HomeMy WebLinkAboutBuilding Permit #661-16 - 110 WOODCREST DRIVE 11/30/2015 (S�eR BUILDING PERMIT �0R a o TOWN OF NORTH ANDOVER o i APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received V I / �q y y7 r �s �RATeu fe" .�`� I gSSACHUS Date Issued: 1 $ r IMPORTANT: Applicant must complete all items on this page r LOCATION Lc/0Je- c'Si off` ve- n n Pr' t PROPERTY OWNER �t 04 M A4 G41, Print 100 Year Structure yesno MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family I ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other �71Sd to to Ll ® Flootlplan ,® eflands ® a 'tershecl ©ist ig,,ctt {�,Ws�„ter°S e1Nf a•�i} � �.« �," �r�` "i.�� � ";st �.'i'#,`� .w �s' fi r*' �..�:, �p � t�� , � '� ,�, ` ' DESCRIPTION OF WORK TO BE PERFORMED: ,`t e>e ti/i'vk q R]-T;e TynSv1 c *'v - y5 Identification- Please,RcrType or Print Clearly 4 Wt G G a Phone: T>F-- y3 y� S� OWNER: Name: A () �t Address: I zv WGo J Ctt ti lDPA< 17, d,�nde -e r' Contractor Name: Ae-ve ` IeA(arc Phone: Email: Address: .2- egS7 �'rt Supervisor's Construction License: (o&ot> Exp. Date: t/faP11f r Home Improvement License: t o,�- 7? Exp. Date: ')L,� 11 G ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:roject CBULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Post: $ 6fee-6a FEE: $ Check No.: � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund o — e Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools [] i Tanning/Massage/Body Art ❑ -• I well ❑ Tobacco Sales ❑ Food Packaging/Sales '` �❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m D FORINT PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION Reviewed on Signature i COMMENTS HEALT H , , Reviewed on Signature i �Tt I COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments I ' Water& Sewer Connection/Signature& Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street &.. � "^e`°'f"�"'°''°r"'�. -. �.x 5S''_.?...�F.d S •SS ti: .It i' "' - Y *-sti r ' �.yzd- . ta. .$ FIRE DEPARTENT = Ternp Dumpstergonsife Mes no Y Located at 1W24 Main Street ., ,,, �l k `��a i�°+ j x Fire Department sign Lure/date rC.®MMENs ;S "� � ��• �� r :: : ' �,, ... i=5. t. •+�, r ;� ` Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ff.: 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 ease) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit 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 4� Floor Plan Or Proposed Interior Work a- Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks i Building Permit Application 46 Certified Surveyed Plot Plan Workers Comp Affidavit 4. Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 4. 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 pPermit Application 4, 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 f Location 110 ! �)�� ` /`-� No. Date -� - _ t • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ S Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ Check# � l.� 29745 Building Inspector s' y � c1pRTly Town of ndover O Y.•, L No. 41-w 1 "t _ _ ,� Pd . 0000 C, LAK h , ver, Mass, —Ad Its coc..ic„ew,cw 1_i. x,95 R4rED 1'Pp��S U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT NT 1 ,�.�., .............. ... BUILDING INSPECTOR has permission to erect ............. buildings on ...�.