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HomeMy WebLinkAboutBuilding Permit #861-2016 - 108 PRESCOTT STREET 2/3/2016 �-S BUILDING PERMIT O No DTH ti TOWN OF NORTH ANDOVER �2 '�'- ..,6 6 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received I CHl15�( Date Issued: gSSA IMPORTANT:Applicant must complete all items on this page LOCATION /D�l �GtSloi T j i Print PROPERTY OWNER Print 100 Year Structure yesOno MAP PARCEL: ZONING DISTRICT: Histor c District yes Machine.Shop Village yes 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 9 Others: ❑ Demolition ❑ Other T-hsu/Giior O Sep ctict ❑1NeIT Floocipla : TWetlands ' 0 �Wa et .rs eialsD riof u' Wate Sewer DESCRIPTION OF WORK TO BE PERFORMED: /� TTIC To P--V$F LJ en Identification- Please Type or Print Clearly OWNER: Name: �h��S4i �SSs,� ,` Phone: 49%J, Address: /D �6'�Sroii S i Contractor Name: POeC /-es^ft e Phone: '�PZP- Yo 7(3� Email: Address-. 2 -e 5'7- �:��. �'T . /cii5.br,✓ �'L, I� Supervisor s:Construction LicenseGa:- 7 Exp. Date:... hHome Improvement License: Exp. Date- ARCH ITECT/ENGI NEER ate: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: $ //00- 00 FEE: $ �0 i Check No.: I Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 OTE: 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doc:Building Permit Revised 2014 i i w a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL { Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinn- ing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes r Planning Board Decision: Comments 7 S Conservation Decision: Comments Water& Sewer Connection/Slgnafure& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENTTemp 00% ter on site yes a , Located at 1.24 Main Street � ;:,, � � ..a x ,- . '• � .Fire Departrnen si.g ature/date: •,.� � �_ • � t 5'`��- ` t Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL.: Movement of Meter location, avast 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 rase) l I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 F Date. . .. ..... .. . . .. . OF MORTH ,'�' o� 1` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION y •'s �9 v 'lsgS°S+^C MUSEtS This certifies that .(�-14 /�Kl? . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . P.�7/. . . . . . . . . . . . . . . . . . . . . . . . . at /.>... .��a� s�.� T . . . . . . . . . . . .. North Andover, Mass. Fee.).),. '. . Lic. No.. / r- 'Z . . . . . . . . . r ( GAS INSPECTOR Check# U j y v 3738 FEENBRO.01 SMORAN Q►C®R�' -------CERTIFICATE OF LIABILITY INSURANCE DAT1/13012301F(MNV2D�YYrn-- -----.- � 015 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 Ileu of such endorsements). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. PHONE FAX (877)816 2156 434 Rte 134 ac No Ext: arC No South Dennis,MA 02660 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:OId Republic General Insurance Corp. 24139 INSURED INSURER B Feeney Brothers Services LLC INSURERC• 103 Clayton St PO Box 220801 INSURER D: Dorchester,MA 02122 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, TERRA 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 SU13JECT TOALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1�TR TYPE OF INSURANCE DD SBR POLICY NUMBER MhOVDDJYYW FOLIC EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 DALLNUE TO RENTED CIAIl.1S•hfADE a OCCUR (2CGO7501501 02/01/2016 42/0112016 