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HomeMy WebLinkAboutBuilding Permit #116-2017 - 15 IRONWOOD ROAD 8/5/2016 t%OR BUILDING PERMIT o ,LED 1 ���Leo 16 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: U Date Received ��A°awreo�Pa�45 1 SSACHUS� Date Issued: 00 IMPORTANT:Applicant must complete all items on this page LOCATION 1 1 Y-o(\Wtud Print PROPERTY OWNER b rLL UM(1A acyt,-'`- Print 100 Year Structure yes no MAP PARCEL: / ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑/addition EJTwo or more family ElIndustrial ®/Alteration No. of units: ❑ Commercial ❑.Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ 0 _ _ a_ x F .. _ ° k t WS 5 - - ❑:^Septic ❑f 1/Velll ® FRlbrdkdplains 6Wetlantls ❑ ,'Waters°hell Dstn L�"Wkate�ItSewer DESCRIPTION OF WORD TO BE PERFORMED: s--P aj; �1 tv �.r� ,°n 14�CW a o1 Y) I/M hA ik*'40 Identification- Please Type or Print Clearly OWNER: Name: t1C C Qn,\k m&AA L— Phone:C�A-t to $3 Address: S YOY1WW)cl Contractor Name: Phone: Ct--Yq 3 S�D 34 e-3 Email d r- t Acldress�Jrb 13aX 34 4 i Supervisor's Construction License: 1 �Z Z- Exp. Date: I s I F Home Improvement License: 1 � 3��� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �Z f '31 FEE: $ Check No.: ImI Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund •'.�-- ....__�:�.s.__,��� ..�-.-_. _-_—.�_ -. -- -- --- - -- ....ws. :mss.- ._..-=-s_.... - 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 4� Copy of Contract �k Floor Plan Or Proposed Interior Work 4. 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 ;6 Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. Copy Of Contract 4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) 4. 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 Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f Public Sewer ❑ Tanning/Massage/Sody 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_ COMMENT'S _CONSERVAT-IOIV_.... , _Reviewed_on_ _-_..__Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street �ARTMENTem� D ,� .. p FI DEP p' umpsfier,on,site���y�esu,i�go4 a4itg Located at 1x24 Main Street ` ` ` a� f '� �'�• 4�`.i �rci"s"` Fll. [Lou;'•'u xOMr N�YxMy.y'3' 'S� c aTrY4Sta.mP-ae'ntgSi:+ nnyat'ureda�tikrt $ A* CEN �e,-fs�`dr".c.','��'�` ^7`�t'tn,r.f''}.i w 7 11�`��! , •-�Yd$„'rti'R�. Nc�tY 1�S�i'X�a ', Y���_-ir ' ,Z' '�X, a,i••`'�yyG��Y .kra' ' � :� , >> �.t, � r �ii { ►�` ,�� � t 4f 1 x.. ,.i.t.• ��« a.t. .a. .f .fif.A.'x.5• �t - X �i,sr�' °: .,. �,.: 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 Location No. �p " � Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $�_ Other Permit Fee $ TOTAL $ Check#79�o 30701 Building Inspector NORT11 Town of a t s ndover O 116 No. C, L K' h ver, Mass, �' CO01* CMIC"a 1WIC" '_ �d pDR�TED ► he 'P���y s u BOARD OF HEALTH Food/Kitchen PERM D Septic System THIS CERTIFIES THAT .................... .�i�k.......... .�„(�r�1Rit.1..... BUILDING INSPECTOR ..................... .................. Foundation has permission to erect .................... ...+buildings on .. ...... .. .. .....�• �/ Rough to be occupied as .r ..�.t...�� .. ... 4� !�...� .. .te-4... .. .��., y Chimney provided that the person accepting this pe 'it 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 theA�tio n, Alteration and Construction of Buildings in the Town of North Andover. q PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONS TIO T Rough Service Final 2BUILDI INSP TOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry.Wall 1T'o Be Done, FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. rA Federal 10 0 05-0405628 RISE Engineering RI contractor Registration No$186 ISF MA contractor Registration No 120979 "" A division ofThielseh Enginccring ENGINEERING` 60 Sbawmut Unit 02,Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Pape 1 PROGRAM TM CONTRACT IS ENTEREO WTO aETWM AJOe CMA-HES 10100MIRWO ono TIM CUMT' M ran WORK As mco"alto"LOW CUSTOMER aaKONE OATS cu9m N Warr CAO Lisa Mcconologue (978)655-5583 02!04!2016 428343 00002 . s¢a+ncEs»s r_.y.-m. ,_ . .._ .___.. . —----. .,. . . � ...�ur�a�srAt�r.. .. _..... ._.._.__ ...�... 15 Ironwood Road .15 Ironwood Road . . . ............. ...__ ................ SERVICE CnY,6TATE.2P M JJW CITY.STATE W - North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION . o HAZARD BARRIER:We have identified that there are recessed lights present in your home.unless the recessed lights=.emittied as IC�mtcd(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 which contain recessed lights will not be insulated 50:00 AiR SEALING:Provide labor and materials to seal areas oryour 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 unheated areas(windows are not generally addressed.) This will require(2)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 weathwixation work,and at no additional cast to the homeowner.a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety orthc indoor air quality. $170.00 I' AIR SEALING.Provide labor and materials to seal areas of your home against wasteful.excess air leakage. This wark wilt be performed in Konen with the use 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 scat your home can include caulks,foams and otter products. Primary amts for scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are:not generally addressed.) This will require(8)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 tae,.watherivation work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis wilt be conducted by tate sub-contractor to ensure die safety of the indoorair quality. $680.00 AIR SEALING ADDER: (4)working hours. $340.00 AUDITOR'S NOTES AUDITOR COULD NOT ACCESS ANY OVERHEAD ATTIC SECTIONS OR 5 KWALL.S!NO ACCESS PANELS.ASSUMED 6"FGB.EXIST. S0.00 DAMMING.Provide labor and materials to instali a 12"layer of R-38 unlaced fiberglass batts to(60)square feet for damming purposes. 5123.00 ATTIC FLAT:Provide labor and materials to install an 8°layer of R-28 Class I Cellulose added to(752)square feet of open attic space. $1,030.24 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(300)square feet of knccevall area. $1.050.00 KNF.EWALL FLOOR:Provide labor and materials to install an 8"layer of R-28 Gass I Cellulose added to(160)square feet of open kneewall floor. $201.60 i Federal ID 0 06-0406629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 920978 RISE ,1 division of'fhielsch Engineering ENGINEERING' 60 Shawmut Unit t12,Canton.MA 02021 CONTRACT � 339-502-6335 FAX 339.502-6345 Page 2 PROGRAM TM CO"TRjkCT is BETVIREN CMA-HES DM CUSTOMMEER FOR VMR(rimAS DescrttaEDam.Dw _�.... .. . . �_._.. .........,._, __.._. _.., . ._.._._.........__.__._ CUSTOMER PNORE DATE CLIENT• WORKOROIat Lisa Mcconologue (978)655-5583 02/04/2016 428343 00002 ....._.u.................. _........_ ._. .._,,._. .. .. . . SEAYICE STREET awma STREET 15 Ironwood Road 15 Ironwood Road ......... _.... _.. _ a..,_ _ ..... __, ,_ .... ._. ._ ..... _.___ .w SERVICE CnY.STATE.&P OWNO Coy.STATE,aP ' North Andover,MA 01845 North Andover,MA 01845 .. __ .. ._ _.,.......... ............__.......__. ...............,�.._._.. .TOB DESC MPTION ATTIC ACCESS:Provide labor and materials to install(2) new,finished plywood,with 2"rigid Thermax board,vveathetstripped attic space access hatch. Prime coat andfor paint is not included. $230.00 ATTIC ACCESS:Provide labor and materials to insulate(1) back of the kneewall hatch with 2"rigid Thermax board,and seal the edge ofthe hatch with wwatherstripping. $60.00 ATTIC ACCESS:Provide labor and materials to make(5) temporary access to an attic area. The opening will be closed with materials similar to those existing. Cinish sanding and painting is not included. $425.00 VENTILATION:Provide labor anis materials to install(2)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fails). 5237.50 VENTILATION:Provide labor and materials to install ventilation chutes in(70)mftcr bays to maintain air flow. $140.00 COMMON WALLS:Provide labor and materials to install 2"FSK faced sami-rigid fiberglass board insulation to(124)square frit of common will arca. $434.00 IUSE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible mcasutes,Columbia Gas offers 75%incentive,not to exceed$1,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional$340 ifsavings 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 weatherization work is complete.We will also conduct a full assessment of the combustion safely of your heating system and water heater.This has a value of$90 and is at no cost to you.Total allowable weathcrizaticm incentive is$3,110. 