�...... '64 ,�.4AT. n. ®, Foundation .......... .... � � � Rough to be occupied as ...97),Ik .... �, ....... .. .L*um w!s....�.�.................................. 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI 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. Federal M0858495829 RISE Engineering RI Contractor Registration No$186 UA Contractor Registration No 129979 A diviem of lUetsc6 Engiaeeriog i 60 Shawmut Unit 02.Canton,MA 02021 CONTRACT ' 339-502-M FAX 334507.6345 pap 2 PROGRAM T,w IS�� ,� 1 CMA-HES E TIMCUSTONERFORvrCWrASDESCRM E CUSTOM PXM TB cum# Adam Ragab (617)834-9181 10/082015 410038 00002 Now=UiRIM'y 6-RDW W"Mur 110 Woodcrest Drive 110 Woodcrest Drive .STATK]W North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION ATTIC ACCESS:Provide labor and materials to butaii(t) easily moved,insulating cover for the attic access folding stair. A small flat surfaoe of plywood will be seated amid the opening within the attic. This will allow the covers integral wuaflw4tiipp"mtg to restrict air leakage. $237.65 VENMATION:Provide labor and materials to install(4)8"diameter roof vents)to increase ventilation in attic area,: The vent can be supplied in(circle color)black,brown,gray or mill finish. $342.00 VENTILATION:Provide labor and materials to install ventilation chutes in(40)rafter bays to maintain air flow. $80.00 RISE F.ngimewing will apply all applicable,eligible incentives to this eonmacL You will only be billed the Net amour. Currently, for eligible mcasurm Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 1001A for the Air Sealing measures up to$600. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air now in your home both before the work is begun,and after the motion work is complete.We will also conduct a full asssessmem of the combustion safety of your hewing system and water heater.This has a value of$90 and is at no cost to you.Total allowable %veatherrzation incentive is 52,690. $90.00 Total: $5,955.46 Program Incentive: $3,110.00 Customer Total: $2,84SAS WE AGRM HEFJMY70 FURNISn SFRVJCES-COWLM til AD[CEVM ABOVo SPt APAIUM&MUM£US OF ""Two Thousand Eight Hundred Forty-Five&451100 Dollars $2,845.45 R MBMAM!WUUDA�111�SMMMMFMDWO YAmC 7 GR MS.WM OP L1.EM91RlMAMCCOmrRAC1 M=ff AYATTMN�. DON SIGN t1TRAVr IF Tt{/BItE�AM BLAW SPACES///f Signature:�o s Nor�TwsC(SPIMCMAYeawmMwumrer�IFWTOlearraowmn Email: �vellygasQhotmail.COm ACCEP'rAnGC�CCa7aALT.TNaA50YaPRlCEB.aFFLiFSCAtICNBARD C ARa 30 oars 84T18CACrORYTOB8ANnA%N=AOS I�aANaAMORMY0e071411 M assFaa�.wrv►�rrwu BaerAoaasounna�aeova OWNER AUTHORIZATION FORM Adam Ragab 1, (Owner's Name) owner of the property located at 110 Woodcrest Drive, North Andover, MA 01845 (Property Address) 110 Woodcrest Drive, North Andover, MA 01845 (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature z� 1 Date I2 pr 611 G�- RN oerR�tor Raglst�Ort l6b lase � no A divisleo of7bNdseb E�eatag law a UI&MC82101 4 b1AMM CONTRACT FAX3394 0?r6M Page 1 PROGRAMOW aoseaanuera�aaosar�aaree CMA4= a a®MINE moraenaneatras npur Adam Ragob c (617)834-9181 10/0812015 410038 00002 c=l �fm 110 Woodte+est Drive 110 Woodcrest Drive -anwraw.awip mum Q� kion Andover,MA 0 809 c Nw&Andover,MA 01845 Minn 0 JOB DFSCREMON AIR SEALING:Pmvide laborlaimffitswas—wo ydar h=eplmt westadd„amass air tealW This walk will be pa0unted In ootroat aifb