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HomeMy WebLinkAboutBuilding Permit #321-2017 - 189 CARLTON LANE 9/26/2016 - \ MORTi{ BUILDING PERMIT oF�t��° 'bgtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * "-T _ � .1k �� �y 1• Permit No#: 39 Date Received A°RAA �SSACHUS�� Date Issued:09 06 IMPORTANT: Applicant must complete all items on this page LOCATION �� �d r IV-To n 2 Print PROPERTY OWNER y 1, Vly, 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 ® Others: ❑ Demolition 11 Other y�Sv/tiTio H aseptic Well ❑ Floodplain. Wetlantls ❑ Watershed�Distnct, Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �1�`t` S��/►na D� v��;y�q �gTrr,c zr%500ibH To K-Yf urri>%lart' 4 Identification- Please Type or Print Clearly OWNER: Name: SoSe Qv 'K 1i Phone: q>F- f�5= 31// Address: �'S' ce,4-1 L to , R k Feer Leblanc POLAR BEAR INSULATION Contractor Name: ���+ Yi;..o Q .at Phone: ___ _ Email: ru-z. Boa Address: P Histum ANDOVER,13-865 MA 01810 ( - - /638 Supervisor's Construction License: /o G C) t 7 Exp. Date: I}FAF _ Home Improvement License: /0)- 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: $ -37(30,010 FEE: $ Check No.: 'x191,5 Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund � _ . .. :- - - - " - _ . '' .. ...J• ~ .'W.. I. . .. .:. .. .. ... _ _ I ::. - - _ . 1. 1. P. ::! . . ... _...--.- _ _ - 1. .,' .: 1. _ _ ..: .:.. I .,. y --` (- :. M'ura'l' Y:: rte. . Location 1 _,,I,,e No. Date , 1. _ 1 • " TOWN OF NORTH ANDOVER . ... ._ a .. - . . P. • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ .Other Permit Fee $ TOTAL $ .._ - . I. Check#_oy_'� . : s -i - g f x . l Building'Inspector �. fir: n... �y4. __ -_ a. ��_ - L ..__ - _ _ v _ - '..._ti.- ...- .. - f. - - - l ,. A_ a:. - :.� .. - .�. - __.. __ y . .� .: .. - ..:.:... �., .,. .. .. ............ . . 1 U 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 Packagm*'Oales ❑' > Private(septic tank, etc. ❑ Pennanent 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 COMMENTS T ' HEALTH_ Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planhl,rng Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,FIRE DEPAR�TMENTwTempDunipster on.siteyes ;,, no � 3 t ' .moi .-'.�,#r,.P ^ t�+ '�s,jyt Located at24 MainrStreet ♦ FTs77r` •aF f �:.1-.2t'S. \ s` + ,�r+"n"s'.� y":w"'��t' K,.'`41�.. t :. '�- `'� i � Depaa�m�entAs�gnaturre/d,, ate ._.n-.— "r'it^+c`.nih.a.":k���F @OMMENTS:w r y ,► r _ il . �s , t r3, ``` a. , a ;•x, dr 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) r ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Pennit 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 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 NORTH q 1 Town of a ndover O to 3:m. ,i6a i - y �. o�h ver, Mass, © 6 ZV/d coc.acMew�cw �1' °R�TEo s U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �� THIS CERTIFIES THAT .:.Z.J st. Qat.'ev!!�.............. .., ..,,,,,, BUILDING INSPECTOR ......... ...... If�foeti7 .. ., ..... Foundation has permission to erect .......................... buildings on ....10.9... ... Rough to be occupied as ..P4aWxru *law!i/. !4 , �t�.ff Chimney provided that the person accepting this permit 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 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 CONS ON S Rough Service ............ ...... ....��P�E6i&W- GAS Final BUILDINGIINSPECTOR Occupancy Permit Required to Occupy Buildinz 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. a fadaral is 0 0844ttt428 RAE a Pit:eae Bert t t mm No ares A dMdon of7bichmcb lisgtaeeriog tapCoatmsmaeor en aro 1t09ta RISENG Company Adbu%City,M480088 CONTRACT 40(1.123•034 FAX401-123.123& I t PROGRAM pap I - >:oe emsutarta a ortemtesa�rmmae t CUA4W a �om�taan�oaces LD .tmerm oa,a worm tvaatarmaut low*Quist» cav (978)475.3111 06114/ 016 436308 00002 mmeamtae steer - cn sterno satammr i89(iati�onRoad r 189CRid aRoad .4 1 ..