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HomeMy WebLinkAboutBuilding Permit #1023-2016 - 110 FARNUM STREET 3/30/2016 BUILDING PERMIT o� NoRTy BUIL TOWN OF NORTH ANDOVER2, /J APPLICATION FOR PLAN EXAMINATION Permit NO: ��// rI- Date Received Sys R�,Eo,Q��-cy SACHUS Date Issued: ORTANT:Applicant must complete all items on this page 1 21 35 N. NINON 14 ION $'"c `�jt� i •x K' ice+a> a+' „� j�� "3«`/+. ' y j , rma aTNERPR®PERO F r - �" TYP E OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑ One family El Addition Two or more family 11 Industrial ❑Alteration No. of units: ❑Commercial ❑ Repair, replacement ElAssessory Bldg Others: ❑ Demolition ❑ Other mfr : o . Z7 ME] eSeS Ite c ' ❑Well x. i o pl tonN :Wetlands ❑ Watershed Distract f`' ' ❑,W_ar/Sewe_r ..: =_ , �° °x46 } DESCRIPTION OF WORK TO BE PREFORMED: c'$t9h'n TTiC 1ti% v 2 -Y CL r Ja�i 4pyoh Identification Please Type or Print Clearly) OWNER: Name: Lav t i Y Sit vtv,,S Phone: S'?1f 79--?b ? -0%3 Address > a.-,.^ ,•'•S T sa4g s 177 �` ' Phone " C®N, ,RACT®R Name�►,�7T'i �c�i�'��►.;�.n�C�•�s..-- _ St,•r n."t + 2, Ygn M1 , 94, ._ SA"+sw. .aq- .. --•�tY. �r«,�,.,,e- ^rs - } 5 Xr• x' ?�r";,; ��b�' ,a,,i 4',34. `' °}'�S'^ fid } #�iyd�� �"ip ��'y� .fit` t - d` ^ j 4 ';*'°{ � --x r , , SuNnervisor's Construction License:: 4/ Exp Datef ° �� � �'," ,,CCyr Home#Im rovementLicenseW=/o -� •t4 °1 � Exp rhDate ARCHITECT/ENGINEER Phone: Address: Reg. No. y,. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. S Total Project Cost: $ 3 6 Do- FEE: $ Check No.: / �Z Receipt No.: NOTE: Persons contracting with unregistered contractors rho not have access to the guaranty fund kS gra ture}of Aggnt/Owner� .;�° ': . s t. . .� Signature of contractor . 1 �.w ,•3 Com. _ < Location No. 7 Date4;-�,oI� • - TOWN OF NORTH ANDOVER u, Certificate of Occupancy $ Building/Frame Permit Fee 475 Foundation Permit Fee $ !� Other Permit Fee $ ` TOTAL $ Check# 301 8.1 ` Building Inspector 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 FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature � COMMENTS S Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments }Water& Sewer Connection/Siqnature& Date Driveway Permit I DPW Town Engineer: Signature: Located 384 Osgood Street ,; f- tt s. i * .�_. S`.�� � ��i�t FIREDEPA_RTMENT °Temp Dumpste�on'site ,yes _�.� ��� no -R: L catetlat�124 Ma nSf�eet WIN r x _ r _ y> t�*� .f x'04 �' Y IFireDepartmentsignature/date - } .(g }q . r 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: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ® Notified for pickup - Date E i Doc.Building Permit Revised 2008 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 o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses a. Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass'check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products 1I0TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 o Engineering Affidavits for Engineered products N 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 Doe:INSPECTIONAL SERVICES DEPARTMENT-BPFORM07 Revised 2.2008 NORTF� Town o ? . : :_ F , Andover O Y A' No. ? l T If h ver, Mass.,% c0c"1c"2wjc« y1' X1,95 RATeo U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ...... IT LD al....... ... . I!i3 ..................................................... BUILDING INSPECTOR 1' � Foundation has permission to erect ............... .......... build' s on ... O ............ ..... •••• ........ ... Rough to be occupied as . ! ... .. .�w1 ....�...... �..'