HomeMy WebLinkAboutBuilding Permit #77-12 - 19 STACY DRIVE 7/28/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 01** � Date Received
Date Issued: " '- 1
IMPORTANT: Applicant must complete all items on this nage
MAP NO: PARCEL "IrZONING DISTRICT: Historic District yes
Machine Shop Village yes (f
100 year-old structure yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
6 -One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
A -Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
[fl Septic Q Well
El Floodplain p Wetlands
-0 Watershed District
0 Water/Sewer
OWNER: N
Address:
DESCRIPTION OF
r. I ULA
(Identification
C(4 2:,t -
TO BE
Type or Print Clearly)
CONTRACTOR Name: 4!f AL ¢ k)r Phone: 5 9 V02- %M `%
Address:
J' n,
Usti
(9Y/1-
Supervisor's Construction License: Exp. Date:
Home Improvement License: Z �) `,W Exp. Date:
ARCHITECT/ENGINEER Awy, Phone:
Address: Reg. No
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ `,fir f FEE: $(
Check No.: / Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified PlotPln. ❑ Stamped Plans El,.? .�' w
TYPE OF SEWERAGE DISPOSAL
!
FW
El
Public Sewer ElTanning/Massage/Body
Art ❑'
Swimm tPools�,
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR20FFICE USE�tOIQLY
INTERDEPARTMENTAL SIGN 604 U FORM } '�
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS.
0
DATE REJECTED DATE APPROVED
❑ ❑
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Com
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located'at' 124din. Street
•;s,
Fire Depa€rtment signature/date y
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.s100-s1o00 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
i
Doc:.Building Permit Revised 2011 June/mi
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
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pe
Addition or Decks
NOTE:
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/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
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi
New Construction (Single and Two Family)
NOTE:
❑ 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 j
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perm
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: Doc.Building Permit Revised 2008mi
Location s Az, L
No. Date
40*Th TOWN OF NORTH ANDOVER
L
A
9 M
> ; : Certificate of Occupancy $
Building/Frame Permit Fee $ a
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #�
2
Building Inspector
ti
z
W
Cd
PO
°
a
x
o
C7
0
o
Uw
a
W
a
o
w°'
�n
w
�
w
►�
W
o
a°'
cn
w
o
U
w°'
w
w
W
W
z
ci)
o
cn
E
IE
y
zip
'C
y
C
W
CD
aoc
O!
c
i
O
cp
C
�C
N
O
45
Z
O
Z
co
C)
F.
0
u
C/)
I
I
Ml
0
6
0
co
O
C■
L
O
Z oL
0.
O CO)
O c
CD
C C
O•—
� p�
y O O
'E m m
O ow
3 .o
CD p L
e_Uv oco
a
� via
c
00 a=..• C
R O
v J .fl
0 CD
C CD
0 CL
C■3 VD
c C
C
■ C
d
CO2
p
LLI
U)
U)
19
W
W
19
W
CA
�o
o
c +r
O y
V C2
CL.
MM
m C
O
O L
E�
c
m 22
:L �
o o.
ECA
o °'
c
0
O 0
r
ts c
4: a *�
�.: y m
:-fimm
fn
en
.�
m
-0
y W
E�
0 0
at
vCD
y m
:4.
�
�O C
cw
Q
acr
'
mom
C2 Ca y Z
i
C � O
CL.
m C
o_,,
O. c
~
CIO
+r0
y m�0..~
W
Cc = m
OC
�dt C
H
y
•m
7 +
u
u
cm
p m C_
COD
O.
O 'O
10.5
_
F-
CA
.0
a= Co
E
IE
y
zip
'C
y
C
W
CD
aoc
O!
c
i
O
cp
C
�C
N
O
45
Z
O
Z
co
C)
F.
0
u
C/)
I
I
Ml
0
6
0
co
O
C■
L
O
Z oL
0.
O CO)
O c
CD
C C
O•—
� p�
y O O
'E m m
O ow
3 .o
CD p L
e_Uv oco
a
� via
c
00 a=..• C
R O
v J .fl
0 CD
C CD
0 CL
C■3 VD
c C
C
■ C
d
CO2
p
LLI
U)
U)
19
W
W
19
W
CA
0
z
i
if
caM
N
0
N
C
A
cm
m
cmC
O
cm
C
�C
N
O
Z
O
Z
o
5
0
a
r..
