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HomeMy WebLinkAboutBuilding Permit #1019-2016 - 1145 OSGOOD STREET 3/30/2016 1 A tiORTHb) L BUILDING PERMIT per"'tso '6�tiO ;6 pL TOWN OF NORTH ANDOVER O APPLICATION FOR PLAN EXAMINATION M r� (�PermitNo#: .1 —Tb' ! Date Received gss'VCHU`'�,t Date Issued: a� ' IMPORTANT: Applicant must complete all items on this page LOCATION // /S� U540ed_ Print PROPERTY OWNER D9ni-el I'k'ea 0-A y �} Print 100 Year Structure yes no MAP fJ PARCEL:.ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg A-Others: ❑ Demolition ❑ Other S/IfVIA>/,a to ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ICKTr(`iOf- 1419/, / QM!k' P1q e-t Identification- Please Type or Print Clearly OWNER: Name: n rn%Y( /Acca f tkY Phone: Address: Peter Leblanc _ Contractor Name: 7 Leine Street Plaistow, N.H. 03865 Address: neo !2 Supervisor's Construction License: 14&A 42 Exp. Date: &z1.g- ' Home Improvement License: /fl �1-G. Exp. Date: 2115114 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTS D ON$125.00 PER S.F. Total Project Cost: $ 33 o 0 . 0y FEE: $ Check No.: --� 192, Receipt No.: 4,77601 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature of Agent/Owner Signature of contractor i I 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 ❑ 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 Planning Board Decision: Comments r Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name 3 Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract a Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location I' 7 No. 1 U ^t - 2 G i Y, Date —A-3,c, t (c, • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 4" Foundation Permit Fee $ Other Permit Fee $ y TOTAL $ Check# Z" �: s Building Inspector � Town of NOF . I\Andover 0 '.'�' ' A No. h ver, Mass, Afclo 30 2DRO COCMICMEWICM y1. �as RATED U BOARD OF HEALTH Food/Kitchen PER T T LD Septic System 10 THIS CERTIFIES THAT H BUILDING INSPECTOR .......... ..1644.41.1 .... ... has permission to erectg �1 4�„ �. Foundation .... .................... buildings .-.. .... .... ...5*................. Rough to be occupied as � %mr. � Chimney provided that the person accepting this permit shall in eve ryres respect conforAto.the terms of the a ati Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Altera on 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 TS 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 to#0&04Mn RISE Engineering M Cont Contractor r RlrSti on nnio86 si RISE A division of Thielsch Engineering tu 28979 ENGIN5ERING 60 Shawmut Unit#2,Canton,MA 02021 �9�02-033; rA.�c 129-502-6345 CONTRACT Page 1 PROGRAM TWOONTRACfCMA-HITS a on CsDsoOieaRFae IAS aESCRremsaow CUST010139t Prrotm OATe MEMO wean oaoEa Daniel McCarthy (978)886-0862 03/03/2016 406372 00006 SERVICE SraEET ---- —-- - -- BUM STRW 1145 Osgood Street 1145 Osgood Street SMI&RCE CUM.STAMVP '.- – as UNG CIM STALE.ZIP North.Andover,MA 01845 Notch Andover,MA 01845 JOB DESCRIPTION PHASE TWO- FOR EXAMPLE ONLY: Proposal is for 2nd phase of wmtherization project,which cannot proceed until 12 months after the I st phase of the project. Prices and program incentives not guaranteed. Please contact your Energy Specialist,to issue you a current proposal. $0.00 BARRIER:A Blower Door Test will not be conducted at your home,due to the presence of asbestos. 