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Home My WebLink AboutBuilding Permit #1220-2016 - 11 ROBINSON COURT 5/20/2016 tAOR lll�l h r I -nI 1J 1/I✓ BUILDING PERMIT o�.1t�eD -6 �, TOWN OF NORTH ANDOVER �� h ''- c * *6 APPLICATION FOR PLAN EXAMINATION * _ h �' �O ♦wrw w 10 Permit No#: ,Z ,ZD �� Date Received �RA C ATED ` gSSACHUS�� Date Issued: 11 IMPORTANT: Applicant must complete all items on this page LOCATION // !cob%n SO vx Co v f'r Print PROPERTY OWNER 3 e tem Y X rb-y S e 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 [I Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg .4 Others: ❑ Demolition ❑ Other Tnstj/a?1a ti ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I�►j'S.� ►i►�q 04Trit A-141 Tp Q-N y Identification- Please Type or Print Clearly OWNER: Name: -rc(,,rmy k1r-dSe Phone: f�F-6yl- »d-Fl Address: db%K oh rovrT Contractor Name: Phone: q>.?�-qv 2-7G3 ? Email: Address' -0 o x qS-? h�a✓�� /9 Supervisor's Construction License: lo%ai7 Exp. Date: Home Improvement License: Exp. Date: ?hlle- 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: $ 3 do- o o FEE: $ 4an Check No.: —I Receipt No.: 3"0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Lqionature of Aqent/Ow er Signaturpnfrnntrarntni W. -W, i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r 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 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes �rlanning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp mumps#er on sit yes no Located at 1x24 Main Street Fire Departmen signature/date ,C®MMEN�TS 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.$10041000 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 4, 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 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 getthis 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 No. Date r� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ —" Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 411 f� 04 Building Inspector NORTfy Town of �� Andover 'k 10 o ; ~ No. * h ver, Mass rim O coc"Ic"awICK y�• 0047-E o �Pp��5 U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ...........Q..ere.m ................a�'... .................................... ................. BUILDING INSPECTOR 1 Foundation has permission to erect .......................... buildings o .. 'k... a �!!+'.�V!!�.. a . ................ • 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 TARTS Rough Service ............... ...7--- eve�AB�u�iING ......................... Final 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. Federal ID#05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 1�1�/ A division of Thiclsch Engineering CT Contractor Registration No 620120 RI E 60 Shawmut,Canton,MA 02021 ENGINEERING CONTRACT 339-502-5197 FAX 339-502-6345 Page 1 PROGRAM THIS CONTRACT is ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRGEO BELOW CUSTOMER PRONE DATE CUENTI WORK ORDER Jeremy Krause (978)641-1728 05/03/2016 434133 00002 SERVICE STREET e111IN6 STREET I I Robinson Court I I Robinson Court inn ((�v SERVICE CITY.STATT;ZIP etLUNG CRY,STATE,ZIP -1 fil North Andover,MA 01845 North Andover,MA 01845 �IY _ JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal area of your home against wasteful,excess air leakage. This work will be p concertwith 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 seat 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)ofair infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherizafton work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contrvctor to ensure the safety of tate indoor air quality. 5680.00 AIR SEALING ADDER: (2)working hours. $170.00 ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class 1 Cellulose added to(522)squats feet of open attic space. 