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HomeMy WebLinkAboutBuilding Permit #1102-2016 - 169 ANDOVER STREET 4/25/2016 All 4 �IJ BUILDING PERMIT o�N�DT"6 00 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Xa „ 1• Permit No#:1 Date Received �SSACHUSti4 Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /6 jC' �9nd0✓r d- e>7- Print PROPERTY OWNER ha&111 Cc('04/'r Print 100 Year Structure no MAP _PARCEL ZONING DISTRICT: Historic District yes � o 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 0 Assessory Bldg Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: x7rco�r- w",// ►r5'0IA)"0e? tP15e pCie t i (°Cww� 5 Pticc i n5 v/T�o►� Q-�� •Ttnrn / �� TGA-rT•yr�,� Identification- Please Type or Print Clearly OWNER: Name: ko ul tj CSD P YK t r 0' Phone: Address: tC 9 Ati aver -5r- Contractor TContractor Name. 2 East Pine Street Phone: Email: Plaistow. N.H. 0 865 Address: ' 97- _38 Supervisor's Construction License: 1 b GO t7 Exp. Date: 'f ���A? •u Home Improvement License: 10 (a Exp. Date: ARCHITECT/ENGINEER Phone: s 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: $ 3?o'o.o o FEE: $ P Check No.: Receipt No.: NOTE: Persons contractinith unregistered contractors do not have access to the guaranty fund KA Location A-,tJ&,feA L1vz.�+ No. IIU2— 2 p11, Date r TOWN OF NORTH ANDOVER Certificate of Occupancy $ s° Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ', ^� f Check 4t I� Building Inspector s - _ I 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 Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on_ Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes t !Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: _ Located 384 Osgood Street FIRE DE;RMA!" Te rnp ®umpste ntsite yes �`y ono [Located atr1;24MainiSfreetf, ��F�ire Dep rtmentsignature/date �`C`OMMENjTS _ `� 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 i ❑ Notified for pickup Call Email IDate 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 IN 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 ;rF 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) :r~ 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 NORTH Town o _ Andover _ t� * h , ver, Mass, Z� CONIC Nl WICR V A01ATEO S V BOARD OF HEALTH PER T T LD Food/Kitchen Septic System THIS CERTIFIES THAT t.or M;tr BUILDING INSPECTOR ........ ...Ing ..................................... ........ ................... ..................... • Foundation ' has permission to erect.......................... buildings on '.... ... , .... � ..... Rough to be occupied as ..tz�-%r►�. �r 1 •• `�•••••••• Chimney ............ provided that the person accepting this permit shal�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 relati to the Ins ectM 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 TARTS Rough Service ............. ...... . ... ....... .. .. ....... ............................ Final BUILDING INSPECTOR 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. . i Few m I4g00� RISE Euomwing aranwo dwevoorwimmo ttoalso sons Ad1vbloo ot7Tb l�aeer�g 69 sh"Me Lw-#02�Q-340-Kit-am I CONTRACT 3594D24M FAX33440L4f4S Page 2 PROGRAM i���wara°aOvawtiomc� CMA41n oe e®esa� WM DATE Shawn Cormier (617)549-2616 03114=6 406563 00007 169 Andover Sheet 169 Andover Street North Andover.MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total. $3,824.65 Program hwwdln: $2.MAO i Customer Tatel: $1.734.65 G VEAorMMMOrrowan= .00 a WrMASMSPMWnitare.rantessuwaF f "'One Thousand Seven Hundred Thirty-Four&65A CO Dollars $1,734.65 ` r �s � o � ovearmw a�� an xanrrne4enwwrwreawn uwnerasvnoraeam� wRa 3/29/16 «ravr tsaoo�muer.rna�aowvars to naa�aamrtaTM 30 ora assvaiOirweswoe+�sounease wrxo�t000mswaac i BSc 4�ueaC TG �U� t�rmrD.oso4osaz9 RISE EngtneerWg MAflmttrFOR 0e91tt11 MM1:10010 A dlvbtoa otThldseb EegtauWag CONTRACT�aq+� t9N9 !ltett>t2,C .lM_S0-IMI VV�YI7�V 1 339•SttLd3iS PAX339�4024M PROGRAM tn®earraacrtatatra®amotsars®tttesa CMA463 atts0owmmawrottmtwawaeta Shawn Cormier (617)549-2616 03/1412016 406563 00007 GCRM go= 169 Andover Sf d 169 Andover Sheet it North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PMSETWO•FOROWMEGMY: pmoesduad112 moadstt@adatstphescofthepmJam Pdomandprogtaminucashcsaagmeamd.Pkea cmmymffEM ySpcdutbkto Cala:you a anrreot ptop=L sono BARRIER:ABlowmDoorratwill cot beocadm Watyorbome7duetothopmmveafaebestm. MAD WALLS:Provide taboeaed mataiais to iasmll blown lo Gees l CeUdose to(75)mpmae fatofextariar walla daoagh am intatior ' euafaoa dng end plug wzdw .Phrgs will be spukled and loft wilt a tough fetid►Flub sending and p pfhnmgfpabmg will be the cusu mces nmpaaubi*.Homoom bas tadved a oopy of the EPA's PAmovate Right Leadaft mfo>n eum Vftuptaiaiog the fmwn el tisk offt lad httsrmd eeinaame Pimm the weadt ftdsn work caw pahmmi Your slgmttme k your rodgetr,m of rcc*aW ogrocn art to proceed SISM00 WALLS:Fmft and install blown i4 Crass I Odlalose to(1305)square fat ofa dn&tmdior elsoml exterior walls.Tbc btatof the appccemasc ofyour wood stdingis att to drill holes into the well sheathingbddnd.The hoks ere then pbgpd and tbewood siding is relaemliod udog emmleas rand finish mails.ToucIHM peindag.If treaded.will be due cummWo respomm1w.lavoicbM will ,• near upon oomsphdaa of iasmUadoa Homeowaahes taxivod a capy ofdue EPA's Rmtovnto Right Lesd,Sefo iafomtadoa guide explaining the pottadisl rink of Cho tmd hanaud cgmmo frwm the westhaimdoa work to bapafmmod.Yoessippne is yaw a�wodgemeat ofroaipt end ttgraemeat to phoned. BASF3NENT CEU.UV(k Provide tabor sad muatetdals to imtnil(l24)Uatxr fat of R 19 wafered fibetgless isrsuladou to the ptximeta of Cha baecmmt calling at the house sM $217A0 CRAWLSPAC&Ptodh taboramd mm c&h so loemU(l4M square fat of R•19 o&oed ttbag m burls loo to ma aawhpm o0ing to be is mama with ft s and cum**1lUing Cha joist cevhy to be Omh wM the joist bottoms.Thea hnmU 1• polybo%=nftfbimb=dlmmAmImL Soni all smos with PSK cepa. SSM-00 CRAWIMACE:Provide laborand momiels to loetall(112)square W ofR•10 dgid ramum UwAdon totbo aawlspue pairaeseswell u p to the sillmdapeima dto bead joist. $414.40 RiSB will apply ail app9cable,digibleb madvesto dds eaatraa You will ady bs bUtod dte Net am cm(kotemf), for eftgiblo mmaaa,tA�mbiaQes offers fS96 iaaocve,not to ateeed S2,ti00 per gest sad as iaaative of 10WA fa the AirSeeft mmanes op to the fastSM end am sdd dozW 53401f savings sm jmdfEed by the auditor. Far thoad dy and beaM of your bomda indoo *quality,we vdU ba wog ablowdoordi of the aveiiable air flow in ymbonebetbbdumduewortisbcgm.and afterthewcada adon work is oomOctL Wo will ulm amcd=a fkdl emummof timmuba dm ufetyofywrheaugsysto and wam hatsr.Tb*basa vdw of$90tad isat no om to yam Totd altaoable weadaimdon iaamivc is$3,110. 