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HomeMy WebLinkAboutBuilding Permit # 6/10/2016 �BUILDING PER IT ®F taoRro-1 141,'Y ttL@D /b TOWN OF NORTH AVE APPLICATION FOR PLAN EXAMINATION ® _ p� l� Date Received,�A ` `W�e�"^`5 PePermitNO#. "ATE D P R �SS•aC HU Date Issued: 611b ®RTANT: Applicant must complete all items on this page LOCATION rL/t/ -5,`Tr,-7- Print PROP RTYOWNER :C el b&PiY7 e s Print 100 Year Structure yes 2no MAP PARCEL. ZONING DISTRICT: Historic District ye Machine Shop Village y 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 A, Others: ❑ Demolition ❑ Other .17—ri!�v/,q H#L4 .orf.,�ri �: nr,.oa d,'"ii✓u;' ': ,m f r /�'r r, r u,F f La"�;.c�„t �,�,. im! .1t" rF r✓ it!f fr. kr ,[ootl I n ❑Wet(antls r.:Wa rs, ed Disfrict;r '" D,Se, c �, ❑,,1Nell,�r,��<,�, A , ,.,r�r�,�� d.-, .:: �h.,, ;, mr !". 1'��ar�.�,a, ✓ .r i 5 �;'>.,r z.r i ` r + ,,.� A1- r:,?.,.,Tr�,r.�i, rr 'S F^..'' ✓f:1' rl rt ..;,�"_1,�,.. '��," i;1 s p^,�,�';•.P,;rF� ..�.: r ,,.,. �a.;�,�f:� ,.a1 K rr c '., ,� . !k -trn-.:r% �^ r„�, 1',e,.' � W�+ �',:,' .;./ 3� rd' � x�'�'9,�.'��rlf. ;� .,r,�7- '�; „w,',,s�`' n.�i�;;'�,�?lr� /u�.. ,. pr.�u z role/,... �: �„. ✓r i�Sl r.a n`.!.. /�; to �r,lr. ,-� r. .,,�"'�s�' /?�,� r✓ .,N' >�.,.,; ��. ' �.,eater,�Sewe:r„�$'w"�,!"�����Y�r r��✓�,�..r��r�`;�”�,_F��%r�,�,���,"� �r..�r�'fib",+/k,,,r�..���,;7r'hr;K"G..l..,,lG,�,'�=�,,.,.r�1,i!,.�rt�#i ,e.,,�.>�� `, � ���' r....,x... DESCRIPTION OF WORK TO BE PERFORMED: ir'Sl/f kkid t4 7-v KS V-eK -iletrio o Identification- Please Type or Print Clearly OWNER: Name: M;et\g el D®yrtell y Phone: Address: -Cr -To kh,�o ; t-1-e eter Leblanc Contractor Name: 2 Fast Pine Street Phone: Email: laasichl$x XT 2 Address: 865 978-407-7638 Supervisor's Construction License: CbGe)1 Exp. Date:Lg,?z2!zr Home Improvement License: !6>-W-6 Exp. Date: b / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: ®® FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wO unregistered contractors do not havef access to the guaranty fund u O®RTH Town of ndover 0 2oo6 J_U , LANE ver,, ass, _/ COC KICKEWICK 04�TE® 9`P�',�,�� lJ BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 41% THIS CERTIFIES THAT ........................ . .. ............... ... ..... .............................. BUILDING INSPECTOR . ............... Foundation has permission to erect .........................®buildongs on ....®. :.. :...... . ........... ............ ® Rough tobe occupied as ...... ... ........... . ........ ... ............. . ...........R. ... .. ..... ...................................... ..... chimney provided that the person accepting this pe mit 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 Inswection, 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 CONS I Rough Service . ..... ... ..... Final B L INSPE OR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvede Building Inspector. Burner Street No. Smoke Det. Federal toil8b-0405629 RISE Engineering RI Contractor Registration No 8168 i. MAContractor Registration No 1211879 RISEms/` A division of7blelseh llrgiaeering ` Company Address,City,MA 00000 CONTRACT^r 401-123-1234 FA\401-123-1234 V N RAC Page 1 PROGRAM USCOWRAMMEREDGMEGIVEEHCMA-AES u �AS also PROM oAs guars wosxoeaax Michael Donnelly (M)932-3254 05/05/2016 433911 samncs staaar anima SIRm 544 Johnson Street 544 Johnson Street I nn QQ; R�!t U V L Seri=Sercm,aswI,aP mwµcrrr,smia w North Andover,MA 01845 North Andover,MA 01845 M py - 9 2016 JOB DESCRIEMON BARRIER:A Bio%%w Door Testµt71 not be conducted at your home,due to the presu:n=of asbestos. $0.00 BARRIER:The following contract is not valid unless accompanied by the Pre-Weatherimtion Barrier Incentive form,signed by your licensed electrician.Work wilt not proceed%Yhh this work until we receive a copy of the form. $0.00 AIR SEALING:Provide labor and materials to seat areas of your home against wasteful,excess air leakage. This%work will be performed in concert with the we of special tools and diagnostic tests to awe that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include calk%foams and other producls. