HomeMy WebLinkAboutBuilding Permit #862-2016 - 166 SALEM STREET 2/3/2016AAU4U?' BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued: Z -A // (/
IMPORTANT: Applicant must complete all items on this page
LOCATION /koro S��YtM 5'
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PROPERTY OWNER_ 7tw► tie r /'LI': .I i•\ YI.
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ZONING DISTRICT.
•: 100 Year Structure
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Hist66cg Disytrict . m
Non -Residential
❑ New Building
❑ One family
Machine Shop Village
v tt�eo iyb��:�,pNd
ti 2 ry�i3�A�
yes no
yes no
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
Others:
❑ Demolition
❑ Other
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Identification - Please Type or Print Clearly
OWNER: Name: Name: 7'r vqv►;,crr vme, r;r, Phone:
Address: / 4 G r7 4 /rte h &�Oc/rd
Contractor Name: P -OC(- I -ePhone:
Email.
Address.:.. ,, . , %Z .r q:�ir ., :,/'-e, ST /4. Sio d✓
, ; ,
Supervisor s�Construction,�License �. (,a.G ,o/> ,.... .... ... ...Exp Date::;.. ..:
Home.lmprovement License: 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. /
r
Total Project Cost: $ ti/ i'Vd . d o FEE: $
r
Check No.: -77 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
0
1. y
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
OF SEWERAGE DISPOSAL
[TYPE
ublic Sewer ❑
TannangtMassage/Body Art ❑
Swumning Pools _ _� ❑.
Well ❑
Tobacco Sales ❑`
Food PackagingYSales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On
Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH'
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
�!Ilanning Board Decision:
G
Conservation Decision:
Comments
Comments
Whiter & Sewer Connection/Signature & Date Driveway Permit
J;PMV Town Engineer: Signature:
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
MOTES and DATA -- (For department use
® Notified for pickup Call Ema
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
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
TOTE: 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 .
TE: 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
TOTE: 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
Doe: Building Permit Revised 2014
P -v
A �ov- 6kj
Location
No. Diate2A-x,115
Aa Ack
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
-hit Fee
Building/Frame Perr st�l—k
Foundati
on Permit Fee
Other Permit Fee $
TOTAL
Check #
29-9. Building Inspector
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Federal ID005"SM
RISE Engineering Ill � 186
co onNo
A division ofTblelwh Engineering RISE
ENGINEERING 60 Sbawmat Unit A Canton, MA 02021
CONTRACT
339-51126335 FAX 339-502-345
PROGRAM
Tlta txxr►rracr is t� acro arsE
CMA-1ll�+SEW0WWA=WCUS=G3tF=VWWAS
tr�.tpp
arsrotM Ptram DAM cum# wowtoaDHt
Jennifer Marin (617)970.4718 1A7/M 413635 00003
SEWtCE arrtua:T STIVET
166 Salem Street 166 Salem Street17
smmcE crrV.STAMaP MLI ti cIrY.STAMEP
North Andover, MA 01845 North Andover, MA 01845ta n\1 201rj
d JOB DESCRIPTION
BARRIER: A Blower Door Test will riot be conducted at your home, due to the presense of asbestos.
$0.00
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 left with a healthful level of
air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary
areas for staling 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 (cf n) of air infiltration will occur, but the actual
number of cfm is not guaranteed.
At the completion of the weathertion 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 ofthe indoor air quality.
$680.00
AIR SEALIIJG: Provide labor and materials to seal areas ofyour home against wastefid, 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 left with a healthful level of
air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary
ares for sealing include air leakage to attics, basements, attached garages and otter unheated areas (windows are not generally
addressed.) This will require (4) working hours. A reduction in cubic feet per minute (cf n) of air infiltration will occur, but the actual
number of c6n is not guaranteed.
At the completion of the weatherization work, and at no additional cost to the homeowner, a final blower door and/or combustion
safety analysis will be conducted by the stub -contractor to ensure the safety of the indoor air quality.