590.00 .,s,6 �a a Federal 10#05.0405629 RISE Engineering PA ConVe torRalitstration No Mil MA RISE A division orThicisch Engineering Contr»etor Registration No 120979 ENGINEERING" 60 ShawmntUnit 92,Canton,MA 01021 CONTRACT 337-502-6333 FAX 339-5024345 Page 3 PROGRAM CONTIIACROMD INTO 89MM r49 CMA-HES wP+OlINEWIGAmOTn'EcusT PW WORKS DEseRmEO a ow -.__......PHONE *ATE __._.._.._� CLMNTV WDKK ORDER Lisa Mcconolo8ue (978)655-5383 02/0412016 428343 00002 _._._......... ...._......... .............._................................. SERVICE STREET SUM sTREET 15 Ironwood(toad 15 Ironwood Road _... . ..__........... __ . ..___..__ ...__ ___.___, __ .._. _ .... . ...... SERVICE CITY.STATE,ZIP BR-WA CITY,STATE,ZW North Andover,MA 01845 North Andover,MA 01845 _ .___.... _._.. ..._, ...._.M.. ......... .� JOB DESCRIPTION Total: $5,219.34 Program Incentive: $3,019.95 Customer Total: $2,151.34 wE AGRm HapAY To FURHUmH 9ERVtms-COMpLim IN AceoRt1WME WIT"AaovE spE=cA noNs.FOR THE SUM OF "'Two Thousand One Hundred Ninety-One&341100 Dollars $2,191.34 UPON tTNN.SNSPE. AIA AL BYVME COSTOMEK.AOREES TO MW AMORRTY VM IN PUU-SITEREST OF 1%RRL se CHARM MONMY ON ANY iNpAA tTAi:A,>N:a. m Y$.SEE RBYlJtlll RhiPOliTANT tnTN DN GUARANTEES,RiotrTB IIEC131W matrutm M10 c wnlACYOR 111rats a inm GN THIS CONTRACT IF THERE ARE ANY"k t r+ACE5 NOTE:TM CONTRACT MAY BE WITHDRAWN BY US W NOT EXECUTO WITIEN GATE OF ACCEPTANCE _.__ .., ......_......._-__............................ ,._...._.,._._. ... ,..._.._.. ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE 'a0 SATISMACTORY To US AND ARE HEREBY ACCEPTER.YOU ARE AW HOMWA TO 00 THE WORK DAYS. AS SPECWIED.PAYMENT VoU an MADE AS OUnMO MOVE FEB 5 26116 .. ........................... ... ......._....._..... Y RISE60 Shawmut Road,Unit 21 Canton,MA 02021 339-502-6335 ENGINEERING' www.RISEengineering.com OWNER AUTHORIZATION FORM ,. (Owner's Name) owner of the property located at: Ifoill 1" (Property Address) (Property Address) hereby authorize f)i P"1(a' 1 ns V L r�n � ::!:= (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. dii is&Ignature Date F 4 B The Commn.nwealllt of Massachusetts Department of Industrial Accidents Ogee of Investigations I Congress Street,Suite 100 = Boston,MA 02114-2017 www.moss.govldin (Workers'Compensation Insurance Affidavit: BttilderstContractorslElectric ans/Plumbers Applicant reformation Please Print 1&gibly Mmic 1Btasine5art}r nicufyan Cndiy d il= r 4^t&QJ& !+o �Y A Address: o 13ox 314 City/State/Zip: W t. 019 3 6 Phone-1 :9 17 3 5`U- 34q 3 Are you an employer''Check the appropriate box: '1`y a of project(required): . am a generacontractor and l 1.� l am;3 zmplo}�cr with� 1 l� [] emplovecs(full andjor part-time).* have'hired the sub-contractors G. l\ew conStrcet-tiCan 2.[] l am a sale proprietor or.partnt r- listed on the attached sheet ,. �Remodeling Partner- ship and have no employees Tfmw sub-contractors have 8. Demolition Worl ing for me in any c-a ac°ity. employees and have workers` p 9. [ Building addition ['No t;'tarl:crs'comp-insurance camp.insurance..= 5V'i`i= . are a corporation and its 10.0 Electrical repairs or additions required.] 3. 1 am a hoincowner doing all% ork officers have exercised their i IT]Plumbing repairs or additions my-sclf. tNo workerscomp. right of exemption per NIGL 12_®Roof repairs insurance required.] c. 152,t 1(4),and"re have,no employees. [No 1workers' 13.0 Other comp.insurance required-] 'Puts•applies that checks box=l rriu also fill cul the acrtii�n belo:t sho%ing their wotttcts"cotnpcasa;icwn policy tn:<irmartnn.. .Homceaunets who submit this affidavit tndim g the-v are doing all work and$=htrc nutgidc rt n tactoTg mast sufimit a ncu•a f y la%ii indirating stn h. !Cmtractors that check this wx trw si-a,ached an additia..al sheet sho lint the name of the a;kl state u'fel,,cr or rio:to,_-c cnitltcs have employ2cs. if the stab-ccntr iaors bavt ctrployces'they mecca Provide thci. wurken,coma.Polk-%11uirtlx7. I am ern emplgre,rthatis proridink,;4,orken-'enmpensatinn in,urance for mr emplo},ees. Melon-is the policy acrd job sire information. Insurance Company Name: 1�1�l,(�i� Policy#or Self-ins, Lic,r�._I1.�?+f�1S�_��'00.3 V+ Expiration Date: Job Site Address: QJQV_k Cilv?