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HomeMy WebLinkAboutBuilding Permit # 1/18/2017 ---------- ----------- %AORTH BUILDING PERMIT yy 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION ti < Permit Date Received in, "tl�gr�tlP. u Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � I V,) 1�\- Print PROPERTY OWNER )'\vr S� ( .&- Print 100 Year Structure yes no MAP . L.) PARCEL: L° """ ZONING DISTRICT:—Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [""I New Building riOne family El Addition [-J Two or more family [I Industrial F- "Alteration No. of units: El Commercial Li Repair, replacement [I Assessory Bldg 0 Others: 0 Demolition El Other DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER- Name: Phone: � , 2.�o "S'", m (C)\'0 Address: k L�- 0 Contractor Name; 1-) VV- Phone: CA'A8 Email: LAW'yl Address 3\4 Li Supervisor's Construction License: Exp. Date: Home Improvement License: 3 Exp. Date: ARCH ITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$1225�. R S.F. Total Project Cost: $ 315-1 . U.-C) FEE: $— I Receipt No.: Check No.: 2�I b 31-q............ NOTE: Persons"C"'O' ntracth,ig with iinregistered contractors do not have access to the guarantyfitnd ...........-............... ......... .............. ............ ............... ORTPI Town of Nj 24, Andover , 0 To No. 17C' L A'4 h ver, Mass, • 'Q C4[MfCHl7 ATE 0 0 4 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........0�......ff .fft.................... ......................................... BUILDING INSPECTOR has permission to erect .......................... buildings on ......... ...........W.h.,110'f......... Foundation Rough to be occupied as ..........AA...­St� ��,���� ........ ............ Chimney ha ME...... ct conform to the terms of the application provided that the person accepting this per .1 ml shall very e 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 CONSTRUCTI A- TA Rough Service .......... .. .. ............................................ Final BUILDING INSPECTOR GAS INSPECTOR OLCu 2ancy Permit Required to Occupy By 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. ) PSE i:tirgi11CC('hig R1 Contractor Rugg tration No BUM RISE CdA Contractor Ftegistrallon Ho IZO919 CT Contractor Ruipstratlon No ENGINEERINC,' rrll"a" ItMid,Cirrltiin,i1:1 (4111)'S4.3711li FAN(-lrtl)-84-3711! CONTRACT Page 1 PRO(i1tmm Ta ftp eawitAcr o ENTri*D iuYU aETt!{E!:RI:Vr CNIA-111S ENGRierAl1.*ANDVIE cu,r)nOrO"VmRKA. OJ:Ilt:inarM BEt,cra CuFtor'R RKdHfi i4�,TL CLJEIJT3 S'79NK dnarR C11T1Stillti Pl]vf (603)965.8766 11 X04,20116 441327 35002 JJERVICE STIMET nILLWO STREriT 125 Water S#rccl 125 Uater Street7. SERVICE CITY.STATE.TIp riSLLING CITY.STATE,IIP Nu►tlt Atldouer,M.1 A 184 5 NorthAndover,IMA Ul8�15 3 t } s i i l If JOD DESCRIPTION '€ AIR SEALING:Provide labor and matcrials to sail areae ol'tour honle artainst"Mtcful,J L;y air leap lge, 'i'his uot"uiil bL Performed in concert uiiir the tL a of pci ial Coals atnd diagnostic rests to asSurtlthat your home trill ha loll uitlt a itraltlllul l4t'cl of air eXchangc and indoor air quality,klatetials to he tlsttd io scat your Itoltic ca, include cuulkz,fil:uns:uta offset pn,ductti, l'rilllan areas ftir SI„thng include air leakage to uttic,.baJ CmL'nt:1,attached barugcs avid oiltcr unhcu[ed ar4tii ttrindtul arc slat rtcneroll} addm'ssL'd) ThiS uill ra)uiry(6)uorkia"ltoun.A r4ductitm ill itlhic feet per minute wfrillofair inrilmanon will oceur.Lout the actual number orcfnt I>not guaranteed. At the completion alftile tvt atlleriruinn stork,and;ti ria addi(iaR:ll ockR(to 111C Nlo€volsoer.:t final hlmler door llrld or Vnnil7tl;{it:tr cafcty artal�sis will he conducted by the sub•contraaw to ensure ilte salcty orihu inavor air quality-. y?1(l.tlf� CL1 IDNI BAR-CUST0)11 BARRIER AIR SFA L NG:Provide lahm and materials to install it-ton ue;illtcistripping and it doorswecp to(I 1 dnor[.