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HomeMy WebLinkAboutBuilding Permit #206-2017 - 155 BEACON HILL BOULEVARD 8/29/2016 BUILDING PERMIT 0 NORTy q TT s�Leo 616 �r TOWN OF NORTH ANDOVER c - p APPLICATION FOR PLAN EXAMINATION * ry V�/� 4 . . Permit No#: � Date Received �, Q�RATFo cH�s�� Date Issued: �ssg IMPORTANT: Applicant must complete all items on this page LOCATION /SS` rllcv 4A/-)- Print ; Print PROPERTY OWNER 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 ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg A Others: ❑ Demolition ❑ OtheryiS„IgT�`o h v ❑ Septic ❑Well ❑ Floodplain Y ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �v11"I Sv/,v-la 7 rAS-c A,ei,4 w � r Identification- Please Type or Print Clearly OWNER: Name: uT L, rew "s S c Phone: Address: / S— ate+ Contractor Name: Kieter Leblan.0 Phone: Email Address: Plaistow,TUff. 03865 978-407-7055 Supervisor's Construction License: Exp. Date: Home Improvement License: 0 t)}'G Exp. Date: 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. Total Project Cost: $ d- ©D FEE: $ © Check No.: ge-0 Receipt No.: ©�d/ NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund Location r77"1L 7/1-vy No. Date • • TOWN OF NORTH ANDOVER :bCertificate of Occupancy $ F Building/Frame Permit Fee $ ��� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# i�V 7 1, 1 1 Buildin6,0spector 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 ,= A Off - r 1 Ze,ping Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Panning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit I DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPART�tiM NTS :Temp ®umpste on site syeno Locatetl at Jig T,n StreetY Fire De -a 4 nsign toe to 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 DANCER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email i 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 46 Building Permit Application ;6 Workers Comp Affidavit ,46 Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract dE 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 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 New Construction (Single and Two Family) 4 Building Permit Application 4 Certified Proposed Plot Plan .3. 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 4 2012 IECC Energy code 4 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 %AORTf H Town s. :� _ Andover p .,. V" No. T 1 y oh 1. ver, Mass, *& Z 6' ?EDIT -wycoc"Ic"RWKK S V BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT ...... .... ...... .. ............. .........................., ......... ........ BUILDING INSPECTOR � �'.has permission to erect... ..... ...... uildings on ....... ... ....... Foundation ,- Rough to be occupied asOW&AN.V4..pwu*. .�. .. . .. w f �.I�l............................. Chimney provided that the person accepting this permit shall in every res ct 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 CONS 10 T Rough Service . ......... . ........... ..... .......... Final BUILDIN SP CTOR 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 To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. DocuSign Envelope ID:D73F195B-4601-4180-8500-12E54528A878 CLEAResult® CONTRACT FOR PRODUCTS / SERVICE WORK This service is brought to you through support from your local utility This Agreement is made by and among Ruth Caisse and 155 Beacon Hill Blvd CLEAResult North Andover,MA 01845-3932 Ate:HES Site ID:S00050170925 50 Washington Street,Suite 3000 Project ID:P00050195639 Westborough,MA 01581 Customer ID:C00050172240 Federal ID No.222457170 Contract ID:20160304-1 WORK (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work'0 which are incorporated herein by reference: Description Quantity Location Insulate Vinyl Sided Wall With 4"Dense Pack Cellulose 928 Living Space $2,236.48 Insulate Rim Joist with 6.25"Fiberglass Batting 102 Living Space $244.80 Sub Total: $2,481.28 Utility Incentive Share $1,860.96 Customer Contribution $620.32 For office use only Printed:7/19/2016 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ 100.00(paid) as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResult,Attn.HES,SO Washington St., Ste.3000,Westborough,MA 01681.Mrial Payment:$ 520.32 as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisfactorycompletion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ 1,86 .96 .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III.DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute ormcerning this Contract,the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Cons urner Affair;and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L.c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third PfC 'g following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 7/24/2016 1 08:42 EDT TBD Date Indicate your selected IIC here,if applicable (OR) Initial here if you want George -Woods 7/19/16 George Woods the Program to assign a CL�t ignature Date Name of CLEAResult Representative(Printed) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. 