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HomeMy WebLinkAboutBuilding Permit #865-2016 - 139 OLYMPIC LANE 2/3/2016 NORTH BUILDING PERMIT o��tyeD +6�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION • M $�5 � P Permit No#: Daa Received t �q °R\rE°�Pp�cy SSACHUS� Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION omn P/c,. Ga n e- Print PROPERTY OWNER F�"� h ec,,r 0 'Print -,'106Ye`ar Structure yesOnoFtrMAP _PARCEL: ZONING�DISTRICT: Historic District yei e Sho Villa e e Mach n p g y 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 ❑ Other10 h �..� .....tea-a F.�.r - --'"_•.---�`f tem.. .. 6 9 f 1 ©S'eptic ®1Nell; ❑ Flootlplain WetJantls '1lVaterfied�D�stnct DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: h t eca f'o Phone: 4� 7� Address: i 3f Contractor Name: rrc i' It b ra K e Phone: l Email: Address &AS T :v,e . 57- tera 1'5; 0 � ✓I, / ..-, :d 3��5� . Supe,rvisor's Construction License: t o G v i Exp., Date:...., Home .Improvement License: lo} ?A4 Exp. Date: r ARCHITECT/ENGINEER Phone: A Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �Z ao.a e FEE: $ Check No.: I 111 Receipt No.: ,M��1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund O_ . _ -_ _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ F OF SEWERAGE DISPOSAL Sewer ❑ Taming/Massage/Body Art ❑ Switnaning 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 m 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 I _ Conservation Decision: Comments Water& Sewer Connection/Signature Date Driveway Permit DPW Town Engineer: Si, nature: Located 384 Osgood Street FIRE DEPARtTMENT Te �P( ",s;t Ie, yes ' F nor ' °r Located at 1►24 Main S reet Fire Department�i.g ature/date =e' ,COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movernent.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.$10o-$100o fine NOTES and DATA-- (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pen-nit 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 4 Building Permit Application 4. Workers Comp Affidavit 4 Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4� 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 4. Building Permit Application � Certified Surveyed Plot Plan a. 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 I 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 IN 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 appeal period is over. The applicant must then et this recorded at the Registry of Deeds. One copy and proof of recording that the pp p pp g must be submitted with the building application Doc:Building Permit Revised 2014 i 2-^'L � Location 'A �Pve 6 kip�PS6-b M 2 No. 1 Y 6�r1 1S° Date 2 TOWN OF NORTH ANDOVER • .fie £ ED$16q� . J. q. Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# ' Y 299-85 Building Inspector h ___ ,+dtr,�s:.u��s,4..v2 a.!abkr,, ,3 � s•X`:.� „_..,�+.��4r.{.�.Sr.---.._<:.��.i�r,.--kM;.��3:r.�,:. i-.�.N� .,,.:.r,.�v-t:,r� oORTH Town Of , : n ove r 4\A No. - h ver, Mass, a 3 htay A_ cocH�cHcw�cK y'►• V BOARD OF HEALTH Food/Kitchen PER T Septic System L D THIS CERTIFIES THAT BUILDING INSPECTOR ............ LAIC....... .. .. ............................................ t `&O Foundation has permission to erect .......................... buildings on ..� Rough to be occupied as ........... x. ................... ........ .. . .' ........................ Chimney :� provided that the person accepting this permit shin 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOWSIARTRough Service ................... .... ................. ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building Rough Display in a Conspicuous Place,on the Premises — Do Not Remove Fiaal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 4 1,2 d Federal ID 005-0405629 1/ RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 RISE A division ofnielsch Engineering ENGINEERING- 60 Shnwmut Unit 02,Canton,NIA 02021 ��Itl�" 1 C i 339-502-6335 FAX 339-502-6345 Ntl Page 1 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RBE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW --PHONE DATE CUE1,ITI WORK ORDER Frank Decaro (978)725-2577 12/09/2015 419439 00003 SERVICE STREET - -- .