� Sam=ear auAmmt ,'I 41� muauo ats:saue m� North Andover,MA 01 i North Andover,MA 01845- - JOB DESCRWnON HEALTH R SAFETY wee ;;Remit tmtaot proceed t>ata merd> 1 vela tbat sal!provide(1)ohm(ale fat per muuae)of mntmaotsair ibwhasbem fmtatW in your home.BLOWElt DWlt=3363 @.So PA QATObMNEEDSTODWALL A BATH VENT FAN Dl:NNED FOR OONrDAMWRIIN AT 60 CFM THIS CAN BE ON T1NII-RSWITCH ToCYCf.E 23 MIN.PER 1 OUL THAN CANAIR W,AAL TO 2370® CFMSO.ONE SUM MAN tSAA PANIMNIC SFI.ECT.LOOT(AT ER.ORt3. HAZARD BARIM we have fdmtfed that thea are recessed revs pre- -is your home.amass the evoeased lights are catifiad $0.00 as X-rated(IrtsA1bu Coatmet Rated)we vall agate a 3•ctareaee space moumdthe f»c m by mmgfrbergies Wdg as a dammbw matafal,ao fnsftlan salt be f»st NW sacs tho top and etosod covitiea sdit ooataia:eoesod lits sal[sot be W dated SO.00 tIEAL?x dt SAFETY wwtbemfmmatioa scarf c mumot PM=W tmta the spaleple of eontbmtion gases is fxcd. $0.00 HEALTH&SAFETY WeathabuilmVID&cannot ptooad tura the ms ffw=&tett issue is feed $0.00 AIRSEALIIMPtovfdeleborandmaterfalsto=dwmsofyomsboate wmte6d,emoasaf kdoigL ThBstorktwllbe Performed fo COMM wdtb 8m mms'cof*wfat toolsand dirm8=ic tests to awe dW your forme suffl be Uft v th a hearth$&laud of air exchange and indoor air quality.Matafels to be and to seal yomw homae emu btcb*a mft foams and other pt ftm Pr=M mem for scaling f wk**leekW to safes,basemems,attached germs mind orbs uml>satedmeas(wfudoars ata not generally ad*c=d)This wt4 NW*c(0?Rocking horns.A radmmctaoa in cubic fat permfmmte(dm)of air bion wit[ooaa.bot the actual nmmtberofeb arm gm a ttteed. At the Completion of the sueutha®tion work,=d at no ado fo>md cost to the baateowner,a barn!busier door andtr comabatfon safety mtelyb ado beaonduaed by the saKontrmmctor to mase the safety of the indoor air gtak. $765.00 DANQdNQ Provide tabor andmeaaWs to imad a 12'*a of R-38 tmfeoed glxqfts bear to(23 1)sgmete fat for damming p $473.55 ATTIC FLAT:Provide labor and materials to imtall a T tmmyer of A 25 Class i Cbllalose addedSpam to Cl152)smNare feet of cpm attic 51,49?.60 ATTIC ACCESS Provide labor and mstamts to iosd9c ftb the back of(1)attic batch vY d&-ri aam. board.weetha0*the pe fameter. $60.00 ATTICAC=PwvideMOT and me iatsto (1)may moveal,iuumimcovatbrtheartfeaooessfbl&sW&. Asmall Bat stmefane 0fplywo0d srdi be ereatcdmotmd tho Vaia the attic ThawwalbwtheameesintegdumbwAWppingto testriet as leakage. $237.65 s Fademl 108NOMM E le wA Aftonaioa ofThidaeb fergiaesd ►RISE ng Compaay Address,City,m&00oo0 451-113-I2i4 FAX401-1234234 CONTRACT ftp 2 PROGRAM CiVLir ESWDICIPER °o sus CILIUM :!;q 3oseph Won (978 75.3111 06114=6 436508 team 810181aataa altar 189 Carleton Road 189Cfr1etoa Road *mwam aa.wmw aarms ar stmap North Andover,MA 01M North Andover,MA 01845- JOB DESCRIPTION VENTILATION:Provide Mu and mataWs to install(3)r drameterroof vant(s)to kcrae a vection is atria arms The vera can be supplied in(circle a tec)Mack.brown,gray or mM fmuh S2S6.50 VENTILATION.-Provide tabor and maniere to imM(I)wed sahaast Bose to Cresting bathroom fen(s). SS0.00 VENTILATION:Provide>abor and ma mMs to ia"vem0sdm'a cb ss in(99)m8a bays tc mamtdn air Hoar OOMb=WALLS Pmvidle labor and mdaWs to lasteffl 20 FSK faoed seme-rW ft gtma board Iml to(610 square feet of 5198.00 common VAB atm. S238.00 INCIIVTIVE RISEF.agar g Col apply aD apptteebie.dig�{e iCrootivss to tbiseotttraet You w%only ba hMed the lfet emotmt Cmrentty,for measmer,CAMbia(las ot3:rtsu irmeu mi,7VA Cot to exceed 52.000 per a year,cad as&ccateve of 100%for the Air SesHag me am ap to*oft 5690 amiaa additioml5340 tfsavtags ami difielby the auscr. FORA LBGTID TIME Cobs ubia QaswM also of eras additicad slo0 iCaentive tosands the aseth tion cork ottmod in this pmpo al.Ths VecW 8=mar lnoeative is avg&ft to homsoaCas Ww