2200-12-RIJ6 i DocuSign Envelope ID:D73F195B-4601-4180-85B0-12E54528A878 la i tV. mass, save CONTRACTOR PERMIT AUTHORIZATION FORM RUTH CAISSE ,owner of the property located at: (Owner's Name,printed) 155 Beacon Hill Blvd No. Andover (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. ncousigned by: X 4n5n47154FRUOR Owner's Signature 7/24/2016 1 08:42 EDT Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: ?ora Q�A� �ylS✓la����► Participating Contractor Date ,ill r a. for Office Use only Rev.12132011 - Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement&o itactor Registration Registration: 102726 Type: DBA Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO Vincent LeBlanc zr; P.O. BOX 958 = 4 ANDOVER, MA 01810 Update Address and return card.Mark reason for change. Address 0 Renewal E] Employment E] Lost Card SCA 1 G 2OM-05111 �re�a1rr�:ranrnenl/f a�C-/l�rit�ac�rrle!!s Office of Consumer Affairs&Business Regulation License or registration valid for individual use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 402726 Type: Office of Consumer Affairs and Business Regulation Expiration. '_7!2!2018 DBA 10 Park Plaza-Suite 5170 p - -' Boston,MA 02116 POLAR BEAR INSULATION CO: Vincent LeBlanc of 51 SO.CANAL ST.#5A>' -•�',; LAWRENCE,MA 01841 Undersecretary Rot valid without signature 1 Massachusetts -Department of Public Safety s Board of Building Regulations and Standards Comtructiun Super%icur Specialty License: CSSL-106017 PETER A LEBLANC P 2 EAST PINE STREET Plaistow NH 03865 nom„ "' Expiration Commissioner 04/28/2018 The Commonwealth of Massachusetts Department of Industrial Accidents far Office of Invesdgations 1 Congress Street,Suite 100 Boston,lVA 021114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): POI,dp 13EAR I�i7Q� PO BOX 958 Address: ANDOVER MA 01810 City/State/Zip: Phone#; Are you an employer?Check the appropriate box: Type of project(required": ` 1.93 I am a employer with— !� 4. ❑ I am a general contractor and I I * have hired the sub-contractors I 6. New construction employees(full and/or part-time). I 12.❑ I am a sole proprietor or partner- listen on the attached sheet. i. ❑RemodeIing ship and have no employees These sun-contactors have 8. ❑Demolition working for me in any capaci y. employees and have workers' i 9. Building addition [No workers'comp.insurance comp.insurance.# required.] 5. C Vie are a corporation and its 10.E l Electrical-cpaL-s or additions 13.❑ I art:a homeowner doing all work officers have exercised their I I 11.0 Plumbing repai.-s or additions myself. [No workers'comp. right of exemption per MGL I 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 0.[1 Other comp.insurance required.] *Any applicant that checks box#I must also 511 out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this Fox must attached?m additional sheet she Nino the Pame of the aub-contracars and smote.,hethe:or no,thos:entities have empioyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an empinver that is Pro i4AAng workers'connpensadon..insuran cefor ray e:Isployees. Belo"Is the polacy and;ob site information. Insurance Company Name:--P O r6 V h Q� : n rV ( 4 h re o Wt Q4>2 y Policy#or Sclf-ins.Lic .#: ?0"1 C Expiration Date: pr A, 470 1 D �dd Job site Address: /5�5.- *Aran �r !( >Q City;Stat:,! l�/ zip: �- of✓' Attach a copy of the workers'compensation policy declaration page(showing the pokey number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/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 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lr19 of the DIA for insurance coverage verification. 'do hereby eerti under the pains and malt a.ofpe?*ry that the information provided above is tree and correct. e Si�r�at-are: sDate:� Phone#: qG 3B Oj Iclal use only. iso not write in this area,to be completed by city or town official I City or Town: PermitrtLicense# 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association;corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house of on the grounds or building appurtenant thereto shall not because of such employment b€.deemed to be an employer." MGL chapter 152,§25C(5)also slates that"every state or local licensing agency shall withhold the issuance or renewal of a license cr permit to operate a busiaess or to construct buiidings is the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insuratice coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the:nmrarce requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)r_ame(s),address(es)and phone number(s)along with their certificate(s)of uisurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,ale not regaired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Departneni of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation poEov,please call the Depar'unent at the number lined'below. Self-insured companies should enter their self Lnsuremce L_erse number on thA appropriate 11e. Cita'or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill o!