$340.00
DAMMWG: Provide labor and materials to install a 12" layer ofR-38 unfaced fiberglass Batts to (164) square feet for damming
per•
$336.20
ATTIC FLAT: Provide labor and materials to install a 14" layer of R-49 Class 1 Cellulose added to (1000) square feet of open attic
SPM.
$1,690.00
ATTIC ACCESS: Provide labor and materials to insulate the back of the attic door with 2" rigid Thenmax board and seal the door's
edge with weatherstripping to restrict air leakage.
$73.91
VENTILATION: Provide labor and materials to install (1) insulated exhaust hose with roof mounted flapper vent to exhaust
existing bathroom fan(s).
$118.75
VENT ILATTON: Provide labor and materials to install ventilation chutes in (36) rafter bays to maintain air flow.
$72.00
STAIRWELL: Provide labor and materials to install Class 1 CCDUlase insulation to the shegrock or plaster ceiling and/or walls of a
stairwell which are common to heated space, through a surface drill and plug method. The holes are plugged with styrofoam plugs,
and spackled to a rough finish Any sanding and painting required arc the customer's responsibility.
� r .
$175.00
Fedeml ID # 0640M
WSE Engineering la Contractor Regtabrallon No 8108
RISEN""
A division of Thielsch Engineering MA Contractor No 120879
ENGINEERING 60Shawmut Unit ACanton, MA02021
339-502.6336 FAX 339,40Z&W CONTRACT
Page 2
PROGRAM
CMA-HF.SX07M FMiMcAS
teEtOW
CUSTOMER PrrM DINE CUENTS WORKORCER
Jennft Marin (617)970-4718 11/17/2015 413635 00003
SERVICE STREET B LM eT[tEkT
166 Salem Street 166 Salem Street
smmm are. STATE. EP 80J.DiO CFMWAMZP
North Andover, MA 01845 North Andover, MA 01845
JOB DESCRIPTION
CRAWLSPACE: Provide labor and materials to install (316) square feet of R-10 rigid Thetmac insulation to the crowlspace
peri ndw wall up to the sill and against the band joist. FIN PIPE EXISTS IN SPACEI
$1,169.20
RISE Engineering will apply all applicable, eligible incentives to this conhact. 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 1001yo for the
Air Sealing measures up to the first $680 and an additional $340 if savings are justified by the auditor.
For the safety and health of your homes indoor air quality, we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is began, and atter the weatherization 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
weetherization incentive is $3,110.
$90.00
OS
Total: $4,745.06
Program Incentive: $3,109.99
Customer Total: $1,635.07
WE AORrf HERM TO FURN14 SERWHM-CMPLEW IN ACMW MCE WRH ABOVE SPECIFICATIONS. FOR THE SUN OF
`*`One Thousand Six Hundred Thirty -Five & 071100 Dollars $1,635.07
UPONFUGIV WECrMANDAPPROYA.BYRISEEN pQQ,,CWTOMAORMTOREWAttOW DWDr RRLDifeRMOFI%W&.aECRAMNOMMYoRANY
UNPAIDaAt MAFIM3*DAY&SEEREVEMFORQiWMANrWGMATMM GUWMTSB,MMMOPS,SMM W, MANDCOMRACTORREWBTRATIOIL
O NOT SIGN THIS CONTRACT IF THERM ARE ANY BLANK SPACES
azt-w —02-.A�
MnHeJdWS=A7A-R1SEE:2J0da
NOTE TW CONTRAer MAY BE FFInrDRAM BY US G ROT EXECUTED VATM DATE 0FACCEPTAMM
30CAM. SPEDRCATi0N8 ARDCONDiRONBARE
DAYS. AS�81�PA"YYENYVpaLBENA At:itO�A80VM AUnIOR®TOOOTRMvxm
1,
OWNER AUTHORIZATION FORM
owner of the proMW WaW at
SQlP x -f -
herr auftft
c x4- s
an authorial subaoftaftr for RISE Emkmft, to ad on my bduff tD obtain a binding
Pem l and to p®r = work on my pmwV•
14a Z7 ma�—
owws swom-l—
The Commonwealth ofMassachusem
Department of Indaastri al f4eeidents
I Congress Stree4 Suite 100
Boston, MA 02114-2017
wrsr>K Was&g®v/dao
Workers' Compensation Insurance Affidavit: Builders/Contractors/)Elecuicians/Plumbers-
TO BE FILED WITH THE PEId]tgrMNG AUTHORITY _
NameBusincss70r
( ganiratioanmdividual): K0 Jl\ l j i5 -re, Ir- l ice. 5 ,,;
Address: ).Z'- 0- ;k Cr
City/State/Zip
Phone#:
Are you an employer? Cl>eck the approprbtc bos:
1. 'Y I am a employes with ny (full and/or part-time).'
