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HomeMy WebLinkAboutBuilding Permit #791-16 - 14 EDMANDS ROAD 1/7/2016 at oaro- -0 J BUILDING PERMIT t 6 0TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Permit Flo#: Date Received � p�RgTEo nPa"�5 �SSaC USEt Date Issued: EMORTANT: Applicant must complete all items on this page l k LOCATIO a N t' U►'� ?- - Pr nt C P11- R 0 Year SSttruc r lyes no [MAPP/aRCEL: Z NIN DIST�,RIT[ _1Hstoric Distric#$ dyesKv [. �. . ,p�� ge Sys . M-0 Machine S.ho Villa e es no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg it Others: ❑ Demolition ❑ Other �rr� �-*� r � r. - H. L Septic �� FI©od Iain t©Wetlands; J: I BOJ 1Natershed f istr�ctf DESCRIPTION OF WORK TO BE PERFORMED: • � s Identification- Please Type or Print Clearly OWNER: Name: —1 ti �`t k 4 � ,`Th Phone: �y you y Address: -7 G 3 ContractorNarrie 1Phone _ > YoT t . ._ _ n�,�� �•.�ll � -_ — as _ PO BOX. - - -- -- E rn a i lPt — _—. 958.�--- - Address��. � ANDOV!�F I K-6 8�{ --� Supeniiso"s /'� o ��_..._.��- .:._� n ld� 7 G Ex�°' Date Home Irnpro�a menti�Lficense ��..�.__.._...:�.>�-_ ________�.� ���„p,� :.r,7Zo ARCHITECT/ENGINEER Phone: ` Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gua;an andSignatureoftcontfac "``�` Location No. Ila Date _ /_ w . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ v TOTAL $ p Check# 29,395 Building Inspector Plans Submitted ❑ Plans Waived.[] Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/MassageBody 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 a Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer ConneetionlSignature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street AFI-RE DEI''ARTIMENT - T me p'Dumpster onsite•-,yes - 3.4 Awe. �.c Located at 124 Main Street ''�� �"; '� ; : ' 3 ' �`, �Fire Department signature/datQs­ ;�o t1: � .2`x`4 +• � . . ,�:. COMMENTS. -' y ' ' ; �, t. t�;{' t ',. �, Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL.: Movement of Meter location, wast or service drops 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 Peimit 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 o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products OTE: 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products :)TE: 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 Clerics 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 r 1 NORTH - r _ , wn . 2 . . ver 0 � - I �h , ver, Mass, CO �f- COC NICKlYVKK.�1' 7,95°'4Areo V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System Y a THIS CERTIFIES THATj� !10 BUILDING INSPECTOR / Foundation has permission to erect.......................... buildings on .............1. ....... ....4 ..... Rough tobe occupied as ........... ....A .. ... .... ..... .........�..... UI. o!................................. 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 Rough - VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 M THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO A 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. Federal ID is i RISE Engineering RI Contractor Registration No t MA Contractor Registration No A division of Thielseh Engineering CT Contractor Registration No i 60 Shawmut Unit 112,Canton,DIA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 R I SEPROGRAM 1 PROGRAM CMA-HES EENGMEEMGuroTHE�aur FOR WINTO ORK ARISS ENGINEERING DESCRIBED BELOW CUSTOMER _. —. PHOla:a —. -.--.. DATE WENT WORK ORDER Terika Smith (847)902-9244 07/14/2015 408-841 t� SERVICE STREET -- - -�BILINS STREET! — \\t( 14 Edmands Road 14 Edmands Road �J SERVICE C W STATE.ZIP- BILUNG CITY.STATE.ZIP^ North Andover,MA 01845 North Andover,MA 0184 D � 5 2p15 JOB DESCRIPTION BARRIER:A Blower Door Test will not be conducted at your home,due to the presensc ofashestos. $0.00 AIR SEALING:Provide labor and materials to seal areas of your homc against wasteful,excess air leakage. This work will be perfomtcd in concert with the use ofspecial 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 unhealed areas(windows are not generally addressed.) This will require(8)verorking hours.A reduction in cubic feet per minute(cfm)ofair infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of tee indoor air quality.THERE ARE WATER PIPES IN KWALL ALSO KWALL SLOPES HAVE RB INS.IF POSABLE DP"6 FINISHED SLOPE/IF POSSABLE AIR SEAL UNFIISHED KWAL SLOPE WHERE RB EXISTS. $680.00 AIR SEALING ADDER: (4)working hours. - j $340.00 i DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass balls to(80)square feet for damming purposes. $164.00 ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class I Cellulose added to(447)square feet of open attic space. i $657.09 SLOPES:Provide labor and materials to install a 6"layer of R-21 Class I Cellulose added to(580)square feet of slope area. Wherever possible baffles will be installed to the entire length of each bay to maintain ventilation space.THERE ARE WATER PIPES IN KWALL