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HomeMy WebLinkAboutBuilding Permit #325-2016 - 16 MOODY STREET 9/15/2015 wn1E 0 9 2 /S' NORTH BUILDING PERMIT o�ttLE° bq"o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ^� * zT 0 1— Permit No#: Date Received �R qq �SSgcH�s��� rEV Date Issued: 1 IMPORTANT:Applicant must complete all items on this page LOCATION //�_�i�� JY -9i Print PROPERTY OWNER I-rka rd L/tvi 7V y" 0 i Print 100 Year Structure yesOno MAP / PARCEL: / ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 ❑ Other SnSJ���'��o Septic Well ❑ Floodplain O'Wetlands ❑ Watershed District ter/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: rLpt rdt/en rttztq Phone: 0I99' Address: 16 olaipd Y Contractor Name:?-� r r l t ct Nr Phone: Email: Address: J' P6q7f 7V Supervisor's Construction License: C551 - !OCA of 7 Exp. Date: `/ o/� Home Improvement License: /0 � 7d-G Exp. Date: o/& a 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: $ 275�D_o� FEE: $ Check No.: �� yy Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access o th guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Flans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature r 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 4 Wafter& Sewer Connection/signature& Date Driveway Permit DPW Town.Engineer: Signature: Located 384 Osgood Street r FIREDEPARTNIENT n=�Ter_ripDumpsterkon}site +,Located�at,12'4{MainiStreet - • � - `-� - �"-�T`""" ' Fire Department�i -' .� 4 F gature/elate•. I COMMENTS._ _._ . 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.$10041000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4� Building Permit Application 4. Workers Comp Affidavit 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 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) 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 Location �0 �i Date t 4 • = TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL - $ Check#�� Building Inspector ,! .ivy i NORTH own of . t EAndover C, h ver, Mass J 20 16 o 'pA COCNIC Nf WtCK S BOARD OF HEALTH Food/Kitchen PER L D Septic System + BUILDING INSPECTOR THIS CERTIFIES_ THAT .... �.... ..... ia ....... ...� ........................ Found ati onhas permission to erect .......... buildings o 0................ Rough )Alt .. Chimney...R4 ......... to be occupied as ........ . ..... provided that the person accepting this permit shall in every respect conform to 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 1 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ARTS Rough Service BUILDING INSPECTOR Final 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. NORTH Town of E ndover \A No. C. 4-- h-, " � verMass o Z0 1, Co[NICNl WICK%N' p�RATIE go) S U BOARD OF HEALTH Food/Kitchen PER kv IL D Septic System THIS CERTIFIES THAT a BUILDING INSPECTOR has permission to erect ............ buildings on Foundation ........... ... . ......A 1 i .. ................ . . . . ... . . Rough to be occupied as ....... .....1 ►� . �!ll�.. '..... .. . .. .. �... .. ......... Chimney provided that the person accepting this permit shall in very respect conform to tho terms of he applicati n 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ARTS Rough Service BUILDING INSPECTOR Final 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. Federal ID 9 RISE Engineering RI Contractor Registration No MA Contractor Registration No A division ol'Thielseh Engineering CT Contractor Registration No 60 Shawmut Unit 42,Canton,TMA 02021 339-502-6335 FAX 339-502-6345 CONTRACT Page 1 R I S E PROGRAM (� `V f F. THIS CONTRACT IS ENTEREOINTO 8ETVlEEft RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING I _ _ _ — _ DESCRIBED BELOW` CUSTOMER PNWIE DATE CLIENT WORK ORDER Richard Ventura J U,,' 3 0 2015 (978)580-0195 06/292015 401421 00003 SERVICE STREET ~ _ — —BILLING STREET -- 16 Moody Street 16 Moody Street SERVICE CITY,STATE,LP -_ — i — _BILLING CITY,STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION WAL1S:Provide laboT and materials to install blown in Class I Cellulose to(294)square feel of exterior walls through a surface drill and plue method. Plugs will be spacklcd and Ietl with a rough finish.Finish sanding and touch-up primine/painting will be the customer's responsibility.Subsequent to your payment,as an added service,RISE Engineering will return when weather pemtits to check for any voids with an infrared scanner. Any major voids that may he found will be filled at no additional cost.GARAGE TO HOUSE/FRONT OF HOUSE IS VINAL SHINGLES.HOME OWNER