do ose of mesial tools sad diegneatie tests m assure that ysnrbuo will be led wbh a be ddM level of airea a and ftbasir witty.Moulds to be aced to seat ysur home can indade codk;&s.wca&asrip ft sad add pndam Pdmoy ow Por sealing btdade driedaptowimbmanamdwilSand other nafaate0 arses(wiadotivs e s wit pmalyaddw>.07)w= hu At tlo sompWwaf the bidin work,ad at no adder cost$*dm bomwwner,a final bower dam aftrounbustion saftmabsbwMWooadmWbydmmboonuuw oasm dwsa&wofdaeb*wairqu tyAUDII nNOT'ESTHE HOUSE IS A GMT 190S RANCH.V SHAPED THE BASEMENT IS 3/4 FINISHED WITH FHW HEAT SUPPLIED BY A DMBCr VENT"%BOILER THE SEC OND RAM HAS A HYDRO-AIR SYSTEM SUSPENDED FROM RAFTERS.THERE M ONLY 3 TO 6 INCH OF INSULATION BETWEEN THE ATTIC AND LIVING SPACE I PBRPOSE THAT THE HYDRO-AIR. SYSTEM HAVE A 10X10 ROOM FRAMED AROUND rr.THROUM THE PROGRAM WE THAN na"TE TILE IWO ROOM AND USEr RMUED BOARD ON THE OUTSIDE FACE OFSTUDED WALL,THIS WILL MUM TIM HYDRO AM SYSTEM OISiDE THE THERMAL.BOUNDRY NEXT WE ALR SEAT.BETWEEN THE ATTIC AND LIVING SPACE,THEN AM8II4CH BLOWN INSULATION ON ATTIC FLOOR.ALSO NEW 6 ROOF VENTS ON BACK SLOPE OF ROOF,SO THEY ARE NOT VISABLE FROM FRAM: ANY WORK IS CONTINGENTS ON THE HOME OWNER HAVING THE 10X10 ROOM FRAMED IN AROUND THE HYDRO- AIR SYSTEK TION l MUST RBOWWrTO ADIFST FOR INSULATION.. $1,275.00 $0.00 DAMM M Provide labw and awls to Iraod1 a Ir Nayer ofR-38 aatbxd M=W bans to(128)sip=feet for deatmiwt F+aF� oo ATTtC FIAT.Providelaborsad affialdsto h*UU as 8.lggerofR-=Chm 1 CdMmaddodto(2016)sgum feetofcpeaadie spMAUDITOR'S MOTES THE HOUSE IS A GIANT 19ti0'S RANCH.V SHAPED THE BASl16 W IS 314 F04SM WITH FIN HEAT SUPPLIED BY A DIRECT VENT95%BOILER THE SEOOND FLOOR HAS A HYDRO-AIR SYSTEM SUSPENDED FROM RAFTERS.THERE IS ONLY 3 TO6INCH OF INSULATION BETWEEN THE ATTIC AND LIVING SPAM L PERI M THAT THE HYINtO%MR SYSTEM HAVE A IGKIO ROOM FRAMED AROUND IT.THROUGH THE PRO(NRAM WE THAN INSULATE THE IQXIO ROOM AND USE r RIDGED BOARD ON THE OUTSIDE FACE OF STUDED WALL,THIS WILL BRING THE HYDRO-AIR,SYSTEM INSIDE TILE THERMAL.BOUNDRY.NEXT WE AIR SEAL. BETWEEN THE ATTIC AND LIVING SPACE,THEN ADD 8IMM BLOWN INSULATION ON ATTIC FLOOR.ALSO NEW 6 ROOF VENTS ON BACK SLOPE OF ROOF,SO THEY ARE N NOT VLSAHLE FROM FRONT. ANY WORK 13 COM'M0EM ON THE HOME OWNER HAVING THE 10X10 ROOM FRANNIED IN AROUND THE HYDRO- AM SYSTEM,THIN I MUST'RB4NSPECf TO ADIEST FOR INSULATION_ $2,620.80 FIX EIISTTNG INSUTATION:Stasb 9w vapor bmeieti flieran jaddoa(2016)sgaaeo Poetofbmbdm is do sale area. $SOL00 KNEEWALLS:Fmv[de labor sad mates to ball r FSK had semi-rigid M j0 ,,bowdhwddwto(I6Q)sq=cfbftaf kmvidl wmTTIS IS FOR THE ROOM WHICH WILL HOUSETHE HYDRO AIR SYSTEM IN THEATTIC S56Q00 A��® CER-nFICA7ff ®F LIAGIL" INSURANCE °' �"` " � 12/182014 THIS CERTIFICATE(S 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 NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S).AUTHORIZED REPRESENTATIVE OR PRODUCER,ANDTHE CERTIFICATE HOLDER. ; IMPORTANT If the cerUffcate holder is an ADDITIONAL 116URED,the policy(ies)must be en orsed If SUBROGATION IS 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 suchendorsement(s) PRODUCER AL NnNE: Automatic Data Processing Insurance Agency,Inc. ( r-NmEXO: (&.C.tv): 1 Adp Boulevard nlmRESS: Roseland,NJ 07068 4V5URER(S)AFFORDING COVERAGE NntC S INsuRER n: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INS ULATION CO INC INSURERe: - DBA:Polar Bear insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E: ENSURER F• COVERAGES CERTIFICATE NUMBER. 