.. .. ... Chimney rm to terms of thea licatio provided that the person accepting this ermlt shall In every respect confo pp Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspectio Alt ration 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 UNLESS CONSTRUCTION ST RTS Rough Service .................... ... ...W................................ 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. I i Smoke Det. Federal ID tt 0"405628 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No:120979 S'* R! E A division of'1 hielsch Engineering ENGINEERING 60 Shawmut Unit Q.Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 1 PROGRAM THIS CONTRACT tS TTEREO Pilo BETWEEN FUSE CMA-HES ENG,INEERatG AND THE CUSTOMER FOR WORK AS DE5CRUIED BELOW CUSTOMER PHONE ��- DATE. CLIENT6 WORK ORDER Laurie Stevens (978)807-0103 03/21/2016 4322361 0---''�0002 SERVICE STREET mune STREET rn Le G {t \V! 110 Farnum Street 110 Famum Street 'SERVICE CM.STATE,ZW �T BILLING CIT1.:STATE.ZIP North Andover.MA 01845 North Andover,MA 01845 { d,6 ,LOB DESCRIPTION ,HAZARD BARRIER:We have identified that there me recessed light present in your home,unless the nxcssed.lights are i l as IC-rated(insulation Contact Rated)we,-will create a 3"clenrnncc space around the fixture:by using 6b4ass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed light witl not be insulated. $0.00 AIR SEALING:Provide labor and materials to scat areas ofyour[ionic against wastefal,excess air leakage. This wort:will be performed in concertm itb the use ofspccinl tools and diagnostic tests to assure that your home rftill be.lell with a healthful levet of air exchange and indoor air quality.Materiats to be used to seal your home can include Cauls,foams andother products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unheated areas(wind are not generally addressed)This will requite(8)working hours..A reduction in cubic feet per minute(cfm)ofair infiltration will occur,but the actual number ofcrm is not guaranteed. At the completion of the A althcrimtion work,and at no additional cost to the homeowner,a:Final blower door and/or combustion safety annlysis will be conducted by the sub-contractor to ensure the safety ofthe indoor air quality. $680.00 DAMMING:Provide labor and materials to install a 12"Inver of R 38 unlaced'fiberglass battlo(40)square feet for damming purposes. :$82.00 ATiIC FLAT:Provide labor and materials to install an 8"layer ofR 28 Class l Cellulose added to(984)square feet of opcnattic space: J ` 51.348.08 ATTIC ACCESS:Provide labor and materials to.insulate the back of(])attic hatch with 2"rigid Thermnx board.Wcdtherstrip the perimeter. $60.00 ATTIC ACCESS:Provide labor and materials to insulate(I) back of the kno6va'll hatch with 2"rigid The ninx board,and sett the edge of the hatch with weatherstripping. $61):00 V ENTILATiON:.Provide labor and materials to install(1)insulated exhaust hose to existing buthrooni fnn(s). $50.00 VENTILATION:Provide labor and materials to install ventilation chutes in(40)rafter bays to maintain airflow. $80.00 COMMON WALLS:Provide labor and materials to insta112"FSK faced semi-rigid fiberglass board insulation to(18)square]Cel of common wall area. $63.00 OVERHANG:i'rovide labor and materials to install 8"R-28 densely packed Class t Cellulose insulation to(30)square feet of exterior overhang located below a heated hoar arca;by drilling holes in the overhang from below. Holes drilled will be plugged. Plugs will be scaled with exterior grade spackle and left in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the customer's responsibility. 