HomeMy WebLinkAboutBuilding Permit #575-2016 - 109 NUTMEG LANE 11/10/2015 Sivs��ll ll-1? -/s
BUILDING PERMIT o`Na oT b.0tio
TOWN OF NORTH ANDOVER -
�'r– o2 LICATION FOR PLAN EXAMINATION _ 7D
Permit No �� Date Received �y ADRA7' D
SSACHUS�
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION i Oi AA e& Lef Ix e-
Print
PROPERTY OWNER �\06-el T_ (=-o r'fv,,.,k✓\
Print 100 Year Structure yes no
MAP PARCEL: ��/ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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 'I-A5 V I et?-t 0 0
ElSeptic O Well ❑ Floodplain ❑Wetlands 1NatersFied D�istnct
4
D 1Nafer/Sewer -- -
DESCRIPTION OF WORK TO BE PERFORMED:
�iCSeal ►'Na /47`7—e I m54.)tg7-/'0VV Tv R"Yrj
Identification- Please Type or Print Clearly
OWNER: Name: ko 6 r r i �,- co C eV-14bq Phone:
Address: /d /1 v 7A4 G Gq K e A^JoveI^
Contractor Name: _Pyre r L e b I g K e Phone: "?;>,F-y o
Email-
Address: ea?5i i`✓ -e i57-vL./ l 7 /
Supervisor's Construction License: l a fa o 1 Exp. Date:
Home Improvement License: IV x ;�L co Exp. Date: ?1211(,
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT_$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COCTBASEDON$125.00 PER S.F.
Total Project Cost: $ 3� U�- FEE: $
Check No.: Receipt No.: �
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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 ❑
I
THE FOLLOWING SECTIONS FAR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
I
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
i
COMMENTS
I
0
HEALTH Reviewed on Signature
I
COMMENTS
f•
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
r
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Con nect'lon/Signature& Date DrivewaV Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE�DEPAR�TMEI�T�- Tenip ~Dumpster onsite, ,yes.
tyLocatedlaf 124iMain�Sf[eet• - �
F:►Departmeitsignature/cl'a"te-__
COMMENTS.
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.$10o-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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
4, 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
New Construction (Single and Two Family)
4, Building Permit Application
Certified Proposed Plot Plan
4� 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)
a. 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
Location i i 'Vyx� V�j C L J
No. ��/ ' 01 Y J Date
. - TOWN OF NORTH ANDOVER '
LEI)l��d•
y
. • Certificate of Occupancy $
' Building/Frame Permit Fee $Av—
Foundation Permit Fee $ '
Other Permit Fee $
TOTAL $
Check#�W
t �
A /Building Inspector
iJ :) t
NORTH q -
own 1 E . .A . - ver
O - 0
6115 aw2w6kr
h ," ver, Mass, W bJjjw 2A6
O
�!- COC.nc„ew.c.. �1'
7,9 RATED ►P�`,`,�5
S V BOARD OF HEALTH
P E R . Food/Kitchen
Septic System
THIS CERTIFIES THAT .............KUT
........ .... ... .. . . .............................................
BUILDING INSPECTOR
�� ..... . �L ................... Foundation.
has permission to erect .......................... buildings on ..
' Rough
to be occupied as ..... .... .. ....�.....�. �,.......................................... Chimney
provided that the person accepting this per 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION T RTS Rough
Service
................. ... ... . .. .. . .. ..................... Final
ILDING 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.
C7 C;
Federal ID#
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thielsch Engineering CT Contractor Registration No
60 Shawmut Unit#2,Canton,MA 02021 CONTRACT
f
339-502-6335 FAX 339-502-6345
R I S E Page 1
PROGRAM '
THIS CONTRACT 95 ENTERED INTO BETWEEN RISE t
CMA-HFS ENGINEERING AND THE CUSTOMER FOR WORK AS I
E NCIN EE RI NG DEscRIaEO BELOW
CUSTOMERO PHONE DATE CLIENT WORKORDER
Robert Gorman n N (978)681-5614 08/27/2015 418659 00002
SERVICE STREET Cu BILLING STREET
109 Nutmeg Lane 109 Nutmeg Lane
i
SERVICE CITY,STATE,ZIP Z BILLING CITY,STATE.ZIP
North Andover,MA 0184 North Andover,MA 01845
�7
JOB DESCRIPTION
AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be
performed in concert with the use of special tools and diagnostic tests to assure 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 caulks,foams and other products. 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 reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual
number of cfm is not guaranteed.