291629 REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE' BEEN iSSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTLYITHSTANDING ANY REQUIREMENT.TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUM=ENT WITH RESPECT TO WMICH THIS i CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT TO ALL THE TER MIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIR TYPE OF INSURANCE MS 01 rmw I POLICY NUMBER emLODXYYY) RWDD:YYYY) LIMITS COMMERCIAL GENERAL UABanY EACH OCCURRENCE S CLANS-LIAUE MOCCUR PRErtiSES IEa accwrcrcel S NED EXP 1Argcarte p.rwr./ 5 PERSONALEA¢rtnju Y S GEWL AGGRECATE I=APPLIES PER. CENERALACCRECATE S POLICY PRO JECT LOC PRODUCTS-COMPAP nGL S ROTHER, S AUTOMOBILE LIABILITY LUMSINtU SINSINLLL 0.111 S tEa aLLWaM ANY AUTO BODILY INJURY(Pu antro! S ALLOSVNED SCHEDULED AU705 AUTOSBODILY INJ URY We acniderel S HIR EDAU7OS NON-017NEE) AUTOS (Per xctidenU S UM3RELLALIAB OCCUR EACHOCCURRENCE EXCESS UAB CLAIdS�LUYDE .1CGREGATE S DEO RETENTIONS S WORMERS COMPENSATIONX S A7UT£ ER ANDEMPLOYERS'LIABILITY ANY PR OPRIETOR.PARTUEREXECUTIL•E YIN El EACH ACCIDENT S 3.000A11D A OFFICER AcGiBEREXCLUDEDI Y N!A N POLVC660990 01101/2015 011O1J2016 (Mandatory in NHI EL DiSEAS E-EA EMPLOYE S ],000,000 Ryes TIOeorrrler ELDISEASE-POuCY UMIT S 1,000,000 �SCRWnONOF OPERATIONS LtIu:L DESCRIP7M OF CPE161TIONS iLor,%n NS!VENCLES(ACORD 101 Ad&t6eal Renar6 Schedule,am he attached if encuaspace is raquk m Columbia Gas massachusetis i CERTIFICATE HOLDER CANCELLATION SHOULO 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 CranStOn,RI 02910 AUTHORIZED REPRESENTATIVE i �1 i.e..—�Yl• 11L.:� AG 1933-2014 ACORD CORPORATION.A0 rights reserved. ACORD 2S(2014101) The ACORD name and logo are registered marks of ACORD G OP ID-BB ��'a®RD,, DATE(MMtDtlIYYilY) CERTIFICATE OF LIABILITY INSURANCE 03/13=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), AUTHORRM 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 WANED,subject to the terns 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 endorsements. PRODUCER CO Durso&Jankowski Ins Agcy LLC NAMENrACT FAX 198 Massachusetts Avenue (ARM°es NO North Andover,MA 01845 Durso&Jankowski Ins.Agcy. ADDRESS: c M s:POLAR-1 ENSURER(S)AFFORDING COVERAGE MAIC S INSURED Polar Bear Insulation Co.Inc- INSURER A:Penn America 32859 P®Box 958 SURER a;Safety Insurance Co. 33618 Andover,NIA 01810 I11SURE-R C: INSURER o: INSURER E' INSURE RF: 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. OL Oull NS TYPE OF INSURANCE POLICY NUMI3ER MMID EFS FO E� U11ITS GENERAL LIABILITY EACH OCCURRENCE S 1,000, A X COMMERCIAL GENERAL LIABILITY AC7052023 03J24P1015 03@4P2016 PREMISES F2 acamenea $ 50,00 CLAIMS.MADE ®OCCUR MEO EXP(Any ane Person) S 51 PERSONAL&ADV INJURY S 1,000,000 GENERALAGGREGATE $ 2,00010 GETrLAGGREGATELIMITAPPLIESPM PRODUCTS-COMPIOPAGG $ 1100010 POLICY r I PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE UMIr S 1,000,00 B ANY AUTO 2100926 01/04/2015 01104FAM 6 (Ea acadern) BODILY INJURY(Par Person) S ALL OWNED AUTOS BODILY INJURY(Peracdderd) $ 1C SCHEDULEDAUTOS PROPERTY DAMAGE S HIREDAUTOS (PER ACCIDENT) X NON-OWNEcDAUTOS 5 5 UMBRELLA IJAB N OCCUR EACH OCCURRENCE 5 1,000,00 EXCESS LIAa A CLAIMS-IIfAOE AC6906M 03024/Z015 0IV2402016 AGGREGATE S DEDUCTIBLE S RETENTION S $ WORKERS COMPENSATION WC STATU- ANDEMPLOYE.RS LIABILITY ANY PROPRIETORIPARTNERIEXECUEIVE YEN EL EACHACCIDENT S OFFICE'RIMEMBEREXCLUDED? Q MIA (Mandatary inNl) E.L.DISEASE-EA EMPLOYEE S I Ifyas,describe under I] DESCRIFnON OFOPERATIONS beiwi I FI 0ISEASE-P000Y UMM S DESCRW ONOFOPEMTIONSILACATIONS/VOUCLES(AUaehACORD107,Ad&aonwRemakeSchadtdo6 fmmmopacolorequired) Insulation Work-Mineral;Additional insured for general liability,vu h scts o work performed on their behalf by the above insured is Yhleisch Inleering CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DATE THEREOF, NOTIC Thleisch Engineering ACCORDANCE EXPIRATIONWITH THE POLICY PROVIS ONS. WILL BE DELIVERED IN Columbia Gas 195 Francis Ave AUTHoRMED R1EP,ErrATME Cranston,R102940 ©1988.2009 ACORD CORPORATION. AU rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD i Ae(0)® CER-TIFICAn OF LIAGIL" INSURANCE Ea�iE(nm��vrvq Lift 12/1812014 i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1 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.I the certificate holder is an ADDITIONAL INSURED,the policy(Ies)must be endorsed.IfSUBROGATION IS 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). PRODUCERPHOAC NAIVE: Automatic Data Processing insurance Agency,Inc. (Ar-Na ExO: (AL nvz 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 MSURERR)AFFORDING COVERAGE NAIC; INSURER A: NorGUARD insurance company 31470 INSURED POLAR BEAR INSULATION CO INC MSURER B: DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 291624 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAL;ED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUbtENT WrrH 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 TERIMS, i EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW%S_ I LTR TYPE OF INSURANCE MSD LYVO1 PMXYNULtBER R.tILODfYYYY) WNIDD:YYYY) LIA115 COAVNERCIAL GENERAL UABM11tY EACH OCCURRENCE S CLAR+IS43AUE F-IOCCUR PREMISES(Ea Lvutrcr:cel S NEDEXPIArr!une Ntxrt S PERSOtb!&A PPP URV S CENT.AGGREGATE LIM,PPUES PER. GENERALACCRECATE S POLICY❑PRO- RQ LOC PRODUCTS-COLIPAP ACG S OTHER. i AILIMIM LLE LIARILrIY rEa zcaidenU ' S MY AUTO BODILY INJURY t1'e Ixrsa.) S ALLOSYKEDSCHEDULED 6001LYIN)URY(Perauidert S AUTOS AUT 05 HIRED AUTO$ t�N-0Y,T:EU - Pet aeutletJ..b(, g i AUTOS 5 uI-BRELLALIM Occult - EACHOCCURRENCE S l EXCESS UAB CLAMISd:IADE AGGREGATE 5 DEO RETENTION S S WORKERS COUPEASATtON x SL\TUTS ER ANDEMPLOYERS'UABanY!N Y ��000 ANY PROPRIETOR.PARTrd:REXECUT16f El EACH.ACCIDENT S wi A OFFICERA7MBEREXCDEDt �N!n N POWC660990 01)01/2015 01,019016 �•0� 1 (Nandatmy in NH) EL DISEASE-EA EAII'LOYEE S L IIf DES dIPTIO OFO EL.OISEASE-POUCYUNIT 5 1,000,00D DESCRIPTIONOF 01'EItAT10A5 urlus DESCRIPTION OF OPERATIONS!LCY-%n D5!VEHICLES(ACORD IOL Ath6t6rel RernarloSchuduk.mw beattached ilmmespam is required) Columbia Gas massachuseus CERTIFICATE HOLDER CANCELLATION SHOULDANYOFTHEABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Theilsch Engineering,Inc. ACCORDANCE W(THTHE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AVFHOOMDREPRESENTATIVE I A�190-2014 ACORD CORPORATION.All rights reserved. ACORD 