HomeMy WebLinkAboutBuilding Permit #874-2016 - 12 STONINGTON STREET 2/10/2016 NORTH q
BUILDING PERMIT O ,it"D 1•�
TOWN OF NORTH ANDOVER o2 rye'`- ,•' .=6
APPLICATION FOR PLAN EXAMINATION 00
Permit No#: �/�// Date Received
ply`
�gSSgcHUS y
Date Issued: �i 16
I ORTANT:Applicant must complete all items on this page
LOCATION /� S3�v1 rata 3ovt S�
Print
PROPERTY OWNER Dq TxY .4.
Print.• 100 Year structure yes no
MAP Q / PARCEL: ZONINO DISTRICT: Historic District es no
_ Y
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 P� Others:
❑ Demolition ❑ Other IAW'a h
❑ Septic ❑Vllell' ❑ Flood lain 0 Wetlands: ❑ U1/atershed 9A,' nct A'
II
❑1lUater�Sewer� _ `
DESCRIPTION OF WORK TO BE PERFORMED:
CXTrt',bT Gtl9 /1 �hSJik��oH Orv►�-e Aal
Identification- Please Type or Print Clearly
OWNER: Name:bc, ; e( -rrtf-ni in Phone:
Address: 57a rl;� — 4�rlo��w
Contractor Name: D,*;t f l r g(a r L Phone: f,��F- qv-)- 2636-
Emah:
Address: . :_1 yes% e Si fa 1-S TOt-J
Supervisor's Construction License: le.Gat Exp Date:, . yA����.
Home Improvement. License: 10 k�r Exp. Date:
ARCHITECT/ENGINEER Phone:
y
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 3 Ob 0, FEE: $
Check No.: �� Receipt No.:_ Q7
`I 7
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL r
Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools ❑
Well[ ❑ Tobacco Sales ❑ Food Packaging/Sales El*-
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
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
4W Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp ®umpster on sit yes no
Located at 1%24 Main Street
Fire Oepartmen si.g atureldate
CO,,MMENTS
i
I
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 lies No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA— (For department use)
I
L1 Notified for pickup Call Email
Date Time Contact Name
j
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products .
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application i
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 I
Doc:Building Permit Revised 2014
,�� SAP,-/Location
No. ' 0 �o Date 02
• - TOWN OF NORTH ANDOVER
•
Certificate of Occupancy $
Building/Frame Permit Fee $ '
_xb Foundation Permit Fee $
Other Permit Fee $ ,
TOTAL $
i
a
Check#
2 -0/ 997 Building"Inspector
r 1 NORTh
W.
a Ail
No. IL -
h q ver, MassT
o > >
A- COC MIG MI WIC�( ��-
7,95 1#ArEiD
11 BOARD OF HEALTH
Food/Kitchen
PERMIT T L D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ..........L.... s .I.�rt.I.......... .. .. ................................................................
�
has'permission to erect .......................... buildings on .� ... .:.......... .... ... ... .. ..... . ..... Foundation
Rough
to be occupied as . ..I.........1 %! . . ....................................... 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 CONSTRUCTION S ARTS Rough
Service
......................t................ ........................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fir-al
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Rd"mti
RISE Engineering w conaaceor t:egtstratlon No
VA Contractor Registration No
A division of rhidsch Eurilueeriog CT Conbactor Registration No
60 Shawmat Unh A Caaton,MA 02021 CONTRACT
.fl. 339,542-6336 FAX 339-502.6345
RISE PROGRAM Page
TkCS CONE RACT 6 ENTHr®iNID BtlMffF111 Rots
CMA-HES wKWEEIMORITHSCUSTOMFoRWORKAS
ENGINEERING _ 14W g. _ MCM60813M
PHONE DATE cueffs aronxoRDeR
Daniel Tiernan (978)828-2641 07/102015 400396 00005
SEWCE aTREar _ eaamo sir
12 Stonington Street 12 Stonington Street
MWICE Off.STATEaP 81L=c"T.SumaP
North Andover,MA 12A4 North Andover,MA 01845
JOB DESCRIPTION
WALLS:Provide labor and materials to install blown in Class Cellulase to(1672)square feet of asbestos-sided exterior watts. Touch-
up paining,if ncedcd,will be the customers responsibility. Invoicing will occur upon completion of installation. Subsequent to your
payment,as an added sc vice.RISE Engineering will return when weather permits to check for any voids with an infrared scanner.