have hW tbeicCd=bk G t home aragy sob beforo lnly 31.2016. A signed proposal for ache rima=ah to be submitted by Angmt 8.2016 and cork mast be completed by September 30,2016. For the safety and baft of year home`s indoor air rpray,ere vA be emtd aft a Koatr daor&Vmdc of the avarftb sir 8owin yotr Name bub bdme dw ssork is beim,and atter the vaeftindu aro*iscomplete.We IM abo conduct a tbD assessment of the combmtloa safety of yourbeatiaggggm and aeterheate:Tbishasa value of S90 and br at ra Cost to yon The mmcimuas attoaeble iacmteve for all memwM bcW ft air sediag 1353.210 690.00 Rftd w i RLU F.nglileering Rl Coatrum,Mal I of No etas iH1Coe01aCt0rl> ea No IBM A Qlvlatoa ot7blefsch Engineering Compauy Ate,City.NA 00000 CONTRACT 401.123.1234 PAX401-123.1234 Pap 3 PROGRAM CK44M+3 a,w c�im cumom PIIOI@ 0118 Guam WORK."m Joseph Quinn (978)973'-3111 06/1412016 436308 00002 GEMUa mer enum saw 189 Catl,eton Road 189 OWdon Road etnwm om'sa ,m+ 00allo air s018,aP Mrth Andover,MA 01845. North Andover,MA 01845- JOB DESCRIPTION Total: 48" Program Incentive: $?,861~00 Cudconer Total: $1.011.30 weAB la30�rTOF1A xS .CQatiLelealA A WfRUV30M88P1 A1Fg1�RR7MSMOF "Nkm Thousand Seven&=100 Dollars $1,011.30 OPOIIR'101t A�OW1L8rN6RR0�lf0 A�B�RFYrN�f0i1H0pOLY1F�PAtOgtf R!Lt.8ED1t�e01R0�tA1AM11 IAtPA>A 01ere.oee iOTav0RWf10P0 10lRWPR� OF =Galva=10�401Sa1t SIOp ilti8 CotI1RACTtR 7ttERi:I�E' 8P i Atit�06�M�8 f} IfO�l�00wRA01�Y88M1Q Ifr06PIfOt�G1F0�[�1 ,WMMPUM ASWI0USUPGO RACE 1NBA00U@ M6 Ig00�/11®COx010d0AiE x.-30 OAS A00l PAY�IRC1.B8 101 taAtlitOl�oA008g1lOIOI RISE60 Shawmut Road, Unit 21 Canton,MA 02021 339-502-6336 ENGINEERING www.RISEengineering.com 1 !� co 0 , N O OWNER AUTHORIZATION FORM W c� Joseph Quinn (Owner's Name) owner of the property located at: 189 Carleton Lane (Property Address) North Andover, MA 01845 (Property Address) hereby authorize �9 °�f, -ro" (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. Zner s Signature Date The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Coigress Street,Suite 100 ' Boston,11M 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): M AR RFAR 1NS111 A77t7td PO BOX 958 Address: ANDOVER( MA 01810 City/State/Zip: Phone �I Are you an employer?Check the appropriate box: Type of project(required): [2.0 .� I am a employer with_ 4 ❑ I am a general contractor and I i employees(full and/or part-time). have hired the sub-contractors 5. ❑New construction 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sun-con-tactors have g• ❑Demolition working for me in any capaci-ty. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its � I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all wort: officers have exercised their ( :1.❑Pluanbing repairs or additions j myself.[No workers'comp. right of exemption per MGL I insurance required.]t c. 152 1(4),and we have no 12.❑Roof repair employees.[No workers' 1311 Other comp.insurance required.] *Any applicant that checks Sox'1 must also ill 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. $Cnntractors that check this b-3x rnlist attached?m additional sheet showip_a the name of the.sub roLkactar--nd state•:hethe:or nc:those entities have empioyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. f am an employer that is p:or-iding worken0crempemadon hnssurancefior inv employees. Belo:'is the policy and job site information. Insurance Company Name: r O c:6 V/g k A _1 n qtr ( 4 K re r p y"Qf vL y Policy#or Sclf-ins. Lic.