50.00 WALLS:Provide labor and materials to install blown in Class Cellulose to(1305)square fad of asbestos sided exterior wells. Touch- up painting,if needed,will be the customer's tesponsibility. Invoicing will occur upon completion of installation. Subsequent to your payment,as an added service,RISE Engineering will return when weather permits to check for any voids with an infrared scanner. Any major voids that may be found will be filled at no additiorml cost 52,414.25 BASEMENT CEILING:Provide labor and materials to install(84)linear feet of R-19 unf teed fiberglass insulation to the perimeter of the basement ceiling at the house sill. 5147.00 GARAGE CEILING:Provide labor and materials to install 10"R-35 Class i Cellulose insulation to(416)square feet ofgmage ceiling located below a Mated Door area,by drilling holes in the ceiling from below. Holes drilled will be plugged. Plugs will be spadded and left in a relatively smooth condition.Finish sanding and touch-up Priming/painting will be the customer's responsibility. $67392 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$680 and an additional$NO 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 wcatherization work is complete.We will also conduct a full assessment of the combustion solely of your heating system and water heater.This has a value of 590 and is at no cost to you. Total allowable v,wherization incentive is$3,110. 590.00 �pR 4 Fedetat®�BSO4656Z6 fltM ging la conteador Regis4afton tto etas sv► tto 1278 A WmIstab dThkbcb ERgReming 60 8hawmut Unit Oa,Canton,MA 02021 CONTRACT 339.5024935 FAX339-602-6345 Page 2 PROGRAM nasommNarae�seeaamosmatasaE CMA-HES �7N@tltSfDaO,FptVOWtAs UUM14ma prow— a►TeCUEWS Daniel Mccmtby► (978)886-0862 03!04/2016 406372 00006 BMW 916m 11 1145 Osgood Sired 1145 Osgood Smear .sra North Andover,MA 01845 North Andovcr,MA 01845 JOB DESCIUMON Total: $3,325.17 Program Incentive: $2,090.00 Customer Total: $1,235.17 WHA BR IRRMrTOFURIUSHSERVICES-COWLEtEtNACCORDANCE wmeABOWSPBCW AYWMFORTUBSUMOF 'One Thousand Two Hundred Thirty-Five&17M00 Dollars $1,235.17 uPmvFnva a�ecnanamaawrora srsaaec a181WI AaBee6Toa9nrA1[aWlraa6aanL Igl�6roF+l�1B11UBMIRM dOQ(imrGNAW a�eatseoaEnFn3tmmrss� Foaae�eria+raa�reuaawon annaAraeestaasrnsoFa�anC .aw��eoaraaeroet�sta�. DO star SUN THIS COMRAt;r IF THM �A-tom--AM BLAW s�Acas naewxranerwwae eras®emrmasawaOA118CFACCEPrARM3D am ��,•0 3'J �eFraxeeaaoaxtnAsr.Txeaeoue' �aw�a ,�e ASPSMM ' 4 OWNER AUTHORIZATION FORM (owrielts ft=) owner of the pmperty located at (Pmpwtir ) 4410o icer, (Property Address) hereby authorize �o �tt f i��Ca— - (Sub= ac W) an authorized sub=ftclor for RISE Engk=Mg,to ad on my behalf to obtain a building permit and to perform work on my property. OidWs Signature Date ►� ,: I The Cot11111omvealth of Massachusetts Departmetlt of Mdaastrial Accidents I Cotta ress Street, Shite 100 Boston, AIA 02114-2017 ' v'* ✓ IHliVW 111IIss.sOVIdia NVorkers' Compensation insurance Affidavit: Builders/('ontractt)rs/Electricians!Plumbers. 1-0 BE FILED WITII THE PERMITTING At-TIIORITI'. Applicant Information Please Print Lep-iblo- Narne (Busine>s Ornaniration/lndixidual): �b ttG T b 14 y/ar%e 0 e"U. .�5'►C Address: P-©. A X qsl: City/State/ZIp: f}hdo,/-er, nil, piilo Phone #: are you in employer'Check the appropriate box: Type of project(required) I ®1:nn a cmpla-,cr with cmplucres fFuli andAll part-trine!` 7. Q New construction '_❑1 am a sole proprrctor ur partnership and have no emploN ecs v orking lire me in $ Replcldel ln� anw capaciiv INo workers"comp insurance required J 9 ❑ Demolition i 01 am a homeowner doing all work myself lNo%;orkers"comp insurance required J' ]0 M Building addition 4 a I ani a homcowmcr and will be humg contractors to conduct all mark on m� property I will ensure that all contractors either ha%c workers compensation m;tuance of are sole 11.0 Electrical repitlrs or additions proprietors with no emplovices 13 R Plumbing repairs or additions 5 I am a general contractor and I hack hired the sub-contractors listed on the attached sheet i 3.❑Roof repairs "I hese sub-contractors have enrploi ees and have workers"comp insurance 6❑lie arc a corporation and it.;officers have exercised there right ufexcmpnan per 1,iGt_c 14 []Other 152.