590.00 i I �aG SGS OWNER AUTHORIZATION FORD! rnrm Shawn a tuwwI, s mv A i 41VI-0--i owner of the properly located at 169 Andover Street hl ^w46 Amftamloftapomm MA InioAmp hereby auduAm 0 f a.�' S.V f r !� (Subcantracbor) an authorized subcmft for for RISE Engineering,to ad on my beW to obtain a building permit and to perform wok on my property i owner's Somire i i The Commoniveralth of Massachusetts Department of industrial Accidents I Congress Street, Sante 100 Boston, I A 02114-2017 i lv"Y;fCnaass.golldia Workers' Com pensalion Insurance Affidavit: Builders/Contracteers/Electricians/Pluntbers. }C)fiE FILED tti71 fi 112E?FRMl FTING At-THORITY. Applicant information Please Print Legibly Name (Business'()r2anizationllndn-[dual): pt) IA#-b e,V ZWt//k M0 A /t). rp c Address: .P©, 9,0 City/State/ZV_9kx do✓-r,r, m.-4, D Jilo Phone g: — Are}on an employer"Check the appropriate hos: I"ype of project(required) I 1 ®t ani a emplovC1 n1111 cmplutrcS(ruli andfor part-time) 7. ❑New construction ❑1 am a sole proprietor or partnership and have no cmplo}ecs W04,1171U til me In 9. Ej Remodeling any capacity (No m)rkers'comp insurance required] t) ❑De.IlltihllDn I am a homemincr doing all mark nnsclf)No morkers•comp insurance regwred J' • ]0 Building addition 4❑1 am a homcownei and t%ill be hiring contractors to conduct all synrk on m) properfx I will ensure that all contractors either have workers compensation insurance or arc sole i i [] Electrical repairs or additioits proprietors with no emplovecs 12 F]Plumbing repairs or additions ®I ani a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors hate employees and itaye workers'comp insurance 13 ❑Roof repairs 6❑ We arca corpnraf Ior.and ns olliccrs h:ryc exercised[herr right ul'esnnpnmi per ft4hL c 14 F1Other l 5?. 1041.and!ye have no employees [No workers'comp Insurance required d ':Ing applicant that checks box '1 must also fill out the section pelota shtm me their workers'compensation polio mf2mnation I lunicowriers who submit this of idayti mdicanne the% ate doing all NNork and then hire outside cantiacinrs mast sub—mit a nc•a allidayn ind;ca:m_such 'Contractors that check this bus must attached an.uddinonal sheet sham in,the name of the sub-cors iClois and stab•%thethcr or not those entities have emplo}ces-1.1'[he sub-contractors have employees.the% must pro%ide then moikers"comp po11cN number 1 nor[tri et)zplq)er tI)crt i.c pial iilinb workers'eart)pe)).cittint)insnrrince fad n:t'e)npl�t ecs. Belaw is the police•and job site i)fnrn)a6atr. Insurance Company Name. DC�� Policy or Self ins Lir Y_ p W Co7E-xpiration Date: bJ o�%e�J7 .lob Site Address ✓r 'S% City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration(late). Failure to secure coy gime as required Under MGL c i i'. §';A is a criminal violation punishable by a fine up to$1,500 00 and/or tine-year imprisonment,as,yell as ci,•il penalties in the form ofa STOP WORK ORDER and a fine of up to 5250.00 a day-against the violator A copy of this