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HomeMy WebLinkAboutBuilding Permit #493-2017 - 124 OLD VILLAGE LANE 11/9/2016 ORTF/ BUILDING PERMIT O�NLED 6��0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ' h T Permit No#: q0t ' ;-01 7 Date Received 11_ ^R"o-"AT I ED �1SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page k0Q,;TI'ONi Pnnt Pll,©PERTYr OW,NER Yh rhG�� y/r'r✓l�j' _ _ _ _-- - — _ —_ - Pent 10D YW$trueture` yes no• 4 MAP _PARCEL. Z N1N6DISTRICT H�stonc �snctr yes x_ .� - no Machme Slop Viilag ,___y eses 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 I Others: ❑ Demolition ❑ Other D Septic ❑Well. DFlootlplain; ❑Wetl'ands. q Watershed DJstnct Wateq'sewer DESCRIPTION OF WORK TO BE PERFORMED: 4' Identification- Please Type or Print Clearly OWNER: Name: 'Yo " 'r-:✓t f Phone: -<y- Address: oAddress: Old :/lfe 2 _ Peter Leba�nc one Contractor Name.. �._____ __ _ _Ph - _ ine _ - Email:. _. .. _ Address: - 978407 s rg �Expa Date: Supervisor's Construction:License _ /�C�d. .-_ _ -�__. = ���011_ _ Home lin rovergo t License: Date::,__ - -- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. Total Project Cost: $ ?600 . 00 FEE: $ `1 I / Check No.: IHS S Receipt No.: 3// 6 6 NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund I Signature of Agent/Ownec _ .Signature of contractor _ a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ j TYPE OF SEWERAGE DISPOSAL j 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_ II COMMENTS CONSERVATION Reviewed on Signature t 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 DPW Town Engineer: Signature: _ 384 7' 7g� EPARTrMENT Te - _ �. _. . Street �_- a _�t = i mpDumpster ona to Located Osgood ree �, _ - V at41r2`4iMaintSteet SI 'Firgf a rtmentssignature/date_ COMMENTSa _ 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 Doc.Building Permit Revised 2014 i 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And i Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) o 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) a Building Permit Application o Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses D Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report a 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 Doe:Building Permit Revised 2014 NORTH own of O 1 No. �! h , ver, Mass, COCKICKl WICK y1' x.95 R�reo �Pa��S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .....ftTlOtii. .. N„ ,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR ..... .... ..... ................. ..... *40f a has permission to erect .......................... buildings on .. 11...... ....V 0 ...... Foundation Rough to be occupied as ....... . .........441ortA.....1_09.1;qohk*PG)A...... Chimney provided that the person accepting this permit shall i 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 CONSTRUCTIO RT Rough Service ............. .. . .... ....................BUILDING..................INSPECTOR.. Final 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. E ...,�.� R is N 60 Shawmut Road, Unit 2 J Canton, MA 02021 J 339-502-6335 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: CCS o/ flr 1 NOV - 2016 (Property'Address) lu, /4/,J4� Uey'F toz-a4 • C r78r'"-_5 , (Property Address) hereby authorize C, Beo,R- TjJx%?JL& , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. Ther Permit will be secured by the insulation contractor, at no additional cost. Itis the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Ow er's 8ignature Date I I 6.2016 Federal ID#OH405629 RISE Engineering RI Contractor Registration No 8198 MA Contractor Registration No 120979 C7 Contractor Registration No920120 RISE60 Shawmut Road,Canton,AIIA 02021 CONTRACT ENGINEERING' 339-502-6335 FAX339-502-6345 Page 1 i.jJ PROGRAM CMA-HES ENGINEERIMANDIFIE FORW RKKAS it DESCRIeEDBEIDW- ClStOwER i. ' i 5. PHONE DME CUENN WORK ORDER Jodi Fina pptP.•r - � ;o i �t, (508)560-3342 10/25/2016 440756 23903 SERVICE STREET- 1 &g1MO3VtEE7 124 Old Village Lan l� V 124 Old Village lane SERVICE CnY.51M.nP --... mum crry.surE zP North Andover,M111845 North Andover,MA 01845 JOB DESCRIPTION HAZARD BARR.]ER:We have identified that there are recessed lights present in yourhome.unless the recessed lights are certified as iC-rated(insulation Contact Rated)we will create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities.%hich contain recessed lights Mill not be insulated $0.00 AIR SEALING:Provide labor and materials to seal'areas of your home against wasteful,excess air leakage. This mark will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful levet of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products: Primary areas for sealing include air leak=age to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(12)%8orking hours..A reduction in cubic feet per minine(cfm)of air infiltration will occur,but the actual number ofcfm isnot guaranteed At the completion of the Wcatherizat ion lwrk,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis Bill be conducted by the sub-contractor to ensure the safety of the indoor air quality. $1,020.00 AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This xork will be performed in concert with theme of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home.can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed) This will require(4)Working hours.A reduction in cubic feet per minute(cfm)ofair infiltration wilt occur,but the actual ntunber ofcfm is not guaranteed. At the compaction of the Weatherization%wrk,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety of the indoor air quality. 5340.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaccd fiberglass baits to(128)square feet for damming purposes. 5262.40 ATTIC.FLAT:Provide labor and materials to install a 6"layer of R-22 Class I Cellulose added to(187)square feet of open attic space. $235.62 ATTIC FLAT:Provide labor and materials to install a 7"layer of R 26 Class I Cellulose added to(1116)square feet of open attic space. $1,450.80 i i Federal 10 i105-0406629 RISE Engineering Rl Contractor Registration No 8186 MA Contractor Registration No 120979 �� CT Contractor Registration No624124 RISE INEERINE 60 Shawmut Road,.Cantoo,MA 02021 C R/'1� p A�r 339-502-6335 FAX339-502-6345 Page 2 PROGRAM. CIVIA-HF5 oEr EBED BB�ctSa FDR want As CU31MER PHOW OAE CUENT# WORKOMER Jodi Fina _ 3 16 (508)560-3342 10/25/2016 440756 23903 9eRY(OE IIIREET Blumo 8REEr 124 Old Village Lane 124 Old Village lane SERVICE Cm',SUN.iIPMWNO c1w ST0.E,DP North Andover,MA 01 North Andover,MA 01845 JOB DESCRIPTION ATTIC FLAT:Remove(1116)square feet of batt style insulation from the attic area. i $837.00 KNEEWALLS Provide labor and materials to install 2" FSK faced semi-rigid fiberpJass board insulation to(288)square feet of kneetkall arca. $1,008.00 KNE"EWALL FLOOR.Provide labor and materials to install a 4"layer of dense packed R-13 Class I Cellulose added to(400) square feet of lknec%all floor. $676.00 KNEEWALL FLOOR:Provide labor and materials to install a 5"layer of R-14 Class I Cellulose added to(144)square feet of open kneemall floor.. $168.48 ATTIC ACCESS:Provide labor and materials to insulate(1) back of the knee%Wl hatch-with 2"rigid board,and seal the edge of the hatch with wat herst ripping. $60.00 ATTIC ACCESS Provide labor and materials to insulate the back of the attic door with 2"rigid insulation board and seal the door's edge with weatherstripping to restrict air leakage. $73.91 ATTIC ACCESS:A linear opening will be made in the roof to access an area to be insulated. Roofing will be reinstalled wben mwrk is complete. Cost is for the first 5 lineal feet of opening $379.94 VENTILATION:Provide tabor and materials to install(3)insulated exhaust hose-with roof mounted flapper vent to exhaust existing bathroom fan(s). $356.25 VENTILATION:Provide labor and materials to install ventilation chutes in(140)rafter bays to maintain air flow. $280.00 COMMON WALLS:Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(100)square feet of common wall area. $350.00 BASEMENT DOOR:Provide labor and materials to insulate the back of the basement door leading to the bulkhead-with 2"rigid board that meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all edges and seams with FSK tape. Federal ID 0 05-MS629 RISE Engineering RI Contractor Registration No 8188 MAContreetor Registration No 120979 CT Contractor Registration N0820120 RI S 60 Shawmut Road,Canton,MA 02021 ENGINEERING 339-.562-6335 ,®, iV1 339-5112-6335 FAX 339-502-6345 �+Op1�D A�+'�` Page 3 PROGRAM US CWIRACTIS ENTERED INA BETXIEEN=9 CMA-FIC'S ENGINE ED AND VIE CUS'AMER FOR WORK AS CUSIO ER PHONE DAE CLIENrt W(MORDER JodiFina (508)560-3342 10/25/2016 440756 23903 SERVICE STREET BILLING STREET 124 Old Village Lane 124-Old Village Lane SERVICE CIN,8TATE,ZIP BILLING crrr'a ATE,DP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION $72.22 