At the completion of the weatherization 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.t FRONT DOOR LEFT DOOR.
$680.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass hafts to(152)square feet for damming
purposes.
$311.60
ATTIC FLAT:Provide labor and materials to install a 4"layer of R-14 Class 1 Cellulose added to(1694)square feet of open attic
space.
$1,914.22
KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(76)square feet of
kneewall area.THIS IS THE GABLE ENDS OF VAULT.
$266.00
ATTIC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. The
cover has integral weather-stripping to restrict air leakage.
$200.00
VENTILATION:Provide labor and materials to install(3)insulated exhaust hose with roof mounted flapper vent to exhaust
existing bathroom fan(s).
$356.25
STORAGE BARRIER:Homeowner is responsible for the removal of the stored items blocking the installation of weatherization
work in the basement- Removal must occur prior to the scheduled work starL
$0.00
RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,
for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the
Air Sealing measures up to the first$680 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 conducting a blower door diagnostic of the available air flow in
your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of
the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable
weatherization incentive is$3,110.
$90.00
Federal ID#
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
r A division of Thieiseh Engineering CT Contractor Registration No
60 Shawmut Unit#2,Canton,MA 02021 CONTRACT
339-502-6335 FAX 339-502-6345
R I S EPage 2
PROGRAM
THIS CONTRACT 15 ENTERED INTO BETWEEN RISE
ENGINEERING CMA—HEr.S, ENGINEERING AND THE CUSTOMER FOR WORK AS
CRIBED BE
CUSTOMER PHONE DATE CLIENT ::WO�RKKDERRobert Gorman (978)681-5614 08/27/2015 418659 2
SERVICE STREET BILLING STREET
109 Nutmeg Lane 109 Nutmeg Lane
SERVICE CITY,STATE,ZIP BILLING CnY.STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
Total: $3,818.07
Program Incentive: $2,770.00
Customer Total: $1,048.07
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
"!"One Thousand Forty-Eight&07/100 Dollars $1,048.07
UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 11;WILL BE CHARGED MONTHLY ON ANY
UNPAID BALANCE AFTER IO DAYS.SEE REVERS FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING.AND CONTRACTOR REGISTRATION.
O NOT S THI NTRACT IF THERE ARE ANY BLANK SPACES
AUTHORIZED TUBE-RISE Engineering COST ER ACCE ICE
NOTE THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT E%ECUTED YOM DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE
30 DAYS SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK
AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE
OWNER AUTHORIZATION FORM
I, ober 7~ 6eym akl
(owner's lame)
owner of the property located at
to /V VT PK '* LIU*
(Prop" dress)
1V !J leo Y &VeA r4a. 0/^s
(Property Address)
hereby authorize
(Suboontrac tor)
an authorized subcontractor for RISE Engineering,to act on my behaff to obtain a building
permit and to perform work on my property.
21
OwWs Signature
Date
`\ The Conttnontvealth of 114'assacirttsetts
Department of Industrial Aechle'nts
- -_ Office of
Ltt esti atrotts
t 2 600 Washington Street
y", .��.
_ Boston,AIA 02111
rvtviutturss.g ov1dht
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anglicarit Information Please Print I,eaibh
Name(Business=Organization/individual): V o lttr A,ear ,nnwg neon e o f
Address:
Cih/State/Zip: yrl�0Of Phone : 7y— 4_ S JIF S'_
Are}ou as employer?Check the appropriate box: Type of project(required):
1. •I am a employer with:_ 4. ❑ 1 am a general contractor and I
employees(hill and/or part time).* have hired the sub-contractors 6- ❑New construction
2.❑ I ate a sole proprietor or partner- Listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
workings for me in any capacity. employees and have workems g ❑Building addition
[\o workers comp.insurance comp.insurance
required.] -5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeo-vvmr doing all stork officers have exercised their 11.❑ Plumbing repairs or additions
myself.[-\o workers:comp. right of exemption per MGL 17_❑ Roof repairs
insurance required.]' c. 152 S 1(4).and tie have no
etnpioyees.[\o workers- 131ROther MR1d/4 rh V1
COMM insurance required.]