statement may he firnwarded to the Office of hiyestiEations ofthe DIA for insurance coverage verification. I do herebl•certif4•tinder thepains andpenalties ofperjnr4•that the Tlt_fOri)ititiiiizproi-ided aboi•e is true and correct. }� �J/ / Stynature. t� ' Date' +++«<// Phone 9' I Official use onh. Do not write in Mis area. to be completed bt•cit),or town offc•ial. City or Town: Permit/License b Issuing Authority(circle one): 1. hoard of Health 2.Building Department 3.Cit)-frown C"lerk s. Electrical inspector a. Plumbing ltaspector 6. Other " I Contact Person: Phone Y: I '`«DRQ® CERTIFICATE OF LIABILITY INSURANCE °ATE`"1""°°"Y ,, `..� 3/23/20166 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: ft the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A atatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COM ACT Linda Bogdanowicz NA Insurance Solutions Corporation PHONE.No (603)382-4600 A EIM A No=(r;o3)382-203a 60 Westville Rd AIL ADDRESS.lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC 9 Plaistow NH 03865 INSURER A:Western World INSURED INSURER B:Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO Box 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER CL1632326134 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. 1�7R TYPE OF INSURANCE ADDL BR POLICY NUMBER MhWO%PYYF EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE 51 OCCUR DAMAGE TORENim 100,000 PREMISES Ea occurrence $ NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JET LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accdentL ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER 0TH- ANDEMPLOYERS'LIABILITY YIN STATUTE ER _ ANY PROPRIETORMARTNER/EXECUTNE E.L.EACH ACCIDENT S OFFICERIMEMBER B(CLUDED? N/A (Mandatory In NH) E.L.DISEASE-FA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA `1988-2014 ACORD ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025r�mmti POLABEA-01 JONEILL DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE -_ F lisrrzais 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 pol)cy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 1 Fax 978 688-7001 11 Saunders Street aNo�� _Lc _(978-. )688 7000 -.- _ _I(ac,NoL( ) _-7 — North Andover,MA 01845 EMAIL ADOBES$: INSURER(S)AFFORDMGCOVERAGE ; NAICR tNSURERA:Nautilus Insurance CO. _ 117370 INSURED INSURER 8:Safety Insurance Company— —j33618 Polar Bear Insulation CO.Inc_ INSURER C; r Peter Leblanc&Steven Leblanc — ------ -— - _ — - P O BOX 956 INSURER 0_ -- — i Andover,.MA 01810 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED- NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR; --- —IQDDUSUBR; - - POUCYEFF j POLICYE; LTR; TYPE OF INSURANCE INSD I WVD POLICY NUMBER MMlD MMIDD LIMITS A COMMERCIAL GENERAL LIABILITY I I ,EACH OCCURRENCE S DAMAGETO-RENTED- CIAIMS-R7AOE _?OCCUR i PREMISEoccurrence) MED EXP(Any one person) PERSONAL✓1 ADV INJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: i i GENERALRGGREGATE 1.5 POLICY JE O LOC .._ . ..— .