WILL REMOVE WHERE NEEDED! $543.90 WALLS:Furnish and install blown in Class I Cellulose to(1147)square feet of vinyl-sided exterior walls.Invoicing will occur upon completion of installation. Subsequent to your payment,as an added service,RISE Engineering will return when weather permits to check for any voids with an infrared scanner. Any major voids that may be found will he filled at no additional cost.GARAGE TO HOUSFJFRONT OF HOUSE 1S VINAL SHINGLES,HOME OWNER WILL REMOVE WHERE NEEDED! $2.121.95 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 100%for the Air Scaling measures up to the first$680 and an additional 5340 ifsavines are justified by the auditor. For the safety and health ofyour home's indoor air quality,we will be conducting a blower door diagnostic ofthe available air flow in your home both before the work is began,and after the weathmi7ation work is Complete.We will also conduct a full assessment of the combustion safety ofyour heating s)slelu and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is S3.110. $90.00 Total: $2,755.85 Program Incentive: $2,089.39 Customer Total: $666.46 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Six Hundred Sixty-Six&46/100 Dollars $666.46 UPON FTHAL I ECTI AND AP AL E F1JGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE 04 FULL INTEREST OF tS:WILL HE CHARGED MONTHLY ON ANY UNPAID - E AFTE 10 D 'R SE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE A�t YELfINthSPACES AUTHO 91GWlTUR •R ISE En0lncedn0 - - USTO AC CEP SCE_ NO •THIS T MAY BE VAT . WU BY US iF NOT FJt..UTM VATMN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 3O DAYS. SATISFACTORY TO US AND ARE HERESY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE OWNER AUTHORIZATION FORM 1, giataec/ Vepytoe (Owner's Name) Or owner of the property located at �� J U.; ? 0 2015 (ProAddress) #,V 100 VVY. r Q. O l bs t[ 5- (Property (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. 0wh-eesYSK*re Date i � \ The Conmtonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street x f Boston, MA 02111 ivivminass.govAlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apnlicarit Information Please Print Leazibly Name (BLIS iness/Organization/lndividLial): PO 14f eQ{` 115 y j4�'tQ Vi �'O TJ�C- Address: Ale. X9 0 X City/State/Zip: &d M Phone #: C(7�' Are you an employer?Check the appropriate box: Type of project(required): 1.A I am a employer with�— 4. ❑ I am a General contractor and I employees(fir[1 and/or part-time). * have hired the sub-contractors 6. E)New construction 2.El am a sole proprietor or partner_ listed on the attached.sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have p 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [\o workers' comp. insurance comp. insurance.= required.] 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [\o workers' comp. right of exemption per MGL 12.[] Roof repairs insurance required-]' c- 152. §1(4).and we have no 1 h employees. (No workers' 3 (Other =A14/47416 comp. insurance required.] *Any applicant that checks box:F'1 must also fill out the section belo\c showing theircorkers'compensation police information. tlonteo\cners who submit this aflidm it indicatins the\ are doine all\cork and then hire outside contractors must submit a new affidavit indicatins such. =Contractors that check this box must attached an additional sheet showine the name of the sub-contractors and state whether or not those entities hare employees. If the sub-contractors have employees-they must prof ide their corkers-comp.policy number. ern:an employer drat is providing workers'compensation instran ce for nits etnplol.ees. Belotv is the policy crud job site information. Insurance Company Name: / 0 t-a U 4 rJ Policy T or Self-ins. Lic.#: p LIG. 6-5-1-0b & S Expiration Date: I 16 Job Site Address:_..,/r_mem y Ste'— Cit\,/State/Zip: na W/tA"Co, Attach a copy of the workers' compensation policy declaration page(showing the policy 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby certify trader Ilse pains mrd penalties of peritity that the information provided above is true and correct. Signature: —' _ Date Phone : 4 Ofricial use only. Do not write in this area,to be completer/bt•citr or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6. Other Contact Person: Phone#: ■", OP 1D:SS CERTIFICATE OF LIABILITY INSURANCE DATE `o3f13/201s3120 5 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(tes)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 endorsem its. PRODUCER CONTACT Durso&Jankowski ins Agcy LLC