"An}-applicant that checks box=t must also all out the section heloar shoxvine their workers-compensation police information.
I lomeotvners who submit this affidavit indicating then are doing all work and then hire outside contractors Letts/5ubmiI a[tett affidavit iadicatine Sud/-
=Contractors that check this box trust attached at additional sheet shoring the name of rbe subcontractors and state uiicther or not those entities haee
employees. If the sub-contractors have et»ptorees.they must provide their .workers'comp.policy number-
1 ant an employer that is providing workers'compensation insurance for zr r entplorees Below is tits polio-anti job site
information.
Insurance Company Name: ' d`i
Policy 9 or Self-ins.Lic.iL: P® Vic—�5C�pj Expiration Date: f bh&
Job Site Address: 2329 A U 1-IM:e6= L tj YN City/StatelZip. ,0_��QVW,
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 SI-500-00 and/or one.•ear imprisonment,as well as civ=il penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator- Be advised that a copy of this statement may be forwarded to the Office of
Investiggations ofthe DIA for insurance coverage verification.
i do hereby eertFf•under the pains and penalties ofP061113-that the information provided above is tnte and correct_
Sianature: Date:
Phone=: !q e
Official use only: Do not irrite in this area,to be completed br city or town official
City or Town: Permit/License I
Issuing Authority(circle one):
I- Board of liealth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector $. Plumbing Inspector
6.Other
Contact Person: Phone IM:
OP ID:SS
'4 CERTIFICATE OF LIABILITY INSURANCE t31
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), AUTHORQED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT- If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A a l tement on this certificate does not confer rights to the
certificate holder in lieu of such endoreement(s).
PRODUCER CONTACT
Durso de Jankowski Ins Agcy LLCNe F
198 Massachusells Avenue Ne=
North Andover,MA 01845 nDoREss:
Durso 8r Jankowski ins.Agcy. POLAR-1
AFPOMw CpyEnp 1E NAIL*
wsueEu
Polar Bear Iris n CO.IM t:ffl ;Penn America 326P O Box 958 e; insurarwe Co. 33818
Andover,MA 01810C-
D:
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 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM.
Imw EXP Lags
L 7YPEOFR�ANCE POUCVNUMBEFI
GENEIM LIABLITY EACH OCCURRENCE i 1,000,
A X COMMERCIAL GENERAL LIABILITY PAC705= 030401o15 0312401016 PREMISEs Ea oeaorence $ 60,00
CLAIMS-MADE ❑X OCCUR MED EV(Arty Orae PMS) $ 51
PERSONAL BADV INJURY $ two,ow
GENERAL AGGREGATE $ 2,0WQX
GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 1,000,
POLICY PRO- LOC $
AUTOMOBILE UAe1LftY COMBINED SINGLE LIMIT S 1,000,00(
B ANY AUTO 2100926 01/0401015 01104FAI G (EDOBODILY INJURY(Per mrson) s
AL.L OWNED AUTOS BODILY INJURY(Per eodde M S
X SCHEDULED AUTOS
MAGE
X HIREDAuros (PERACCIDENr) 8
X NON-0WNEDAuTOS S
$
UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAR CLAIMS-MADE ACS906365 032401015 03124010t6 AGGREGATE i
DEDUCTIBLE $
RETENTION S $
WORIOM COMPENSATION WC STATU
AND E7IPWYERS'LUUHIUTY
ANY PROPRIETOR/PARTNERIDCECIJTIVE YIN EL EACH ACCIDENT i
( in NN)
EXCLUDED4 NIA
ms�ss,, E.LDISEASE-EAEMPLOY i
DESCRIPTION OF OPERATIONS bdoer I EL DISEASE-POLICY UMIT $
lOESCRtP ION OPERA710NS/ /VEIOCLES(Atleeh 10f, Rumrl:e BelWdub,ff reeore apeee in reeprIONO
Insulation or Mineraa,,p'30 1 irL�u or ne bit W
a=Pngwork perfonneder bekaff by th above�neu�is Thielsch
CERTIFICATE HOLDER CANCELLATION
THIELS2
SHOULD ANY OF THE ABOVE OESCrneD POLICIES BE CANCELLED BEFORE
Thielsch Insert
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ng ACCORDANCE WITH THE POLICY PROVISIONS.