-——. _ - BILLING STREET - 139 Olympic Lane 139 Olympic Lane SERVICE CITY,STATE,ZIP DILUNG CITY,STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 1 5 201x3 JOB DESCRIPTION PHASE ONE-Proposal for this calendar year. $0.00 AIR SEALING:Provide labor and materials to seal areas ofyour home against wisleful,excess air leakage. This work will be perromcd in concert with the use of special tools and diagnostic tests 10 assure that your home will be lefl with a healthful level of air exchange and indoor air quality.Materials to he used to seal your home can include caulks,foams and other products. Primary areas for scaling include air leakage to attics,basements,attached,aragcs and Other unheated areas(windows arc not generally addressed.) This will require(8)working hours.A reduction in cubic feet per minute(e(m)of air infthrntion will occur,but the actual number of crm is not guaranteed. At the completion Of the weatheriration work,and at no additional cost to the homeowner,a final blower door and/or combustion snfety analysis will be conducted by the sub-contractor to ensure the safety of tare indoor air quality. $680.00 AIR SEALING ADDER: (2)working hours. $170.00 DAMMING:Providc labor and materials to install a 12"layer of R-38 unfaced fiberglass batts to(80)square feet for damming purposes. $164.00 ATTIC FLAT:Provide labor and materinls to install a 6"layer or R-21 Class 1 Cellulose added to(848)square feet of open attic space. $1,068.48 STORAGE BARRIER:Homeowner is responsible for the removal orthe stored items blocking the installation ofw'catheriration work in the attic. Removal must occur prior to the scheduled work start. $0.00 ATTIC ACCESS:Provide labor and materials to install(1) easily moved.insulating cover for the attic access folding stair. A small flat surface of plywood Will be created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. $237.65 VEN'11LA'170N:Provide labor and materials to install ventilation chutes in(102)ra er hays to maintain air flow. $204.00 RISE Engineering will apply all applicable,eligible incentive-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 savines 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 now in your home both before the work is begun,and a0cr the weatheri7ation work is complete.1VC will also conduct a full assessment of the combustion safety of your heating system and water hcater.This has a value orS90 and is at no cost to you. Total allowable weatheriiation incentive is$3.110. $90.00 j Y Federal ID 9 054405629 RISE Engineering RI MA Contraator Registration No 8186 ctorRegistration No 120979 RISE A divisinn ufThicisch Engineering ENGINEERING- 60 Shawrout Unit 42,Canton,MA 02021 CONTRACT CONTT 339-502-033i FA\339-502-6345 6�'►L Page 2 PROGRAM THIS CONTRACT LS ENTERED INTO BETWEEN RISE CMA-IIES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER -_— -�_ -PHONE DATE CLIENTO WVORKORDER Frank Decaro (978)725-2577 12/09/2015 419439 00003 SERVICE STREET 4�- _^- BIWNG STREET _ - — 139 Olympic Lane 139 Olympic Lane SERVICE CITY,STATE,ZIP _ DILUNG CITY,STATE,LP __ North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,614.13 Program Incentive: $2,105.60 Customer Total: $508.53 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ""Five Hundred Eight&53/900 Dollars $508.53 UPON FIN SPECTION D APPROVAL -E ENGI ING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 18 WILL BE CHARGED MONTHLY ON ANY UNPAID B CE AFTE D E FORT RTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEOULUIG CONTRACTOR REGISTRATION. _ ONO IGN THIS CONTRACT IF THERE ARE ANY 6 $ ES AAI R SIGNATL •RISE EABIn B _ ^; GUS ER ACCEPTANC NOTE:THIS CONTRACT Y t - RAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE _- ACCCPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE(YORK AS SPECIFIED.PAYMENT VALL BE MADE AS OUTLJNESED ABOVE t ' DEC � 5 2015 . �M OWNER AUTHORIZATION FORM t, FY'Qva 1L._ !fie ca ce (Owner's Name) i owner of the property loomed at l 4 D (Property Address) Al• J4 L000 Grp v . P" �'kS (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. i n i i I i Owner's nature Date r t i i I The Commonwealth of iWassaehaasetl's Department of industrial AeeLdents I Congress Stlre4 Suite 100 Boston,K4-02114-2017 www.massgay/rlia '%Yorkers'Compensation Insurance Affidavit:lauilders/1^_ontrsctocs/P-Iectricians/Plumbefs- To 3-E SLED WnH WU s F-RMrr NG AUTHORITY- _ ADpNcarnt Information Please Print I bly Name l3usincss/Or fin nal _ v — ( gang n/individ ) Address: City/StaPhone##: ?c Art:yoo an employer?beef;the appropriate boa: 7i ytDe of pro feet(,geared)- 1_'Y I am a rmployer with i1 —0-3r—(full andlas part-time)' 7- L New eonstru�ioa 201 am a sole prop+iaor or pwinerybip and b,,,,o®ployees working forme in 8. Remodeling any amity_[Pio workers'comp_it>stt+= required-] 4_ Demolition 3-01 ata a htrm=Mmcr doing alt work my,:lL[No workers'comp-insurance regturcd I t 10�i Building addition 4-n i am a bomcowaer and wilt be hiring coahactors to cooducs all work on my property- I will 1 �'�[Electrical ails or additions cast=that all contractors either-bar-workers'oomp=sation insumancc or ata sok LI rep proprietors with no employees- 12-[]PIumbing repairs or additions 5.01 am a gcocral contractor and I have bbmd the sub-eoarnctors listed on the attached shod 23.[]Roof repairs These sub-c t actors bavc employees and have workers'tromp_innirancct 6_0 We arc a corporation and its offices bave exercised their right of exemption L per mGother 152,§1(4)�and we bave no employee.[No workers'comp-insurance raqui=&] 'Any applicant that checks box#I meat also 611 W the section below showing their workers"compensation polity information, t Homeawnas-bo submit this affidavit iadi®ting they arcdoing all work and thea birc outside contnxtors must submit n ew af5davit iodieatia9 such tCootntctom that ch¢k this box moxa umcbcd an additional sheer showing clic nacre of the sub-matractnrs and sate wbctb r or not those cutitirs have employees_ If the sub-contractors have cmployaes,they must provide their workas'comp.polity Dumb=- 1 aro are employer that is providing Workers'compensation insurancefor my employees. Eelow is the policy and job site InformaEdon- a Insurance Company Name: U Policy#or Self-ins-Lic_#: yvJG ; J Expiration mate Job site Address: 139 City/State/Lip: y� , ►\p�a .1-e .iktttach a copy of the workers'x011; tWsatien policy declaration page(showing the policy number Efto'elpiratiot°date). Failure to secure coverage as required under MGL c- 152,§25A is a criminal violation punishable by a fine up to$I,500-00 1nd/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKORDER and a fine of up to$250.00 a Jay against the violator_A copy of this statement may be forwarded to the Office of investigations ofthe DIA for kLW—ce :overage verification. t do f."e$y certify under thepains andpenalices ofperjFurV that the informadon provided above is trere and correct signature: z t`r �/ `t ;= Date: 'hone t i Of lciaal case only. Do not write in rhes area,to be completed by+d ty or town 065:1aL City or Town_ pernrit/Lkense# Issuing Authority(circle one): - I-Board of Health 2_Building DV2rtment 3-City/Tovim Cleric 4-IElectricaI Inspector 5:i<°lumlbing Inspector 6-Other j Contact Person_ Phone#: I 1!4/2016 Preview:Certificates of Insurance DATE(L7!SDDYYYY) AC(:;PRV 'CERTIFICATE OF LIABILITY INSURANCE o1104rz016 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.It 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: PHONE Ax Automatic Data Processing Insurance Agency,Inc. IA:C.tin.Enc t•,rAIL 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERIS)AFFORDING COVERAGE NAIC7 INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 I Andover,MA 01810 1INSURER O: I INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL!C:ES Or INSURANCE LISTED BELO'.V HAVE BEEN ISSUED TO THE INSURED NA10ED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIWITHSTANDING ANY REOU;REI:?ENT.TERM OR CONDSTiOr•I OF ANY CONTRACT OR OTHER DOCUIaENT tZ:TH RESPECT TO':HiCH THIS CEP.TIF;CATE 14AY BE ISSUED OR t AY PERTAIN.THE iNSURANCE AFFORDED DY THE POL'C+ES DESCR'.BED HEREIN 1S SUB.iECT TO ALL THE TERMS. EXCLUSIOtJS AND COND)T:ONIS OF SUCH POLICIES LIMITS SHOWN t'AY HAVE BEEN REDUCED BY PAID CLAiL SS INSR I TYPE OF INSURANCE c POLICY NULIBER UL bUtiRl (I"WDD YYYY UCY P I LIMITS LTR IN„D \'ND ! R1G7LICY EYYi COMMERCIAL GENERAL LIABILITY {LACI.