ALSO KWALL SLOPES HAVE RB INS.IF POSABLE DP"6 FINISHED SLOPE/IF POSSABLE AIR SEAL UNFIISHED KWAL SLOPE WHERE RB EXISTS, S1,078.80 ATTIC ACCESS:Provide labor and materials to insulate the back of(I)attic hatch with 2"rigid Thermax board.Weatherstrip the perimeter. $60.00 VENTILATION:Provide labor and materials to install(I)8"diameter roof vent($)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,brown,gray or mill finish. $8550 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s). $118.75 VENTILATION:Provide labor and materials to install ventilation chutes in(38)rafter bays to maintain air flow. $76.00 ' Federal ID# RISE Engineering RI Contractor Registration No MA Contractor Registration No A division of Thielsch Engineering CT Contractor Registration No 60 Shawmut Unit#2,Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 R IS PROGRAM THIS CONTRACT IS ENTERED KM BETWEEN RISE ENGINEERING, CMA-HES DENG�RIIN LLANDTHECUSTOMERFORWORKAS CUSTOMER i PHONE DATE ^_ CUENTA ORKORDER Terika Smith (847)902-9244 07/14/2015 4-0!78 0002 SERVICE STREET BILLING IIING STREET - 14 Edmands Road — _ 14 Edmands Road SERVICE CITY,STATE,ZIP BILLING CRY,STATF MP `✓ _ _,_ North Andover,MA 01845 North Andover,MA S 2�1� - _ -.-------- - —S — JOB DESCRIPTION \ VENTILATION:Provide labor and materials to install(8)4"X 16"rectangular aluminum soffit vents to incre en itld—on in attic areas.Specify color.White or Gray. $200.00 BASEMENT CEILING:Provide labor and materials to install(142)linear feet of R-19 unlaced fiberglass insulation to the perimeter or the basement ceiling at the house sill. $248.50 BASEMENT DOOR:Provide labor and materials to insulate the hack 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. Seat all edges and scams with FSK tape. $72.22 CRAWLSPACE:Provide labor and materials to install(160)square feet of 6 ml polyethylene over open ground in designated crawlspacclearthen basement areas. $123.20 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible mcasures,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 weatherizaiion work is complete.We will also conduct a full assessment of the combustion safety ofyour heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is 53.110. $90.00 Total: $3,994.06 Program Incentive: $3,906.99 Customer Total: $887.07 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF **"Eight Hundred Eighty-Seven&07/900 Dollars $887.07 UPON RIAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL DE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER SO DAYS.SEE iteym Fon IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDUUq5LMQ CONTRACTOR REGISTRATION. 7DOOT SIGN THIS CONTRACT IF THERE AR BLANK SPACES A SKSNATU -RISE ring — CUS MER ACCEPTANCE NOTE:THIS CONTRACT MAY DE WITHDRAWN 0Y US IF NOT E%ECUTEO IHTH 1 GATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT.THE ABOVE PRICES.SPECIFlGITIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORK AS SPECIFIED.PAYMENT WILL BE GLADE AS OUTLINED ABOVE s OWNER AUTHORIZA TON FORM Te V.1 K0 (Owner's Name) owner of the property located at /2d - (Property Address) uPa r - a (Property Address) hereby authorize (Subcontractor) `l an authorized subcontractor for RISE Engineering,to act on my behaff to d� uuildm permit and to perform work on my property. is gn Date The Commonwealth of Massachuseas jDepartment oflndustrialAcculenis I Congress Street;Suite 100 Boston,MA 02114-2017 www.mass gov/dia Uip- Compensation Insurance Affidavit.Bur7ders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDllcant Information Please Print Leeibly Name(BusinesslOrganiration/Individual):_ [lo /,A1 J Yk to Ti'O14 l'0 111c Address: 6 r 8,0, �C City/State/Zip: 11 o, J 0 V•-t F MOPhone#: Are you an employer?Check tie appropriate boy: Type of project(required): I_ I am a employer with emplayoes(fun antler pari time)_• 7- ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for cue in 8. ❑Remodeling any deity-[No workers'comp.insurance :aNirod-1 9. ❑Demolition 3.❑I am a homarwmar doing all work myself(No workers comp.insurance required_)t 10❑Building addition 4. 1 am a homeowner and will be hiring eonttactors to conduct all work on 1 will ❑ �8 my PmpenY caa..r that all contractors eitber have workers'compensation insurance or I I. additions pensat are sole Electrical nus or prvprictors with no employees. 12.❑Plumbing repairs or additions S Q 1 am a general contractor and 1 have bired the subcontractors listed on the attached shoo These sub-contractors have employees and have workers'comp.insurwxr-t 13.❑Roof repairs 6.❑We are a corporation and its officers have otrieisod their right of ucmptioo per MGL c 14.❑Other 152,11(4),and we have no employees..[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information t Homeownes who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such. rContractors that chock this box mats attached an additional shoo showing the name of the subconnactom and sate wbaberor oot tbosc catitics have cmployom If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. y Insurance Company Name: 1/?p �Gv i�CA Policy#or Self-ins.Lic.