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HomeMy WebLinkAboutBuilding Permit # 11/9/2016 0` BUILDING PERMIT cc �ORTy TOWN OF NORTH ANDOVER =: :`'- APPLICATION FOR PLAN EXAMINATION .=A Permit NoM q7 _ -Oi 7 Date Received id'r p�R,TEU �SsgcHusk� Date Issued: t� 1NIPORTANT: Applicant must complete all items on this page F K �" '?l� - :€'" .� a �r� /ma��.✓"�,.< ri s r ! ti pROPERTY OVIINER � h�'"� � yp MAP PARGEL ZONING DISTRICT H�stor�c Distract yes no Machine Shop Ui[lage yes rap.: TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial n Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other ❑Septic ❑1lllell ❑ Fload lam D Wetlands ❑ Watershed D�stnct' P p 1 .aterlSeViier DESCRIPTION OF WORK TO BE PERFORMED: ter,Ip e1 Identification- Please Type or Print Clearly OWNER: Name: ad. ►r,q Phone: 55&V Address: 0®0( L Contractor Name � Il" � . Phone P. Email Address . c ' 40 5upervlsor's Construction License Hflme Im ro�ement L�certs „_ � - Exp Date .. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEB SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST-BASED ON$925.00 PER S.F. Total Project Cost: $ � �® . ® o FEE: $ Check No.: TK3 Receipt No.: -311 (00 NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund Si `nature of AentlOwner Signature of contractor � NQRTk own of 2 n over o � � W �► No. ver, Mass LAKE COC-0c"Emcm ATED U BOARD OF HEALTH Food/Kitchen PERMIT .T L D�jSeptic System THIS CERTIFIES THAT .. ,... � rr�.... ...............�.N..�................ , BUILDING INSPECTOR has permission to erect.......................... buildings on .. . .. ...... .... A#. ,ir.....A,D,., Foundation .� .. .�. . ........ 0 00A Rough to be occupied as ...... � .....�. ��I�� ........... Chimney provided that the person accepting this permit shalt i 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 CONSTRUCTIO RT Rough ............... ...,.................... Service ..............A. .. BUILDING. INSPECTOR Final GAS INSPECTOR OccupyLLey Permit Required to Occupy Buildin 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. RISE 60 Shawrnut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING' www.RISEengineering.com AUTHORIZATIONOWNER (Owner's Name) owner of the property located at: s (Property Address) (Proper y Address) hereby authorize 4.'. � rt (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. Ther Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Ow W---sl lig nature Date 6.2016 Federal ID#06-0406629 IRISE Enghtming RI Contractor Registration No 0186 MAContractor Roolstration No 120079 RISE ' 60 Sbawtoul flond,Coulon,AIA 02021 CT Contractor Registration Na020120 ENGINEERING' 339-502-6335 FAX339-502.6345 CONTRACT Pago I n < PROGRAM 'An MA-1F- ENGICOEURIRINAOGAND1N116 MUnMD DUMMRWNRKAIS DESCRISEDSELOW CO3MMER PHONC DATE 'CU—ENTT--WORX ORDER Jodi Fina (508)560-3342 10125/2016 440756 23903 SERVICE:CMUCT IT, 7 124 Old Village Lai DIWNO 87PECT 124 Old Village Lane SERVICE CIMSIM,MP11R.L.1140 CITY,OTATU.ZIP Notili Andover,Mi.() 81 North Andover,MA 01845 ,JOB DESCRIMON HAZARD BARRIFR:We have identified that there are recessed lights present in your home.unless ilia recessed lightsore certified as IC-rated(insulation Contact Rated)Nva will create it 3"clearance space around the fixture by using fiberghms blanket iruallation its It damming material,no insulation NNill be installed across the top and closed cavities mbich contain recessed lights twill not be insulated, 110.00 —ri IFEW,—IW(j—Provide labor—and materials' to seal areas 770—ur borne—aga—in.q`=%nsl ef—ul,excesstir eakage. T 1)is work%011 be perl'ornied in