2S(2014,ob The ACORD name and logo are legislated rnarlcs of ACORD Y`\ The C01111710111vealth of 1I4Iassachctsetts Department of Industrial Accidents : ► _ Office ofInvestigations 600 fflashington Street _ F' Boston,AfA 02111 www-mass 9 ov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers . licarit Information I'Iease I�rint LeaibI� \ame (BusinessjOrganization/individual): �0 [q}� t ¢gt �" � � � AO ® �- Address: Citv1State/Zip: flirt®tyfPhone#: Are you an employer?Check the appropriate box: Tyype of project(required): 1. •I am a employer with _ 7 4• ❑ 1 am a-eeneral contractor and I entplov ees(full and!or part-time).' have hired the sub-contractors 6 ❑\ett:construction 2_❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me in any capacity_ employees and have workers [\o workers' comp.insurance comp.insurance.'� 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I atm a homeotvtler doing all work- officers have exercised their IL 117 Plumbing repairs or additions myself.[-\o workers`comp. right of exemption per MGL 12_Q Roof repairs insurance required.]T c_ 152_S 1(4),and tie have no etnpiovees.[No workers` 13.[R_Other �A1,J A 740 tfi comp.insurance required.] `An}-applicant that cheers box=I mast also fill out the section M-ow showing their%vorkers compensation policy infor.natinn. r I lonteowtters who submit this affidavit indicating they are doing all.vork and then hire outside contractors tiros[submit a nett-affidavit indicating suds Contractor that check this box must attached an additional street showing the name of the sub-contractors and nate tdtether or not thuse entities have empiovees_ If the sub-contractors(tate employees_they must provide their workers'comp.policy number_ 1 ant an enrplo}ger that is provi,-Tng;porkers'contpeitsation insurance for nor emplat:ees Below is the police'ant!job site information. Insurance Company Name: 1 9 Policv 9 or Self-ins.Lic. JDo vie- &0 Expiration Date: P bh& Job Site Address: / (0 t:✓oe d Cit Sr Qf,tifp City!State2i : v`r'ter Attach a copy of the workers'compensation policy declaration page(sho%xing 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of die DIA for insurance coverage verification. - Ido hereby rertifi•to der the pains and penalties ofperjttn'that flee information provided above is trtte ane!correct. Sianature: P Date /f�3 8l/5^ Phone=: ?® Official use ottde- Do not write in this area,to be completed be'city or toren official City or Town: PermitlLicense R Issuing Authority(circle one): I_ Board of Health ?. Building Department 3_City/To«•n Clerk 4. Electrical Inspector 5. Plumbing Inspector G.Other Contact Person: Phone n: of race of Consumer Affairs d usiness R�e��°n - - 10 Park Plaza-Suite 0 70 Boston Massachtlse� stration Improvement Contractor Regi HomeP - Re96on- 102726 -_ - Tvae= DBA Tr# 2=49 Expiration_ 7t2i2016 POLAR BEAR WSULATtON CO- Vincent LeBlanc _ .---- P.O. BOX 958Lesson for ehaage. ANDOVER, MA 01810 _Updau Addressandreturn-- pmploymea ❑Lost Card - Address Renewal �y - 01216 0PS-CA1 Ei 59M4 r'� 9 Massachusetts -Department of public Safety 3oard of Building Regulations and Standards Construction Supen iyor Specialt. . License:CSSL 106017 11 r p$TSR A LBBLAN+C r 2 EAST pM SMET-' 11-44 plaistow NH M65 Expiration P'� 0412812018 commissioner i i