-,t in t'c evert the Office of investig»tion:,has to contact v;u regarding tl,e aprliwmt. PIease be sure to fill in the perni t/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennit%license applications Ln any given year,reed only submit one afidavit indicating current Policy information(:f necessary)and wide,-"Job Site Address"the applicani should write -all locations in (city or town):"A copy of the affidavit that has been officially stamped or marked by the city or tow^i may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a iicense or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said pbrson is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax#617-727-7749 www.mass.gov/dia 6/10/2016 Preview:Certificates of Insurance A�& CERTIFICATE OF LIABILITY INSURANCE DATEr fim 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(Sb 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 terns 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: PHONE Automatic Data Processing Insurance Agency,Inc. JAM.No.Eat: (A(G Not 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 UISURERtS)AfFORDMG COVERAGE fiAlC s INSURER A:NmGUARD insurance C=PaM 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 95B Andover,MA 01810 wSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 503587 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. LTR TYPE OF WSURfVII:E INSD POLICY EFF POLICY EXP WVD POLICY NUMBER MAVDD7YYYY) MIDD+ LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-IAADE ❑OCCUR PREM IASiEa occurrence) S MED EXP(Anyone person) S PERSONAL 8 AIN INJURY S UENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S FCLR^Y F1 JET LOC PF?00l:CTS.COL'ROP AC-5 OTHER: S AUTOMOBILE LIABILITY IEa acddenfi ANY AUTO BODILY INJURY(Pa p—..) S ALL OVINED SCHEDULED AUTOS AUTOS BODILY INJURY[Per acdE_rej S HIRED AUTOS AUTOS (Per (Perxciderrtl PROPLKIYD?T-a 1 S S UMBRELLA LltU1OCCUR EACH OCCUfiRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DEDI I-ETENTIOkS 5 WORKERS COMPENSATION �( ri• AND EMPLOYERS'LIABILnV STATUTE FR AN A OFFICEUIEMSE2PEXCLUDED'(��I� Ya NIA N POWC772258 01/01/2016 01/01/2017 E1..EACHACdDENT s 1,000,080 (Mandatory in NMI E.L.DISEASE-T:A OAPLOYEE S 1,000,000 II yg desuibe under DESCRIPTION OF OPERATIONS bs'ca+ EL.DISEASE-POLICY LIMIT S 1.000,000 I I I � T DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it morespace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St./suite 2035 North Andover,MA 01B45 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https:liadpia.adp.con-dicetief/#/runlprevie,%v/503587/900012975 I/I ACO® CERTIFICATE OF LIABILITY INSURANCE DATE(MNYDD/YYY1) 16..� 1 6/10/2016 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 Linda BOgdanoWicZ Insurance Solutions Corporation PHONE(Aor RM (603)382-4600 IA C No (603)362-2034 60 Westville RdE-MAIL ADDRESS:liadab@isc-iasurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow MR 03865 INSURERA:Western World INSURED INSURER B:Nautilus Insurance (croup Polar Bear Insulation Company Inc INSURERC: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBERCL1632326134 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 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 ADDL S B POLICY EFF POLICY EXP LIMITSL R POLICY NUMBER M YY M YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE ❑8 OCCUR IS DAMAGETORENTED 100 000 PREMES Ea occurrence $ � NPPS274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 8 POLICY I PEa LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT EaCOaccident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccldtj $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR HCLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION Am026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION I SPER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE I IER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑NIA (Mandatory In NFA E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE ENPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 'A Keith Maglia/SJA � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NS025 rent 4nn