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(8)working hours A redaction in cubic feet per minute(efm)of air infiltration will occur,but the actual number of efm is not guaranteed At the completion of the weathcriiation work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 DAMMING Provide labor and materials to install a 12'layer of R-38 unfaced fiberglass baits to(112)square feet for damming Purposes. $229.60 ATTIC FLAT:Provide labor and materials to install a 14'layer of R 49 Class I Cellulose added to(474)square feet of open attic space- $801.06 SLOPES Provide tabor and materials to install a 6'layer of R-2I Class I Cellulose added to(294)square feet of slope area. Wherever possible baffles wvill be installed to the entire length of each bay to maintain ventilation space. $546.84 ATTIC ACCESS:Provide labor and materials to insudate the back of(1)attic hatch with 2'rigid Thermax board Weatherstrip the perimeter. $60.00 VENTILATION:Provide labor and materials to Install(4)8'diameter roof vent(s)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,brown,gray or mill finish. $342.00 VENTILATION:Provide labor and materials to install ventilation chutes in(43)rafter bays to maintain air flow. $86.00 COMMON WALLS Provide labor and materials to install R 13 unlaced fiberglass to 48 square feet of common wall. Then install I"rigid board insulation that meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all scams with FSK tape. $175.20 BASEMENT CEILING:Provide labor and materials to install(118)linear feet of R 19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. Federal to 005-0406629 RISE Engineering RI Contractor Reglstrallon No 8166 A division of 7bielseh Fagineering MA Contractor Registratlon No 120979 RISE Company G CONTRACT Address,City,MA 00000 ENGINEERIN 401-123-1234 FAX401-123-1234 Page 2 PICOGRAM CMA HES urs cusp PROM DAIS CUEWD WORKORLaR MichaelDonneUy (508)932-3254 05/05/2016 433911 00002 DEnViOn SVUW Bunko elzwr 544 Johnson Street 544 Johnson Street SERV=Cr1f.=1P ZP Dauka CW.sm$aP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRI PION $206.50 BASEMENT DOOR Provide labor and materials to insulate the back of the basement door leading to the bulkhead with 2"rigid board that meets the sections R 316.5.4 and 316.6 requirements of building code. Seal all edges and seams with FSK,tape. 572.22 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures,Columbia Gras offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Scaling measwrs up to the first$690 and an additional$340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality,we will be conductinga blower door diagnostic of the available air flow in your home both before the work is begin,and after the meatherimWn work is complete.We wail also conduct a full assessment of the combustion safety of your healingsystem and water heater.This has n value of$90 and is at no cost to you Total allowable %eathernmtion incentive isS3,110. $90.00 D - 9 216 MAS Total: $3,289.42 Program Incentive: $2,249.43 CusbDmer Total: $1,039.98 W EAGMOMMYTOPURMS11 SEIWCES-COMPLETE IN ACCORDANCE WRN ASOVESMOCAMNS.FORTHESIrd OF ***One Thousand Thir"ne&981100 Dollars $1,039.98 0UPOM rikALtkSPaCBON ROVAL E-.E21�J0.CtArMMHRAGRMIDREiQAMOUN VWiNFUILMVMTOPI%WIIJ.9ECHARGEDr101111"ONANY ANSMULL IE SEH SF4)RWCRtgrn' M M IMON GUARAN7E63.ROM OF REC1810N.8Wat0U1111%AHD REG5 UMPI. DONOTSIONTHIS CONTMTIFTHF-REAREMY 111,AN PAC ALw atON u=-RmE Cub ACCOM— CE NDIE:IMCCNEtAOTMAYsaWifiMM1WUSIVI401 ECUMOWI11rW DAZE OFACCEPLUiCa ACCEP1ANCa0FCONIMM-WEABOVHPRIt�.4 SPECIFAAIIONSANDCOMVOHSARa 3D opys ASUPEC10RYWUSAr MMEE5 5A13OnDIEDACARaAU1SOR�01e0011EWgix AS aPECIHEO.PAYMHNrYrILL6E EgpH A9 ouuuxEVAewa a RISE60 Shawmut Road,Unit 2 J Canton,MA 02029 339-M-6335 ENGINEERING www.RiSEengineering.com OWNER AUTHORIZATION FORM I, 1k7 'Ch q c VO 12 M , (Owner's Name) owner of the property located at: aiqcSGTV (Property Address) ?