$)to res(rict air lulkatx. j7*,till Fal1w IC FI_kt:ProAdc labor and matcrials to install an S"laws orR-25 C'I s I Cellulose added to(147)square list offloored space. S"b4 60 DAMMING.Prolvidu labor;nld materials to install a 12"ILiver ol'It-38 unfirced 136cr&'t';h;tlis]n(ON)syo:uc tei;t Ordamming purposes. S 13q.4(I A'1"I'1C FLAT:Provide labor and materials to inslall a t'1"la)ct ofR-19 C hLis I Ccilolow added to(104)stplan;1Cl;l of ollen Jtttie space. S 17>,i6 ATTIC FLAT.-Provide labor and!materials 10 install a 9"to space. }cr ut'tt-3 t C'lltss t C'dluto,c added to{(201))stluaru teat ofupeJl:otic $�l:ri.Sl(I ATTIC FLAP:Rutnovs(1 00)sgtriuc:feet of ha[t style insutatioa Crunt tltt;attic ttleei. S75.00SWITS:Provide labor and roateriets to install a 6"layer of It-19 Chess I C.'etlulose added 1 (191)aluare feel ofstopd urala. S355.26 KNEP WALLS:Provide labor and molerials to histaii R-33 faeed f xtgtass in(93)silunry feet oi'vnwvwntt. 'them iusts(t 2"rigid board insulation.Seal all scams with FSI:taps:. 5339,95 RIsE Eng-ineel-ing F'ederalto905,040.5i629 �Y RI Contractor R4agistralion No 51116 FAA Contractor kegistrallon No 120979 CT Contractor Reglstratiun Na RISE ' 60sllanmilt Road,t':trrton.X9:1 (401)784.37(tfi FAX(401)'k4-3710 CONTRACT Page 2 I'ROGkA;1( 70/15COMiVTISEnrEREDInTOBETVr4E?JRISG CUSTOM-ER DVWMED BELOW PHONE DATE ctJE1'rr0 WOUKDRDER Christina PoorPHONE 11104/2016 441327 35()02 SERVICE STREET BILLJF1tr STREET 127 Nater Strut 125 Water Street BERV;a Ctry.STATE.217 . BILLJIYS CJTY,STATE,TIP - North Andover.MA 01X445 North Andover,IMA 0I845 JOB DESCRIPTION REMOVAL-, Rcmuvc(17)square fl,'Ul of/Fan st}•le insulation Iloln the kn&kv.-dl arra SJ?.ES KNL-'E:11°,11..1.1'LOUR:Provide labor and materials ID install a I=t"l;ner of R a+3 Cfass 1 C011110.c added Io t 120)sgtlare tact of span womall Boor. 5lR2.�4tF ATTIC ACCESS,Provide labor and nmteriafs to insulate 11) !Jack JFt'thc l:n�rtazal[hnEch wiEh?"rigid board,JnFd seal the edge car Ihu hash mllr svealltcrstrippl"g. $GU.{1tl A'rrlC ACL ESS:Provide Ialaar and nmtcrials to insulate tFa back UrthC nllFa door with 2"Ffld Jrk5lEialinn board arld sL'td die d(FUf edge with wt:admtstripping to restrict air leakage. HIcas 573.(x( I'll.eV110N.Provide labor and mutcriats to instalt( i)1W"diameter"musbroom"roofvcnt(s)m locreace%colilatioB ill attic. The vent can be supplied in(eircic color)black,brown_gray Lir Jnill finislf. 5119.10 VIXIII-ATION:Provide labor and fnatcriats it)instalt ventilation chutes if,(59)railer bniti to I11,14o3iu air blots_ S1lS.ttU VEN'r11.M10,4:Provide labor and materials to install(•1)'t"X 16"reetalat'lar al'Emnumsol)it vents It,increase ventilation Iii aldc areas.SpcCUy color.While or airily. S100.00 COMMON WALLS;Provide labor and materials to install R-13 uui'nced libcrglass tel:SIC square lint oi'eomnlon wall, '1'lien install 1"rigid board insulation that OWN tile Netions R-316.5.4 and 316.6 requirements ot'buitding ctade, Setd ali scants with l'sK lops:. 