INA Contractor Regtstratlon No 120979 El GINEERINIC-' ou Shawviaut Unit Q,Canton.NIA 02021 339-a0263]S FAX339-S0263dS CONTRACT Page 2 PROGRAM CMA-HES &iaurcoERINGAARDTHECUSTOUMFOo RWORKAS Dr�aEDirriow arsrosaFn PHONE -DATE CUFxro VTORxoRDER Meghan Nettleton (978)633-3193 03/25/2016 431843 00003 sFavlcs sTRFfiT eatDaD aTrTEET - ' 34 Elm Street 2 34 Elm Street 2 armee 6rTY.=ATE.DP --- CUM arc STATEaP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION COMMON WAUS:Provide labor and materials to install 3.5"R-13 faced ftbergglass ball insulation to(24)square feet of common Nall area.2"rigid Iibereass insulation Lvill be installed over the surface. 587.60 CRAWtSPACE-Provide labor and materials to install(448)square fat of 6 ml polyethylene over open ground in designated craiftacdrarthm basement mmUNDER MAIN HOUSE.IF OVER MAIN HOUSE GETS ATTIC INS. $344.96 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently. for e1Geiible messwcs�Columbia Gas ollin 7595 incentive.not to creed SZW0 per cotendar)ear,and an incentive of 100%for the Air Sealing measures up to the first S680 and on additional$340 if savings are justified by the auditor. For the safety and health ofymir home's indoor air quality,woe will be Conducting a blower door'diagnosticof the available air flow in your home both before the%vork Is begin,and after the wveather?mdan%vadt is complete.We will also conduct a full assessment of the combustion safety of)our heating system and.vrater haver.This has a value of S90 and is at no con to you.Total allowable Tetmhcriration incentive Is 53.110. 590.00 sit Total: $3,319.79 Program Incentive: $2,592.34 Customer Total: $727.45 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPIECrFICA-DONS.FOR THE SUM OF "'Seven Hundred Twenty-Seven&451900 Dollars $727.45 UPON FOM VAPECRONAND APPROVALOY RISE CAGINE RIM CUSTOM AGREES TO REWr AMOUNT Wer IN FULL.INTEREST OF t%WLL BE CHARGES MONTHLY ON ANY UA7AtD OAIANta rb MYS.SEERhYEA5EF0A DIPdrrANrO7FOinrAT10N ON QUNUNIEES,RtWRa OF RECAtOtLSCHEDULUtO,AtiO CONTRACTOR RECISTNATON. - — O NOT S113N THIS CONTRACT IF THER///EJ/{J//AARE ANY�hAJNK SPACES - — --••.. C-4-- -- —•. Q15 /. ACCFY7���ANCE /lA -__ NOTE:THIS CONTRACT MAY BEINIM AMN MY US WNOT E=UTW WM01 DATE OF AaEPTARCe / �`�I'ZO16._.... ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPEMCATTOW AND CONDmONS ME 30 SAY& SAWFACTORYTO US AM ME HERMACCEPTEO.YOU ABEAunrOA1mm to mm ORK AS aPECS M PAYMENT%)nL Be MADE AS SUTURED A110110 RIS NGO Shawmut Road,Unit 2 1 Canton,MA 020211339-602-6336 ENGINEERING www.RI$Eengineering.com Efficiericy Energized. OWNER AUTHORIZATION ION FORM 1, M6WAN Ne'TT .c--ToN (Owner's Name) - —' owner of the property located at: SH EWA %T (Property Address) ' N(5RT14 RNI OJffR , (Property Address) ' hereby authorize_�01ct r Q ect �dt 1�� ,t (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. Owne s ignature q - 2 - 2016 Date The Commonwealth of Massachusetts Department of IndustrialAccidents ®fftce of Investigationg 600 Washington Street Boston,MA. 02111 U www<masSgoV1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/1•ndividual): Address: PO BOX 958 —OVE0,MA 01810 t3' p: Phone#: .Ci /State/Zi FnI n employer?Check the appropriate box: Type of project(required): a employer with4. ❑I am a general contractor and I 6, ❑New construction loyees(full and/or part-time).* have hired the sub-contractors a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling and have no employees These sub-contractorshave S. ❑Demblition ing for me in any capacity. workers'comp,insurance. g• ❑Building addition orkers'comp.insurance 5. ❑ We are a corporation and its red.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption perM(3L 11.❑Plumbing repairs or additions lf. [No workers'comp, c.152, §1(4),and we have no 12,F1 Roof repairs nce required.]i employees.[No workers' comp,insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submitthis 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 of the sub-contractors and their workers'comp.policy information. lam an employer that isproviding workers'compensation insurance for my employees. Beloln is thepoliey andjob site information. Insurance Company Name: Oo C6A a P p� Policy#or Self-ins.Lie.#: ?DU)`e `"7 Expiration Date: 1�O r lj, Job Site Address:_ 3 9!