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HomeMy WebLinkAboutBuilding Permit #466-2017 - 10 PINE RIDGE ROAD 11/2/2016 BUILDING PERMIT IP TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION F a 1o�p µ 1e Permit No#: Date Received �gSsACHus���y Date Issued: AL�YMPOR­TANNT : Applicant must complete all items on this page LOATfONi7 �- _ �� -P l5 PF200E,RTY OWNSR' s . io, �"�"� Pnnt& �i0©Year,Structureye � P PARCEL' -�2" Z®N'1'NG DISTR'lCT`Hist"oriiclDist��ct� ye nod IVIA r � _ —_ `_ lUlachneShop�V�lla9;e,'.�PAL - n -�� .� __�_ _ ___, _ r-�_ 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 ❑ Others: ❑ Demolition ®.Other �,,rsa?htd�Z�►TIG�/l _ _�w_� _�, ❑�Fl.00dplain, a Wetl'an`ds ;� Tis w iNate�shed et: D�Septie ❑UVeI� _ _ --- - ,v�`Water_/Se,,wer�_ __ ��--�-- DESCRIPTION OF WORK TO BE PERFORMED: P. Identification- Please Type or Print Clearly ' Phone: -q�/- 3�y OWNER: Name: y Address: O PYoe Peter L eblanc . 3 Oontra_aur Name ----� -4u .-. r Email, _ �-- - IA 1 975 TA fi S`upervis6ri's`Construcfi©n,License .�.n/D�O o l7 - Expo - _ s � _ -� �- - + Homeslmp=r©cement Licese_k_ /6JV4._ Expy ®`ated_._ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ y!Od-4 cJ FEE: $ — Receipt No.: '3 i I H c Check No.: 11 �� NOTE: Persons contracts g with unregistered contractors do not have access to the guaranty fund 5ignatureof,Agent/Owner.. Signaturezof"contr ctor _ f Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 1 I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS rp�-HEALTH Reviewed on Signature COMMENTS 5+ , Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street IFIRE DEPARUTMENT `i '�" - „ at 124 M51 rt -=Temp ®umpsternsite eyes. ` q ated �r2. MainlStreetr k , Fire art 1 Dep mentsignature/da Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email I Date Time Contact Name Doc.Building Pennit Revised 2014 Location )oZoo No. Date t • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ • Building/Frame Permit Fee $ A Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# 3 1 1 1 4 (,/ Building Inspector NORTH '9 Town of ndover 0 . . 0 No. —� h * ver, Mass, // • 0/ A�R�TED t0C.1C..w'cw %11' S BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........pckr 4* .......................................................... BUILDING INSPECTOR has permission to erect .......................... buildings on �0........ INE �. R �. � Foundation ................... ..... ...... ............... .. .. .....0.6 �41�� �^ C to Ro g to be occupied as ....... .......................................:.�.......I......��............� �,.�.�. .�t.1!. .N Chimn y . .... u e provided that the person accepting this permit 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 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 NSPECTORUNLESS CONSTRU/. .4. TA TS Rough Service ....... .......... ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. . t � � I Federal 10#OS4)405629 RISE Engineering R1 Contractor lieglalrallmNO81" MA Contractor Regist atton ft 120979 CT Contractor Registration Nr► 60 RISE �. ENGINEERING Sharvmnt Road,Canton,NIA I�1L !�Z CONTp,ATT (401)784-3700 FAX(401)714-37+10 1.r page i PROGRAM THIS CONTRA==UFFEMEa aro sETwEErt RtsE CMA-311rS srarNEomaaAMOn CUSTO a:nsaeWORStA:" DESCROMSELOW CUSTOMER -. POW DATE CLIENT, NONIC ORGFJt Joe Cinscruli (978)9893424 10/0712016 401423 35004 StRVICE STPUMT T ... EXAM STREET 10 Pine Ridge Road 10 Wine Ridge toad SERVICE CRY.'JTATE.zr CUM COY.STAMM North Andover,MA 01845 North Andover:MA 01845 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal"meas ofy our home against wasteful,excess air leakage. Ibis work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be lett with a healthful level of air exchange and indoor air quality.Materials to be used to seal your hone can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and outer unheated areas(windows.—not.generally addressed.)This will require(10)wnrldng hours.A reduction-in cubic feet per minute(ef n)of air infiltration will occur.but the actual number of cfm is trot guaranteed. At the completion of the Aveatheriration work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contactor to ensure the safety of the indoor air quality. 5850.00 AIR SEALING:Provide labor and materials to install Q-lat m-catherstripping and a doomvTxp to(3)door(s)to restrict au leakage. S225.00 DAMMING:Provide labor and materials to install a 12'layer of 1t 38 unlaced fiberglass baits to(133)Square feet for damming purposes. S2i2.65 ATTIC FLAT:Provide tabor and materials to install a 9"layer of R-33 Class I Cellulose added to.(1176)square feet ofopen attic Spam. $l_681.68 VENTILATION:Provide labor and materials to install(2)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s).. 