5138,70 COhthti}N WAU S:Provide tabor and materitds to install R-13 unfaccd Fiberglass to 17 square treel oreuntnton wall. Then ostull V rigid board insulation Ilial Erects t1Fa sections R-316,5.4 and 316.6 requiretncuts ut'huilding code. Seal all scat';with FSK iapa. 563.!13 BASEMEiNT C1 1(.NG:Provide labor and materials to install(120)linear feet of 1-19 unracud fiberglass insulation to the ------- perimeter of fill:basement ceiling at the 11ouse Sill, BASEM13N'r DOOR:Provide labor and materials to insulate the back of the hastMenl ttottr(ending to the bulkhead with 2"rigid S?l 0.00 board that meets the sections]t-316.5:1 and 316.6 requirements of building code. Seal all edeas and seams with 1=SI:tape. i IUSE ia1lgI1leCt-iIjg Federal JO 005.0405629 Rt Contractor Registration No 8786 ® MA Contractor Registration No 120979 ®` CT Contractor Reglstration No ENGINEERING ld!Shawwni Rand,0311101,NIA (401)784-3700 FAX(401)'784-3710 CONTRACT Page 3 PROGIMM TMS CONTRACT IS ENTERCOINTO BEWASN AIGH CMA-II ES EHGrNECA NG WiD THE CWTOWR FOR VTORX AS DE3CRI$EO BELOW CUSTOh4ER PRONE DATE CtIENTL WORRORDEn Christina,Poor PHONE l 1iO4i2016 441327 35002 SERVICE STREET - BILLiItC STREET 125 Water Street 125 Water Suet t SERVICE C41Y,STATE,TSP OILLINO CITY,STATE,XIP North Andover.MA 01845 North Andover,MA 01815 JOB DESORiPTION RISTs Engineering will npPly all applieablu,eligible incentives to this COMMU. YOU will Only be bitted the Net:►mount. Currently, rot eligible MeaSEtws,Columbia Gas o1len 75%incentive,nUt io I:-4$2.000 pt;r coloidar 4ear,and an incentive IV']00%14r the Air Sealing R1eaSUR:&Up to(Ile first$680 and an addiihsital 5340 if Savings uru ju,lified by flte auditor. For'lie salet%and health of your honie's-indoor air quality.mir will he conducting a Woo ur door diagHostie of the available air flow in your home bolt babre the wort,is be;un,:Old after the ucatheriiatiun mark iti emTTpleie.We avilt also conduct a full assc."n►ent of the combustion safely of your hewing xystcrn and water hcutcr.This has it value or.$90 and is at no Cost io You. `fatal allowable weatberi7ation inccn(i1c is$3,l 1p. he Pennit kill be sCl:rrred bithe insulation contr`ilcior,at no ildd111onal Cost.It iti the liornu mur`S MspolisiblEny to Close out this pe(mil by Contacting their municipality at ilte u)rnplction of tilis Tvork. 590.00 Total: $3,459,60 Program Incentive: $2,675.00 Customer Total: $7$6,60 WE AGREE HERESY TO FURNISH SERVICES-COMPLETE IN ACCOROANC6 WITH ABOVII SPECIRCATIONS FOIL THE SUM OF ***Seven Hundred Eighty-Four&60!100 Dollars $784.60 UA04 FWAL INSPECTION AND APPROVAL BY RISS ENOWURINO.CUSTOMER AGREES TOREMIT AMOUNT DUEIH FULL 04T'EREST OFlY TaL RE CHANOEOMONTHLY"ANY UNPAID 13ALANCE AFTt' SDHAYS,SEE REVERSE FOR IMPOKTAto IN -R0411On 0- —QUARAt7Tt:E5,RIGi1TS OF RECISION,$[t1EgSkLIYG,AVD COM!{AClOR riflOISTRAT10ry. � - AUTHORVED816NATURE•RISEEnglneering CUSTOMER ACCEPTANCE -f/1 (J.��f/r♦T "" NOTE;TK19 CONTRACT MAY BE MTHDRAWN BY 418 IF NOT EXECUTED WITHIN DATE OF ACCL•PTAlICE ACCEPTANCE( CONTRACT-THE ABOVE PRSCES,SPECIFICATIONS AND CONDMONS ARE DAYS, SAMFACYORY TO U8 AND ARE HFIIEOY AccemO.YOtt ARE AUTTiORIZC{3 TQ o THC WORK AS SPECIFIUM PAYMENT WILL Sr.MADE AS OUTLINED ABOVE The Commonwealth of Massachusetts /17) Department of IndustrialAccidents office of Investigations I Congress Street,Suite 100 Boston,MA 021142017 www.massgov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers a 11fortion 1'Itaae !tint lie Name (Business/Organization/Individual): Address: 69 X 149 C P w)I U-\ ri 3 Phone #: of project(required): Are you an employer check the appropriate box: Type i.MrI am a employer with 4. 1 am a general contractor and 1 6, New construction employees (full and/or part-time).* have hired the sub-contractors 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling 2. ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition comp,insurance,t [No workers' comp. insurance nlo,,,Electrical repairs or additions required.] 5. [] We are a corporation and its [)Plumbing repairs or additions 3.[11 am a homeowner doing all work officers have exercised their 11. right of exemption per MGL 12.