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$2,000 per calendar year,and an incentive of 100%for the Air Scaling measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the.safety and health of your home's 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%eatherization work is complete.We will also conduct a full assessment of the combustion safety of your heating system'and,.wtcr heater.This has a value of$90 and is at no cost to you Total allocable mtherization incentive is$3.110. The Permit will be secured by the insolation contractor,at no additional cost.It is the homeottnces responsibility to closeout this permit by contacting their municipality at the completion of this work. $90.00 V D f V - 3 52016 I I Total: $7,660.62 Program Incentive: $3,110.00 Customer Total: $4,550.62 W EAGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Four Thousand Five Hundred Fifty&62!100 Dollars ;4,550.62 UPON R APPROV RN14 OMES ARENTAMMWDM IN R L RMMSTOF 1%WI LBE CHARMED AMNLY ON ANY UNP SODA FOR 0*QRVINTWFORMkTARON CUARIWEES,RION15OFRECISION,SCHEOULING,ANDCQUIRACIDRRE001RA7ON. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SP ES D SIONAVRE- E EryiwNq7 PT ACCEANCE NM 7115 CONWCTIAY BE WITHDRAWN BY US IF NOTEXECUEO WIieN DALE OFACCEPURCE ACCEPTANCE CFCONTRMCT-'OLE ABOVE PRICES,SPECIRCA1014 AND COND{70NS ARE 30 DAYS. SAUFACIRED.PAUS N D ARE E HEREBY �aw£D.YOU ARE E AUIHCFMD 10 DO1iE WORK i �I The Commonwealth ofMassachusetts --- Deparhnent o fI'ndustrialAccidents Office oflnvemagadons 1 Coi:<gress Stree4 Suite 100 Boston,MA 02114-20.17 www.mass govMa Workers' Compensation Insurance Affidavit: AvvRcaut rmation Builders/Contractors/EleciricianslPIwnbers Info Please Print LegiblyNaII18(Business/OrganizatioMndividual):_ J�9 ,:ger n -— — I/11 N iiII Address: -PO BOX 958 ANMVEA MA Q78 ti PCity/State/Zip: Phone#: Are you an employer?Check thepa propriate box: — — -- I J9 I am a employer with_!; — 4. [] I am a general contractor and I I�Pe of project(required): employees(full and/or part-time).* have hired the sub-contractors 5• ❑Drew construction 2.[] I am a sole proprietor or partner- listed on the attached sheet l ' i. ❑Remodeling ship and have no employees These sub-con�ctors have working for me in any capacity. employees and have workers' 8. 0 Demolition [No workers'comp.insurance comp.instzranceJ [7-3.0- . ❑Building addition required.j 5. [] V►re are a corporation and its 0 Electrical mains or additions t 3.❑ I am a homeowner doing all work officers have exercised their .(�Plumbing repairs or additions myself [No workers'comp_ right of exemption per MGL insurance required.]t c. 152,§i(4),sad we have no � .0 Roof repair employees.[No workers' Other I comp.insurance required.] *Any applicant ihaz checks box 1 must also 5U out the section below showing their workers'compensariun policy information Homeowners who submit this affidavit indicating they are doing all work and they hire outside contractors must 'Contractors that check this hox must at en aMinara sheet she�i Q r. �r submit a new affidavit indicating such em io ees. if the sub-contractors have employees, �the P-Me o.he subsortractars and t��fieth�or na tho-- have p;y P Pees,they must provide their workers comp.policy number. f am an empinver that is projAftg:porkers'co,tpensatier information. � ga.�InYea. Below is thopor� y and job site Insurance Company Name: 1''� f} y^v C h t n tun�ef yl y Policy#or ScL=ins.Lic.9:_ Expiration Date:_oi o) �a! Job Sitc Address: p 2 I lj v i►I R S C 2 a( City/S 'Zit;: tt2ch a copy of the workers'compensation policy declarationa (showinga as re p �' the be poL-:y number and expiration dgte)• Failure to secure coverage required under Section 25A of MGL c.152 can lead to the imposition of criminal fine up to$i,500.U0 and/or P one-year' penalties a imprisonment a _ Y p _sonurent,as well as civil penalties in p of up to$ZSO.Ot?a day� Behe form of 3 STOP?�OltK ORDER the v: e and d against .olaror. lila advised that n coG of = _ a fine Ln Jestigartons-.3f the DIA for insurance coverage Y this may be forwarded to the Office of �,-verification. 