5767.34 "EEWALLS:Provide labor and materials to install R-13 faced fiberglass to(252)square feet ofkneewall. Then insta112"rigid board insulation.Seal all scams with FSI:tape. 5919.80 KNEEWALL FLOOR:Provide labor and materials to install a 14"layer of R49 Class I Cellulose added to(180)square feet of open necuTill door. $273.60 ATTIC ACCESS:Provide labor and materials to insulate the back of(1)attic hatch with.2"rigid Thermae board.Weatherstrip the perimeter. $60.00 ATTIC ACCESS:Provide labor and materials to install(1) new,finished plywood.kneewall space access hatch.The hatch will be insulated with code compliant 2"rigid I hcrmnx board,weatinr-stripped,and held closed by eye hooks. (hood surfaces will be unfinished. Prime coat ami+or paint is not included.) -S120.00 ATTIC ACCESS:Provide labor and materials to make(1) access opening from one attic area to another by cutting a passage through sheathing. This access will be left opera as it is between my common unheated non fire%%illed attic areas. 531.31 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose to existing bathroom fan(s). $50.00 Federal ID#05.0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 }r/' A division ofThielsch Engineering CT Contractor Registration No 620120 RISE 60 Sbawmut,Canton,i•YA 02021 ENGINEERING CONTRACT 339-502-5197 FAX 339-502.4345 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT! WORK ORDER Jeremy Krause (978)641-1728 05/03/2016 434133 00002 SERVICE STREET MUZIG STREET 11 Robinson Court I I Robinson Court SERVICE CrFY,STATE,ZIP SUM CRY,STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION VENTILATION:Provide'labor and materials to install ventilation chutes in(58)rafter bays to maintain air flow. $116.00 COMMON WALLS:Provide labor and materials to install blowT!in Class i Cellulose to(60)square feet of 4"common+,,all through an interior surface drill and plug method. Plugs+vitl be spadcled and left in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the customer's responsibility.HGmeo++ner has received a copy of the EPA's Renovate Right Lead-Safe information guide explaining the potential risk of the lead hazard exposure from the wcatherization work to he performed.Your signature is your ackno+Ycdgemcni of receipt and agreement to proceed. 5111.00 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 52,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional 5340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality,Ave will be tonducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the wcatheri7ation work is complete.We will also conduct a full assessment of til combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable w•eatherization incentive is 53,110. 590.00 C �I } _J16 U U Total: $3,389.05 Program Incentive: $2,776.79 Customer Total: $612.26 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ""Six Hundred Twelve+&26/100 Dollars $612,26 UPON FINAL INS CTWRI AIA APPROVAL BY RISE ENGAMERLYG CUSTOMER AGREES TO ROW AMOUNT DUE IN FULL INTEREST OF T%VALL DE CHARGED MONTHLY ON ATNY UNPAID GALA! 70 DAYS.SEE REVERSE FOR IMPORTANT MFORNAIM ON GUARANrEEA RWMTS OF RECISION,SCHEOULWG,AND eo?I MCTOR REGIS TION. DO NOT SIGN THIS CONTRACT IF THERE RE ANY BI.A PAC ALRN Si En01ne"M�p TOMERh NOTE!TWS CONTRACT MAY BE VMHDRAV?I BY US IF NOT EXECUTED WITHIN 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 00 THE WORK AS SPECIFIED.PAYMENT MALL BE MADE AS OUTLINED ABOVE RISECanton,MA 020211339-502-6336 ••��== 60 Shawmut Road,ilnft 2 E www.FtISEengineering.com ineerin ENGINEERING g 9 OWNER AUTHORIZATION FORM ,. Jeremy Krause (Owner's Name) owner of the property located at: 11 Robinson Court, North Andover, MA (Property Address) (Property Address) hereby authorize (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. i slurs A � �J Date Dy �' 2fl16 • The Commonwealth ofMassachusetts Department of lndusWa[Accidents Office oflnvesfiga&ng 600 Washington Street Boston,MA 02111 www.massgov/daa Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers _AnplicanlL Information Please Print Legltbly Name(Business/organization/fu(lividual): Address: PO BCTat 958 City/State/Zip-Phone A.Ke you an employer?Check the appropriate box: _ 1. ' I am a employer with _ 4. Type ofproject(required): ❑I am a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheget. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. jNo workers'comp.insurance 5. ❑ We aie a corporation and its 9. ❑Building addition required.] ,officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions Myself [No workers'comp. c.152, §1(4),and we have no insurance required.]r employees. 12.❑Roofrepairs [No workers' comp,insurance required.] 13.❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy irdormstion. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lam an employer Mat is providing workers'compensation insurance for my employees. Below is tltepolicy and job site information. Insurance Company Name:_ r4A to r Policy#or Self-ins.Lie. Expiration Date: -p t P7. Ao -l> I _ Job Site Address'--/( U t'✓A SO v1 e- j Ci /State/Zi � p. n- 19/1'd veto r 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-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 here ce fp J ry IiY nder itie pains and penalties o er u that the irifo>wtation provided above is true and correct: Si ature: Date: _ Nione#: O fficialonly. Do not write in this area,to be completed by city or toren official Town: Permit/License# ority(circle one): I.Board of Health 2.Building Department 3,City/Tovm Clerk 4.Electrical Inspector 5.Plumbinglnspector 6.Other Contact Person• Phone 4. AC40 CERTIFICATE OF LIABILITY INSURANCE FDAT3/ 3EAA//2026OD/YYYY) 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 CONTA AME cr Linda Bog danowicz Insurance Solutions Corporation PHONE . (603)382-4600 FNC No:(603)392-2034 60 Westville Rd E-MAIL ADDRESS:lindab@ise-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A Western World INSURED INSURER B NaUtiluS Insurance Group Polar Bear Insulation Company Inc INSURER C: Po Box 958 INSURER O: 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. 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. INSRI TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER WDDIYYY MWDD/YYY LIMITS $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑R OCCUR DAM AGE TO RENTED. S 100,000 REMISES Eaoccu NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY❑JEa LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS H AUTOS Per accident S 5 $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 S WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVE ❑N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S l DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) 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 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA `- f~19W2014 ACORD ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025oni mi POLABEA-01 JONEI LL DAT ' DIYYCEp` lFldpTE OF LIABILITY INSURANCE 6l20i61/ ,r 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 NAME: Durso&Jankowski Insurance A enc PHONE --- — i FAX g y 11 Saunders Street ac NL EJ_(978)688-700D _ f(a>c,Nn:(t 978)688-7001_ North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Nautilus Insurance Co. _ 117370 INSURED INSURER S:Safety Insurance Company_ 133618 _ Polar Bear Insulation Co.Inc. INsuREae: Peter Leblanc&Steven Leblanc INSURER D P O Box 958 — - —= -- Andover,MA 01810 INSURER E; _ -- — INSURER F: COVERAGES - 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 CLAIMS. – ---- INSR AODLIISUBR: � POLICY EFF-'-POLICY EXP - -- - LTR TYPE OF INSURANCE 'INSD I WVD POLICY NUMBER I MIWD I MWDD UMns A