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HomeMy WebLinkAboutBuilding Permit #1168-2016 - 114 MARBLEHEAD STREET 5/10/2016 BUILDING PERMIT o` ttO oT"�+ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 70 Rq c [M[w!w Permit No#: Date Received s —116 SACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page I , LOCATION ch lelb eTi- Print PROPERTY OWNER k'tv h W► 1 (0 Print 100"Year Structure. yes . Ono MAP. PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg X Others: ❑ Demolition ❑ Other V/ei7 pa vI ElSeptic ❑Well' ❑ Floodplain ❑''Wetlands ❑ Watershed District 0 Water/Sewer_ DESCRIPTION OF WORK TO BE PERFORMED: Seri h' , �'t1-r �. 1N SV R T1'617 7v �-yy . y-en? y Identification- Please Type or Print Clearly OWNER: Name: keyi✓I t o Wo e Phone: Address: i(. 4racf S r Contractor Name: Peter Leblanc Phone. Email: 2 East Pr We j3treej Address: Plaistow., N.H. 03865 . 978-407-7638 �= Supervisor's Construction License` IOL e I Exp. Date: Home.Improvement License: Exp. Date: 2 bLG II 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 ) 00. 60 FEE: $ �� Check No.: Receipt No.: NOTE: Persons contracltinj with unregistered contractors do not have access to the guaranty fund Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application �. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4, Floor Plan Or Proposed Interior Work 4 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) I :. Mass check Energy Compliance Report (If Applicable) 4. 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer [] Tanning/Massage/Body Art Jwimming Pools ❑ Well ❑ Tobacco Sales ood Packagiag/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 Sign-'----- COMMENTS i natureCOMMENTS HEALTH Reviewed on Si nature COMMENTS - � r Zoning Board of Appeals: Variance, Petition No: 4 Zoning Decision/receipt submitted yes 4Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si r - ef ;FR 14 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 d Electrical Inspector r® requires approval Yes p � l�roval of DAIVG Z®1VE LITERATURE: IVo MGL Chapter 166 Section 21A—F and G min.$10$1000 fine �® NOTES and DATA (For department use) f Date Ll Notified for pickup Call Email � Time Contact Name i 10c-Building permit Revised 2014 , Location "At"t t � No. _ -2 Date � �L) • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee TOTAL $_r' Check# 30349 f Building Inspector NORTH Town_ of 0 oh ver, Mass, a 2LAKS �� COCMICNIWICK �- �A �V Ll BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System t BUILDING INSPECTOR THIS CERTIFIES THAT ................ ..L914.1 .........U. Q ...... ............. .... p g .'.�.. .......... . .� :. ... Foundation has permission to erect .......................... buildin s � Rough to be occupied as ... .. �....�.�.%�r�. ' .,rerms �'4�. .... ~ICA Chimney provided that the person accepting this I. t shall in every respect conform to the of te 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 CONSTRUCTION RTS Rough Service ................. .... ...�.................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. t ( dl5; &, s,r r" RPSE EngeFi39 FoetoA dhis+on nrThiNEagiteeriog Rx Ob0445MUS omrctorReglafrsyo n No itENGNEERiNG• FAA Contractoritegietration No t2a979 GO S>tau mu[itait N3 Cantoa.►L4 CT coabactprReglstratlon No (401)704-3700 FAX(401)7"3710 CONTE A CT PROGRAA! Page 1 CUA HES -_ -_.