[]Roof repairs myself, [No workers' comp. insurance required,] t c. 152, §1(4), and we have no 13,C] Other--- employees. [No workers' comp.insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have they must provide their workers'comp,policy number, employees. If the sub-contractors have employees, I am an employer that Is providing workers'compensation insurance for my einployees. Below is flee policy and job site information. Insurance Company Name: c Expiration Date: Policy#or Self-ins. Lic. No 41 Job Site Address- City/State/Zip:. Attach 9 copy of the workers' compensation policy declaration page(showing the policy number 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 civil penalties 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. I do hereby certify under the pains and penalties ofperjuty that the information provided above is true and correct. SiSW1 �n�ia - - 'S P n #- -t Official use only, Do not write in this area,to be completed by city or town official. City or Town: permit/License issuing Authority (circle one): i I 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing 71uspector 6.Other Phone#-. Contact Person. .. AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(H[MIDDrYYY1f) 1011812016 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: It 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: Meg Munroe MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE WC.(413)536-0804 ac Ne: E-MAIL ADDRESS: mmunroe@Jdayton.Com 1649 NORTHAMPTON ST.,RTE 5 INSURER(S)AFFORDING COVERAGE NAIC 11 HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER B: GAUTHIER INSULATION INC INSLIRER0: INSURER D; PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F; COVERAGES CERTIFICATE NUMBER: 94521 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. /NSR DDLTYPE OF INSURANCE INSD SUER POLICY NUMBER MMIDDIYYY MWD17606Y­EFF UMYYP LTR ._ LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE M OCCUR PREMISES Ea occur encs $ . MED EXP(Any one person) $ NIA PERSONAS.&ADV INJURY $ Ot:WLAGGREGATE LIMIT APPLIES PEM GENERAL AGGREGATE $ JECT POLICY M PRO LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDL SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS UTOS NON-OWNED PsOaccident) tTY tTY^DAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $� DED RETENTION$ $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED9 FW—A] WA wa MAARP300327 10/30/2016 10/30/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 NIA DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Ramat"Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensationtinvestigations/. 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. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M.Cro�v)ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD DATE(MWDWVYYY) ACa CERTIFICATE OF LIABILITY INSURANCE 7/14/2016 ON IS THIS RTIFICATE IS ISSUED AS AMATTER A TEOR NEGATIVELY AMEND, EXTEND OR ALTER AND CONFERS NO RIGHTS COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY ect BEi_OW. THIS CERTIFICATE OF INSURANCE. DOES NOT COIIST[TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate hoid�r I KaAOin poll��Amay5equ re an endorsee poll, ment, A statement ront hits certificate does not conferDrigh site the the terms and conditions of the poi y, certificate holder In lieu of such endorsements . c T cT Nancy Usher NAME: (433)8347374 PRODUCER PHONE (413)536-0_&04 bac o Martin J Clayton insurance Agency, Inc. I=.MAIL ADDRESS: NAIL 1649 Northampton Street INSURER(S)AFFdR01NGC01#ERAGE — P. 0. Bax 989 NATIO MA 01041-0989 INSURPRA:Nationwide Mutual-Har Holyoke tivsuRlRe:Allitrd World Natl Assurance