PREMISES Eaoocurrence S 300,00 MED EXP(Any one person) $ 10,00 PERSONAL BADVINJURY $ 1,000,00 GERLAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,00 POIJCY�JECT LOC PRODUCTS-CON1PIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOYISIED SCHEDULED BODILY INJURY eraocldlen $ AUTOS AUTOS (Per ) N"wOWNE0 PROPEkYY DAMAGE $ HIRED AUTOS AUTOS Peraocident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS•I.tADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X PER OTH AND EMPLOYERS'LIABILITY YIN STATUTE ER •__ A ANY PROPRIETORIPARTNERIEXECUTNE 2CW07501501 02/0112015 02101/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMFLISER EXCLUDED? rW] NIA (Mandatory In NH) EL.DISEASE-EAEMPLOYES 1,000,00 Hyyes,describe under DESCRIPTIONOFOPERATIONSbeaN E.LDISEASE-POLICY LIMIT $ 1,000,00 L _L DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) I ' CERTIFICATE HOLDER CANCELLATION I 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 Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Sss ©1988-2014 ACORM CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and'logo are registered marks of ACORD:s NORT!j Town of ndover 0 y.: w ti oils ....... oLAKI h ver, Mass, COCMICMEWICM y�• RATED AllIry U BOARD OF HEALTH Food/Kitchen PERML T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect g Foundation .......................... buildings on ..1.04 .......... .1�!�i�.`r.R. .. ....... ........ Rough � J to be occupied as ...................... .... .... ....i . . .. .....�............................ Chimney 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 3d PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOlTtt 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. Nov, 13, 2015 2:20PM No, 0495 P. 2 Federal ro a 06-0d06829 RISE Engitoeering RI Contractor Registration No 8166 RIARA Contractor Reglatratlon No 920919 A division of Tbielscb Eogiaeering ENGINEERING 60 Sbawinat Unit 42,Canton,MA 02021 CONTRACT 33940633S FAX 0 Page 1 Fwr-w PROGRAM THA CONTRACT Kt E�rrHtecr INTO e+EtvIEtau Ptafi CMA-HTS' BNGVNEI=AMTHE CWTOMMFOR WORK AS OESCW90 9e.0n cua"MER f PHM DATE CUEWTC Vm"ORDER Abigail Assam c\j (978)869-1942 10!27/2415 416447 00002 St7iY10E STREET �nn{�� oil"STtreer 108 Prescott Street U 108 Prescott Street 6ERVICE CITY,STATE,ZMBILL=CITV,6TATE,LP Nortb Andover,MA 01 Z+. North Andover,MA 01845 ® JOB DESCH&TYON AUDITOR'S NOTES HOUSE BELOW BUILDWF ATR FLOW STANDARD BLOWER DOOR-1061®CFM50 BLD.STANDARD=1343 Q CFM50 AT 70% -9401WWO CUSTOMER MUST INSTALL BATHROOM VENT FAN TO MAKE AIR FLOW STANDARD. LOOK AT EFI.ORG WISPER FAN. CONTACT ME WHEN INSTALLED. $0.00 AUDITOR'S NOTES HOUSE 8PLOW BUILDINP ATR FLOW STANDARD BLOWER DOOR=1061®CFM50 BLD.STANDARD 1343®CFM50 AT 70% -940 @CFMSO CUSTOMER MUST INSTALL BATHROOM VENT FAN TO MAKE AIR FLOW STANDARD. LOOK AT EFLOXG 'WISPER FAN. CONTACT MTi WMN INSTALLED. $0.00 DAMMING:Provide tabor and materials to install a 12"layer of R-38 unfaced fiberglass batts to(48)square fat for damming purposes. $98.40 ATTIC FLAT:Provide labor and materials to iWall a 4°layer of R 14 Class 1 Cellulose added to(916)square het of open attic space, $922.08 VENTILATION:Provide labor and mataaials to install ventilation chutes in(26)rafter bays to maintain air Hoar. 552.00 RISE Enginaxing will apply all applicable,eligible incentives to this cooma You will only be billed the Nct amount