-•• •._..._.. _ �eF3�Ot rg���Fe1WEE�rral5a Kevin Willoe - `-" -- ----------•---•----.-._.._.__ --- micarr tror� �� stavrcesTrtE� (G17)5)0-7313 DATE �O aromc `-• :� 'i --- ------------- U4/04120tb 429179 116 Marblehead StreetMaste --------- 00003 [ 'ER"CE•arra►aie am-------•----- ---•.- -• -- 116 Marblehead Street Masle --'- - North Andover,MA 01845 — - eararD aTv,arAtEav— --------- -- - - ------ North q[tdovil MA 01845 JOB DESCRIPTION AIR SEALING:Protide Iahm and - Perfnrmed in oattcetl With the rrst 0nfmrerials to seal alas of)vltr home aircxchangc and indoor air 'poet tl(DO1S and dtsgnostic tests 10� t u�t�ful.aC0.'SS air leakage. This vrtrk will be areas fin-scaling9ualiq_Materials 10 be used to senl)mrr Isom c that)mrr Mmtc tvi)I be icft with a hcaithfid level nl' addressed. iIl ludo air leakage m anies baseutents cast include caulks.f number of a misis no 1g�l (8)enrk' attached gtaa8a and other wheand Dams and other Products. Priman. guaranteed. how A reducthm ie cubic feet per minute(efnll Drool r nfilttrttiun dowsaril of rcrternll)• At the ea occur,but the actual TrttPk q,or ftc"alfter'nlion tvtrik,turd at tut additionai cost t0 the hunternrTrcr a final bhntrr +all tc analysis sill iro cOndDtycd h)dee stdn Dna trwo,to evrsrrrc the•:ores)of the indoor air r door and/or contbagiun Prality. 01"1MINri:Pmvidc1ah0rand materials !'ttm<rscs. to instail a 12"ker 0fR-38 unraced I heMass bans t0(741 squaro fa t for damming S68il ATTIC Ft.A•r:Provide lalxu• _ space. and materials to insWII a 13"imtr 0fR-15 Class I(cllulosc added to(796)square tecl of 5151.70 vpert tttiic A'17iC ACCESS:PnTtide Iahm mrd in aerials to insulate dre bark of the attic d Will With TtvallTcrstripping to ns[ria air leakage. S1.297.49 Dor Milt 2"rigid Th__board and seal rbc doors VENTILATION: mat Provide labor and erials to install i 3)12"ditaneter" '71to tent ctuT br st lied in circle rnitu)blacl,hmttTt. tpP 1 torr finish. "ntrnc�ntls)to men'I vc illation in attic $73.91 gory or mill finish. VENTILATION:Prustide lek0rand tttahxials to iaatill(1)insulated cxlgast hose with nmtm Waisting bathroom farts)• 5357.30 uunkd flapper vera to cxhanat VL•'NTilA77ON:Provide labor and materials uT install ventilation chores in lG0)ratter bats to maimain air RuTv. SI 18.75 t3A c meCEILli4G:Protide labor and to to inspol(lag)lienar roti of R-19 tmfam oft haserttem tailing at the house sit! rglass insulation t0 the5120.00 Perimeter 1tfSE Eugirrncrhrg.aiflttpply all applicable eligible intitq pt this contract, Yuu trill tort for Scaji c ntcttstttcs,Colo Zap fins Ofrer,75Yo incentive,nm to exceed 52.000 Air Sealing measurer )be billed the Nut amount (;urrend); 5260.71 att to the firs)5680 and ort additiwta1334U ii:satin Par cadlen r gs are justified by the auditor meentitr of 10[I9L for sloe For the.relay and health of )vur home )rota hrneg x indoor air gvalin;tot will be conductible a bloTtyr door diagnostic of the etmilable air limy in [ both bcforc dramurbri isbegun Micilleats lveotheriaat+on amt;is complete.We will also e0nduq a full a ntmbastion saCcty of} ttt'atheriraliun)necntite k 53,11 R tater•This has n smlur 01'590 mrd is at rat CSGSwable of i oust to you, Toms allowable S9ul I I RISE RI SE Engineering A Ql�isimt of Federal I Ct0r R9j;ftV g Thictsch Engl..i.g Ri ConeraeDDr Regtsir�tton No 8188 ENGINEERING- P+A Ccn&3MrRegtglTM NO 120979 les fi0 ShaTrrt�Dt Coll NZ,Cunfun.3s7A CTC-b3CtWRegw on ND (401)7Hd_3700 FXX(40 1)704-3710 'L®e�Ig u C+ pp��•e-RT �T +�Ne PROGRAM Page 2 QnRCAfEt,--_ -- '—_ _ _.