51,17:90 • Federal ID#05.040S629 RISE Engineering RI contractor Registration No 8186 NIA Contractor Registration No 120979 RISE A division of."ielsch Engineering ENGINEERING' 60 Shn►vmut Unit 112,Canton,MA 02021 339-502-6335 FAX 339-502-6345 Page 2 PROGRAM THIS CONTRACT IS ENTERED WTO BETWEEN ROE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DEscaiumBe mV CUSTOMER ._.._. � PHONE DATE.. CLIENTO WORK ORDER Laurie Stevens (978)807-0103 03/2112016 432236 00002 SERVICE STRUT BILLING STREET 110 Famum Street 110 Farnuln Street SERVICE CITY,STATE.ZIP 6112IND COY.STATE.ZIP North Andover;MA 01845 North Andover,MA 01843 JOB DESCRIPTION GARAGE CEILING:Provide labor and materials to install 8^R-28 densely packed Class I Cellulose insulation to(5f 7)square feet of garage ceiling located below a heated floor arta,by drillin.holes in the ceiling from below. Holes drilled will be plugged.,Plugs will he spackled'and feft in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the Customers responsibility. $1,023.66 :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 exceed 52.000 per calendar year.and an incentive of I OOOA for the Air Scaling measures up to the first 5680 and an additional 5340 if savings are justified by the auditor. For the safety and health of your homes 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 wcatheriration work is complete,We will also conduct a full assessment of the combustion safety ofyour our heating system and►rater heater.This has a value of$90 and is at no cost to you. Total allowable wcatherization incentivels;$3.110. $90.00 �/J�'/ F MAR 2 2 2016 i Total: $3,654.64 Program Incentive; $2,770.0' Customer Total: $884.63 wE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WRH ABOVE SPECIFICATIONS.FOR THE SUM OF ***..Eight Hundred Eighty-Four&631100 Dollars $884.63 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE PJ FULL INTERESTOF 1%WILL BE CHARGED 14ONMY ON ANY UNPAID BALANCE AFTER IO DAYS.SE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES.RIGHTS OF RECISION,SCHEDULING.AND CONTRACTOR RCOtSTRATION. DO NOT SIGN THIS CONTRACT IF THERE E ANY BLANK SPACES U �Wo YURE.1113E 'Wdt n0 _ C � ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRA►YN BY US IF NOT EXECUTED WITHIN.__..-m DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT.THE ABOVE PRICES,SPECIFICATIONS AND.CONOITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO"THE YIORK AS:SPECIFIED.PAYMENT YNaLBE MADE AS OUTLINED ABOVE. RISE6 0 Shawmut Road,Unit 21 Canton,MA 020211339-502-6335 ENGINEERING: wwmRISEengineering.com OWNER AUTHORIZATION FORM z-C4,4- s Q ri: (Owner's Name) f`y► t� t:� t>.— ll :, owner of the propertylocated at: ,. 2 2 016 �1 L !la f Q✓t� s ` (Property Address) % % 4 i/-0-6x, _/0z C?- Q L , (Property Address) hereby authorize ;)O ft. (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. ignature � Date v 7"lae Commonwetaltlt o,f Massachusetts Department of Industri%cal Accidents I Congress ess S'tt eet, Suite 100 Boston, MA 02114-1017 ' w v�� ✓ IVww nutss.boi1di a Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plum hers. I-O BL PILED t!'I"1'II'I-1IE PERMITTING AUTHORITY. Applicant Information Please Print L"ihly Hanle f.Basine s'Organization/indit•iduai): PO tA('br°G F � f�SV��a�i°0 r/J r�d. r�►C , Address: P 4 go City1State1Z.ip: 9hcoo✓.e F, pt/I�, o4lo Phone #: Are you an entployer?Check the appropriate hoz: Type of project(required): I ®i am a employer ovnh 4 rntployces(futi ant.For part-time)" 7. ❑ New construction '_❑1 atn a sole proprietor or partnership and have nn employees yo--orking ti,r me to S. [] Remodel inE arr capacity 110 x%otkcis'comp insurance required] i 3®i am nn a homcocr di+in g a8 cork myself 1tVit%tiort;cr'ram9 El Demoltion p insurance required]' 10❑ Building addition m 4❑1 am a homeowner and will be Turin_contractors to conduct all work on \ properto I will ensure that all contractors