5237.50 VENTILATION:Provide laborand materials to install ventilation chutes in(95)rafter bays to maintain air flow. 5190.00 GARAGE CEILING:"Provide labor and materials to install 10"R-35 densely packed Class i Cellulose insulation to"506 square feet ofgarage ceiling located below a heated floor area,by drilling holes in the ceiling from below. Holes drilled will be plugger!. Plugs will be sparkled and left in a relatively smooth condition.Finish sanding and touch-up priminglpainting will be the caaomer's responsibility. $1,047.42 ID OCT 1 3 2016 .r Fede►al ro 0 054405M RISE Engineering Rl Contractor Registntlon No 8186 FC14NE MA Contractor Registration No 120979 ��� CT Corrtraeto►Registration No 60 Shaumut Road,C'artton.NIA CONTRACT tsotl'784i^x00 VAX t4oij7"37to Page 2 PROGRAM TM CONTRACT0 ENT&wM WTO GETWUN ME CMA-11E8 EMWNEERRID ARp T11E eUSTOMER FORTiORK Aa DFSpODfDaFlOM. vuONE,....__ pATE - CUEgT! uroaK ODER Joe Cinsemli (978)989-3424 10!07/2016 401423 35004 GKAJNQ STREET 10 Pine Ridge Road 10 Pine Ridge Road SERV=CITY.$TAMaC _ ._.- GUa M CrrY.STAM 2P North Andover.,MA 01845 North Andover;MA 01845 JOB DESCRIPTION RISE Engineering vols apply all applicable.cligiiblc incentives to this contract You will only be billed the Nct amount Currently. for eligible nteasurcs Columbia Cra offer 750%incentive,not to accred$2.000 per calendar year,and an incentive of 100%16 for the Air Scaling measures up to the fins SW and an additional$340 ifsavings arcjustified by the auditor. For the safety and health of tour holies indoor air quality.Tve will be conducting a btoaer door diagnostic of the available air flow in y w home both before the N wk is begun,and after the%xvatheriaation work is complete.We will also conduct a full assessment of the combustion safety of your heating system and Nater heater.This has a value of S90 mid is at no cm to voti..Total alloNTeble%vatheriration incentive is 53.110. S90.o0 �' � � IE: 6 G t X096 Total: $4,594.25 Program Incentive: $3,110.00' Customer Total: $1,484.25 WEAGREE HEREeY To R RNISH SERVICES-COMPLETE in ACCORDANCE vMW ABOVE SI MMATIONS.FOR THE SUM OF '"'One Thousand Four Hundred Eighty-Four&251100 Dollars $1,484.25 UPON F1MAL WZPE.CTKWANO AVPRWALGYXgM£MOMRMD.QRTOYER ACRES TO REM?AMOUNT WE IN FlAL WTEREST OP t%W;LL SE GURCED UCKTHLYOUANY t11R+AiDOALANCEAiTEIt]OOAYS 3EEREYEAEE FOR R�OR1ANrRiFORMATgN OH OUMA1mEF3.TOQIT50F AECiS10H.>9QUEDIIl�t0.ANO tONTRACTORAECISTRATION. 00 NOT Si N THIS CONTRACT IF THERE ARE (t BLANK SPACES AUTNORIffDSKiN►TVAE-RISE�. � PNCE i f NOTE:T10300NTRAt:T MAY tIENDTNfNTAYM 9Y USWNOT E1tEWTEO tlVffltP/ DATE OF ACCEPTANCE —7ACCEPTANCE OF cONniACT:THE Avow PfuCE".L'3PEG1FlCATIONS PHD CONpnIOHS ARE J SATISFACTORY TO US AND ARE HEREBY ACCEPTED,You ARE AUTROReED TO 00 THE WORK DAYS. AS.SPECIRED.PAYMENT NtLL GE MADE AS OUTURED ABOVE RISE60 Shawmbt Road,!Unit 2 Canton,MA 02021 339-502-6335 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner s Name) owner of,theproperty located at: _ J (prop/f Addre (property Address) hereby authorize. (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perforin work on my:property.This form is only valid with a signed contract. Ther Permit will be secured by the nsulatio�n contractor,nthe r municipality at the completion of th s work. to dose out this permit by co 9 Owner's Signat fie Date OCT ) 2016 The Commonwealth ofMassachusetts _ :_.___-- Deparbnent oflndustrialAccidents Office of Invesfigations I Congress Street,Suite 100 t Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t 18R gr_�R INS(ti A77�fW8 Address: PO" BOX 958 DOVER AAA 01810 f-itl/State/Zip:_ Phone �5— Are you an employer?Check the appropriate box. --� I am a employer with_ 4. E] I am a general contractor and I Type of project(required): employees(full and/or Part-time).* have hired the sub-contractors 5 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. j' ,. ❑Remodeling ship and have no employees These sub-con�ctors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.# 9- ❑Building addition required.j 5. ❑ Ifrre are a corporAon and its 10.El Electrical repairs or additions f7 I am a homeowner doing all work officers have exercised their 1 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repair insurance require d.j t c. 152, §1(4),and we have no i employees.[No workers' 13.0 Other comp.insurance required.] *Anyapplicant that checks box R1 must also 511 out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such_ tCnntractors this check this Mx must at*�ched 1t addiin�osheet shszvsna the rare a.th _s ags�d ste:fiethe:or no-.tho;;errtities Save employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. i am ar_empl�ver that is pr oiWng workems'cr-:npens aIior Mstcrmree,�or My a information. ploye BEloa�is ':spo>lcy 3trd ji=bsi Insurance Company Name: 1-10 i Cr W,.f7&v� --j.11 y^y C4 K e n lrvt�c,n.s� Policy#or Scl ins.Lic.