-.... CMA-HESCCNMQM qpj EHTEAEDMT09ETM@pNADi6 Kevin Willoe - - __ DEECAmEoeEaO°s*o+�n�eiTowcas Pie (617)510-7 _._`.__.---•- - DATE __• ---- --------- aEAweE sntfiET 313 ' D'�CR _ 116 MarbleheadStt�eet Roast, - -_ -- ��12016 429179 00003 __ _ - - -- -- - - --- - - —_ Marblehead ---------- 116 - cnY,srA*fi,2V Street Mast, _ North Andover.MA 01845 - -- -- -._- - _ eit1d+D afY,smTE.iw------ ---- ----- -- -North Andover,MA 01845 JOB 1DESCRDP77ON -- -- --- Total: $3,149.89 pram Incentive: $2,554.92 WE AGREE HEREBY TO NR7CI5l1 SERVICES.COMPLETE ACCORDANCE WCustO mer Total: $594,97 ITH AaOVE SPED-A-ft.FOR THE..OP "•Five Hundred Ninets uPDA MAL D+9PEcrrouauD APPA ._ UnPA1DeAlgeJDEA�E_RSODAY_g.9EE�Dy RWE y-Four g 971400 Dollar eEyERs OAD'pIgT07AfiRADAEESTp $594.97 IDPDATAHT� •unDA OA 611AR�Tl65.l�HTg DO NOT SIGN THIS CONTRACT w =-mcm aFao F, THEREAMA Y LA K pS/P/pg�/�` AufApqQED SIDNATIJAE•RDE Eg4mpJp0 � -_ ___.... _ -_ :(. -� __ __ W9TDf2 JINN . !A)lE Tmo COUT 44CTMAYOIMUMI IIJOYUS row E+EprTEDYJRMA - /r /// •_ --_ _ _. ._ S 9 DATE op--T-Um or DAYS. A=pACyM TDIRy HERE .9PEC�rfCA ASSpEeMMM Tp $AAD COpWT{Ong ____. 0.PnYDEDARE YA'LL efi AlGpg^DME AeTHORLvED TO DD THE WDNR ABM U � 6 RiSE60 Siwrfmut Road.Unit 21 Caston,f4A 02021 1339-502-6335 E\GINE_RING wM-1-RISEengineering.com OWNER AUTHORVATIOM FORM K_evin__Willoe o.,rner of titio propony?oCatad at. 116 Marblehead Street -- North Andover, MA 01845 hero y attmofO ze 3n authorized authorized subcontractor for RISE Engineering.to act on my oohaM to obtain a building r.•ttrmit and to nrrfnrm wnrc on my nrnnealy Tho-4 form;.nn1 watrcf:vitt:n cinnnd mnimm a O�.nvr's gnaturo wov/ Date The Commonwealth ofMassachusetts Department oflndushialAccidents Office oflnvestigationg 600 Washington Street U Boston,MA 02II1 www,ma-m0 'Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/�Plu tubers A licant Information • �.'Iease Print Le i Name(Business/Organization/Individual): Address: PO BOX 9M City/.State/Zip: Phone#: Ivo Sl�'S� L guan employer?Check the appropriate box: _ a employer with�_ 4. - Type of project(required): ❑I am a general contractor and X loyees(full and/orpart time).* have hired the sub-contractors 6• ❑New consizuction a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling and have no employees These sub-contractors have 8. ❑Demolition ing for me in any capacity. workers'comp,insurance. orkers'comp.insurance 5. ❑ We ai e a corporation and its 9. ❑Building addition red.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemptionper1VIGL 11.[]Plumbingrepairs or edditions lf.[No workers' comp. c.152,§1(4),and we have nonce required]i employees.[No workers' i2•❑Roofrepairs comp,insurance required] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information; T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mt subit a nw g tContractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers'comp.policy information.usmeaffidavit indicatinsuch. lam an employer•that is providing workers'compensation insurance for information. my employees. Below is the policy and job site Insurance Company Name: d t Policy#or Self-ins.Lic.