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HomeMy WebLinkAboutBuilding Permit #788-2016 - 14 LINDEN AVENUE 1/7/2016 �AORTH BUILDING PERMITt`LeD ✓p' t� "rV` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION .: .. � t :y Permit ,No#: Date Received SRA °Rareo^Qa q5 �SSgCHU Date Issued: IMPORTANT: Applicant must complete all items on this page Pr'nt P,�ROPEF2TY ®WNE`R 0.0- Prin 10©1'ea Strue u ee yes no MAP� PPRCE_ Z®NIN_1401 ST Historic ®'i tr ct yes no Machine Shop Village yes I 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 N Others: ❑ Demolition ❑ Other Tr 147-1,0V? Septi ®W I- ;+ ''' (WFloodpla n ® 1N��, ® Watershed Distr;c""`t ` Wate/Sewer DESCRIPTION OF WORK TO BE PERFORMED: l4if"Fetn nG/gl( IN5vlrfile^ l��rr5eP4�� Identification- Please Type or Print Clearly OWNER: Name: Pr in vt ;k ea q e Phone: g7p-AF3 - /ZL& 01 Address: �r?*.'. �."' ,� s' ;:*'.tiy.*e: '�.t, -"cr.c aYL a;w ,, - •r v `xja?P `� BEAR)NSULAI`( 1� F r Add re s� mu Isor s Construe'ion License t o x Home Improvement Licen e�..:;���..Y,D.a-7�(�?v, � x Exp J®ate ZZ6 7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. i Total Project Cost: $_? 3 on_®o FEE: $ Check No.: ��Q I� Receipt No.: DOTE: Persons contracting with unregistered contractors do not have accesslo the guaranty fund - -. -- - - - -. -- - — �Signafiure`of Agent/Ovvner Signattare of,co,rifractor {� . `. -., ;i iii , ;. 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 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 *J T Conservation Decision: Comments Water& Sewer ConnectioniSignature& Date Driveway Permit ]DPW Town Engineer: Signature: L - - � � ARTMEf01T ' Tem-�' `'`�K'-° rr a ca- 84 Osgood e � Located 3 g Street ste o FEDEP�gt .ump $ ri�site� Located a 1.24 lain�Street� , '' !,� t , xy� cR��a� 'a-.....7�'S/'"�2- A �°9'�;i ` -• �4�.�,,,���;J ?k.- , z� `` -�. Fire Department signay ure/dates*rt } .t ' �,s' •k �� . �„` ;;; t, nor.�t,`,���x+Lt``i�.�,1+.'"r*'��'(�': � y� �a ��, �'r -3rd .v'S. .'�a•�'��riv .�T .yf3�'�" t` g�`�a '�,' CO,MMEIVI;S '�”. ;�`�� x;+����,�s�.�t ;1i,t 's ,_ ..�.. � •1�;���a;4x `�>��'�+� ���� �, ,a, .,,T-�+ 4:�.r -�,,�, l Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, avast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For department ease) U Notified for pickup Call Email Date Time Contact Name 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 i ❑ 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 DTE:. All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Perm it'Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Two Sets of BuildingPlans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ ' Engineering Affidavits for Engineered products ATE: All du mpsterermits require sign off from Fire D P q g apartment 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 No. Date ► �� �� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ f �' Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ t Check it s Building Inspector NORTH Town of : Andover , h ver, Mas �� is SCOC NIC Hl W1C.«.�1' 4.4TED U BOARD OF HEALTH PERM T Food/Kitchen Septic System LD BUILDING INSPECTOR THIS CERTIFIES THAT :...................la.t4l�!!. .. mej .. . ........ ...................:.............. C.N� Foundation has permission to erect .......................... buildings on .�... ..... ....................... ................................. �. 01i Rough to be occupied as ........Av% P-.seJ% ... .. .....................~.............. .............................................. Chimney provided that the person accepting this peel s�all 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST S Rough Service ................................... ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Regicired 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. View ~ Federal ID#05-MS629 � RISE Engineering RI Contractor Registration No 8186 RISE A division ofThieisch Engineering CT Contractor Registration o 20120 C7 Contractor Registration No fi201T0 ENGINEERING 60 Shawmut,Canton,AIA 02021 CONTRACT CZ 339-502-5197 FAX 339-502-6345 '�i R!1 Page 1 PROGRAM TM CONTRACT IS ENTERED 0410 BETWEEN RISE CMA-}IES ERWISCRINO AND THE CUSTOMER FOR WORK AS DESCRI Waa.Ow CUSTOMER PHONE DATE CLIENT WORK ORDER Kenneth Wedge (978)683-1826 09/28/2015 422298 00003 SERVICE STREET BIWNQ STREET 14 Linden Avenue 14 Linden Avenue SERVICE CITY.STATE,ZIP aWHG CITY,STATE.ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be lcfl 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 scaling include air leakage to attics,basements,attached garages and other unhealed areas(windows are not generally addressed.) This will require(7)working hours. A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weathcrirntion 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 the indoor air quality. $595.00 KNEEWALL SLOPE:Provide tabor and materials to install 11-19 unlaced fiberglass to(192)square feet of wall. Then install 1"rigid board insulation. Seal all sears with FSK tape. $787?0 WALLS:Furnish and install blown in Class 1 Cellulose to(864)square foci of vinyl-sided exterior walls.Invoicing will occur upon completion of installation. Subsequent to your payment,as an added service,RiSE Engineering will return vt3ten weather permits to check for any voids with an infrared scanner. Any major voids that may be found will be filled at no additional cost. $1,598.40 BASEMENT CEILING:Provide labor and materials to install(108)linear feet of R-19 unfaced fiberglass insulation to the perimeter ofthe basement ceiling at the house sill. $189.00 BASEMENT DOOR:'Provide labor and materials to insulate the back of the basement door icadinge 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 scams with FSK tape. $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 1001/6 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 ofyour homes indoor air quality,we will he conducting a blower door diagnostic ofthc available air flow in your home both before the work is begun,and after the weatherintion work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 IFn!1 OCT - 6 2015 Federal ID#O&MS629 11U�,� RISE Engineering RI Contractor Registration No 8186 R 1 S E MA Contractor Registration No 120979 A division of Thicisch Engineering CT Contractor Registration No 620120 ENGINEERING 60 Shnwinut,Canton,MA 02021 CONTRACT 339-502-5197 fAX 339-5024345 Page 2 PROGRAM THIS CONTRACT W ENTERED INTO BETWEEN RISE CMA-HES ENCIRMINO ANDTHE CUSTOMER FOR WORN AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT/ WORK ORDER Kenneth Wedge (978)683-1826 09/28/2015 422298 00003 SERVICE STREET MURM STREET 14 Linden Avenue 14 Linden Avenue SERVICE CrrY.STATE.ZIP BILLING CIM,STATE.ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $3,331.82 Program incentive: $2,670.11 Customer Total: $661.71 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Six Hundred Sixty-One&711100 Dollars $661.71 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING,CUSTOMER AGREES TO REMIT AMOUNT DUE PI FULL INTEREST OF t%WILL BE CHARGED MONTHLY ON ANY UNPAM AFMIGOAYS.SEEREYEFtSEFORIMPORTANt OWORMATIONON GUARANTEES.RIGHTS OF RECmNkN.SCHEDULDIG.AIM CONTRACTOR REGtSMTION. �= DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES I AUTHOR TUBE RISE