°stalei"Zip: YN&'%VCot' 14 _lS Attach a copy of the work ers'compensation police declaration page(shoving the polio number and expiration date). Failure to secure coverage as required under Section 25A of h4GL c. 152 can lead to the imposition of crilrtin l penalties o;a fine up to S1,500.00and/or one-year imprisonment,:1.,well as dill permitit.'s in the forret ofa STOP WORK ODDER and a fine of alp to$250.00.a day against.the Virtiatcer. Be advised that a copy of this statement may be fon arded to the Office of Investigations of the DIA for.in;urance coverage verification. I do hereby certify under the pains and penaltics of perjury that the information provided above is true and correct. Simaturc: `'t-' ``"`�- Date: �1�� �•t Phone V.15( A-I's -5 SU• 3413 3_ Official use onky. Do not write in this area,to be completed by city or torn official. City or Town:. _ PermitfL cense# 14s-uing authority(circle one); 1.board of Health 2.Building Department 3.( ityll'o%n Uerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phitne 11: MMIDDNYM A`OREP CERTIFICATE OF LIABILITY INSURANCE �go2o 16 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 NAME: Nancy Usher Martin i Clayton Insurance Agency, Inc. ( )PHONE 413 536-0804 FAX (413)534-7874 1A/C.No.Ext): A/C Nip): 1649 Northampton Street ADDRESS: DDRESS: P. 0. BOX 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harle svi1le NATIO INSURED INSURER B Allied World Natl Assurance Co Gauthier Insulation INSURER C; P.O. BOX 344 INSURER D: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1663001850 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 ADDL SUBR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD I WVD POLICY NUMBER M D Y D LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE a OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ X GL43487F 7/6/2016 7/6/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO POLICY PRODUCTS-COMPIOP AGG $ JECT LOC 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED peOacERTYtDAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ B EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ BE020792125-194985 10/18/2015 10/18/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSUREDS) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE may' Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD MPIMM-d with pdfFactory trial version www.pdffactorv.com A!` DATE(MM/DD/YYYY) /11- CERTIFICATE OF LIABILITY INSURANCE 05/13/2016 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 NAMEACT Kaitlyn Daysh MARTIN J. CLAYTON INSURANCE AGENCY INC HONE Ext): (413)536-0804 FAX AE-MAIL kdaysh mjclavton.com 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAIL# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER 8: GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 52708 REVISION NUMBER: THIS IS TOCERTIFY 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 ADSL UBR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS Y EXP LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE __ $ DAMAGE CLAIMS-MADE F]OCCUR PREMISES(Ea $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECTPRO- [:] LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB FOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X1 SPER I TATUTE ETH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE WA E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA MAARP300327 10/30/2015 10/30/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-comi)ensationAnvestioations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS. 3 POND ROAD AUTHORIZED REPRESENTATIVE GLOUCESTER MA 01930 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02,116 Home Improvement Contractor Registration. Registration: 173410 Type: Individual Expiration: 10!1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 _.__ _ _ _. ___._ .._.. IPSWICH, MA 01938 Y Update Address and return card.Mark reason for change. ( Address Renewal Employment ! Lost Card SCA 7 Q 20WOW Y r"7ler, flrirrk"e"Weler" llr r.71<tA r{rJt rtJ<;//7 t Offiee of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: k73410 egistraUan: 1MENT Type: Office of Consumer Affairs and Business Regulation Expiration: 10/1/2016 _ Individual IO Park Plaza-Suite 5190 Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX RD {/ __ IPSWICH,MA 01938 Undersecretary ��""^""` of valid wi out signature ��_ Massachusetts [?cpnrtment O/Public Safety 803rd of Building Regulations and Standards ("rrlPbkr9l•1iNi1P!yar�rti..�r 5#����ia�lty — License;CUL-142562 � % KURTRGAWMI," P.n Box 344 q Ipswkrh MA 0193h M VP v s P ExPi halon GarPP��rs�ane:P 05�15/241�Y r