„ . o � � (Property A dress) hereby authorize / (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf toob in a building permit and to perform work on my property.This form is only valid with a signed contract. ees Signatu Date The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigationg 600 Washington Street Boston,MA 02111 www.mnss gov1d1a Workers' Compensation Insur"ce A_Cfiidavit:Builders/Contractors)Electricians/Plumbers Applicant Information 'lease Print Leaiblv Name(Business/Organization/1'ndividual): Address: PO BOK 358 City/State/Zip: Phone#: Agou an employer?Check the appropriate box: _ Type oi'project(required):1. am a employer with_ &_ 4. ❑I am a general contractor and I employees(full and/or part-time).* have hired sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demblition working for mein any capacity, workers'comp.insurance, [No workers'coin ,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 MGL 11.❑Plumbing repairs or additions myself Wo workers'comp. c.152, §1(4),and we have no 12,(�Roofrepairs insurance required.]i employees.[No workers' comp,insurance required.l 13 ❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submitthis affidavit ind!Qatingthey 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 isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: nor p� Policy#or Self=ins.Lic.#: W.(f 7> - ExpirationDate: Job Site Address: �`{ 6t t1 j(�q S/` City/State/Zip:- �1_ Attach a copy of the workers,compensation policy declaration page(showingthepolicy number ! �� p y umber 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 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 DIA for insurance coverage verification. Y do hereby ce 'y oder the pains andpenalties ofperjury tliat the information-Provided above is true and correct. Si nature: • Date: ?hone#: 9 > rFF0jfjff-7Wa1 use only. Do not Write in this area,to he completedby city or toren official.Town: JPermit/License# Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbiugInspector 6.Other Contact Person: Phone#: ��®6®gam®® �+ DATE(MM/DD/YYYY) 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 endorsements). PRODUCER CONTACT Linda BO danowicZ NAME: g Insurance Solutions CorporationPHONE (603)382-4600 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 31autilus Insurance Caron Polar Bear Insulation Company Inc INSURER C; PO Box 958 INSURER D. INSURER E: Andover NSA 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 WTH 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 ADDL S BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MWDDIYYY MMMQFYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 Al A CLAIMS-MADE ❑R OCCUR PREMSESOEaoccuDnce $ 100,000 R NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 R POLICY[_—]JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNEWEXECUTIVE ❑ E.L.EACH ACCIDENT $ 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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace 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 Engineerigg \ 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 P-�^ - - v( j ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r901a0n POLASEA-01 JONEiLL DATE(MrnroonrryY) CERTIFICATE OF LIABILITY INSURANCE F1�s�201s 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 Durso&Jankowski Insurance Agency PHONE 978 688 7000 FAX 978 688 7001 11 Saunders Street ac No �_t -_;(978)688-7000 —_-- _i:(' ,NoL ) North Andover, MA 01845 ADDRESS: INSURER(S)AFFORDING COVERAGE ; NAIC _ INSURER A:Nautilus Insurance CO_ _ 117370 INSURED INSURER B:Safety Insurance Company— 133618 Polar Bear Insulation CO.Inc. INSURER C:_. Peter Leblanc&Steven Leblanc INSURERD: P 0 Box 958 -- --- - — .--- 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSR TYPE OFINSURANCE --- ---ADDLISIIBR; - -- PDLICYEFF [ OL(6YEXP hlrfS LTR; _ :INSD I WVD: POLICY NUMBER I MPNDD t MPM/DD tl A 'COMMERCIAL GENERAL LIABILITY ! ; ,EACH OCCURRENCE S 1 - DAMAGE TO RENTED --- CLAIMS-MADE OCCUR - )PREMISE5JEa occurtence) MED EXP(Any one person) S PER SONALR ADV INJURY _ 1 S _ GEN'L AGGREGATE LIMIT APPLIES PER: { i GENERAL AGGREGATE I S iX ` PRO- POLICY _LOC PRODUCTS-COMP/OP AGG S -- - - S OTHER: AUTOMOBILE LIABILITY I 1 COMBINED SINGLE LIMIT S — i Ea accident-- 1.000,000 B ANY AUTO2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) is ALL OWNED :_ ;SCHEDULED i — i — X BODILYINJURY(Peraccident)!S .