§.1141.and we have no emplo\'ccs IN,,)workers"comp insurance required J *An% applicant that chccl.s box='1 must also till out the section below show iii their workers-coinpensanon polici ininrmation lonieowners wbo sabmit this aflidiva indica-unE the` are Join_all-.rork and then hire outside contractors must submit a new atiida it ind,caim such =Contractors that cheer:this box must attached an additional sheet showing the rime of the sub-conaaciois and state whether of not those entities have employees If the sub-cuntiacturs have emploN ecs.the% must provide thou woikcrs'comp pohcN number !frill an eniploj-er thtit is pro iidhig rt'Orkers*compensation insurance for lett-enrplorees. Below is the polies acid job site it fOrmatioli. Insurance Company Nanle._�_p Gy Pollen :1 or Self-Ins Lic I W Co 7Expiration Date: dJ 0 Job Site Address oSaood S/ City/State/'Lip: 17.19fl jwer attach a copy of the Workers' coin ensation police declaration page(showing the policy number and expiration date). Failure to secure coverage as required under:�9GL c 15'_ §25A is a criminal violation punishable by a tine up to$1,500 00 and!or one-year imprisonment_as well as civil penalties in the form of a STIP WORK ORDER and a tine of up to$250-00 a day agaillst the violator A cope 01'11115 statement may he forxvarded to the Office of investigations of the DIA for insurance coverage verification. I filo herehr certifj•under•the pains wind penalties of perjug that the hiforinatiou pro above is true fend rorrec•t r e / Si;IlatLlre. ti' Date 6 Phone P: �- _���� Official use onlr. Do not write in this area. to be completed b)'cit)'or town official. City or Town: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department ?. City/ToNvii ('Ierk 4. Electrical Inspector 5. Plumbing inspector 6. Cather Contact Person: Phone r: Ams aneon OMc of Consumer 10-'a&PIM- 02116 - et� _ ome avemeni�Go R IWO Type- DBX T* 25M - 712016 LATjOt4 OO poLAR BEAR INS Vincent LeBlanc - p_O_BOX 958 fl'($� ,- :_ _ _ afarc ge. ANDOVMA = - - _-gp� � AddrMO drmmeall tayment 0 Lad cat _ _ = Adm Op5.CA1 cs� ��� T P °p 1K 03M DNYY .416..� F 4::)RV CERTIFICATE OF LIABILITY INSURANCE D3/23/2016Y) 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 B danowicz NAME: Insurance Solutions CorporationPHONE (603)382-4600 AX No_(603)382-2034 M. I60 Westville Rd E-MAILlindab@isc-insurance.com ADDRESS: INSURER AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A Western World INSURED INSURER B:Nautilus Insurance Group Polar Bear Insulation Company Inc -INSURER C: PO BOR 958 INSURER D: 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. INSR TYPE OF INSURANCE ADDL S BR POLICY EFF POLICY EXP LTR POLICY NUMBER IMMIDDIYYYYJ, MM/DD/YY LIMITS X COMMERCIAL GENERAL LIABILITY 1,000 000 EACH OCCURRENCE $ , A CLAIMS-MADE F OCCUR PREMIDAMASES(,.ETORENTED 100,000 PREMISES Ea occurrence $ NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 % POLICY❑JE° F-]LOCPRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accklenty ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED tid P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per ..Z $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE _$ 1,000,00 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION 7PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTNE ❑N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOY $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 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 ,�A 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 onunii POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(M/2016 rY) 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 1S 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 A/c No. (978)688.7000 !