either have%%orkcrs'compensation insurance or are soic 1 I Electrical repairs or additions proprietors ovith no employees 12 ❑Plumbing repairs or additions 5®f am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comb insurance 6❑We arc a cn-poration and r1S officers have escrciscd their right ofexemptrnn per MGI_c 14 nOther 152.:1(4).and we have no employees jNo workers comp insurance required) "Any applicant that checks box<I must also fill our the section below showing then ocorkers'compensation polio inibrin tion I Iootcow'ners oyho submit this affidavit mdicatinE they are doing all ,vork-and then hire outside contractors must submit a new affidavit indicaun,such Conlrucinrs that check this box must attached an additional sheet showin the name of the sub-conti acioi sand_tate whether or not those entities have emploTces If the sub-contractors hayc employers,they must pro\ide their %voikers'comp pohc) number I ant an enWlt?yer that is•pros idinb workers'compensation insurance for int'entph�vees_ Below is tite polig and joh site h forniation. Insurance Company Nanle:A_Qq_ir- Polio = or Self-ins Lic. Y W Co 7� �a. T—P Expiration Date: d! di�etd/7 Job Site Address: City/State/Zip: A, 1�11QaBd-ll' Attach a copy of otic tit orl:er. compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverasie as required under MGL c 152, §25A is a criminal violation punishable by a iine up to$1,500 00 and/or one year imprisimment as'~�ell as civil penalties iii the Form of a STOP FORK ORDER and a fine(if up to 5250.00 a dad•against the violator A cope nfthis statement mai be forwarded to the Office of-Investigations ofthe DIA for insurance co veme,e verification. I do hereby c ei fy under the paigns and penalties of peritio-that the information pro iTitled ahore is true and Correct. Si_nature: trpj, ___yo Date Phone r: Official itse ottly. Do not write in this wren. to be completed br cin-or lown ojfic•ittl Citv or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health ?, Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector fi. Cather Contact Person: Phone N: '`°�RD® CERTIFICATE OF LIABILITY INSURANCE FD3i23�16'' 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 Linda Bogdanowicz NAME Insurance Solutions Corporation PHONE (603)382-4600 No):(603)392-2034 60 Westville Rd E-MAIL ADDRESS:liadab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A.Western World INSURED INSURER B:Nautilus Insurance thou Polar Bear Insulation Company Inc INSURER C: PO BOX 958 INSURERD: INSURER E Andover 14A 01810 INSURER F: COVERAGES CERTIFICATE NUMBER CL1632326134 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. NOTWTHSTANDING 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 I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LT POLICY NUMBER M Y MWDDrYYY LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED A CLAIMS-MADE $ OCCUR PREMISES(Ea on".nce $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL 8ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JELOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ 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 AUTOS Per accident $ $ R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS.LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY YIN AT ER ANY PROPRIETOR/PARTNERtEXECUTIVE OFFICER/MEMBER EXCLUDED? F—] NIA EL.