#:_ W'C '7� f—� Expiration Date: " Oi Job Site Address:_ // W'41 b/rh .0 rj j City/State/Zip:_4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequired under Section 25A ofMGL 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 ofthis statement maybe forwarded to the Office of Investigations of the D9 for insurance coverage verification. Ido hereby ce *y nder thepains and enalties o P P fperjury that the vrforntation provided above is true and correct: S' ature: G Date: 'hone#: 9 >�' yD)—;> _� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing use (circle one): I.Board of Health 2.Building Department 3.Qty/T9Vm Clerk 4.Electrical Inspector 5 Plumbing Inspector 6.Other Contact Person: Phone#: AC40RLIO® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) �..►� 3/23/2016 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 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 endorsemen4s. PRODUCER CONT ACT Linda Bogdanowicz Insurance Solutions Corporation PHONE (603)382—$600 No):(603)392-2034 60 Westville Rd E-MAIL ADDRESSlindab@isc-iasurance.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 D: INSURER E Andover MA 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. 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. ILT R t TYPE OF INSURANCE ADD SUER POLICY EFF POLICY EXP. LTR POLICY NUMBER MM/DD/YY MWDO/YYY LIMITS $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence S NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) S 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO- JECT 1:1 LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident ANY AUTO BODILY INJURY(Per person) S ALLOWNEDSCHEDULED AUTOS AUTOS (BODILY INJURY PeraccidenU $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident S $ R UMBRELLA LIAB HOCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 IDED I I RETENTIONS I AN026107 3/24/2016 3/24/2017 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-1N/A E.L.EACH ACCIDENT S (Mandatory In NH) rEL. DISEASE-EA EMPLOYE S It yes,describe under DESCRIPTION OF OPERATIONS below DISEASE-POLICY LIMIT S 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/grrtnnn POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE FDaT1/6/2 DrrrYv) 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 BE'T'WEEN THE ISSUING(NSURER(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 — Fax 11 Saunders Street g y a/c Ny�_(978)688.7000 _ ;(aic,-Nok(978)688 7001 North Andover MA 018 MCA — N ADDRESS: INSURERS)AFFORDING COVERAGE ; NAIC F - — �_, _ INSURER a:Nautilus Insurance Co. _ 117370 _ INSURED INSURER 8:Safety Insurance Company_ 133618 Polar Bear Insulation CO.Inc. INSURER C: Peter Leblanc&Steven Leblanc INSURER D: � P O Box 958 — --- --- —.._ --- Andover,MA 01810 INSURER E: INSURER F: COVERAGES - 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -- --- —_— iNSR i - -- — — 'ADDI SUBR; POLICY EFF POL ICY EXP LTR i TYPEOFINSURANCE IVSD WVDs POLICY NUMBER i IN MM/DD LIMnS A ;COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S _— CLAIMS-A1ADE OCCUR -' ;D/{MAGE TOREN IED ---- -- `PREMISIE; Ea ocwrrencel :5 ;MED EXP(Any one person) ;s PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: ! GENERAL AGGREGATE i S i PRO- 1. _ POLICY' JECT OG I _ _ L i — — ; PRODUCTS GOMPIOP AGG S 7*1 OTHER: i i - S AUTOMOBILE LIABILITY1 COMBINED SINGLE LIMIT I S , i(Ea accident _ 1 000,OOO ANY AUTO .2100926 ` 01JO412016.'01104/2017 1 BODILY INJURY(Perperson) i S i ALL OVtWED ; Jr; SCHEDULED ; I --'—— ^— _ - — AUTOS ;AUTOS j BODILY INJURY(Per accident):S I iv NON-OWNED j ;PROPERTY DAMAGE - ` XHIREO AUTOS �� S _— AUTOS i_(Peracd�ml :UMBRELLA LIAB OCCUR ;EACH CCCURRE.RCE S ) A EXCESS LIAB CLAIMS-vIADEI: AGGREGATE ;5 DED RETENTIONS } — S - .. `WORKERS COMPENSATION :PER OTH- ' :AND EMPLOYERS`LIABILITY —"`STA-TTE i ER YIN! 