COMMERCIAL GENERAL LIABILITY ' ;EACH OCCURRENCE 'S I i --- - i CLAIMS MADE !OCCUR DAMAGETO `PREMIEa occurrence) S -- -- -- ;MED EXP(Any one person) _ 'S_ — —` •.PERSONAL&ADV INJURY IS GEN'L AGGREGATE LIMIT APPLIES PER: I i GENERAL AGGREGATE j S PRO- € POLICY': JECT _ LOC PRODUCTS-COMP/OP AGG 5 OTHER: - - - -_.5 !AUTOMOBILE LIABILITY j 1 COMBINED SINGLE LIMIT j S – i Eepccident-_ 1.000,000 BANY AUTO 2100926 01104/2016;01/04/2017 1 BODILY INJURY(Per person) I S ALL OWNED SCHEDULED I - i !AUTOS X ;AUTOS 1 BODILY INJURY(Per awdent)'S NON-OWNED i !PROPERTY DAMADE X 'HIRED AUTOS X AUTOS 5... .. UMBRELLA UAB o r c _ OCCURRENCE OCCUR EACH OCC CU__ A - .i EXCESS LIARCLAIMSaV1ADE i J? AGGREGATE _ _- i SS --DED RETENTION 5--- - � I - — WORKERS COMPENSATION 1 PER OTH- ' :AND EMPLOYERS'LIABILITY i—'-STA---' . . - TUTE ER YIN. ANY PROPRIETOR)PARTNERIEXECUT!vE rr----�� 1 'EL EACH ACCIDENT ;S ;ANY EXCLUDED? "!NIA! I — --"'i - (Mandatory in NH) [E`L DISEASE-EA EMPLOYEE- If MPLO_Y_EE-5 If yes,describe under DESCRIPTION OF OPERATIONS below ! i E E.L.DISEASE-POLICY LIMIT i S 1 i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 CERTIFICA T E 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 9 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORS REPRESENTATIVE +r n+noo nn+n nnnon nnonnonrtnnd nu-...ds,.-,...,...,,.,a 1/4/2016 Preview:Certificates of Insurance -CERTIFICATE OF LIABILITY iNSURAI`dC€ DATE 1:.1ltDDYYYY) �- 01/04/2016 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 endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COUTACL :7At.SE- PHONE AJ Automatic Data Processing insurance Agency,inc IA4No.Eat 1 VC t•n i Adp Boulevard ADDRESS: Roseland,NJ 07068 D:SURERIS)AFFOP.01)IG COVERAGE NA1Ca U.SURER:A: NorGUARD Insurance Company I) 3147D INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER c: I PO BOX 958I Andover,ie1A 0181 D INSURER D: 'INSURER E: 1 IIisuRER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL:CtES OF 11ISURAtICE LISTED BELOa HAVE 6EE e!ISSUED TO THE UISUP,ED NAI::ED A.BOvE FOR THE POLICY PERIOD INUCA TLD HO i.!THSTAr:D!r-IG A^,.Y REOU!REI E(-IT.TERU OR COt-JD:T!Or•7 Or Aid)*COUITR.ACT OR OTHER DOCUME(4T S.,TH RESPECT TO:iH:CH THIS CERT!F:C:.TE TRAY GE tSSUEe OF.!.t.:Y PERTA'.tI.THE;NSUr'2ANCE AFFORDED BY THE P0-1:0Cc DESCIRMED HEREIN:a'SUB.iECT TO ALL Ti E TERL',S. EXCLUS:O' :,F!D COrID!T:O:dS OF SUCH POL!C!ES L!t.';TS SHOt!,'-!VAY HAVE BEEN REDUCED BY PAT)CLAa?S ILTRI TYPE OEItISUR.VICE IVSD S:JD AUULaUdH POLICY NUMBER lIt.:!LOD YYYYS It1::D0:YYYYiI MUTS COMMERCIAL GENERAL LIABILITY I i:—I-- SFitEl.l LIED Evi, r GEI:L AGQFEUAIcUI.111:.1°I'UE51=tE. :>E::EEE LnGL:r:EI�1 )5 .:!It; L IJEa �! .. II°i::•L'+_iaS :.I=CI' "C-_; AUTOMOBILE LLABILnY :'?a..r. L•alrc.Lcu:Aur I^ '—I I 1 l UI•: i E_L••IL':ICJUi:a�:psr:gni : -LC C':::.EL• •rcGLLEL -UI:^_ ECUIL'i e.P Y; d.. AFcil; 3 AW'Ut :.L -- •.11:• ,y W.SRELLALUM 1•�_CLf -ntr;:C;_!:I•-Ei:l=. EXCESS LIAB I CLaL1 l.S:,UE AUCK!AC41 t i I ULU i HEi EIa A:t.j I t'ORKERS CO:aPe ISATION X r'd: •:1 r. AUDELIPLOYERS'LIABILITY I �l•,IL ft I Eh I YtU )r,E I; 1.000.000 1. t v�:I!a N PO:aiC77?258 i D1/0112Q?6 0210?2Q1' EL E•:c1-a::c:c�:.1 � FPllcii-1.;�!.tFftli Ea�L CcGt (t.7—eat""in tit!) LJ EL.La5E•u. tr,Ir a-L::`E. ' 1.000,000 i-C, i nil:rr ci_r.:.ncl_>__: I ( I t!.U1=st i•c a ui.m 1,000AOO 1 or:-11-10"OF OPERATIONS i IOCATtOrtS:YEHILtES(ACORO let,ACtlieor4`1 Rem�lq Sch:eule.mrl be aiocl:ed it mwesrace is regiared) 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 AUTHORL'ED REPRESE11TATWE I A9 1988-2014 ACORO CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD grgdefion Office OfCO�mer s and 5170 - ��1�assae�is� - V8ffi� TVPM- DBA Tc# 2 19 ALAR SI=AR INSXJL&-fIOM CO- 70— �fi � LeBia c - - -- - -_-_ BOX 958aqMk�ANDOVER, MA 0 aior Q� AAdeess eura� OFS-�A1 c;SUNFC�7-� CSSLI81226 ryeM LMAM �j815m47 WE 03M