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Home My WebLink AboutBuilding Permit #882-15 - 192 LACY STREET 5/6/2015BUILDING PERMIT TOWN OF NORTH ANDOVER a APPLICATION FOR PLAN EXAMINATION Permit No#: r Date Received Date Issued: TANT: ADDlicant must complete all items on this LOCATION 5, Print PROPERTY OWNER A4 AR to $Ali f h A — 19V cle � �!!--�� Print 100 Year Structure yes no MAP ' / PARCEL:06ZZ 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: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg 19 Others: ❑ Demolition ❑ OtherJ� T1'r .j h5� hcr- `o &I ❑ Septic ❑ Well 0 Floodplain ❑ Wetlands ❑ Watershed District I ❑ Water/Sewer RIPTION OF WORK TO BE PERFORMED: 4 eqf i Identification - Please Type or Print Clearly OWNER: Name: ✓ta; Li4 n S ^ ")A Phone: 4?�4k/ ;YrC Address - Contractor Name: rTr,r- c -e 8 fA K e- Phone: Email: Icl,a Svl�� n a; Address: cif TT ` t Supervisor's Construction License:rSSG -Io6 o/7 Exp. Date: o Home Improvement License: IOd?.)-4 Exp. Date: 7/--lA/,� 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: $ '�3 io0 -0-6 FEE: $ 4-6— Check '6—Check No.: I. � �1 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 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 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .planning Board Decision: Comments zonservation Decision: Comments Wafter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE' D PED PE AR�MENlT e Ternp�Du 84 Osgood p6 ,F Located 3 odtreet S d _.�. t mpster�con>Esitey�es._ Jno ! L?ocatedjaf�12,4iIVlain�St�eet rFire Department4s gnature/dated 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 NU I Lb and DA I A — Wor cletaartment use ❑ Notified for pickup Call Emai Date Time Contact Nam 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 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 E: 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 I ECC 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 Location /7r No. J Date A 5 Check #—I � 0, TOWN OF NORTH ANDOVER -, Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector v � O Z cn C o� � 03 rmlll� O D co. v' O— .a iw vCD Q o cr — cD m O W c CLO CD CO 41D cn � v O 0 Z O cD z z N m O Z m U) O M 0 i m X 55 V+ z Z 2 cn U) = < CD N O r_-. CD n m Q m 00 v Cn � FD" o. OA 0 0 .-* CL� m CD Cn y W y O m x �. w N D co a v r . OMMO 0 a) o , (=D COD r CD 'a J --lo O < to 0- h U CD o 0, Cr �=r Q D CD Cn � 0 QO = N < CD o CDU) 7 C C CD Q� W( rNk te: r D U) .�+ •� .• • *** O o Z ^ � O Ay CD CD U)CD CSD U) 0 0� Err D CD :1 C CD -0 !'e o CL N Ln W T :;oT ;;o T :;oTI n .Z7 O rD(D O oZ (D -n m D S D CA m fLn D cm m m C A Z m ql pCq C 3 z m 0 :3S M OOC O � v a r Z z m O rD �. n N 3 O rz — s m :3 WO D U 0 M m D i a Conser ation Services Group 50 Washington St. Suite 3000 Westborough, MA 01581 CONTRACTOR WORK ORDER Printed: 5/1/2015 Work Order Id: S65236P68222C238 Contractor Information Customer/Site Details Air Sealing Incentive Polar Bear Insulation Nathan Smith Email: 3slnpublic@mindspring.com PO Box 958 192 Lacy St Phone (Eve): 978-681-8543 Living Space Attic Stair Cover Thermal Barrier with carpentry Phone Da ( y) Andover, MA 01810 North Andover, MA 01845-3309 Site S00002065236 Installed Measures Total $3,360.64 Road Blocks Type Status Notes Moisture FIXED signs of staining on roof deck, customer has had ice dams in the past had roof replaced havent had ice dams in years. no mold growth WorkOrder Notes Payments Incentive Payments Weatherization Incentive Total Installed Measures Air Sealing Incentive $1,373.61 Location Description Quantity Unit $ Total $ Living Space Attic Stair Cover Thermal Barrier with carpentry 1 $260.23 $260.23 Door Sweep 2 $23.18 $46.36 Exterior Door Weather Stripping 2 $27.59 $55.18 Living Space Perform Air Sealing at Estimated 62.5 CFM50 12 $84.32 $1,011.84 Attic Propavent 2' or 4' 5 $3.83 $19.15 Living Space Attic Floor Open Blow Cellulose 8" 840 $1.60 $1,344.00 Living Space Attic Floor Open Blow Cellulose 6" 338 $1.47 $496.86 Damming 58 $2.19 $127.02 Installed Measures Total $3,360.64 Road Blocks Type Status Notes Moisture FIXED signs of staining on roof deck, customer has had ice dams in the past had roof replaced havent had ice dams in years. no mold growth WorkOrder Notes Payments Incentive Payments Weatherization Incentive $1,490.27 Air Sealing Incentive $1,373.61 Total Incentive Payments $2,863.88 Customer Share Total Customer Share $496.76 Less Deposit Of $165.58 Customer Share Balance (Due Contractor) $331.18 Conservation Services Group - 50 Washington Street Suite 3000 - Westborough, MA 01581 - (508) 836-9500 (%GCONTRACT FOR Conser atlon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Nathan Smith 192 Lacy St North Andover, MA 01845-3309 Site ID: 500002065236 Project ID: P00000068222 Customer ID: C00000075255 Contract ID: 20150417 ASPAL Conservation Services Group (CSG) Attn: RCS 50 Washington Street, Suite 3000 Westborough, MA 01581 Reg. No. 173484 Federal ID No. 222457170 (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these "avriiises" in a professional mariner and in accordance with the terms of this Contract, including the attached recommendations/worlc order describing the work in detail (the "Work") which are incorporated herein by reference: Description Quantity Location Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 Living Space „ .