2-E] I am a sole proprietor or Partnsrsbip and have no employees working For me in
any capacity. (No workers' comp. insmanm required-]
301 am a bomoownc doing ail work my�Ii (No workers' comp_ instrance regi .) t
4-[]l am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that a contractors either have workers' t - pens=ion insurance or ane sole
proprietors with no tmployerc
5.0 i am a general contractor and I have hired the sub contractors listed on the attached sheet.
These sub-conuaetots have employees and have workers' comp. inaaance_t
611 We arc a corporation and its oSieets have ocereised tbcir right oFaceaptice per MGL c.
1(4), and we have no employees. [No workers' comp. insurance rapir,&]
Type of project (required):
7- New construction
lir Remodeling
9- 0 Demolition
I0 0 Building addition
11.0 Electrical repairs or additions
12. D PIumbing repairs or additions
13.E]Roof repairs
14. []Other
-Any applicant that checks box #1 mast also fill out the section below showing their workcets' compensation policy iafotniation
t Homeowners who submit this affidavit indicating they are doing all work and thea bite outside contactors must submit a new affidavit indicating sueb.
tCootractors that check this box must artacbed no additional she" sbawiug the name of tbesub-moaactors_and sate wbctbcr or not those entities have
®ployoes_. - If the sub -contractors have employes, they must provide their workers' comp. policy number.
1 arca are employer that es providing workers' COrrtperesafion insurance for my emplayees. Below is the policy and job site
information.
Lnsurance Company Name:
i 42 G
Policy # or Self -ins. Lie_ #:
1 0 vJG
Expiration Date: 24/ //-. /
lob Site Address: ) 0 G -S I io m City/Stat&zip- /& .� 11(�� e
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required colder MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD 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 Investigation, ofthe DIA for ;,,atrar.ce
:overage verification.
do hereby certify under the plains and pena14k s of petjaary that the information prOt+ided abotie es true and correct
iimature: t
'hone #: —fi- _,
Oficial use only. Do not write in this area, to be completed by City or tom, of `ieiaL
City or Town_ Permie/L;cense #
Issuing Authority (circle one):
I_ board Of Health 2. Buildartg DVartmaent 3. Cityfrown Clerk 4- Electrical Inspector 5- Plumbing Inspector
6- Other
Contact Person:
Phone #:
IW2016
Preview: Certificates of Insurance
0 CERTIFICATE OF LIABILITY INSURANCE
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DATE 0+
011 f 04!201166
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 1S 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
CUNIACT
NAME'
(a c Ni . Ezt1: wlc. No):
Automatic Data Processing Insurance Agency, Inc.
1 Adp Boulevard
t• DRE
ADDRESS:
1'ISURER(S) AFFORDING COVERAGE tiA1C?