concert with the use of special tools and diagnostic tests to assure that your honte vill be left Will it healthful level of air exchange and indoor air qLrility.Materials to be used to scal your home call inch0e caulks,folans and other products. Primary areas for scaling include air leakage to allies,basements,attached garages and other unheated areas(vIindom,tire not generally addressed.) This will require(12)working hours.A reduction in cubic feat per inintile(cfm)ofair infiltration%Nill occur,but ilia act irril nuniber of cho is not guarantced, At the Completion of the matherizat ion work,and at no additional cost to the hoincowler,it final blower Our und/or combustion salliely analysisaill be conducted by the subrconlraelor to ensure tatesafetyor the indoor air quality, S1,020.00 Alit SI..-'AIANQ provide labor and materials to seal areas of your home against waslcftil,excess air lcakagc. ThisMork will int performed in concert with the rise or special tools and diagnost it;tests to azure that your home W11[)a fell Will it healthful level of air exchange and indoor air t1mlity,Materials to be tried to seal your home can include caulks,foams and other products, primary areas for sealing include air leakage to fill ics,bawnicins,attached garages and other unlicawd areas(windows are riot generally addressed.) This will require(4)N%orking hours.A reduction in Cubic I'M per minute(conn)ofair infiltration will occur,but the actual number ofcfirn is not guaranteed. At the completion ortlic%watherization work,and at no additional cost to the hoincowier,a final blumr doorani/or combustion satiety analysis Nkill be conducted by the sub-contractor to ensure ilia safely of the indoor air quality. $340.00 DAMMING:Provide labor and materials to install a 12"layer or R-38 unfaced fiNuglass KIM to(128)square feet for damming purposes. 5262.40 ATTIC PLAT:provide labor and materials to install a 6"layer of ft-22Class I Cellulose ridded to(187)s(lutwe Ilect or open attic Space. $235,62 ATTIC FLAT:Provide labor mid materials to install a 7"layer of It-26 Class I Cellulose added to(1 116)square feet of open attic space. $1,450.90 Ferforal 10 006-0406629 RISE Engineering RI Contractor Registration No 0186 MAContractor Registration No 120979 CTContraclor Registration No620120 RISE ENGINEERING' CONTRACT 339-502.6335 FAX339-502-63-15 Page 2 PROGRAM 111M COUIRACTIS ENTERED IN10 DIM 119N RISE CMA411S CNOINEERINID AND 149 CUSWK-R FOR WORK AS 090CRIDEDUELOW CUSIDWR PHONE DAIS CUMA w(MonDER Jodi Fina (508)560-3342 10/25/2016 4140756 23903 131WHO SWET OF--iRcer 124 Old Village Utri 124 Old Village Latin SERVICE C(IYSlAlE,ZP alwom my,OlATE,MP North Andover,MA 01 North Andover,MA 01&15 JOB DESSCRIFFION AT'ric FLAT:Removc(1 116)square feet of batt style insulation from the attic area. $937.00 KNI"EWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(288)sqmrc feet of kneewall area, $1,008.00 KNIA"WALL FLOOR:Provide labor and materials to install a 4"layer ofdLnse packed R-13 Class I Cellulose ad(fed to(400) squar c feet of kneewull floor, $676.00 KNI-TWALL FLOOR:Provide labor and materials to install it 5"layer of R-19 Class I Cellulose added to 144)s(pruc feet of open kneev,all floor- $168.48 A'1 TIC Provide labor anal materials to insulate(1) back oftlic knmell hatch Will 2"rigid board,and seal the edge of the hatch with matherstripping, $60,00 —UTICACCLS'&lloi Telabor and materials to insulate the back of*tfic attic doorlvith 2"rigid insulation hoard and scat the door's edge Will%watherstripping to restrict air leakage, $73.91 A'I"l'ICACCI.,%.Alirituir(ipcningNwilit)L,niadeiiitlicroot"tosicce.