EnpineeAllg CUSTOMER ACCEPTANCE NOTE;THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT•THE ADOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORED TO DO THE WORK —AS,Ps CIFIED.PAYMENT WILL BE MADE AS OUTUNED ABOVE OCT - 52015 L r .r'.vw OWNER AUTHORIZATION FORM } Kenneth Wedge (Owners Name) owner of the property located at 14 Linden Ave, North Andover, MA 01845 (Property Address) 14 Linden Ave, North Andover, MA 01845 (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. Owners Signature Date OCT - 5 2015 i The Commonwealth of Massachusetts fment o Department Industrial Accidents P I Congress Street,Suite 100 Boston,MA 02114-2017 wwn:mas&gov/dia %Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY_ Applicant Information Please Print Le- 'blv f Name(BusinesslOrganization/Individual): f Address: C��. 8,C) yC City/StatelZip: A o t, -t F M #1970 Phone#: / 7ek 61 •-5%�> 5"� Axe you an employal Caeck the approprbee box: Type of project(required)- Lal am a employer with_employees(full and/or part-time)-o 7- New construction 2.C]I am a sole proprietor or partnership and have Do employees working for me in 8. ❑Re�IIOd nstr any city.[No workers'comp.insurance required.] Ung 3.Q I am a bomoownar doing all work myself:[No workers'comp.insurance required.)t 9- ❑Demolition 4.Q i am a homeowner and will be hiring contractors to conduct all work on my property_ 1 will 100 Building addition erasure that all contractors either have workers'campeasation insrranoe or arc sole 11.[]Electrical repairs or additions proprietors with no em b P Yar- 12. Plumb" or additions Plumbing sus s 1 ❑ g nP .❑ am a general contractor sad I have hired the subcontractors listed on the attached shad These sub-contractors have employe=and have workers'comp.insurances 13.QRoof repairs 6.0 We are a corporation sad its officers bavc exercised their right of exemption per MGL C. 14.E]Other 152,§1(4).and we have Do employers.[No workers'comp.insurance rcquitnd.] 'Any applicant that checks box#I must also 511 out the section below showing their workers'compensation polity imformatioa t Homeowners who submit this afridavit indicating they are doing all work and then hire outside contractors must submit a new afntdavit indicating such iCootrac lots that check this box must attached am add'uioiW sheet showing the name of the cob-contractors and state wbdhc or not those entities" have ®ployccs. If the sub-nonreactors have employees,they must provide their workers'comp.policy Dumber. I am an employer that is providing workers'corapensadon insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: lob Site Address: L,NA �YH !/-� Ci /Stato0 � -erl 6 ry P�_ 11- Ar od Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 md/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 lay against the violator-A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. I do hereby certify under the pains and penaldes of perjury that the information provided above is true and correct, ` y� -��-- 'iz mature: �t L..z�_ .�!L �j --- Date: I VA� Ione#: o �' r) r 0,0ic141 use only. Do not write in this area,to be.completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector 5:Plumbing Inspector 6.Other Contact Person. Phone#: I POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE FDA lis✓016 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 PHONE 978 688-7000 FAX _ ; 978 688-7001 11 Saunders Street ac,�°E>R): ---.