Cuttcntly. for eligible measures,Columbia Gas oflus 756A incentive,not to excood 52,000 per calendar year,and an inetntive of 100%for the Air Sealing faeasures up to the first Sal)and an additional 5340 if savings areiustifled by the auditor. For the safety and health of your home's indoor air quality,eve will be conducting a blovmr door diagnosde of the available air flour in your home both before the work is begun,and after the wcatbgization worts is oomplete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has 9 value of$90 and is at no cost to you. Trial allowable aasdreritation incentive is 33,110. $90.00 f Nov. 13. 2015 2:20PM No- 0495 P. 3 :. f; FeaeaitosoB • WSE Engine iog No 8188 RISE A diridos Of> U#UWH" ENGINEERING 60 ShowmatUait aa,Cxot^au MU CONTRACT 339,502.6335 FAX 339-592-6345 Paps 2 MOG12AM Taseam aaemomwWomma f CMA—.S 6mG a asiw Vwcu$Forufow=" eesaeeeoaanw gwroM aim om cU Mn acarow Abigail Assani (9781869-1942 l0/Z7/2015 416447 00002 ser=eraser sum SIRM 108 Prescott Street 108 Prescott Street IF aw.e►m 2p eum orr.ermaa North Andover,MA 01845 North Aazlover,MA 01845 JOB DIESCR WON Total: $1,162.48 Program Incentive: $894.36 Customer Total: $288.12 WEASMHMWToPAM StElA=-00MPL W A=MPAMMNAMOSPWWAF1 MFMTMBuwOF ""Two Htmdred Siudyaght&12MOO Dollars 5268.12 UFOM alwio6lmONtlroagvlovALBr atlEBNGIIlSIe1C.dJSF011N1 MMIEbC Fa a6�Mf AMOCM►OeewFW.wT3RFBTOF sliaeu.eeewYea�MOgn+Lrawyav uMFNoeaurmoFrsMmoats.a�x�aewae�aeMrrrtwFowenator a►uam�wo�noaF ecFm�aiMs.aooanww�ose�nanm so"THIS CON'M=IF THEM ARE AW BUWK SPACES 71Mre-ase )l`�` Qyy� 1 //�_/��\. MO'f@Umco71magW0EwIfl 1WUSIFMaFWMCU MMINM1 ollTeaeQOefP7Np7? •' � 1 r ^1MR0� a7CUMM OF GW"U r-TM?MVe F WML SPEW= R OM cOMD1- AM 30 arve A�9soo�inwiea�uaaeeeims�eon°�MO�omootaeww+a Nov. 13. 2015 2:20PM No. 0495 P. 4 I OWNER AWHORRAT1ON FORM (Owner's NNW wowafttre properiybPoled at O /w'eca4V tir } Al - t4 Wo reg , � k_ ot� y car r,�►au�e (StirxonMaRM an aWwkmd eta RISE Erekwktg,toad an nV lbol to thin a bLWng penryt and to pelt mwwk on my p gmft. CkwtWs Signabee lil)- Zot Date The Commonwealth o_f.l assachuse]Ts Department o�industrial ACC dents 1 Congress Stree4.quite 100 Boston,lLl-02114-2017 www.mazs&gov/dial Workers'Connpensation InsuranceAfiiidavit:]Builders/Contractors/lElcc-uicians/Plumbefs- g®���IL�D�'dl eYr'd-I�dE PE��PIG rI<U�F®li%a lt_ Aoo]icant Information _ Tease 1'sin Name (Business/Oroanizatiowindividual): t/ I A 1'j �Y•; 1 ti j. i i Gri (`I'_ ?i i. Address: i`- City/StatelLip: i'i = r;,-j:% Phone Are you nn employer?Owclx the nppmpdnte bot: Type of project(required): 3 1. ' 1 am a employer with �1-pyccs(full nodlor part-rime)_' 7- 01 New Construction 201 am a sole,proprietor for or psiacr hip and have no cmployccs working forme in 11_ []Remodeling any cap-ity-(Ko workers'comp_instaaace tegt»rod_l on 3-01 am a homeowner doing all work mys`lC(No workers'comp-i—recfui d.l t I O g- 01�°g 0 Building addition rs 4-F1 1 am a bomeownand will be hiring coatractos to condtrcl alt work on my property- I will � cnaum tbat all contractors other bavc workeran s'compensation insace or are sole 11_E_t7 Electrical repairs or additions prvgnctors with no cmploycrs 12.[]Plumbing rt:patrs or additions 5.0 I am a gescral conu-actor and l bavc birad tba sub-mouzaots listed os the attached sb=L 13.FlRoof repairs Tbcsc sub-contractors have employes and have workers'cotnp_incUram-r r 6-El we arca corporation and its ofhecrs bave cxcrased their right of exemption per MGL C- 152, 1� �Otlltx 152,§1(4),and we bave no employccs.