Roseland, NJ 07068
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IttSURER A: NorGUARD insurance Company I 31470
INSURED
INSURERS:
POLAR BEAR INSULATION CO INC
PO SOX 958
INSURER C:
Andover, MA 0181 D
INSURER O:
INSURER E:
INSURER F:
COVERAGES GERTIFICAI E NUMBInK: 4t91u.T KhVIJ1UN NUmtltK:
THIS IS TO CERTIFY THAT THE POL!C:ES OF INSURANCE LISTED BELO.: HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTY:ITHSTANDIPIG ANY REOUIRELIENT. TERL6 OR COND!T!ON OF ANY CONTRACT OR OTHER DOCUTAIENT t" iTH RESPECT TO'i:HiCH THIS
CERTIFICATE IAAY 6E ;SSUED OR LIAY PERTA;td. THE iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE!N iS SUBJECT TO ALL THE T ERIAS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES L;t:;ITS SHOWN i:'AY HAVE SEEN REDUCFD G1' PAID CLAEt'S
NSR
LTR
OF INSURANCE
INSOPN
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POLICY NUMBER
btitDOYYYi' LCATS
YTYPE
COMMERCIAL GENERAL LIABILITY
CLAILIS-LI: IA: •.(:L!i
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WORKERS COMPENSATION
AtJD Et1PLOYERS'LU.BIUTY Y;JJ
AN, 1iil_PIaEII I.I:IHII:Eli E:(ECt:TI•:t
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01101,2017
X 1 1-1i,ILIE :
EL EAQF AI;LIUtI'.1 -1.060,000
EL OIcElSc ti, tl.!YU:`'LE i 1,000,000
E.LDI_E;•st PCLIU" UT:UI Is 1.000.000
DESCRIPTION OF OPERATIONS; LOCATIONS; VEHICLES (ACORD 101. Additional Remarks Scnedute. may be atbchM ii mo:espace Js reyoiredJ
I-- -,--- I.HIV I.CLLN I I V IV
Theilsch Engineering, Inc.
195 Frances Ave
Cranston, RI 02910
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORLED REPRESENTATIVE_
;l,..
A'& 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
POLABEA-01 JONEILL
AcoRo CERTIFICATE OF LIABILITY INSURANCE
DATE /YYY17
1/66/20/20 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
Durso & Jankowski Insurance Agency
11 Saunders Street
North Andover, MA 01845
CONTACT
NAME:
PHONE 978 688-7000 Fax
A/c N, o. EMe )_u (a/c, No): (978) 688-7001
ADDRESS:
INSURERS) AFFORDING COVERAGE
I NAIC A
INSURER A: Nautilus Insurance Co.
17370
_
INSURED
INSURER B: Safety Insurance Company
33618
Polar Bear Insulation Co. Inc.
Peter Leblanc & Steven Leblanc
P 0 Box 958
INSURER C:
INSURER 0:
NN538691
-- —--
03@4/2016
Andover, MA 01810
INSURER E:
INSURER F:
1
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 I
LTR
TYPE OF INSURANCE
ADD L
INSD
UBR
D
POLICY NUMBER
POLICY EFF
MWD
POLICY EXP
MMI))
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE I
$ 1,000,000
......
��
CLAIMS -MADE 1 - 1 OCCUR
NN538691
03/24/2015
03@4/2016
OA'AGE TORENTEb---
PREMISES (Ea occunence) i
$ 50,000
_
1
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
I
POLICY �] JET LOC
PRODUCTS -COMP/OP AGG
$ 1,000,000
OTHER:
----
I
� $ -`
B
AUTOMOBILE
LIABILITY
ANY AUTO
j
2100926
i
01/04/2016
{ 01/04/2017
COMBINED SINGLE LIMIT
Ea accident —
$ 1,000,000
BODILY INJURY (Per person)$
ALL OWNED SCHEDULED
X
AUTOS —I AUTOS
I
BODILY INJURY (Per accident)
_
$
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EACH OCCURRENCE
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WORKERS COMPENSATION
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DESCRIPTION OF OPERATIONS below
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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
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Cranston, RI 02910
AUTHORIZED REPRESENTA17VE
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