__ PRODUCTS-COMP/OP AGG'S -- _ OTHER: AUTOMOBILE LIABILITY j i COMBINED SINGLE uml I is 1 000,000 1Ea accident,— --_- _- B _ :ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Perperson) is ALLOWNED ; 1 SCHEDULED I i BOOILYINJURY(Peracddent)±5 AUTOS ;AUTOS ' HIRED AUTOS X E NON-OWNED PROPERTY DAMAGE S ._ -AUTOS ,S UMBRELLA LIAB OCCUR 'EACH OCCURRENCE A i EXCESS LIAR —— - -l— — _ --I.CLAIMS-MADE i I t AGGREGATE _ s DEC) RETENTIONS WORKERS COMPENSATION i PER ;AND EMPLOYERS'LIABILITY _).STATUTE ! ER. - Y/N :ANY PROPRIEfORIPARTNERIECECUTIVE 1 EL EACH ACCIDENT :S OFFICER/1,4EIABER EXCLUDED? �;NIA j I :-- --- ---- -- _ (Mandatory in NH) EL DISEASE-EA EMPLOYEE!$ If yes,describe under DESCRIPTIONOFOPERATIONSbelornv l !EL DISEASE-POLICY LIMIT i S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached it 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 I i I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE _ +000 nn-r n Armon An 1/4/2016 Preview:Certificates of Insurance A4V CERTIFICATE OF LIABILITY INSURANCE DATE n.,r.,ODYYYY) CGI 01/0412016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy.certain Policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in iieu of such endorsement(s). PRODUCER CoRIACr :JAFIE: PHONE Fxa Automatic Data Processing Insurance Agency,Inc- JAiC.No.EW: INC.Uoi. 1 Adp Boulevard aonREss: Roseland,NJ D7068 I:ISURERISI AFFOFMING COVERAGE NAICX Jrr5URER:.: NorGUARD Insurance Company 31470 INSURED INSURER B' POLAR BEAR INSULATION CO INC uI ' PO BOX 958 INSURER C: Andover,MA 01810 INSURER D: INSURER E. MSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS tS TO CERTIFY TH.T THE POL•G!ES OF INSURANCE LISTED BEL07:HAVE OEEPJ;C-SVED TO THE INSURED NAidL"D AGO-!E FOR THE F04.CY PERIOD INDICATED.PIOTXITHSTArJ0Ir-IG ANY REOUtREC:ENT. ERI..*,OR COND;T!Ofd OF ANY CONTRACT OR OTHER DOCUt:a[aJT:PITH RESPECT TO'.7HICH THIS CERT'.F;CATE LiAY BE ISSUED OR L IA;Y PERT:.:M.THE iNSURANCE AFFORDED G'r THE FOLK:CS DESCRIBED HERE:N:S SUBJECT TO ALL THE TERLiS. EXCLUSIONS AND CONDITIONS OF SUCH POL:C!ES LtI.ITS SHO1711 t'AY H:i!E BEEN REDUCED GYPAi)CL%..E;S II INSR POLICY t P DUCT • i LTR TYPE OF INSURANCE It1SD Vivo POLICY NUMBER III.:I DO.YYYYJ 4]L1.'DO:YYYYii L6IITS COMMERCIAL GENERAL LIABILITY Lt:.,:r.CCCtraa:E[.tit +�:. ( t Iii:ELV�c�li-�J_-�•_�:'..: 5 Itl-:BCL:•L:-:.lii tLJLIC= I=. Gtt:L A;O�LECA I L LC.UI:d`FLIt5 FETE. %E: :.L AGL htG.11: 1'Ii:J r— IAi:LI���JECI f_!ftli. I ":.1 C.L•sit:W:0!.111 AUTOr.OBILE LUDILITY `t3::.__.a; "i: :off 1•.i i bC'Ufl`'It:JLI::Pr y,::Td: ALL.': m xrtcLLEo .;I_IL`Yd• {{{I{I{I{''.'.�.��������' +1._ ECL'ILY ILJCT-. J°:-::CCrHri o I.;:t..'e':'.[:tl' y 1I w:1t1:1" •:.I.V,I•.�. I t-1}itU all t:= I.+LS is 6'.=L'LUIB -„L!: IIIc~C::C=Cri-itAC_ EY.CESS UAB I L'L:JIJ�LIAUL LIN_:i I IELIE%II;;I.. i-JORKERS CO.PENSATION X AJIDEtIPLOYERS'LIARItITYSI:+ELIE EIE Y.n 1,000,000 :.Y.�R:cf%rJtnacr:.!iu lie.<'Ll,li ;a) N POl^.IC7722sa a011Q?:20?6 0710?20?7 ELr=:.i:E.:caL+tl.l A " = FFICEf:•LSLIBHEEr::LLI'•eii! da.Y;.NH) I---1 tLL•L;=st. 1.QDQ.DDD [tslsmuci:crcr-tlE:.ua_�::o:: ItL.urt:•st rein ulau Is 1,000,000 1 I OESCRIP1103 OF OPERATIONS i LOLATIM45 i VEHICLES(ACORO I01.AddiliUn9 RCm�K55CI1LWlli.M.TJ OC 3IOCRCd it MWC MWiS rcquifMI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN TheHsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHDRLED REPRESENTATIVE I AL 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD - i i I I I i �fll7Si��AfWS m. 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