#: ?o\,JC Expiration Date: of Ab; J.?y Jo);site Address:_ /o D�rn� d — Citi States Zip: n t wr A1,4 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-ye ar 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 violaror. Be advised that a copy of this statement may be forwarded to ttte 0119-ce of Inve-stigations of the DIA for insurance coverage verification. do herEoy certi [c;tdeF the pains and enaltie:o er'u that Me iR or;nation provided above is true and correct. .�.�` Si»na�are: °Date' 0 1 �/6 Phone#: q>y yob' 7& -M EBO only. o not write in this area,to be cotfrpieted by city or town afficiuL Town: Permit/1License# l hority(circle one): health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#• A6Zl® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) tai r 6/10/2016 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 endorsemen s. PRODUCER CONNTACT Linda Bogdanowicz NA Insurance Solutions Corporation PHONEEIM, (603)382-4600 FCX NANo):(603)382-2034 60 Westville Rd E-MAIL lindab@isc-insurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A Western World INSURED INSURER B Hauti.luS Insurance Group Polar Bear Insulation Company Inc INSURER C: PO Box 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBERCL1632326134 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. NOTVVITHSTANDING 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 TYPE OF INSURANCE ADDL BR POLICY NUMBER MMDY EFF YYF POLICYD/YY� LIMITS LT X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR PREM SES IMAGE ToEa occu ante $100,000 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 8 POLICY❑JET F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 1 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 Peraccident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR HCLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.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 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addttlonal Remarks Schedule,may be attached If 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 REPRESENTATIVE Keith Maglia/SJA - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I NS025 nn 140 n 6/10/2016 Preview:Certificates of Insurance ACORL?® CERTIFICATE OF LIABILITY INSURANCE FDATEIMMmD,YYYY) 06110/2016 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: Automatic Data ProcessingInsurance Agency, PHONE 9 cY>Inc. (A/C.No.Ext):E-MAac Nm 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERS)AFFORDING COVERAGE NAM d .SURER A: NorGUARDInsuran=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: 503587 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 11 LTR TYPE OF INSURANCE INS POLICY POLICY NUMBER MMDRYYYY MIDDI LIMA COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE FlOCCUR PREIdISES(Ea occurrence) S MED EXP(Any one Person) S PERSONAL 8 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY❑PRO- ❑ JECT LOC PRODUCTS-CCMP!OP AG 5 OTHER: S AUTOMOBILEUABIUTY 5INGLELIMII(Ea accident) 5 ANY AUTO BODILY INJURY(Pe:person) S ALL OWNED SCHEDULED BODILY INJURY(Paaccidem) 5 AUTOS AUTOS I�rON-OWNED S HIRED AUTOS All (Per accident Is UMBRELLALIAS OCCUR EACHOCCURRENCE S EXCESS UAB CLAIMS4.1ADE AGGREGATE s DED RETENTIONS s WORKERS COMPENSATION X I STATUTE ER AND EMPLOYERS'LIABILITY ANPROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT S 1,000,000 A OFFY ICERWMEMBEREXCLUDED? Y❑NIA N POWC772258 01/01/2016 01/01/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 11 yes,describe under DESCRIPTI ON OF OPERATIONS balm, E.L.DISEASE-POUCY LIMIT S 1,600,600 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H morospaoe is requbvd) 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 st 1 suite 2035 North Andover,MA 01845 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.conilicertcf/4/run/preview/503587/900012975 1/1 Office of Consumer Affairs and Business Regulation 10 Park Plaza.- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration j=^: Registration: 102726 Type: DBA ____ '•Y' - - Expiration: 712/2018 Tr# 419291 POLAR BEAR INSULATION CO. - Vincent LeBlanc P.O. BOK 958 ANDOVER, MA 01810 = Update Address and return card.Mark reason for change. SCA 1 0 2OM-Wtl Address f-1 Renewal R Employment Lost Card JfIC'�n7ltnlanrriCli�/7J UfCif41111(/4YlfI.iL�IJ Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:" 1()2726 Type: Office of Consumer Affairs and Business Regulation Expiration:.:�712%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 riot valid without signature it ti Massachusetts-'Department of Public Safety Board of Building Regulations and Standards 01nstruction Supenisur Specialty License: CSSLA06017 ' In PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 0386-5 Expiration Commissioner 04/28/2018 o