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) III 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 Reith Maglia/SJA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r9ni4ntl POLASEA-01 JONEIL L CERTIFICATE OF LIABILITY INSURANCE FDA7E(MNIIDDNYYY)� 1/6/2016 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 endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE — —" I FAX 11 Saunders Street ac No Fxt_(978).688.7000 ! No):1978)688-7001 North Andover,MA 01845 E-MAIL - "— ADDRESS: i _INSURER(S)AFFORDING COVERAGE _ � _NAIC# _ INSURER A:NaUtiluS Insurance CO. — .17370 — INSURED INSURER B:Safety Insurance Co!lpany— 3361$ Polar Bear Insulation Co.Inc. f — INSURER C: Peter Leblanc&Steven Leblanc i P O Box 958 INSURER D_ —_ Andover,MA 01810 INSURER E: -- 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. -— — Lt -- - � POCYEFF j POLICYEXP LTR TYPE OF INSURANCE :INSD I WVD I POLICY NUMBER MMM MM/DD LIMITS A COMMERCIAL GENERAL LIABILITY I i EACH OCCURRENCE S iDAM CLAIMS MADE I OCCUR AGE TO NTED' PREM SE$JEa occurrence) S - - -- ME XP(Any one person) DE :S PERSONAL&ADV INJURY -,S GEN"L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is - ---- POLICY PRO _LOC PRODUCTS-COMPlOPAGG OTHER: _ O - --"-— 1 S AUTOMOBILE LIABILITY I COMBINED SINGLE LIMTi S 1,000,000 B -. ANY AUTO 2100926 01/0472016:01/0412017: BODILY INJURY(Per person) ;S ALL OWNED ii ) l SCHEDULED i 1 I AUTOS :AUTOS E BODILY INJURY(Per accident)'S ;NON-OWNED i PROPERTY DAMAGE ` HIRED AUTOS ii AUTOSt (Par .�t_enS _ ..— -'--- - - -'-- UMBRELLA LIAB OCCUR :ERCH OCCURRENCE S I — _ --- -- — A EXCESS LIAB 1 CLAIMS-MADE; I I AGGREGATE S OED RETENTIONS S WORKERS COMPENSATIONi PER -TT—H - ; AND EMPLOYERS'LIABILITY STATUTE 1 i ER.. iANY PROPRIETORIPARTNERIEXECY/N 'rUTIVE ' , i j E.L EACH ACCIDENT S OFFICERlMEIdBEREXCLUDED? � NIA� --- — -- ------ — i(Mandatoryin NH) i E.L DISEASE-EA EMPLOYEE'$ If yes,describe under -- DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT S i I j { i 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 Thieisch 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 195 Francis Ave ACCORDANCE WrfH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORRED REPRESENTATIVE u%-l000 nni n Af%rm:Cm f•fTO0f115A'rt/1IV All IW2016 Preview:Certificates of Insurance OAT Y)CERTIFICAT€ OF LIABILITY INSURANCE` 01/04120/6 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 po}icy(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 HANE: PHO!JEAX Automatic Data Processing Insurance Agency,Inc_ 1A:C.No-Extc wIC. i Adp Boulevard ADDRESS: Roseland,NJ 07068 UISURERIS)AFFORDING COVERAGE 1 NAICy I..SURER:.: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C. PO BOX 958 Andover,MA 01810 INSURER o_ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLIC=ES OF IHSURANCE LISTED SELO-HAVE BEEN:ESVED TO THE INSURED NAL;LD r50='E FOR THE POLICY PERIOD INDICATED.Ido i�::^•THSTAHOIHG ANY REOU:REI Et1T.TE-Pi.:OR CONDITION OF ANY CONTRACT OR OTHER DOCUi:;E(IT;4;TH RESPECT TO:;HiCH THIS CERT'F:CATS L!AY BE ISSUED OR LI:„PERTAIN.THE 3dSVPANCE AFFORDED BY THE POLICIES DESCRIBED HERE:Id iS SILBJECT TO ALL THE TERt.;S. EXCLUSIONS APID CONDITIOI•JS OF SUCH POLICES LIVNTS SHO1:T1 F.'AY HAVE 5CE-IJ REDUCED BY PAD CLAL"S AUVLINS TYPE OF UllL'x F P LtcY 1• 1 Le.:1TS LTR IVSD 1•NO POLICY NUMBER Ilt.hYDD:YYYY3 IIA.I:DO:YYYY1! 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I fandwory in NHl U 6L.Ot5E:•,t 6a ttu°L:Js6- ' 1,000.000 s•s:ny_:,:c•, [rs:.IaimctL:ICI-E1.:.Ni.1.S:,:::,:: tL.urEst-reuc-ucln 1,000,000 I DESCRIPTION OF OPERATIONS i LOCATIONS i VEHICLES(ACORO 101,AtltiGonat R-1a Sehetlute.MTJ be oteetud i1 more Space IS renlired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theiisch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Ow S,&M Rego`%Ou _ Office of c� to 5170 _ 0-2116 -BOStOr6lvb= DBA.ctor on - 2s Tao - POS BEAR INSt3LNTtOt� Minta t_�yeBlanC ANDOVM MA fl U _- _- _ p�fieAAdrMMd MW' co Los�Csr+1 ==` Address u Rnewai - -=- - DaZ Rag -wc!..ia:�' F giaistacw lilt 8