— AUTOS __ ;AUTOS i X : „ NON-OWNED I 1 PROPERTY DAMAGE :S '— _HIRED AUTOS _AUTOS I.(Per accident _ _._—_ UMBRELLA LIABOCCUR =EACH OCCURRENCE S ) A ;IXCESSLIABCLAIMS-MADEI AGGREGATE i S DED RETENTION S s S WORKERS COMPENSATION :PER OTH- AND EMPLOYERS'LIABILITY $TAME t_ +ER YIN! i :ANY PROPRIETORIPAP.TNERIEXECUTIVE r- ! ` EL EACH ACCIDENT !S :OFFlCERIt,,E1dBER EXCLUDED? u!N/Al . 1 (Mandatory in NH) E.L DISEASE-EA Eh1PLOYEE°S If yes•describe under — DESCRIPTION OF OPERATIONS below t EL DISEASE-POLICY LIMIT;S i 1 f t 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 CERTIFICATE HOLDER _ _ CANCELLATION / SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thieisch En ineerin Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED' IN g g ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE i000 O(�iA nrnon rnonnon•rtnnt nu-..�t,a...........,....t 3/23/2016 Print certificates:Certificates of Insurance -`oma" CERTIFICATE OF LIABILITY INSURANCE DATE104/2016 Y) 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 Automatic Data Processing Insurance Agency,Inc. A c.No,Ext): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERS)AFFORDING COVERAGE NAIC it INSURERA: NorGUARD Insuranw Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC PINSURER C: O BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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 MIAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERL'IS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN KIAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUUL LTR TYPE OF INSURANCE INSD bUBK POLICY EFF P WVD POLICY NUMBER MWDD/YYYY MMIDD(YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAl1.IS-F.IADE ❑OCCUR PREMISES(Eaoccurrence) $ MED EXP(Any one person) S PERSONAL 8 ADV INJURY S GENL AGGREGATE LIGHT APPLIES PER: GENERAL AGGREGATE S POLICY❑'ECT F—]LOC PRODUCTS-COMPiOP AGG S OTHER: S AUTOMOBILE LIABILITY GOLIBINEDSINGLE LIMII $ (Ea—ident) ANY AUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED aures nuroS a:v-BODILY INJURY(Pcidrrd) 5 NONOWNEDPROPERIG S HIRED AUTOS AUTOS (Per—dcnp S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION x I PER AND EMPLOYERS'LIABILITY STATUTE ER AIJY F33CPF2tETOR/PARTNEREXECUUVE YIN E-L.EACH ACCIDENT S 1,800,808 A OFFICER,f.thIBEREXCWDED? Y❑NIA N POWC772258 01/01/2016 01/01/2017 - -- (MandatorylnNH) E-L-DISEASE-EA EMPLOYEE S 1,000,000 ''.. DESCRIPTION OF OPERATIONS bcdo.v E.L.DISEASE-POLICY LIMIT S 1,800,000 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(ACORD fel,Additional Remarks Schedule,may be attached it more space is required) 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 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD https://adpia.adp.comlicertef/It/run/printeerts/421984 1/1 "wY,�w''m _, _ \'��,,:/" /C✓"�' ��C/� ®���m/d"i'L✓"'.A°r�FP^M'�&:i"tl',^�,' CfA' ''.��4t�� /:,�a�"R�Br" / �a.dF'Y:/ C''a�i :b Office of Consumer Affairs and Business Regulation 10 Parr plaza ® Suite 5170 Boston, Massachusetts 02116 Dome Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 —.----- ANDOVER, MA 01810 Update Address and return card.Mark reason for change. SCA 1 0 20M-05/11n Address [—] Renewal ❑ Employment F] Lost Card r'-�/rr° cfra/I'r iYld/rll<^crrlfr c�'`'/(dl,i.ir!!fI/!la'�f.` Office of Consumer Affairs&Business Regulation License or registration valid for individual use only C ;( HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102726 Type: office of Consumer Affairs and Business Regulation rr„` Expiration: 7/2/2018 DBA 10 Park Plaza-Suite 5170 � Boston,MA 02116 POLAR BEAR INSULATION CO. Vincent LeBlanc 51 SO. CANAL ST.#5A LAWRENCE,MA 01841 Undersecretary Not valid without signature cUsetts It �Wr1x��l�P sub:luu�nA.i�ilwµcs�l�alu��I�i¢::rru�o����u%Pu,uN�Gus Safety d St andair¢:ls 'uu �¢:a:aarnuw �u lwa°: ism °wlwR:�`iaalt� - :n se: C,SL-106017 PETER A LEBLANC � 2 EAST PINE STREET Plaistow NH 03865 t:`:xo°rirru u,:w:tieau's„a. 04/28/2018