Any n4or voids that may be found wiil be filled at no additional cast.
$3.344.00
BASEMENT CERMG:Provide labor and materials to install(78)linear feet of R-19 unfaced fiberglass insulation to the perimeter
of the basement ceiling at the house sip.
$13650
RISE Engineering will apply all applicably eligible incentives to this contract. You willonly be billed the Nd amount. Currently,
for eligible measures,Columbia Gas offers 75%incentive.not to exceed$2,000 Per calendar year,and an meari[ve of 100%for the
Air Sealing measum up to the fust 5680 and an additional$340 if savings arejustified by the auditor.
For the safety ad health of your haute's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in
W full assessment of
weatheriratian work is complete. a will also conduct a
your home both before the work is begun.and after the P
the combustion sat'eijr of your heating system and water heater.This has a value of S90 and is at no cost to you.Total allowable
weatherization incentive Is$3,1 10.
$90.00
Total: $3,570.50
Program Incentive: $2,088.99
Customer Toted: $1,480.51
wE AoREE!MEREBY TO FURKWN SERVICES-COMM W AcI'.QFmANCEwrrtt ABOVE SPEW;MmONS.FOR THE mm of
—One Thousand Four Hundred Eighty&511100 Dollars $1,480.51
UPORFeral. ANDAPPWJALIMMEM OMWMCUSTOMaRAORMTORMTAtA JWMsi FULLMMMRof I%Vm.L6ECr1MMMOlMMYONAMr
LWWOMOMANCB mDAYS.SEE ItEVERBSPORaMORYANT DiFOHIBA1NfNON ouAwwTEES.RilRITOOP RECISION,aelEDlRD[O.AND CONTRACTOR RBWBIRATOIi
vo NOT SIGN TM CONTRACT W THERE
WM MCON7 A=WAYW-WMW=W6YtMWWTa7�CU[ED. OAIEOFACCSPTANCE
i
AC=ffMCEOPCONTRACr.TNEAaoVEMW%SPECW= OMXWC0=M=AXE
30 DAYS. AASSSPEWMPAYYMMWWUSEr aAsAA800 ��
•
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•
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OWER AUTHORIZATION FORS
a
(OM&B tire)
owner of the ply at
JUL 1 3 2015
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ttE:rEby BUthofb�8,
an m thorbmd a rdor far RESE fthmeft.to act on my bd alf fo obtatn a burg
perp t and to pefam on my pop".
cNalve Shue
Deb
he Colrna Onwealth ofmassachusem
Deparlmenj���ndtsstr&lf4cc8denLs
I Congress Stree4 Suite 100
Boston,AM 02.1_74-2017
www-mass g'ov/da¢
Workers'Connpensatioa Insurance Affidavit:$uilders/Contmctors/ETe•ctridanslPlumbers-
B'®
Applicant Imforanation Please PrintLeWbh�
Flame (Busintss/Or do ual : ti l i i `tet `r- ,
lt� tt/Intlivid ) ( / t 1 ��' t i'- .�tom. i��i � /i �;+'�i l < i i,�.•
Address_
city/stat e/Zap: �t ,;. ; , t:.� �— i�j— ".1i Phone#:
Arr yoo no employ-?Cbech the agpmprbic bos: Tye mGp>ogect(,required):
I.Q I am a employer with ice_ yccs(fall sadto;part-tine)' ?_ New consiructlOII
2-0 I am a sole proprietor or parun=,.hip wd haver no®ploys s woricing for tic in g. Ej, cm Rg
amaro
any amity.(No rk—s'comp.inzsumnce qubx CLI 9_ I1anoTition
odelino
3-01 am a homarwae doing nlI work mysdL(No wodcers'comp-inm=neercquircd 1 t
10�Building addition
4.®i am a boatcown x and wnll be hiring contractors to conduct all work on my property. I will dal—1
casur,- nt all contractors citbce have work='Compensation insurance or are sole I I_E_I aectric al repairs or additions
proprietors with no cmphoyees, 12.D PIumbing repairs or additions
5�I am a geoc al Coom-actor and I bare hired the sub-counxtors listed on the attached shocL -13_FJRoof 7
iFs
These stub-contractors have employes and have wa$as'comp.iastaanc_r a
6.0 We arc a corporation and its o$'icus bavc mecised their righr ofexeapoon per MGL e 14'0 Other
. 157§I(4),sad we bavc no cmployos-(No workai cotup.insm-aate roquittd_]
'Any applicant that choirs box 9I must also MI out the section below showing their worker'o=pensation policy kformatioa
t Homeowners who submit this affndavn iodk2tingthcy arc doing all wort:and thea birc outside eonum +ors must submit a new allidavit indicating such-
tcoanactom that check this box mare attached an additional sheet showing the name of the sub-coouaaors and sate wbetbu or oot th05C uirtics have
®playocs, If the sub-contractors have ,ploys s,they must provide their workers,comp.policy number
(ain are employer that isproviding workers'coertpensat7on ieesurancejor,pry employees: Belowcs the policy aradJob site
informar'don.