9 J s uu aerevy cern utdeF the airs and enalti oj' perjury dint lite rrt ornatian pruvsded above is true and correct. Si at�re: Date. Phone#: q)y- yo)- 7&M [[6.Other ial use only. Do not write in this area,to be cofrpleted by city or town official or Town: Permit/License# ng Authority(circle one): ard of health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector act Person: Phone#: AC RE® CERTIFICATE OF LIABILITY INSURANCE6/io(N'" 2o 6n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Linda Bogdanowicz Insurance Solutions Corporation PHONE (603)382-4600 FAX No (603)362-2034 60 Westville Rd EMAIL ADDRESS:lindab@ise-insurance.com INSURER AFFORDING COVERAGE NAIC 4 Plaistow NH 03865 INSURERA.West:ern 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 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 WTH 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 D POLICY EFF POLICY EXP L POLICY NUMBER M Y MWDDrYYY LIMITS $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE $ OCCUR PREMISES Ea occurrence $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one perm) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 8 POLICYRO- ECT L� PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULAUTOSED BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccide $ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ M026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NFA E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddBional Remarks Schedule,may be attached N more space le required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE !A A Reith Maglia/SJA (��-- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD � INS025Mantr 6/10/2016 Preview:Certificates of Insurance •4�RO® CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDO/YYY) THIS CERTIFICATE 1012016 IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER.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 endorsement(s). PRODUCER A NAME: ' Automatic Data Processing Insurance Agency.inc. PNONE 1 Adp Boulevard 'NO'E:1` taa No Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC Q INSURED INSURER A: NorGUARD Insurance Company 31470 POLAR BEAR INSULATION CO INC INSURER B: PO BOX 958 INSURER C: Andover,MA 01810 INSURER D: INSURER£: COVERAGE$ CERTIFINSURER F: CERTIFICATE NUMBER: 503587 REVISION NUMBER: THIS ISTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NgMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OFANY 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. nOF INSURANCE INSOWVOPOUCYNUMBERENERAL UABILIIY MMIDDIYYYY (MMIDDIYYYY LIMITS DE ❑OCCUR EACH OCCURRENCE S PRELIISES(Ea occurmnce) S LIED EXP(Any ono person) S UMR APPLIES PER: PERSONAL&ADV INJURY S CT ❑LACGENERAL AGGREGATE PRODUCTS-COMP,MP AGG S AUTOMOBILE LIABILITY S ANYAUTO (Ea acddemi L S ALL OWNED SCHEDULED BODILY INJURY ip-porsonl S AUTOS AUTOS WON-OWNED BODILY INJURY IPe acdde,u) S HIRED AUTOS AUTOS Wer accidelll S UMBRELLALUIB S OCCUR EXCESS UAB CWR1SaMADE EACH OCCURRENCE S DED RETENTIONS AGGREGATE Is WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY X AnyF'RCPRIETOR++PARTt,ER'EXECUTIVE YIN STATUTE ER A CFFICER%HEIJBER EXCLUDED? Y NIA N POWC772258 EACH ACCIDENT (Mandatory in NH) E.L.01101/2016 01/01/2017 S 1.000,000 nyyP OESCRITICt,OF OPERATIONS be— El DISEASE-EA EP.gPLOYE S 11000.000 _ eL.DISEASE-POULwUMIT S 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AdMWnal Remaricq Schad,Ile,may ho aUachod H morespaoa is ropuiretl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood st/suite 2035 North Andover,MA 01845 AUTHORG'.ED REPRESENTATNE ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ORD CORPORATION.Mit rights reserved. l 4 APr Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration - Registration: 102726 - - - Type: DBA Expiration: 7/2/2018 Tri 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOK 958 ANDOVER, MA 01810 .. - Update Address and return card.Mark reason for change. SCA 1 0 20kiA51iit Address [] Renewal E]Employment ❑ Lost Card J/c`�arrnsarrrr�ra///o�C%1`jnun�rrsells � Office of ConsumerAffairs&Bnsmess Pegulation License or reparation valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102726 Type: Office of Consumer Affairs and Business Regulation Expiration:.:7/2/2018 DBA 10 Pm'k Pl=-suite 5170 POLAR BEAR INSULATION COBoston,MA 02116,: . Vincent LeBlanc 51 SO.CANAL ST.;bA '" LAWRENCE,MA 01841 Undersecretary Nk valid witbout signature I Massachusetts -'Department of Public Safety Board of Building Regulations and Standards Cilimtructiun Super%irwr Specialty �icense: CSSL406017 PETER A LEBLANC ` 2 EAST PINE STREET p Plaistow NH 03865 P 921�j Expiration commissioner 04128/2018 e Location d No. YC7'3 ?O 1 Date /t- `� ok O/C • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 7 7 ,1 { � <� Building Inspector