(ruc root(978).688 7001 North Andover,MA 01845 E-MAIL — ADDRESS • INSURER(S)AFFORDING COVERAGE _ � NAIC F INSURER A:Nautilus Insurance Co. _ 117370 INSURED INSURER 8:We•r InSUrance Company_ 13a3618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc - D INSURER I P O Box 958 I—ER 0 -- — -- - Andover,MA 01810 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ LTR; TYPE OF INSURANCE VIVO. POLICY EFF j POLICY EXi' i LIMITS INSD V/VD POLICY NUMBER � MM/D MMIDD A ;COMMERCIAL GENERAL LIABILITY I I F ,EACH OCCURRENCE S ___ CLAIMS MADE OCCUR DAMAGE TOFRENTEO'- - - — i PREMISES(Ea occurrence) ;MED EXP(Any one person) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 16 t � , — ECT LOC ' 1 �+ ,POLICY PRODUCTS-COMPIOPAGG •S --OTHER- — --- � � :-- -- - --- S _ i AUTOMOBILE LIABILITY !COMBINED SINGLE LIMIT iS 1,000,000 g — i(Ea accident.— _ . ANY AUTO 2100926 01/04/2016'01104/2017 BODILY INJURY(Per person) i S ALL OWNED ix ;SCHEDULED j BODILY INJURY(Per accident) S AUTOS i AUTOS ____ ' x -HIRED AUTOS X ; NON-OWNED j I ;PROPERTY DAMAGE S - - _AUTOS (Pera—aeno _ i .- — — i UMBRELLA LIAB OCCUR EACH OCCURRENCE S ) A EXCESS LIAB I CLAIMS-MADE: AGGREGATE S j —— -' — _ — OED RETENTIONS WORKERS COMPENSATION _ 1 PER :OTH- :AND EMPLOYERS'LIABILITY Y/N j _I STATUTE ! ER _ ELEACHACCIDENT !ANY PROPRIETOR/PARTNERlEXECUTIVE Is ;OFFICERIMEIABEREXCLUDED? I�IN/AI (Mandatory in NH) I E-L DISEASE-EA EMPLOYEE S If yes,describe under -- DESCRIPTION OF OPERATIONS below ? E.L DISEASE-POLICY LIMIT;S DESCRIPTION OF OPERATIONS I 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 Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS_ 195 Francis Ave Cranston,RI 02910 AU7HOROM REPRESENTATIVE +i rl 1000 nn4A Af%^MM 9%no13AOAT1Apr A11 --_A 114/2016 Preview:Certificates of Insurance Ate® CERTIFICATE OF LIABILITY INSURANCE GATE 171lSUDYYYY) lft./ I 011041ZO16 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 CONIACr tiALtE: PHO!IE A% Automatic Data Processing Insurance Agency,Inc IA:L No.E.11: IAtC.No). I Adp Boulevard ADDRESS: Roseland,NJ 07068 IDSURERIS)AFFOMIM COVERAGE NAIC3 ),.!SURER A: NorGUARD Insurance Company I 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC PINSURER C: O BOX 958 Andover,MA 01810 INSURER D: )NSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL:CeES OF INSURAUCE LISTED BELOY:HAVE BEEN!$$LIED TO THE 1PISURED r•JA7:7E13 A60:'E FOR THE POLICY PERIOD INDICATEED.PJOT.'IITHSTAI-JDIr-IG ANY REOUJREr Er'IT.TERra OR COt•1DIT!OH OF ANY CONTPACT OR OTHER DOCUi EIIT Yi;TH RESPECT TO;`HIGH THIS CEPP.F:CATE 1-1AY BE ISSUEO OR L:AT PERTAU-1.THE iNSURANCE AFFORDED BYTHE POL'CiES DESCRIBED HEREIN:S SUBJECT TO ALL THE TERL:S. EXCLUSIONS AND COND;TIO,.S OF SUCH POLJC:ES L7 F?S SHOl4'J•11.'AY HA'JE BEL-AJ REDUCED GY PAID CLAS.'S INSR TYPE OF INSURANCE PUUCT 11 P LtCT P 1 LTR I INSD e'IVD POLICY NULiBER It.riOD:YYYY) IJA11T]D'YWYi LG ATS CO'.V,IERCIAL GENERAL LIABILITY L.'ter C!-L:L{!:Etch 0. .••..wc I::.: c Ii<tL1t�cS Icy J_-.�•-ate:•= t.M1Ulr:f°•.cam;:._prsa^. I-Er:S_'r.aL>aC.u.Ju:= I5 Gtt;L.?Gi;FEG%•IcULt1f AWLIESPEr;. %EI:EE�L:.6ClaG:.it �l)•Its �— ('i:LtC' JtrNt.�— �1 y AUTOL:OaiLE LL1 Bi LITY '"Lt.;r.. a mruL u:Ju m: ALL C::Ld' _a'-EVLLEU E::L'IL:'If:JI_li�:Pc-S]D_d.q a UG:13RELLALIAB 'Lk ci ;::=:LI-3iLM EXCESSUA9 1 �L%.tt.1S3t:.L"L :.CSI:L.>cJE - ULD f I;L-i EN I1:J1.j \'lORKERS COLSPENSATiOrrNO&APLOYERS'LIABILITY X EL t'tH H I J A , =i•.IL IL Lh Yeti ;a rt: na�n_I:T:•Itu�{;e::LLttI'.E ( E:.cr%•rpigr.l I' 1.000.000 A rI.E1t LIEta6tlf E•:atC i f U:J t o N POWC772258 1 01101.2016 01/0112017 to anOAl.,y in NH) L L L•1-zi:A.La LLn t:. tE S 1,000,000 r, es:-::,_• OI.IIf 1,000,000 L�cSLl71•ltt�i:•.F::I'tl::.!Iii cb,:�,_ � IL.L.L`I_E:.=L I DESCRIP11ON OF OPERATIONS i LOCATIONS i VEHICLES fACORO 161.AtltlitiDnJ Pm k5 SehWUie..Tj bo.I=INtlit—Csp—is required) CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPJRATION 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(2014101) The ACORD name and logo are registered marks of ACORD