*'_�VKEENUE •,rc w _LACAS I.I:•UE ❑LCCL Ic 1-(itLBSt�'IE:r__ _ LIEU E.P rAr.;.o2 yitiarE Gtr:L AC{kEL'Al E 1.111-111 AHILIE5 PEE. GENEKAL AU;B ihQ-,I E PCUC"❑JEI:1 Pli4 F-1 U:1_ _ crtl3i: AUTOMOBILE LIABILITY It ..,d. ,V.'i,U I C• I 6CUtL+`II:JLIi:'d..i+=r::vnl 5 r�(_L L I.EV SLFEL LLED :,LIDS ACI CS BCL'IL'i IhJI.IC_IP«a.:.r-cu; I:.:t:r" I:t(ti rucEu;,Llrs awes � IPS-,--...,ua U6:BRELLALIAB _-!,UH fa-C:C�CIi+itDat H EXCESS LIAR CLA11.151.17.UE tnGGRE+:.I E DtU I:EIEI.II:i:S , 1 WORKERS COMPENSATION X =1.IL1E EI:~ ANDEMPLOYERS'LIABILITY Y;tl� ( _ 1,000,000 ih:�Iiir:PlaE1CI PARI FET E:tECGiisE ^ EL EA.A-:,CCIUFI.1 A rfFl.Ef:'6&.IBEfie ritL( Gl +tt1A N POt:+C7722s8 01:01;2016 Q1/Q7'_�Q1' 7,000,000 (M.andalory in NH) t�t� E.L"C9 ci5t ti,Eil1'Li,`'tE 1,000.000 L'�tS'L I:II'itrr:r�i-CI'Elia lli:t:S b::�:: j E.L.L`L E:•SE-1:11;M711-11.111 DESCRIPTION OF OPERATIONS;LOCATIONS I VEHICLES IACORD 1171.Additional P.e ks Sch,dul.m i be afoched A--pace is required) 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 AD 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLASEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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(les)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 aHONEx _98 , �FAX 688-7000 _—(97_8 688-7001 11 Saunders Street North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)_AFFORDING COVERAGE NAIC0 INSURER A:Nautilus Insurance Co. 117370 INSURED INSURERS:Safety Insurance Company— 33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc - - P O Box 958 INSURER D: Andover,MA 01810 INSURER E: — INSURER 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. INSR ADD L—13 POLICY EFF 1 POU EXP LTR TYPE OF INSURANCE 1 INSO I WVD! POLICY NUMBER MMLIMITS /D I MM/DD A I X !COMMERCIAL GENERAL LIABILITYI ! ! j I EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE `L -- OCCUR i �NN538691 i 03/24/2015103r24/2016 I PREMISES(Ea occurrence) '$ 501000 i MED EXP Anyone person) 1S 5,000 ! 1,000,000 1 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I I I i GENERAL AGGREGATE 1$ 21000,000 X1 POLICY f—j JET I�I LOC ? I i PRODUCTS-COMPIOPAGG $ 1,000,000 OTHER: ( i - -- s AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT j$ Ea accide1,000,000 ! nt ?_ ___ _ B ! ANY AUTO i ; 12100926 1 01/04/2016'01/04/2017 I BODILY INJURY(Per person) i$ ALL OWNED I SCHEDULED 1 I ! BODILY INJURY(Per accident);$ _ I +If _ NON-OWNED i I PROPERTY DAMAGE $ I X 'HIRED AUTOS ,AUTOS j(Peraocidenl- $ -_--- i I UMBRELLA LIA8 ;OCCUR I j EACH OCCURRENCE $ 1,000,000 _ f A EXCESS LI CLAIMS�JIADE j �AN019284 i 03/24/2015`03/24/2016�AGGREGATE !$ �.._.; I _. -. -_.-_; -- - ! Is DED RETENTION$ i WORKERS COMPENSATION i ! ! PER 0TH- AND EMPLOYERS'LIABILITY j I —1_STATUTE YIN' iANY PROPRIETORIPARTNERIEXECUTIVE ( I j E.L EACH $ OFFICERIMEIdBEREXCLUDED? N/AI j(Mandatory in NH) I ! ( i !E.L.DISEASE-EA EMPLOYEE!$ If yes,describe under DESCRIPTION OF OPERATIONS below 1 + i E.L.DISEASE-POLICY LIMIT 1$ I I I I 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 ThIeISCh 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 AUTHORIZED REPRESENTATIVE r,% ,000 on,,A Ar�r%nm l ^maAO A Tr/1S1 An-.,.tis.....,..,,-,,,,,� 'c ` . � Wio� ,,Of Consumer sand Offic , s 5170 10 p Playa-SM 02116 v�ment Oki.* _ ��Tys 2=49 BEAR iS�iS��- `TION C V'mwnt LeBlanc .O958 == gator chwep- P .SOX DWER, Mq 01$'tQ - __ = `=� �A �,na�a�ca� ' ` [3 totc'd All1 = _ v R►ewal �SP1° '01t - _ a O�A1 s� .&1p�2i6 JS 7id 1511=9 T�Y3 e' ptais��'NE 03865 '