Co ---- INSURED — INSURER C Gauthier Insulation INSURER D: P.O. BOX 344 — INSURER El -------'�'�� MA 01938 IN UReRF: IPSWICH REVISION NUMBER: 'Y PERIOD COVERAGES CERTIFICATE NUMBER:CL1663...... THIS IS TO CERTIFY THAT THE PO IIYIREOUIREME­F—INSUNT TERM OR CONDITIONVO ANY CONTRAC�SOD DESCRIBED HERE N SCUMENT WSLfBJE TRESPECT TO ALL THECH THIS TERMS, INDICATED. NOTWITHSTANDING A CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES — EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED EFF PPOLICY P5 LIMITS Apo 5 BR POUCYNUMBER 1,000,000 lL7R TYPE OF INSURANCE EACH OCCURRENCE $ _ X COMMERCIAL GENERAL LIABILITY 0M E TO R TED $ 50,000 PREMISEEAQct�rrse. A .. 5,000 p� CLAtMS-MADE DKOCGUR 7/6/2016 7/6/2017 MED EXP(An orse arson) $ )[ OL43487F 1,000,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE I- 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ X POLICY❑Jmc D LOC $ 2,000,000 I OTHER: Ea accident G $ AUTOMOBILE LIp13I1611Y BODILY INJURY(Per person) $ _ ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED PROPERTY DAMAGE $ AUTOS AUTOS Per ecCident�� NON0WNED $ HIRED AUTOS AUTOS EACH OCCURRENCE $ ---11-0—0Q.0—0 0 X UMBRELLA LIAR OCCUR i AGGREGATE $ 1,000.000 EXCESS LIAR CLAtMS•MADE 10/18/2015 10/18/2016 $ $ g$p20792125-194985 OTH- Den RETENTION 3T TU E E WORKERS COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYERS'LIABILtTY Y I N ANY PROPRIETORIPARTNERlEXECUTIVE L___.I NIA E,L,DISEA� SE-EAFMPLOYE $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E,L.DISEASE-POLICY LIMIT $ If yyes describe under 'Df MRIPT10N OF OPERA IONS below 11 LES (ACOFIp 10i,AddliRemarks Schedule,may D ait more space is roqulred) oescRIPTION OF OPERATIONS I LOCATIONS I VEHAR CT,EARESULTr EVERSOURCF� AND tiA'TIOIiAL GRID ARE LISTED AS ADDITIONAL AL INSUREDS ON A PRIMARY NON-CONTRIBUTORY BASIS CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CLEARESULT ACCOpDANCEIWITH T ME POLICY pHOVi510NSB WILL BE DELIVERED IN ATTK% CONTRACTOR SERVICES DEPT 5fl WASHINGTON STREET AUTHORIZED REPRESENTATIVE WESTBOROU(#H, KA 015$; Daniel Sullivan/MSG ©i98S-ZUi4 ACORD CORPORATION• All rights reserved. ACORD 25(2014KIi) The ACORD name and logo are registered marks of ACORD MrIer bd with pdfFactory trial version www. dffacto com // A Q,4 F" KM R GA UTH CSSL-102562 P�Q , t ;� 11 .1 lPmkh.MA 0192 . /�% > ) M512017 ........... ......................................... .. ..... Office of Consumer Affairs and B S 70 s Regulation 10 Park Plaza- Scute Boston, Massac efts 02116 Home improvement ctor Registration Registration: 173410 Type: individual Expiration: 1011/2018 Trlf 29/320 KURT GAUTHI �r KURT GAUTHIER 1'I9 COUNTY ROAD IPSWICH, MA 01938 err �sIf. Update Address and return card.Msrk reason for change. �d Q Address Renewal ❑ E0100yment Lost Card I SCA1 i$ 2DFA-Q6lit VNX.Mt11.,11ll!ob4�ffwada4eA Registration valid for individual ase only before the office of Consumer Affairs&Buoness Regulation expkation date. If found return W ! HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regalation RegisEratt043410 Type, 10 Park Plaza-Suite 5170 l=xplrati __ B individual goon,MA 02116 Kt�RT GAUfHII<Ri �.. KURT GAUL 1-IIEl2 RISE 60 Shawmut Roast Unit 2 i Canton, MA 020211339-502-6335 ENGINEERING" www.RISEengineering.corn AUTHORIZATIONOWNER (Owner's Name) owner of the property located at; J7 (Property Address) (Property Address) hereby authorize4 (Subcontractor) an authorized subcontractor for RISE Engineering, to tact on my behalf to obtain a building permit and to perform work on nay property. This form is only valid with a signed contract. The 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. r Owner's Signature Date t 6.2016