�/fn City/State/Zip: _ J0✓-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 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 WORK ORDER and a fine ofup to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA,for insurance coverage verification. I do hereby ce 'y rider the pains and penaltles ofperjury that the information provided above is true and correct. Si ature: Date: ?hone#: >�' ya�- ' F0jjJT,o1.a only. Do not iprite in this area,to be completed by city or town official. Town: Permit/License# hority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• ®R ® CERTIFICATE T DATE(MM/DD/YYYY) /-' ls �F���1�� ®F ��� '�'�� 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 endorsement(s). CONTACT Linda Bogdanowicz PRODUCER NAME: Insurance $Olut10IIS Corporation PHONE (603)382-4600 a/c No:(603)382-2034 Ea,E-MANo IL lindab@isc-insuraace.com 60 Westville Rd ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865INSURERA:Western World INSURED INSURERS-'Nautilus Insurance Caron 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. NOTWTHSTANDING 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. rA DDL S BR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE M/ POLICY NUMBER MDD/YYY MM/DD/YYY $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENT ED $ 100,000 CLAIMS-MADE 51 OCCUR PREMISES Ea occurrence R NPP9274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY❑JECTT 0 LOC Is OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY(Per person) $ ANY AUTO ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS $ X UMBRELLA LIABOCCUR EACH OCCURRENCE $ 1,0001000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 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 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave 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 r2n1an11 ____c`__1 POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE FDATE(MMMDrrrM �= 1612016 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 pol(cy(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 PRODUCER NAME: --.--- I FAX — Durso&Jankowski Insurance Agency PHONE 97$ 688 7000 -!(A/C,Ne:(978)688 7001_ 11 Saunders Street A/c No_�-( ._ �._ ) ---- EMAIL North Andover, MA 01845 - INSURER(S)AFFORDING CO_VEAAGE _ i_ NAIL - —_.— — gSURERA-Nautilus Insurance Co. — 417370 INSURED INSURER B:Safety Insurance Company_ - 33618 Polar Bear Insulation Co-Inc. INSURER C: _ -----------! ---------- Peter Leblanc&Steven Leblanc INSURER D __ — -- I --- — P 0 Box 958 -- t 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 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 AUDL5lIBR; - POLICY EFF POLICY EXP Uh1nS LTR; TYPE OF INSURANCE !INSD 4 VND t POLICY NUMBER I MPAIDD '. MMlDD A COMMERCIAL GENERAL LtAaiLnY ! EACH OCCURRENCE 5 —_ DAMAGE TO RERTEO CLAIMS-MADE OCCUR t PREMISE�Ea occurrence) S MED EXP(Any one person) 5 -- - -- ------- --- - ` PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: ! GERALAGGREGATE $ EN - r `^PRO- i PRODLrGTS-COMPIOPAGG i S )� POLICY __JECT =LOC - - S -- i OTHER: AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I S 1,000,000 i Ea accident)-_ C3 ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) I S ALL OWNED SCHEDULED ! BODILY INJURY(Per accident):S AUTOS :AUTOS i '.PROPERTY DAMAGE NON-OWNED I -5 �( HIRED AUTOS i( AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE S 1 — --- i-- A EXCESS LIAR CLAIMMADE AGGREGATE S_ i :- :S OED RETENTIONS ER ER WORKERS COMPENSATION _ STANCE :_ :ANDEMPLOYERS'LIABILITY YIN! ; AtJY PROPRIETORIPAP-TNERIEXECUTIVE I _E.L EACH ACCIDENT :S OFFICERIMEIABER EXCLUDED? 4 N I A I - (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE S byes,describe under ( E.L.DISEASE-POLICY LIMIT(S DESCRIPTION OF OPERATIONS below i 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 CERT(FICA T E HOLDER CANCELLATION 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 iQa. nn-in Amnon A-r'rnat All�..�L,G.-r...�...,..,.J 1/4/2016 Preview:Certificates of Insurance ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYY) ��- 01/04/2016 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: PHONE FAX Automatic Data Processing Insurance Agency,Inc. A/c,No ExI: (Arc,No 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429705 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM1DDNYYV (MWDD)YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 10 NTE CLAIMS MADE FIOCCUR PREMISES(Ea occurrence) S MED EXP(Auy one person) S PERSONAL 8 ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 POLICY❑PRO ❑LOC PROLNJCTS-COfdPiOP AGG $ JECT OTHER: S AUTOMOBILE LIABILITY COMBINET)SINGLE lEa x ideut) 'I S ANY AUTO BODILY INJURY(Per parson) S ALL OWNED AUSCHEDULED ­ AUTO BODILY INJURY(Pe accidenl) S NON OO G OS ;� S HIREDAUTOS AUTe accid«,9 $ UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ WORKERS COMPENSATION �( AND EMPLOYERS'LIABILITYVIN STATUTE ER ANY PROPRIETOR+PARTNERENECUTIVE E.L.EACH ACCIDENT S 1,000,000 A OFFICERif.4EMSEREXCLUDED? Y❑NIA N POWC772258 01/01/2016 01/01/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 II yes,d—ibo we id1,000,000 DESCRIPTION OF OPERATIONS be., E.L.DISEASE�POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if moruspace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GLCAC ACCORDANCE WITH THE POLICY PROVISIONS. 350 ESSEX STREET Lawrence,MA 01840 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACO RD 25(2014/01) The ACORD name and logo are registered marks of ACORD �rt�4 (4/ esS i ogdodon � G�01:ComAf 8 ld� ! plan-etc 5170 - �➢211 ® o acaset FMAdation �rtentD ^r � � 02�26 l_ ION Co- Vincent LeBlanc P-0.Box 958 -- _ cs Upds� pl�ent O Lock"", Addeess `tom I�enetva� J OFA GA1 ca 501612ifi glsisto�Imo.0396 _