(No workers'comp_insurz ere raquittd.l 'Any applicant tbw cbecks box 91 must also 611 out the section below sbowing their workers"motion policy infoanxiou t Homcowners wbo submit this affidavit indicating they arc doing all work and than bim outside coutractors must submit a neer+aflidavir indicating retch. lCoottaceocs that check this.box uamt aruwbcd as additional sbca sbowing the name of ncc sub-conuzcu*s"and care wbabcr or not those enter bavc coployccs_ If the sub-contractors have ernploycm,tbcy must provide their workers-comp.policy numbcr- 1 am arz e7npdoyer that is providing ryorkers'compenSation insurance for Iny employees Eelow zs&,policy and job rile 1-for madon- _ a insurance Company Name: j '� ✓ G i Policy#or Self-ins-Lic_#: 7yi✓JG 7��-=' J Expiration Date: 421'� Job Site Address: f7 (� (��SlO/�/� 'S% City/Sratel�ip: n- 1�h 410✓e r/ .&Mch a copy of the workers"compensation policy declaration page(sh0v/iug file(soUcy number Ermi etpirntion date}- Failure to secure coverage as required under MGL c_ 152,§25A is a criminal violation punishable by a fine up to$1500-00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKORDER and a fine of up to$250-00 a Jay against the violator-A copy of this statement may be forwarded to the Office of investigations fthe DIA for insa nce :overage verification. r do hereby carfifyr sender thepains ayid penalds of perJrary that the inforrraa&n proqrted above is&ue nerd Correa iienature: IC �:- L - i. zr y-, ,t-:- Date: 'hone N: 2-2 —j of 4- 0jTwiad nese only. Do not write ire a&area,to be completed by city ar town o frGEIIZ City or Town: PeEmit/Lkemse# Issuing Authority(circle one): I-Board of Health 2-Building DVartwerlt 3.Ci6yll'own Clerk 4-Electrical Inspector 6:P]uMtbing IInspector 6-Other Contact Person: Phone#: 1/4/2016 Preview:Certificates of Insurance © DATE Y) A �� CERTIFICATE OF LIABILITY INSURANCE 0110412016� 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 15 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: PHO'IE AX Automatic Data Processing Insurance Agency,Inc. la EzN: rAle N., 1 Adp Boulevard ADDRESS: Roseland,N,1 07068 INSURER(S)AFFORDING COVERAGE IiAIC 9 INSURER A: NorGUARD insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,@1A 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO.,'HAVE BEEN ISSUED TO THE INSURED NAMED ABO`lE FOR THE POLICY PERIOD INDICATED.NOT.•:)THSTANDING ANY REOU;REi:4ENT-TERM OR CONDiT!ON OF ANY CONTPACT OR OTHER DOCULIENT VNTH RESPECT TO:.HiCH THIS CERTIFICATE M.AY BE ISSUED OR I:AY PERTAIN.THE iNSURANCE AFFORDED BY THE POL.CiES DESCRIBED HEREIN iS SUBJECT TO ALL THE TERLIS. EXCLUSIONS AND CONDITIONS Or SUCH POLICIES LU.IITS SHOW74 MAY HAVE SEEN REDUCED BY PAID CLAN'S MR I AUUL UbK1 POLICY F P LICY P I LGSITS LTR TYPE OF IN INSO VND POLICY NUGIBER IA'?XOD+YYYY1 It•1GI;DO:YYyV; COMMERCIAL GENERAL LIABILITY U i CLAVASI.1:•Lc F-1!c,.LI. L14U tl.f'r:,r.;sI,_[ssari (tI:LAC-CREC-AIt LII-UI AITLIES PEI'. LECEI':.L AG i=IiECAIE > 1'I;LIC` JtCI �L:;:: 1=Iv!;Ci'ti:iS :r:i.tl'.CI::•Cl S —1`1-11i: AUTOL:OBILEUABILITy ; WI.t IN:tL'JI:CLt LC:II I: Ati IL: U(:UIL' RLL C:N.cD SCFcC•LLED %.LICS :.C'I CS liCUIL"INJI-10 H°u;a..rscl+i S I:t 1.f'•:.I:tL � � 1'Itivl't�I'+ -•.:1.