Y)
7-10
u
O
M
a
90
U
Q
s
v
P4
am
O
Z C�
CL.
O y
G C
CO OM
CO)
.CO2 CD
FE m m
co O CD
CL
y=.r
3.0
co
G3 L
e_vv o a
c
ev
Cc
a
COD zCD
0 CL
C.± h
� C
C■�
■ C
_c
C.
H
0
W
N
Y/
oe
W
W
19
W
N
°o
w
v
v
U)
O
P-4
z
a
�c
o
w
o
w
U
Cd
w
a
O
U
w
ts.
x�
O
w
0,
W
i
w
U)
w
a0
U
a
w
w"
w.
w
a
w
C
c0
z
cn
o
o
cn
i
if
caM
N
0
N
C
A
cm
m
cmC
O
cm
C
�C
N
O
Z
O
Z
o
5
0
a
r..
Y)
7-10
u
O
M
a
90
U
Q
s
v
P4
am
O
Z C�
CL.
O y
G C
CO OM
CO)
.CO2 CD
FE m m
co O CD
CL
y=.r
3.0
co
G3 L
e_vv o a
c
ev
Cc
a
COD zCD
0 CL
C.± h
� C
C■�
■ C
_c
C.
H
0
W
N
Y/
oe
W
W
19
W
N
CO C
c
Q `
C H
O
C
"~
O
V V
CL C
M
O W
CD C
;Z O
O cc
N �
E lite
m c
m�
o a
E c
VN
0 0
r:
m C
Q O.:l
�.: N R
m
p
Z'Nca
cm
CDpp
O J
32
m
N O
€ CD
.o
m O
v3
H O >
O
p� O C
C Q
aC.0
m O V
V y Q
v'�Z
C p O
d
Q
m
H m G
_
®
m� o
d
~
N m s
W
G'0r
C =
L.
40�+
M
E
o •G
N
vm
o o c
COD
CL
_
E-
U
� y 7m
.� a *
i
if
caM
N
0
N
C
A
cm
m
cmC
O
cm
C
�C
N
O
Z
O
Z
o
5
0
a
r..
Y)
7-10
u
O
M
a
90
U
Q
s
v
P4
am
O
Z C�
CL.
O y
G C
CO OM
CO)
.CO2 CD
FE m m
co O CD
CL
y=.r
3.0
co
G3 L
e_vv o a
c
ev
Cc
a
COD zCD
0 CL
C.± h
� C
C■�
■ C
_c
C.
H
0
W
N
Y/
oe
W
W
19
W
N
E
O
1=4
0
L
O
14
�¢
O
w
cn
xa
o
a
PQ
o
V,
G
w
w
>
U
iu
w"
o
w
a
a
w
id
iw
o
w
a
v,
U
a
W
w
%
cn
w"
O
a
��
w
is
u",
w
w
w
G
�
as
o
z
�
cn
Q
x
O
cn
0
uni
z
E
a
ca
H
fA
C
O
cm
CD
cm
12
O
cm
C
�C
N
m
Z
0
Z
O
s
0
z
0
w
w
O
M
I
OR
O
co
L
O
v
ZAO�
ii
O y
D O
I =cm
O■�
V)
W ■�
M� m m
0 CD
3�
CD
CD L
Q
O d
CL Ca
o 4-�
C
!- to
C.3 J .O
CO2CD
CL
C3 y
c C
C■�
■ C
CO)
0
N
W
19
W
N
OZ
o �
`
c
O H
• r.+ C
'
O
V C3
X06.
c■ c
M m
m c
0 L
y �
EQ
0 CF
v
m o
= ca
O.
y0+
y
E 5
`rt
m
Vi
c�
VO
r+
v�
u ..
Of
m c
y
c3
y
m
c
7c
.�
Cocm
.0
ev
,C C
y m
:C y
m
E�
`m o
nc3
Q! O c
c Q
act
C
M •��
C O
d
CD
m
p
=
m
y=,,
d
VD
ev t m
W
c
■a
. D m
H
y
E
•m
M
O •y
CS
LU
V
p
C42CL
m C.