Insurance Company Name: fj ;4
Policy#or Self-ins_Lic_#: :o(,JG 71---r=, J Expiration
lob Site Address: ll S 1D h,toQ A N a1�-t 2 ____City/Statef�p: _„ender �
PaEtacla 2 copy of the workers'compere 6®n policy declaration page(showing the policy nui nbec 211d e3pirn601e date)-
Failure to secure coverage as required under MGL c. 152,§25A.is a criminal violation punishable by a fine up to SI,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 5250.00 a
iay against the violator-A copy of this statement may be forwarded to the Office of Investigations of the DIA for;n nce
;overage verification.
I da hereby cerci•fp sender€w oraiaas and penald=of perifury float the infer. ion prot'aded rrhaere es true and eartrect
iiznature- (1i i. eel ��;_,i -,' _ - - Date'
'hone#: ilk % ;5,c
09 -a'arse mnfy. DO nee write ere¢then area M be complefed dry city or town o-O'ieia2
City os"f'ow><n_ IDennit(1[,iceanse# -
Issuing Authority(circle one):
I-Board of Health Z Building DVnrnment 3.Cnsy(T Own Clerk 4.IElectricgl Inspector S:Plumbing Inspector
6-Other
Contact Person: phone#:
POLABEA-01 JONEILL
'4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE/6/2
AT1/6/2 D/YYYI)
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 yJ:(978)688-7000 (nc Na):(978 688-7001
11 Saunders Street _ )
North Andover,MA 01845 E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE 1 NAIC#
INSURER A:Nautilus Insurance Co. 17370
INSURED A` INSURERS:Safety Insurance Company 33618 _
Polar Bear Insulation Co.Inc. INSURER C
Peter Leblanc&Steven Leblanc
P 0 Box 958 INSURER 0:
Andover,MA 01810 INSURER E_:
� INSURER F: ------ ----------- i .---- -
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.
ILTR TYPE OF INSURANCE �AINSD WVD DUI _ POLICY NUMBER MM/DD EFF MNOIIUDD p
Y I LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
—� DAMTI;E TOREN'Eb—---__ ---
CLAIMS-MADE ,�OCCUR NN538691 03/24/2015 03/24/2016 PREMISES(Ea occurrence) )+$ 50,000
_ u _ MED EXP(Any one person) is 5,000
PERSONAL&ADV INJURY_ I$ 1,000;000
I GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X1 POLICY F JECT
PRO- U LOC PRODUCTS-COMP/OP AGG $ 1,000,000
OTHER: is —
AUTOMOBILE uABILnY ii COMBINED SINGLE LIMIT jj$ 1,000,000
B �._� I Ea accident _ _-_
ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) $ _
ALL OWNED SCHEDULED
n BODILY INJURY(Per accident) $
AUTOS L_ AUTOS —.1
1X1 X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS .(Per accident)__�__.—___
F 11
M UMBRELLA LIAB X OCCUR ( EACH OCCURRENCE - $ 1,000,000
A CESS LIAB CLAIMS-MADE I fAN019284 03/24/2015 03/24/2016 AGGREGATE_ $
DEDETENTION$ I I $
WORKERS COMPENSATION
I PER OTH-
AND EMPLOYERS'LIABILITY f _STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N �E.L-
.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A —``—
(Mandatory in NH) DISEASE-EA EMPLOYEE+$
If yes,describe underEDISEASE-POLICY LIMIT $
,DESCRIPTION OF OPERATIONS below ,
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 Thielsch 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
9 9 ACCORDANCE WITH THE POLICY PROVISIONS.