PHONE FAX 198 Massachusetts Avenue = North Andover,MA 01845 ADDRESS:. Durso&Jankowski Ins.Agcy. PRODUCE ¢P )LAR-1 INSURER(S)AFFORDING COVERAGE NAIC i INSURED Polar Bear Insulation Co.Inc. INSURER A:Penn America 32859 P O Box 958 INSURER 8:S Insurance CO. 33618 Andover,MA 01810 I�URER C INSURER D 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 CLAUS. INSRLTR TYPE OF INSURANCE POLICY NUMBER LILY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 A X COMMERCIAL GENERAL LIABILITY PAC7052023 08/24/2(115 03/242016 PREMISES ocamerce $ 50, CLAIMS-MADE I OCCUR MED EXP(Any one person) $ 5, PERSONAL&ADV INJURY $ 1,000, GENERAL AGGREGATE $ 2.000,00 GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 11000, 17 POLICY PRO- LOC $ AUTOMOBI E LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 8 ANY AUTO 2100926 01/042015 01/042016 (Eaaedderd) BODILY INJURY(Per person) $ ALL OYMED AUTOS BODILY INJURY(Per acddenl) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (PER ACCIDENT) X No"wNEDAUTOS $ M F 5 UMBRELLA LUIB I X1 OCCUR EACH OCCURRENCE $ 1,000, EXCESS LJAB A CLAJMSMADE At:6906385 031242015 032402M6 AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC TH- AND EMPLOYERS'LIABILITY YIN S1 PER ANY PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOY $ It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OP1E�R�ATIONS/LOCATIONS/VEHICLESS(AUaeh ACORD 101,Addidonsl Rsmmkts tShdsrdul%N more space is requlmd) Insulation o work pnfor 1@a oo thel�ibehalt by miabbo ei lnasured is Thleisch Engineering CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thie1SCh Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. Columbia Gas 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENrATR/E 4&9"L ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009M) The ACORD name and logo are registered marks of ACORD 9/14/2015 Print certificates:Certificates of Insurance ACC>o® CERTIFICATE OF LIABILITY INSURANCE F°°'�'M""°°"'""' `„� 72/182014 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, i IMPORTANT:if the certificate holder is an ADDITIONAL INURED,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 I certificate holder in lieu of such endorsement(s). PRODUCER LUNIALT NAME: Automatic Data Processing Insurance Agency,Inc. P N Ex : I AX (A C.1 1 Adp Boulevard AooaEss: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIL t INSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER e: DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 9SB INSURER D: Andover,MA 01810 INSURER E: 1 I INSURER F: I COVERAGES CERTIFICATE NUMBER: 291629 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 SUBJ ECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMMNYYY) OAA D/WY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE ❑OCCUR PREMISES(Eaoccunence) S MEDEXP(Anyone personi S PERSONAL&ADV INJURY S { I GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S POLICYPRO- PRODUCTS-COMP,OP AGG S ❑Jeer ❑Loc OTHER: S I AUTOMOBILE LIABILITY COMBINED SINLLE LIMIT S (EaANY AUTO BODILY[NJ URY(Per person) S ALL OSCHEDULED AUUTOSS AUTOS BODILY INJURY(Per acciderU S HIREDAUTOS AUTOS (Pera"WenG S S UMB RELLALIAB OCCUR EACHOCCURRENCE S 1 EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATON - ANDEMPLOYERS'LWBRTIY X STATUTE ER ANY PROPRIETDR/PARTNERrEXECUTIVE Y/N EACH ACCIDENT S 10000 A OFFICERA.EMBER EXCLUDED? Y❑N/A N POWC66099D 01,01/2015 01012E.L. , , 016 I 00 (Mandatory in W E.L.DISEASE-EA EMPLOYEE S 11000.000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT S 1,0001000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be arached Umore space Is required) Columbia Gas massachusetts I 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,R1(2910 AUTHORIZED REPRESENTATIVE AQ 19882014 ACORD CORPORATION.All rights reserved. I ACORD25(201401) The ACORD name and logo are registered marks ofACORD https://adpia.adp.com/iceAef/#/run/printcerts/283910 i/1 i Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite5170 02 0 6 Boston,Massachuse _ Registration ement Contracor Home improvRegistration, on- 102726 - _ 'Type: DBA T� 252249 _ " = Expiration: 7/2/2016 POLAR BEAR INSULATION CO- - Vincent LeBlanc -- P.O, BOX 958 n for change- VER MA 01810 rd,Mark reason ANDD U date Address and return ca Employment ❑ Lost Card p Address Renewal �s DPS-CA1 0 50M.411"4101216, t of Public SafetY t Massachusettsod ngDRegulat Regulations and Standards Board o construction Super,icor Specialtc N License: CSSL-106017 PETER A LEBLJkK 2 EAST PINE STREET _ Plaistow NH 03865 Expiration �, — 04/28/2018 Commissioner