H
=
H
Lyp
z
.0 0
$ aim
E
a
ca
H
fA
C
O
cm
CD
cm
12
O
cm
C
�C
N
m
Z
0
Z
O
s
0
z
0
w
w
O
M
I
OR
O
co
L
O
v
ZAO�
ii
O y
D O
I =cm
O■�
V)
W ■�
M� m m
0 CD
3�
CD
CD L
Q
O d
CL Ca
o 4-�
C
!- to
C.3 J .O
CO2CD
CL
C3 y
c C
C■�
■ C
CO)
0
N
W
19
W
N
3-1 AA-
GAm& Clav
of Maiikh�
-1
Gas
X, -
1-4d
t
Office of Consumer Affairs and usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration.
POLAR BEAR INSULATION CO
Vincent LeBlanc
P.O. BOX 958
ANDOVER, MA 01810
0PS-CA1 is 50M -"04-G101216
G6V��Office ot�o�u emirs B i es. gu a on
-- HOME IMPROVEMENT CONTRACTOR
Registration: , 102726 Type:
s Expiration: 712/-2-012 DBA
P BEAR INSULATIQN cO
Vincent LeBlanc
51 SO. CANAL ST. v#5A?
LAWRENCE, MA 01$41 Undersecretary
Registration: 102726
Type: DBA
Expiration: 7!2/2012 Tr# 298090
a _ ! Y Update Address and return card. Mark reason for change.
Address j Renewal Ij Employment Lost Card
License or registration valid for individul use only
before the expiration date. 1f found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite.5170
Boston, MA 02116
d 1
'Not valid without signature
31 ."s-whusett. Department ;)r Public 4•jitt%
Board of Buililim" Re-ulatIIri, <Entlt.tltctat tfs
,. C-011strQction Supervise m ac clt1 L€ e� sR
:- cet's" CS Si_ 99352
Restricted to: WS
VINCENT LEBLANC
24 LANDING DRIVE
METHUEN, MA 01844 =
Expiration: 1/30/2Q12
Tr=:. 99352 -
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'Y www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
inliranf Ynfnrrnn+;--
Name (Business/OrganizatioOndividual):
Address: ,J
i.
Ci /State/,Zt �
t3' p._ �A E U E10 i , (� 1 VV Phone #: �/ - %3
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached shget. t
ship and have no employees
These sub -contractors have
working for mein any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. &�We
are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp, insurance required.]
*Any applicant that checks box #1 must also fill out the section below sho - th ' f
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demblition
9. [❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.[AOther 4V CU 1 PA-
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside ontrac oors must sumia new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:_ Rdj� j,�9 — J l
pp Q - Expiration Date.--//, oZd
Job Site Address: [ I City/State/Zip: s(_
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 $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
Investigations of the DIA for insurance coverage verification.
I do herebyVer'ify underhepains and penalties ofperjury that the information provided above is true and correct:
1R n
V) `
ufftcial use only. Do not write in this area, to be completed by city 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 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 apartinents 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
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance -or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance 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 insurance
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) name(s), address(es) and phone numbers) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required 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 Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy; please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City 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 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town 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 license or permit not related tor any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person 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 Cxm,.;uonweabh of Massachusetts
Department[ Of Industrial Accidents
®flee of Investigations
600 Washington Street
Boston; MA 0211 1,
TO. # 617-727-4900 ext 406 or 1-877-MA.SS.AFE
Revised 5-26-05 Fax # 617,727-7749
www.mass.gov/dna
OP ff): SS
- c
� CERTIFICATE OF LIABILITY I SURANCE
���'
a3t24n1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CSTFIRCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E K TEND OR ALTER THE COVERAGE AFFORDED BY THE POUCiES
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(res) riiusI be endorsed. IF SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain porgy may require an endorsement. A statement on alis cerilTicate does not confer rights to the
certificate holder in fieri of such endorsernent(s]
PRODUCERCONTACT
978-688-7
A Bay State Gas Co
Durso0
Jankowski ins Agcy LLC
978-688-7001
198 Massachusetts AvenueC'ft
-NAM
PHONE Eax No
EU (Ar
ADS
North Andover, MA 01845
Charles S. Randone
cDsMNNMszwa: POLAR -1
MMMBW AFFOAcIM COVERAGE j MARS;
EACKOCCxURRENCE 5 1,000:00
INSURED Polar Bir insulation Co. Inc.
INMM A _ Penn America 132859
B_Safety Insurance Co. 33618
P O Box 958
Andover, NIA 01810
INSURER c:
INStRER D -
� 03!24!11
INSURER E-
MED EXP (Any me pen m) S 5, 004
INWRER F -
COVERAGES CERTIFICATE NUMBER: REVISION NUMBE
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWaRSTANDING ANY REQUIREMENT. TERNI OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAW, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HERRN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS.