'ANY PR P IETOR!PARTN (EXECLrIVE - - - NT I E -5 'EL H ACCID EA C i _ ` FfICERli�1 IA ER EXCLUDED? � I O E 9 LUD_D. (Mandatory in NH) °EL DISEASE-EA EMPLOYEE S If ves•describe under I ! —— —' -' - -- - -- DESCRIPTION OF OPERATIONS below E.LSEA I SE-POLICY LLIMITi S D DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addition(iiernwits 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 CER T IFICA T E HOLDER CANCELLATION i I i SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thieisch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n 400 nn-rll Arr^on r.nonnonrrnar All 1/4/2016 Preview:Certificates of Insurance r t/Cil� /_' LIABILITY t o 0 i 0tnr DATE 1:1!.tDDYYYY) � CERTIFICATE OF LIABILITY ilNSURAINCE �i olroanole THIS CERTIFICATE 1S 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 poiicy(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 CONIAC1 NAI.IE- PKIN It FAx Automatic Data Processing Insurance Agency,Inc. IA--C-nn.Em: INC.Hol. I Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERIS)AFFORoING COVERAGE I NAICY It)SURER A. NorGUARD Insurance Company ! 31470 INSURED INSURER 8' POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER_ THIS IS TO CERTIFY THAT THE PQL:CiES OF INSL+rG.rICE LISTED GELOV;HALE BEEP:IESUED TO THE INSURED NAI::ED A-EO•:E FOR THE POKY PERIOD UaDEC:,TEO t•10T.'•:lTHSTAHDtf)G AP:'i REOUIRErEI'IL icRLf OR COND:TIOPr OF—"'IV CONTRACT OR OTHER DOCUI:I£IaT'.7;T4 RESPECT TO:VHiCH THIS CERT!F:C:.TE Lt;.Y Bc ISSUED OR LI;.Y PERTJ.%i-!.THE:rISLIPA ICE AFFORDED GF THE POL!CES DESCR?BED HERE:ta:S SUBJECT TO ALL THE TERL.S, EXCLUS:ONIS AI•:D COND!T=OIdS OF SUCH POL!C!ES Uf.';TS SHOWN N R'F,Y!-fn c EEE)REDUCED BY PAID CLA;:.'S INSR TYPE Puu0' P ucY LTR IirSD YND POLICY IIU.%BER IIt1IS'CD.YYYY) I:1I WD:YYYYiI 117:175 CO.S.IERCIAL GENERAL LIABILITY MAUI: Fli•" I I J'r%L-11:�ES le.l l:'a:•_u::t•: 13 C-1I:L.'.GGI:BL:;•l c UL111 AFPLIE_FEy. 77 1'- r6r•. I tl At TO14031LE LueILaY I :.I_r,. a LN..LLe uuu '(I–'-"I1LjC!i j rIKEU;.Ltt_� ' ,I.LI_`l.t._U ECCESS DAs 'ULU Izl;tElal::L:, tvORKE118 1:11r1PEHSATIOH ('• AHD EI.:PLOYERS LIABILITY Y:n .utl•.-E ;ii N' P,01AIC77M58 01101:20:6(0110'M17 'L E•:c�:.,:Clcz:.I 5 7.000.000 � eFl�Er t.�17UH)E:��t icGt 1,000,000 ( endatwY n l z-- LI.LA s: .t:• L'•'c5tlill'U61:%.r cP.I:.:.net�a.:_.- =_.0+9E:•s_ vcu',r' - 1,000,000 I � I DESCRIPIIOti of OPERATtouS-LOCATIONS i vEHICLES(ACORO rot.AeditionJ Rema-s_mmwm.ma;toe amt,no d....F, Ls requited) - 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 AUTHORIZED REPRESENTATIVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I Office of Co e' S��� j � � _ 02116 -®MCbMpr0VeMWt C II-Gtr �babw- #Q2726 Regis TVPM- DaA Tr* 25M - O_ poLAR SEAR INStsi-p�i�i�i - vit[1cent LeBlanc p_o.SOX 958 _=_ - _=_ _` ,essoaor cue. ANDOVER.It A O4g'to ::7_ ~Up�Addr� � amt D Lostci d = _= Address newai =�CSSLA" Q?