— (-c'"°� )68 -- North Andover,MA 01845 A DRIESS: INSURER(S)AFFORDING COVERAGE _ INSURER A:Nautilus Insurance CO. 173_70 INSURED INSURER B: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 F: 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. INSR TYPE OF INSURANCE AD�SUBRPOLICY EFF j POLICY EXP LIMITS LTR INSD I D POLICY NUMBER MM/D I MMID� A X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE I$ 1,000,000 AMAG��CLAIMS-MADE " I OCCUR INN538691 03/24/2015 03/24/2016 PREMISS aEoccurrence $ 50,000 I MED EXP(Any one person) $ _5,000 PERSONAL&ADV INJURY_ $ 1,0001000 GEN'L AGGREGATE LIMIT APPLIES PER: (GENERAL AGGREGATE _I$ 2,000,000 X i POLICY LI PRO- 1-1LOC ( PRODUCTS-COMP/OP AGG $ 1,000,000 1 JECT OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I$ 1,000,000 (Ea acc dent) B ANY AUTO 2100926 01/M016101/04/2017 BODILY INJURY(Per person) Is _ ALL OWNED (X SCHEDULED I BODILY INJURY(Per accident) $ AUTOS �^�AUTOS --------------- i PROPERTY DAMAGE $ X .HIRED AUTOS X NON-OWNED 1 AUTOS j (Peraccident I I $.. . _ UMBRELLA LIABX I OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB 1 CLAIMS-MADE AN019284 03P24/2015 I`03/24/2016 1 AGGREGATE $ DED I RETENTION$ _ I I $ WORKERS COMPENSATION I PER I OTH- STATUTE AND EMPLOYERS'LIABILITY ER Y ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ i E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1 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 AUTHORIZED REPRESENTATIVE IFN-4Q°°')n4A Af-^On d-f%00f%0AT1AK1 A11..wl.sw.wwww•w.l 1/4/2016 Preview:Certificates of Insurance DATE(M?6MDNYYY) AcoRV CERTIFICATE OF LIABILITY INSURANCE 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(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 NAME:C : PHONE Automatic Data Processing Insurance Agency,Inc. " Ext): (A1C.Noy, 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC Ir INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC Po Box 958 INSURER C: ' ' Andover,MA 01810 INSURER D: INSURER E: 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 REOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED 13Y 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 LTR TYPE OFINSURANCE INSD WVO POLICY NUMBER POLICYLI 1 (MMIDDlYYYY) (MMlOD;YWY' LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CUAf1:1S-ktAUE OCCUR PREt:IISES IEaorcum,ncel S NED EXP Iimpone person) S PERSONAL 6 ADV INJURY S GENL AGGREGATE LIHI I APPLIES PER: GENERALAGGREGA'IE S v❑PRG ❑ POUC. ¢C1' LOC PRODUCTS-COPaF':'OP l.GG 5 OTHER: $ AUTOMOBILE LIABILITY (A)MBINLU SI'UL hl S IEa accident) ANY AUTO BODILY INJURY iPr.Per—I S ALL CAWED SCHEDULED BODILY INJURY IPer aaldenll S AUTOS AUTOS NON-OINNED PRUPLRIYUALIAlit, ItIREDAUTOS HAUTOS (Per acudrxdl S S UMBRELLALIAS OCCUR EACH OCCURRENCE EXCESS LIAR U.CLAIIAS-MADE AGGREGATE S - DED RETENTIONS S WORKERS COMPENSATIONU AND EMPLOYERS'LIABILITY YIN X STATUTE ER ANY PROPriIETOR++PARTN'ER-EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 A OFFICEWMEMBErEXCLUDED? Y❑N!A N POWC772258 01101/2016 01/01/2017 (Mandatory in NH) E.L.DISEASE-rA EMPLOYEE S 1.000.000 11-,s desrnbc under DC=SCRIPTICN GF GPERATIONS blow E.L.DISEASE-POLICY UMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES(ACORD 101.Additional Remarks Schedute,may be aMched A mwe space 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 A©1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i s g, lation DI Office of Consumer,SI&5170 10 Pa&Pia�a - 02116 Bosman-Massa+hl 10II me�tovem��Ol1tCd Ox $1 R oce tf12 O TYPE DBA 252M ii2a0l O. POLALR BEAR tNSu�T[ON - Vnce80X 95LeBj8nC - = = ,�1hr cbm P.O. - : _ - -_- -- DOVER, MA 01810 .. :- _- : ups Address SAd retinm D Lost Cara _ -1 Address O RMeWA OPS�A; `'' l I j UP _ __:._r_ 5 i:..a• Board [:snit:ucdon Supers=sOr SS�p.�ed:ln- .{ LWC RV/tt pEMALRB 1 2ZAVPM s�1�E g p;ai►stow PK 0386 _ ,,,,na:ss�siane: i i I