GLCAC11
TYPE OF INSURANCE
SHOULD ANY OF T HE ABOVE DESC,RII3ED POLICIES BE CANCELLED BEFORE
POLICY NUIM3E i
IMMORM POLICYEFF
PQUCYP
! RAIiS
A Bay State Gas Co
GENERALLIABIUTY
350 Essex Street
AUTHHOOR123M RREPRIE TATIVE
!
EACKOCCxURRENCE 5 1,000:00
DAMAGE TO RENTED
egg «Harm s 50,E
A
X COMMERCIAL GENERAL UASIUW
CLA m&wDE a OCWR
PAC6864084
� 03!24!11
03124112
MED EXP (Any me pen m) S 5, 004
PERSONAL &ADV INJURY S 1,000,
GENaALAGGREGATE (5 UK
t
TLA eG[s EGAMUM[TAPPLIESP✓�t
PROfAfCiS-f0(11�lOPACaYi S 1,000,
'
S
POLICY ; PRO- ;i Loc
;
B
AI)TONOSILELIABILIIV
ANY AUTO
i
00926
01/04111
01/I24/12
�
jCOMSINM )SINME LIMIT Is 1,0K000
i
SODILY MLIURY (Per Pw=1 5
ALL OWNED AUTOS
�
�
BOD Y KILRY (per=zwM J S
X
X
X
SCHEDULED AUTOS
= IIIREDAUTOs
NON-OWIN D AUTOS
PROPERTY DAMAGE 5
i s
Is
UMBR1311► LIAR I X
OCCUR
ii
EACH OCCURRENCE $ 1,000,00
AGGREc ' s
A
EXCESS Lias
�i° °DE(
AC6864W_
03124111
; 03MV12
DEDUCTIBLE
5
RETENTION $
i
NtOR1Q3 S COMPaaATION
ANDEE7PLOYERS LIABILITY YIN
ANYPROPRI=TQ•itlP "JN/A'•
'
ORCE A1113 BER DCCLUDED? u
wo
i
tj
j
tt
-
1
I
I
STATUm-
X ORY LL IMITT5 ER
EL EACH ACCFO�31r i S
L END?L 5
EDISEASE-EAWNW
E L DISUSE -POuCY LIMIT S
y�
DESCRIPTi OPERAMONS balm
f
I
+i
t
i
1
DISC 2ipiION OF Q -E RATIONSI LOCATIONS! VEHICLES (A1Wgh AC0RD 103 A"30110 Wks Scbedffig if amn space is r�rts d)
G.LC.A.C., National Grid Corporate Services LLC DBA National Grid, Action
Inc, Boston loos Company, Color" Gas C , Essen Gas Company & Bay State
Gas Co.; are addrtiorml lrisured for general Iiabifi y writ respects to work
performed on their behalf by the above.
CANCELLATION
CERTIFICATE HOLDER
GLCAC11
SHOULD ANY OF T HE ABOVE DESC,RII3ED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE wiLL BE DELIVERED IN
G.LCAC.
ACCORDANCE WITH THE POLICY PROVISIONS.
A Bay State Gas Co
350 Essex Street
AUTHHOOR123M RREPRIE TATIVE
Lawrence, MA 01840
I
ww- www- . wnAll L f,f� eacnn,ni
u
ACORD 26 (2009108) The ACORD name and logo are registered marks of ACORD
^�ghtFax Rl-i 1/19/2011 20:14:22 AM PAGE 2/002 Fax Server
A.CORD. CERTIFICATE OF UABILI Y INSURANCE RATEomwN m 01119=11
MWCOMCATEISMED ASA UCn1R OFOVORMAIM CMV AND ITERS LMLO RL( M UPOtN M E CERTFMTE (COLDER: 7M
CEMNICAIE DOES NO iAFFUMATiVMY GR "WAIMMY Aim DMUD CRALTER-*W COVERAGE AFFORDED OV -DIE POUCiES SELOW
THIS CE A'r= OF gVRRumM DOES NOT L7Di�Sii7'M A COKTRACT SEiWEBd'iHE iSSIlHIG � AL±Fiif)R72ED �pR£St�TiATIYE
OR PFdMXJCM AND D.1E C ERTZMATEHOLD.