%saii-,treatolvinstilated. Roofing%vil I be re hist ill led when stork is complete. Cost is for file first 5 lineal feet of opening, $379.94 VENTILATION:provide labor and ninterials to Install(3)insulated exhaust hose with roof mounted flapper vent to exhaust existingImthroorn tan(s). $356.25 VENTILATION:Provide labor and materialstoinstall ventilation Chutes in(1 q,0)rafter bays to maintain air flow. $280.00 COMMON WALLS:llroviile labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(100)square feet orcornmon moll arca, $350,00 BASEMENT DOOR:Provide labor and materials to insulate the Luck ortite(xiscitient door lending to file IAfthead Wth 2"rigid board that meets the sections R-316,5."1 and 316.6 requiremerasol'building code. Seal all edgesand scams vith FW tape. „caA'wt➢�n .n�Nm%,. I rodoral ID 0 OS-0466629 RISE En iuming RI Contractor Registration No 6966 MAConttactor Rogistrallon No 126979 CT Contractor Rottlntratlon No626126 RISE 60 Shawmtat Road,Canton,DIA 02021 CONTRACT ENGINEERING' 339-502-6335 FAX 339-502-63-15 Page 3 PROGRAM C'MA-IMS 010"IISERINGA°o°IISC 3 WArRFORWORRKna DESCRIDED BELOW f CUS"IC¢JFaR PHONE DATE CUCNrD WORKORDER Jodi Fina (508)560-3342 10/25/2016 N0756 23903 SERVICE WISEST RIWNO STREET 124 Old Village Matte 124 Old Village Lane SERVICE CHY,STA1E,7jP BILLING,CHY,aTA'IE,Zip North Andover,MA 01645 North Andover,MA 01845 JOB DDSCRIPTION X72.22 R1 SE IaaaginecriRg will apply all applicable,eligible incentives tothis contract. You will only be hilted the Net amount. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendaryear,and an incentive of 100%for the Air&:cling measures up to the first$680 and an additional$340 if savings are justified by the nt1ditor. For Che safety and health of your home's indoor air quality,tic will lie conductinga blower door diagnostic of the available air flow in your home lxTth before the work is begun,and allur the wcatherization work is complete.We will alit)conduct at full assessment ol'the combustion safety ofyour hcatingsystean and tarter heater.'['his has a value of S'90 and is at no cost to you. Total allowable wcatherizaation incentive is$3,110. The Permit will be seethed by the insulation contractor,at no additional cost.It is the hotncowler s responsibility to close out this permit by contacting their municipality at the completion orthis work, 590.011 : o Tonal: $7,6601.62 Program Incentive: $3,110.00 Customer Total: $4,550.62 W E AGREE HEREBY TO FURNISH SFRVICFS-COMPt.FTF IN ACCORUANCF W ITH ABOVE SPWIPICATIONS,FOR 714E SUM Or 'FourThousand Five Hundred Fier&621100 Dollam $4,660.6 UNPAIp1]ALAHCE SODA T"�Ia FOR OUARArnEES,RIGHT$OrRECIIHON,OCHEDUIJND,ANDCONTRAC DREMIRAVON. Y UPO@I r"71 9:U" E AND AI P E RE:VF 'k}Fi REOIt'EtA1144t" Rotel �.Br t t)a NC5T 5I4tt THIS CCtNTR T t THERE RUATAMOUNTOUS IIttE ANN FULL DY B ANkti 9P WICS c CHARGED „„.,AMIZiDSIC�MVRE-x EUrowoling �-� cu �RACCE WME NOPE:TIIIS CONRACTIMY BE WIIHDnAWN BY UR IF NOT EXECUTE D Wf'EDN DATEOPACCEPVJICE --- -- �.--.-�..-.-..-- ACCEPTAIICE O'FCC"IRACT-THE AIMS PRICES,SPECINCATaOPaS AND CONDITIONS ARE 30 DAYS. SADSFACIDRY 10413 AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO'iHE WORK ----•--------.,.-. AN aPEcinin.PAYm;P mu.aE hVtDE AS OUTLINED ABOVE The Covimonwealth ofMrrssachusetts Departmefit ofl'radustrialAccidents Office oflnVesflgations i .I Congress street,suite 100 BO"04,1LA 021142017 Wo www-wars govldla rkers' Compensation Insurance Affidavit: $ceders/Contractors/Electricians/plumbers A ;acaaat�laforma>;iom Please Print Le 'bl Name(Business/Qrganizatian/lndividuai): Address: PO 130X 958 � i3flU�l� MA ��LI1 t3 Uy/State/Zip: Phone 4: 9-),FS— Arc you art ernplvyva i Cltech the appropriate box: stn a employer with 4. ❑ am a general contractor and I T- a of pr0j"t(rcqusred"k employees(full and/or part-time).