#: (ems iiJG 7��d j, Expiration Date- ll--,2,9 lob Site Address: I A dCity/StatdZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tarda MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 rnd/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 j Jay against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. do hereby certify under the pains and penalties of perjary that the information provided above is true and correct zitmature: �� �e�—, _ _�- ..�_----------- Date- "hone#: O-Okial use only. Do not write in this area,to be completed by city or town ofjSeiat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.- Plumbing Inspector 6-Other Contact Person: Phone#: �-� POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE 116/2016 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 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 FADDRESSS: Durso&Jankowski Insurance Agency 688-7000 a No):(978)688-700111 Saunders Street ) lNorth Andover,MA 01845 INSURERS)AFFORDING COVERAGE _ NAIC# INSURER A:Nautilus Insurance Co. 17370 INSURED INSURER B:Safety Insurance Company 33618 Polar Bear Insulation Co.Inc. INSURER C Peter Leblanc&Steven Leblanc P O BOX 958 _INSURERR_: 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. 4 - - — - POLI iLTR TYPE OF INSURANCE Aja Syuryp POLICY NUMBER MM/D/E� MM/DD EXP LIMITS A X I COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE Is 1,000,000 CLAIMS-MADE OCCUR NN538691 03/2412015 03/24/2016 PREM S S E occurrence) I_$ __ _ 50,000 MED EXP(Any one person) _ $ 5,000 j PERSONAL&ADV INJURY_ ,$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE AGGREGATE _ s _ 2,000,000 X POLICY PRO �LOC PROD_UCTS-COMP/OP AGG1$$ 1,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I$ 1,000,000 ` (Ea accadent) B ANY AUTO 2100926 101/04/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNED �( SCHEDULED I LILY INJURY(Per accident) $ r ALTOS AUTOS I--—---- --_ --- -- ! NAUTOS NON-0WNED PROPERTY DAMAGE $ X HIRED AUTOS , I _LPer accident �$ UMBRELLA LIAB X I OCCUR EACH OCCURRENCE $ 1,000,000 A I EXCESS LIAB CLAIMS-MADE AN019284 03/24/2015 03/24/2016 AGGREGATE _ $ �- — DED I RETENTION$ I I WORKERS COMPENSATION I IS SER I OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE ER ! ANY PROPRIETOR/PARTNER/EXECUTIVE EL-EACH ACCIDENT _ S OFFICERIMEMBEREXCLUDED9 N/A s (Mandatory in NH) E-L.DISEASE-EA EMPLOYEE $ Ifyes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 AUTHORIZED REPRESENTATIVE 1 1/4/2016 Preview:Certificates of Insurance ® DATE(MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCEF 01/0412016 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 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 I certificate holder In lieu of such endorsement(s). CONTA PRODUCER NAME: PHONE I Automatic Data Processing Insurance Agency,Inc. nlc No Ext): AIG No 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAtC 0 INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: I POLAR BEAR INSULATION CO INC INSURERC: PO BOX 958 Andover,MA 01810 INSURER D: INSURER IF: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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. FULIGY t;" POLICY EXF LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MINODIYYYY MIDLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE DOCCUR PREMISES Ea oomnence) $ MED EXP(Anyone person) $ I PERSONAL&ADV INJURY $ GEIJL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY El JECT F-1 LOC PRODUCTS-COMP/OP AGG $ OTHER: S AUTOMOBILE LIABILITY EaatIIN ) S ANY AUTO BODILY INJURY(Pax person) S ALLOWNED SCHEDULED I AUTOS AUTOS BODILY INJURY(Per aocide d) $ HIRED AUTOSAUTOOSWNED Per accident)$ UMBRELLA LIAR HOCCUR EACH OCCURRENCE E EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONxERI AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACG DENT $ 1:000,000 A OFFfCERrt�MSEREXCLUDEm N/A N POWC772258 01/09/2016 01/01/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 It yes,desedbo under 1,000,000 DESCRIPTION OF OPERATIONS bd— E.L.DISEASE-POLICY UMIT $ __Ti DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schodu to,may be attached U more spam Is"utred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thettsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i AI � �Qy6toniviesg j�gtl�BhOIl n�"r yrs and Office of Co to - 10 park.plam- Svi 51700211b Boston,lViassachuSe �s 9 moon °°eme Qon or R+ Reg o =726 I10me .a 252M T11Pm- DBA 6 01 pOLpR BEAR INSU�-p`TtQI�eO- Vncent LeBlanc P.O.BOX 958 - _ resson for a6ange- p�pOVER, MA Oq 810 =- 'Ugh Address�d return es umpl�ea ❑Lost Card _ - Address Renewal Qp3.CAi u p12t6 " yheGSnLi':?i5Sat5 - d ward i:: :C^-- �t;ncee,n 5npenisur Sped21T-Y ' 27ASy�yi�S �T - - PisistoW P9 03865 _ 04d812048 warr�-sus��r=ac-