Columbia Gas
195 Francis Ave AunIORRED RNPRIMMATIVE
Cranston,R102910 46jp-
0 1988-21)(19
ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIAG ILRY INSURANCE a'12R82014 n
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVE LY 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 1
f
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. �
IMPORTANT:i the certificate holders an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION 6 WANED,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 nL
NM1E:
Automatic Data Processing Insurance Agency.Inc. (ArNaEx(k fnL Nok
1 Adp Boulevard ADDRESS:
Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAM;
INSURER A: NorGUARD insurance Company 31470
INSURED POLAR BEAR INSULATION CO INC INSURER B:
DBA:Polar Bear Insulation CO Inc LUSURER c:
PO BOX 958 IYSURER D:
Andover,MA 01810 INSURER E:
INSURER F•
COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER
THIS IS TO CERTIFY THAT-THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED MAIMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREA/ENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUSIEWT LVTTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT TO ALL THE TERMS. I
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. If
LTR TYPE OF INSURANCE INSD WVD POUCYKMMER R.NttIDYYYY) 08IDI)YYYY) LIAtIrS i
COMMERCIAL GENERAL UABM1nY EACH OCCURRENCE S
CLAWS TUEOCCUR PREMISES HEa c' S
-uunerceI
WED EXP tk4,reIx,ww S
PE1lSOM1LE W:U)URY S
CENL ACGREGATE LIGHT APPLIES PEIL GENERALACCRECATE S
POLICY PRO-
ECT �LOC PRODUCTS-COMPAPAGG 5
)
OTHER �
AUT0169BILF LiAIILDY IEa'aide% DEF S
ANY AUTO BODILY INJURY(Pa anon) S 1I
ALL Ch SCHEDULED BODILY INJURY(Pv zcuder� S
nubs AUTOS
HIRED AUTOS NDN-01FNEU Pei ac 01 L S
AUTOS i
S
UNSRELLILIAB OCCUR EACHOCCURI(ENCE S
EXCESS UAB CL+Ut6-t1ADE ACGREGATE 5
DEC) I I RETENTIoNs S
WORKERS COxPEP6A790N x STATUTE ER
ANDEMPLOYERS'MaILITY I.�,Qt�
ANY PIIOPlIfETOR.PARTtaREXECUTISE YM El-EACHACCQcNT S
A OFFMERA-ZtIBEREXCWMD, M !A N PMVC6609M 01,01,2015 01,0112016 �
(Natdatmy m NH) El -EAEMPLOYEE S �+ QOIIO
. 11 Yrs.deatnte=fa
DESCRI'AONOFOPEI(ATIONSL4Iwv EL.OISEME-POUCYUWIT S 1.
OESCRIPTION OF OPFR1'i!O14$lLOCATIOAii lVEIIClES(ACORD l01 Ark6t6na!Rernarlo Sche&te.maybe attache!if marefpace is requ'ved)
Columbia Gas massachusetis
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Theitsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave 1
Cranston.R102910 _ 1
AV)HrrORIff`D�REPRESENTATNE ,
merle...: Jul lid..,.
ACS 1988-2014ACORD CORPORATION.AB rights reserved.
ACORD 2S(2014,01) The ACORD name and logo are registered maria of ACORD
i
i
r
d usiness Regulation
M RoeOffice of Consumer Affairs Suite 5170
10 Park Plaza- -
�goston,Massachusetts 42116
rovement Contractor Registration
Home imp . 102726
- -- TYpe: DBA Tr4 2=49
_- - Expiration: 7/212016
pOLAR BEAR INSULATION CO. _ —
Vincent LeBlanc
p.O. BOX 958 _ Mark reason for change.
ANDOVER, MA 01810 Lost card
--:update Address and return�Employment ❑
ti li Address ❑ReneNval ,J
01216
OPS-CA1 a 50Ni�04�04'Cs1
tMassachusetts -'Department of public SafietY
kv Board or Building Regulations and Standards
Con.tructionsupenisorSpecialt� T
License:Cf*L 106017 I,Y
PETER A LEBLW
2 FAST PINE STREET _
Plaistow N14 03865 _
f Ejxpiration
04/28/2018
commissioner