•Wt _ Ut.MRELLA LIAB r'LH &iCh:=C4Cldfitr:Lt S EXCESS UAB CL:d1.15-Lt:.C•E %'GGHtL%.I E ' UEL` 1'E,th 11Ct.s i 1 V+ORKERS COMPENSATION 1 x �'Ii,II:IE EI--~ AND EMPLOYERS'LIABILITY Y,III I ( 1,000,000 .r,:ITicPwtlpl P•;enal�xtcurr't v ua N POLNC772258 01:01:2015 01/012017 EL E't ACCIL_l.l �s A :+ILEfd.KLt6tl'E<,LLC GZ St tntiat'L'.tE 5 1,000,000 (M.ndalory in NH) �• I EL.VISEn' +.`' :I :5.::c5:'Crt:cn_c-r ets:_liu=uc:cFCP�Nr.IICcs t-L.el_Ese P u wall 1.000.000 i DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(ACORO 401.Additional RC1na,ks Schedule,may be alm0.vt!it—c,"ec c 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 AUTHORLED REPRESENTATIVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL ,acoRO CERTIFICATE OF LIABILITY INSURANCE DATE(M1WDD/YYY1f7 `—� vs/2ols 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 NAME: PHONE ---� - _—' X 11 Saunders Street A/c N1�:(978)688-7000 FA!C No):(978)688-7001 North Andover,MA 01845 E-MAIL -- - — ADDRESS: INSURER(S)AFFORDINGCOVE_RAGE I NAIC:f__ INSURER A:Nautilus Insurance Co. _ 17370 INSURED INSURER B:Safety Insurance Company_ 33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc INSURER D: P O 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 VVITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S 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 aR POLICY EFF POLICY EXP LIMITS LTR Y INSD WVO POLICY NUMBER MM/D MM/DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X NNS38691 03124/2015 03/24/2016 DAMMGE TOEa occu — - --- — CLAIMS MADE OCCUR PREMISES(Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY_ _$-- 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY(�JECT F LOC PRODUCTS-COMP/OP AGG $ 1,000,000 -— OTHER: I$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT J$ 1,000,000 Ea accident) B ANY AUTO 2100926 01/04/2016 01/0412017 BODILY INJURY(Per person) I$ ALL OWNED FX_ SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS X HIRED AUTOS I X NON-OWNED PROPERTY DAMAGE $ AUTOS _(PeraccidentZ_ a � ( ,$ UMBRELLA LUAB X OCCUR j j EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADEI AN019284 03124/2015 03/24/2016 AGGREGATE $ I DED RETENTION$ I $ WORKERS COMPENSATION1 AND EMPLOYERS'LIABILITY I I STATUTE J, I OERH _I ANY PROPRIETOR/PARTNEWEXECUTIVE YN/A E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI$ if yes,describe under E.L DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS below 1 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 Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATNE I i✓t�/� e,%-In**On7A Ar�f%nr%nnonno A"f%k/ Art-:..Ls..-............1 j Of Consumer S ��7� 10 -parkPlaza-She os OZ�-Z B�stQ���assacl�tis. �TETQ G6IIGtQZ �� ot� 102726 - OIIie DSA �6 -F* 252M— on_ 7P1120 _=S>__ ION CO. POOR BEAR!NS Vl[1CegOX LeBlanc -_ _ ` l greasonforCbRU e- P.Q. 18't0 = : 'up�AdareSssadremmes ent D Lastcard ANDOVER, MA 0 J zmp� : !Address 1 Remw� :.maGto12i6 OP-`+JAZ ^•��Si:j :..j pis :-S}1L liT�Sini1c ISO -Special-t r1 S- se_G�+SL-1fl6o4Y -�� " A LBBLANIC piaisws,Ng Oder" LV ��- j `0,. 6 i v PsC.CS� t k C-k--{�,�Y,�p,J LocationA ' �r �� t 6W (jpS -b m 1i 2,- No.. ,No. . — 3 �P�_1 Date 2l� c y-b 3 — 'yo r • - TOWN OF NORTH ANDOVER � -- Certificate of Occupancy $ d Building/Frame Permit Fee $tO Foundation Permit Fee $ Other Permit Fee $ J TOTAL $ Check# eD 29-985 Building Inspector f