195 Francis Ave
Cranston,RI 02910
AUTHORQED REPRESENTATIVE
n-t 000 nn-te A/1f%Mn f-An0f1K2A"^Ili
14/2016 Preview:Certificates of Insurance
-CERTIFICATE OF LIABILITY INSURANCE GATE R3!tiDDYYYY)
��- 0110 412 0 1 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 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 CONIACr
NAME:
Automatic Data Processing Insurance Agency,Inc. ra c�i.E:D: to+C.Not:
t•wA1L
1 Adp Boulevard ADDRESS:
Roseland,NJ 07068 ItiSURER(S)AFFORDING COVERAGE NAICV
USURER A: NorGUARD insurance Company I 31470
INSURED INSURER e:
POLAR BEAR INSULATION CO INC INSURER C: I
PO BOX 958
Andover,MA 01810 INSURER o:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF It-ISURANCE LISTED BELOA'HAVE BEEN ISSUED TO THE:11SURED NANIE-D r ECIVE FOR THE POLICY PERIOD
INDICATED.NOT%VITHSTANDING ANY REOU;RELIENT.TEPLI OR CONDITION OF ANY CONTRACT OR OTHER DOCUTAEIIT 4?TH RESPECT TO::HIGH THIS
CEP.TIF;CATE fAAY BE ISSUED OR is AY PERTAR-1.THE iNSURAPICE AFFORDED BY THE POL'CIES DESCR!BED HERE!N iS SUB.iEC T TO ALL THE T ERI:;S.
EXCLUSIONS AND CONDITi0a1S OF SUCH POL!C!ES LR:11TS SHOWIJ t?Al'HAVE BEEP!REDUCED BY PAID CLA:LJS
wy-R uCY r POLICY P + LL`.1R5
L-SR TYPE OF INSURANCE IVSD 5'ND POLICY NUMBER IL161'DD+YVYY) R.1I=WYYYYi
COMMERCIAL GENERAL LIABILITY I t:.Jf L=+J:,Lg11iEi.CE
CLAILIS4.1-AN: CCL4. PFiEfdt�E`Ica 0L_ _,.= 3
NED
1=EIi5Ct:%.L`.,1U'i It.JLF::" I
6tF;L;1C-0iEGA!EU4I1!:.I°PLIES FEF: GENEF", AGURECAIE
!`CLI:;: JEG I IGI LDL:
1-1 F] FItr:Ci'•�iS AUG is
IY:tIa' �
AUTOI.:OBILE LIABILITY I ,'3.t INE :W:LLt
:;LL r;;t.SLs S•'FEPULEO HCDIL'f n:J1;Ii�ll°e r:.❑;tcmi S
AUKS AUKS
1:CI( C,."'1.FU UAIXIU_t -
FII•:i=U i.l:t:;S i.U!-S ,I•i�:.__=�a,lt
I-
UtC$RELLA LIAB
.:CIF.' U-:::;CCI`iE1tCE
EXCESS LIAR CLAIM-'UAL•E �•L;I3tiEr_:I E
DED IiE1 EI<I IC'LS
WORKERS COMPENSATION X �ti•I H:F
AND EMPLOYERS*LIABILITY y;rll I:II: - 1.000,000
id:�19i::PIdEI!:-I:,1;•fif1:E1 E:iEC1:TIvE v I n IIM 7 ! I 10111)1,0171 E.L EAQFr.CCII_I.l
A :rFI.Er-;. 111sH:E LIc U= �N A A P„1...7.2258 101.01,20,& 1.000,000
wandatory in NH) It.L.DISu�St LA ErJftf;'t i
1.000.000
L'•tS�lill'NCi:CI Ci°�Ivtli:l:5 hc-�;: IEL.L`L Eavt-1';?U::'Ut:ul Is
i
DESCRIPTION OF OPERATIONS?LOCATIONS I VEHICLES JA CORD tat.Additional Rc ks SthM.I,may be atbchcd it mo-csPa a rcQ,&d)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave
Cranston,RI 07.910 AUTHORLED REPRESEIITATIVE
I
Ac 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
I J
Regasfion
A aud�
4f Comer 17p _
Office
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5
10 Fa& 02116
Bosons `on
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'onm=QOII�GtOr R� oc� 'tE12726
DSA 2M - -
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Lp,Tiota CO-
ppLAR.BEAR INSts
Vincent LeBlanc _ = -
p.O.BOX 958 q$'tQ -- �_ - l— ����"�g��cara
ANDOVER, MA 0 _ =
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