* have hired the sub-contractors ❑New cvnstruction 2.❑ T am a sole proprietor or partner_ listed on the attached sheet. i ' i. ❑Remodeling ship and have no employees 'These sub-contractors have working forme in any capaci f. employees and have workers' 8. El Demolition [No workers' comp.insurance comp.insurance.t 9- Q Binding addition required.] 5. ❑ V&are a corporation and its 10 Electrical repairs or additions C! 3. 1 am a homeowner doing all work officers have exercised their 11 ❑Plumbing repairs or additions myself.[No workers'comp, right of exemption per MGL insurance required.]t c. 152, §i(4),and we have no 12 0 Roof repairs employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that chocks box 41 must also fill out GSD section below showing their workers'compensation ppliey infom3atinn. i3orneotvners who submit this affidavit indicating they are fining all work and then hire outside contractors mustsubmit a new affidavit indicating such. tCantractors thrix ehpck this i?ax must attached an additional sheet shewing Lhe pmLFsh empioyeas. If the su6•caniractors have employees,they must provide their workers'camp.policy numborand v" tc::hethe:Or ne.those entities have cm xrr etnpdrVer ghat fspraLidirrg Frari';e;s'eor;t}rstatier►:zsrcranceJaa my eMpinyees Below is 'repptzcr air jobsi#e irfarrnataan. Insurance Company Name: u �trr4Kee Policy#or Scif-ins.Lic. Expiration Date: .Tab Sitc Address 1 2_%) I'l City/Stats/Zip:_ tta4h a copy of klte workers'compensation policy declaratio:r page(shrvvirg fire policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the Policy impnum of criminal penalties of a fine up to�;1,5flD.t)0 artd/or one-year lntprisonment, as well as civil penalties in the form of a S TOP+CORK ORDER enc!a fine of up to$250.Gt7 a day against the violator. Be advised that a copy of this statement mar be for�yat ned to Me O.�ce of Lrivestigatious�,f the DIA for insurance coverage verification. da herEby cerci aitcler the a%izs and ertalfiw.o'' erjury ifirrt lite Fn or n &I,provided above is tare end correct Si store: °Date: ,Rhone#• q>5;- yo)- 7& �gj Official use only, ila not write in this ares,to 6e cotxrpteted by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector b. Other Contact Person• Phone#• AC) CERTIFICATE OF LIABILITY INSURANCEDATE{MMIDD/YYYY) SL 6/10/2016 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pot€cy(iee) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 4N'OAME1 Linda Bogdanowicz insurance solutions Corporation P}{DNE (603)382-4600 FAX No,(603)342-2034 60 Westville Rd ML".,:iindab@isc-insurance.com INSURER($)AFFORDING COVERAGE MAIC# Plaistow N8 03865 INSURER A.We stern World INSURED INSURERB-Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO Box 958 INSURERD; 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. INT R TYPE OF INSURANCE ADO 5 BR POLICY NUMBER POLICY EFF MMowyYYP LIMFrS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE 51 OCCUR DAMAGETORENTED PREMISES Ea $ 100,000 PREMIoccurrence NPP8274967 3/24/2016 3/24/2017 MED EXP Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 '. S POLICY❑PECO- F--]LOC PRODUCTS-COMPIOPAGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE Perac $ WREO AUTOS AUTOS cldent $ X UMBRELLA LIAS OCCUR EACH OCCURRENCE $ 1,000,000, B EXCESS LIAR iCtAIMS•MAOE AGGREGATE $ 1,000,000 OED I I RETENTIONS 1AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N 5'ATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In Nl) E.L.OISF $155 E«A EMPLOYE $ if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarke Schedule,maybe attached 11 more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRP-SENTATkVE Keith Maglia/SJA O 1988--2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1NSW5f7n140l) 611012016 Preview:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCE DATE IMMMDNMI 06110!2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$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. IAAPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.IF SUBROGATION i5 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 A NAME: Automatic Data Processing Insurance Agency,Inc. NCNr EKt 1 Adp Boulevard AIC.Ne. Roseland,NJ 07668 AOURESS: 1RSURER(S)AFFORDING COVERAGE NAIC p INSURER A: NnrOUARD Fnsoroncc Company 31470 INSURED '. POLAR BEAR INSULATION CO INC INSURER D: PO BOX 958 INSURER c: Andover,MA 01810 INSURER D: INSURER E: COVERAGESINSNRER P: CERTIFICATE NUMBER: 503587 REVISION NUMBER• THIS IS TO CERTIFY THAT THE POLICIH5 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE ENSURED NAMED ABOVE FOR THE-POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT.TERAS OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO LVHICH 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 CLAIM145. LTR TYPE OF INSURANCE INSO PIVD POLICY NUMBER COIAMERCIAL GENERAL UASILfTY MM/DDIYYYY) 1MlD1YYYYY LIMITS CLEACHOCCURRENCE S AIF.15�61ADE ❑OCCUR ^x lip IISLIST4 mnrnS 5 LIEQ EXP fA y OrLo PCr3On) 5 GENL AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY 5 POLICY❑JECT ❑LOC GENERAL AGGREGATE 5 '.. PODUC IS COI,IP;OP AGG S OTHER: f' '. AUTOMOBILE LtABILtTY S ANYAUTO (Eamdawtl S' ALL D:VNED SCHEDULED BODILY INJURY IPa Pelson) S AUTOS AUTOS C'pN- VaniD BODILY INJURY(P.rz[ideN) 5 HIRED AUTOS AUTOSC Iry.ycdawil s UMBRELLALM OCCUR _ S EXCESS UAB CLAIMS-F.IADE EACH OCCURRENCE S OED RETEIJTIONS AGGREGATE is WORFtERS COMPENSATION S AND EMPLOYERS'LUIBILITY Y!NX $TATVTE ER A ANY FRCPfiIJETCfL'PAHTN£CLEXECUTIVE CFFICEF0.IEI:IBER EXCLUDED? NIA N POWC7722SB D11D112016 01J0112DiT EL.EACHACC1DEI11 5 1,000,000 (Mandatory In NHI N ySC (PTI NOFC E.L.DISEASE- OESCHIPTICF;OF CPEF2ATIDIFS Lo'a-n EA EF.IPLQVE 5 1,000,000 EA.DISEASE.POLICYUe1)T s 1,000,000 DBSCRiPTION OF OPERATIONS F LOCATIONS VERICLES IACARD t03,AddillOnal Remarks 5ctredulc,ma/be altaetred 1!mare spaco is rcquirctl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE;ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood sL 1 suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2014/0 1) The ACORD name and logo are registered mOrks of ACORD CORPORATION.All rights reserved. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home hnpr©vement Contractor Registration Registration: 102726 Type: DBA Expiration: 71212018 TrA 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Update address and return card.Mark reason for change. SCA t 0 2OR-05111 � Address (] Renewal ® Employment © Lost Card �.../1!C' i('CsIIP)lll+llPPf'llf!!PP C���'�(l7JJllCfPIJCI�.i l Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before tllo expiration date. If found return to: „ Registration: 102725 Type: Office of Consumer Affairs and Business Regulation 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 I F assachusetts -"Oe srta�ent of Ruhi4 c.Safety " Board c,!Building Reguiaations vind a'tandsr s _kwerbse: O+SL-406017 v" a' v-i- PETER A:l EBLAN 2 EAST PM STREli.'i Plaistow NH 038165 cnt�°3r� saaauaer 04/28/2018 m