RTAt'f:_ ay,
ff� fiotEs h*Hw 1s m ADCnU*4ALB t1- A on 6Ss eoe6Sat�-
�POsmt z�g1�s m O
Wpo! CaDd'A'1MOLKofdwpaSeadeinpc5ci"= y-*ffOld -
:�rDb�tslLr>�er iatT�ral sLrrlLel�.
PRODUCER
DURSO & JANKOWSM WS
NORTH ANDOVEt. MA 01W
22FM
04SURED
POLAR SEAR HaU AMON CC) INC
C OWACT
HANaFAX
PHONE
(AA Not EX* FAX
E-f03L
ADDRESS:
PRODUCER
CUS70im ID ft
MVRERp AFFORDING COVERAGE
BLRtfP.ER A: TRA rVnERS IIsi S SAW
1NSfRER M
tlE009R C:
INSURER D:
PA_ Rm 958 iINSIiRER
ANDOVER MA 01310 F:
COVERAGM CER-WWATEPILVM3M REittSSOf1 rftfPSBEf
THE ISTOCERRFYTRATTFIEPOUCMOF ULtVM BELOW SMVE BEEK'SSLiEDTOTHEMSUREMNAIRDASOYEFORTMPOLMYPER=RMCATEM
jaymms-zomowiAM 28=00Am3wr.TERRI OR 00Hm:w" OPANYOOMirRACTCRC fER DOCUUENTWT M MWECFTn �
WMMTFiI9 OX -M MAY BE ISSUED
ORMYPERTARL TFMR AimHYTfMP0L1CM HSI@KtSSUBJECTTL3 L7H5TE825.FSIxI AMD LONDfiIG1SSOFSUCHPOtiC�
LS6 MSHOM 9"HAYE MMV REOMM BY PAID CLNW
NSR
TYPEGFUMMOME
LTR
GENERALLIARKM
ccuwjE=VU-GSNEPALL1A8LJ7Y
CIAftJS MA S OCCUR.
GefL AGGREGATE LMAT APPLESPEPC
PMICY PROSECT LDC
AUTO 08n.9 LUUMLf Y
ANYAUTO
ALL AUTOS
SCIMDULE AUTOS
HTtED AUTOS
UMBRELLA LAS OCCUR
EXCESS UAS CLAIMS-MAM
DEDU=9LE
REnRfl ioN S
ADDLE POUCT EFF DATE POUZY EXP DATE Mum
POLICYIa' m VwAmYYm (MMIA "
Rm wVc EACH OCCURRENCE $
DANAG£TO FMNTED S
{Fa a�sa>eme}
MED EXP (Any o— person) S
PERSONAL SZ ADV MURY S
GENERAL AGGREGATE S
pRODUM. COMFIOFAGG S
COMB84M SINGLE $
Lear (Ea acrid-*)
BOD VNJURY a^
8 00ILY RAwRY S
PPC, PEEFrrY DWAG>= S
(Per accidem
SACH OCCURRENCE $
AGATE
S
WC5rA7 0RYL1WriS
WORKER'S G=PENSA-n0H Ai Hi
E mcnrEITS LIA umv YM U899fSL09t3 73 1}1J0�12fl13 fl311i3/2fl12 E L. EACH - F SJILOE NS
AMYPROK-WrDFVP� Y EI. DSEA6E EA�`f� S
E L DISEASE - POLICY L&VT S
(aduttRory in r"
0 Y04 deacrmstndw
DE9CISFDON OF OPERATIOMS b0fM
OESCFA lI3N OF '
egg,LACESpFlyCERMPrAiEMEM3To'tmCERZAcA38OO7DIRAFB3MM9OESMScamp CDVE AGEr .
CERnMAM HOMrmR
GLCAC&DAYSUIENa OO
350 ESSEX STREET
IAWRENC K MA 01840
A0OFtD 25 (209109i
smog
1,000.040
3,400,000
3.0m.ODO
CANCELLATION
SHOULD MY OFTM ABOVE DESCRIBED POUCIES M CMURELLM BEFOM
37ii:EoUtATiED+t WE gHEWOF, Nor=WVL W DBS flit ACCORDANCE
fAfPiH THE POL11Y PROViSIcm
AUTHORG9M JOWWWWrATIM
Charles J Clark
19M2009 A0ORD CORPORATM. AN ti9t ras-VB 1.