#: ?O\,J C ')�2,zS � Expiration Date: of/oi bo 1 Job Site Address:_l �7 ( 'A�f /,r y'o VL City/Stat:./zip: n. anJa✓tT Attach a copy of tho 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$1,500.00 and%or one-year imprisonment,as well as civil penalties in the form of g STOP WORK ORDER and a fine of up to$250.00 a day, against the violater. Be advised that a copy of this statement may be forwarded to file Office of Lrvestiganons of the DIA for insurance coverage verification. V do hereby cern under the pains and enaltie_,i ofperjury that tate in ornation provided above is true and correct. Sisnj "IDateL. a d G Phone#: ye)- 7& 3 6 Qf ccial use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermittLicense# i 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 M 6/1012016 Preview:Certificates of Insurance ACCORoos110/2® CERTIFICATE OF LIABILITY INSURANCE DATE110/2IYYYY) of s 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 lieu of such endorsement(s). PRODUCER CONTACT NAME, PHONE Automatic Data Processing Insurance Agency,Inc. ac.Ho.Ext): uC . � .Noy 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: NorGUARD Insurancecompany 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURERC: PO BOX 958 Andover,MA 01810 INSURER D: 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 INSURANCE INSO WVD POUCYNUMBER MWDDIYYYY) WDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE FIOCCUR PREMISES(Ea occurrence) 5 MED EXP(Any one Person) S PERSONAL&ADV INJURY S GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY F]PROT ❑LCC PRODUCTS-CCMP!OP ACG S IEC OTHER: $ AUTOMOBILE LIABILITY fEa accidenlI S ANY AUTO BODILY INJURY(Per Person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) 5 HIREDAUTOS NON-OWNED S AUTOS tPer accidml! Is UMBRELLALIABOCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION XAND EMPLOYERS'LY/N ABILITY STATUTE ER ANY PROPMETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT S 1,000,000 A OFFICER/AIEMBEREXCLUDED? a NIA N POWC772258 01101/2016 01101/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B morespaw 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.I suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE l A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https-.//adpia.adp.comlicertcf/#/runipreview/503597/900012975 l/l DATE(MWDD/YYYY) ACOORO® CERTIFICATE OF LIABILITY INSURANCE 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 NAME: Insurance Solutions CorporationPHONE (603)382-4600 AX No:(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insuraace.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A Western World INSURED INSURERB:Nautilus Insurance Group Polar Bear Insulation Company Inc INSURER C: 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. INSR TYPE OF INSURANCE D L S POLICY EFF POLICY EXP LIMITS LT POLICY NUMBER YY YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F OCCUR PREM SES Ea occu DAMAGE TO ence $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PET �LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea aaident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident R UMBRELLA LAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (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 H more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA -- @ 1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r?nt4ofi Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 dLL- Type: DBA Expiration: 7!2!2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Update Address and return card.Mark reason for change. SCA 1 0 2OM-05/11 Address [] Renewal ❑ Employment Ej Lost Card ale�fanrnmrmeril(�a%GPIIISfQC�f/SC((3 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: 102726 Type: Office of Consumer Affairs and Business Regulation fi Expiration: '7/2i2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION CO. Vincent LeBlanc 51 SO.CANAL ST.#5A LAWRENCE,MA 01841 Undersecretary V Not valid without signature • ,v L Massachusetts -Department of Public Safety �--�' Board of Building Regulations and Standards Cnn+tructiun Supert isor Spccialt% �icense: CSSL-106017 w Y d 1 l PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 03865 07121 Expiration Commissioner 04/28/2018