___....._,_..., , .•, $1,011.84 At Stair Cover Therma1 Barrier with carpentry _ _. _ , „1 Liwng Space $260.23 DoorSweep,........_ _.,......._...._.v_... ..........?.,....N/A.,._..._.,._._. .... _._....- _...,...6,36..1 Exterior Door WeatherStripping. ,w ., . _ 2 N/A _ ,. _ ..... ._ . m.. $55.18 Sub Total: $1,373.6i"- 1,373.61Utility UtilityIncentive Share $1,373.61 Customer Contribution $0.00 affa For office use only Printed: 4117/2015 Page 1 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work, the Cus omer Share of the Contract Price as follows: Payment #1: $ as a Deposit payable to CSG upon signing the Contract (not to e3ood 1/3 of the total retail costs). Mail check & contract to CSG, Attn: RCS, 50 Washington St., Ste, 3000, Westborough, MA 01581. Final Payment: $ as the final payment for the Work shall be payable to the Independent Installation Contractor ("HC") upon satisfact r tion the Work. Customer understands that he/she willnot be requimil to pay the Utility Incentive Share of the Contract price in the amount of $�tClrfg' s to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. 44 JJ Ill. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in adva rtee that in the event that the IIC has a dispute concenung this Contract, the IIC may submit such dispute to a piivate arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be mquiird to submit to such arbitaation as provided in M.G.L c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Cus t i+aah e D t� Indica y u selectedUCheere, if applicable tUR) Initial here if you want (� the Program to assign a CSG Signature ate ( Name of CSG Representative (Printed) Participating Contractor TERIIIS AND CONDITIONS APPEAR ON THE REVERSE. 2200-2-1/15 (%G CONTRACT FOR Conser anon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among Nathan Smith 192 Lacy St North Andover, MA 01845-3309 Site 1D: S00002065236 Project ID: P00000068222 Customer ID: C00000075255 Contract TD: 20150417 WORK / and ( Conservation Services Group (CSG) Attn: RCS 50 Washington Street, Suite 3000 Westborough, MA 01581 Reg. No. 173484 Federal ID No. 222457170 (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these "Premises" in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the work in detail (the "Work") which are incorporated herein by reference: Description Quantity Location Attic Floor Open Blow Cellulose 8" __.. _._ . _ _......... ............. ,. _...... , -__. _ .. Living Space ._.._.... _........._. _.... __..:.......__......,. $1; 344.00 Attic Floor Open Blow Cellulose 6 ,. _._ _..._,,._..,,_...__ _., 338_u496 86 Damming. 68. , a_ N/A........-,. ._. .. _ - $127;02.. 5 _.,. Attic _ _.....- ,.: , _ ... , w.. $1915 Sub Total: $1,987.03 Utility incentive Share $1,490.27 Customer Contribution $496.76 lam! . R For office use only Printed: 4117/2015 Page 2 of 2 11, PAYMENT Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows: Payment #1: $ �� as a Deposit payable to CSG upon signing the Contract (not tc ed 1/3/ lie total retail costs). Mail check & contract to CSG, Attn: RCS, 50 Washington St., Ste. 3000, Westborough, MA 01581. Inial Payment; $ 'i ( ! t 0 as the final payment for the Work shall be payable to the Independent Installation Contractor ("HC") upon satisf ri�(�}mpd o the Work Customer understands that he/she will not be required to pay (lie Utility Incentive Share of the Contract price in the amount of $tom-& C7ianges to individual lure items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The 11C and Customer hereby mutually We in advance that in the event that the IIC has a dispute concerning this Contract, the IIC may submit such dispute to a private arbitration seance which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L. c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day�wing the of this agreement. DO NOT SIGN THIS CONTRACT If THERE ARE ANY BLANK SPACES. Customer re a hidica e / sole ted IIC fere, if applicable Nil) hritial here if you want �a',�r� pp the Program o assign a CSG Signature Date ai e of CSG Representative (Printed) Participating Contractor ww"111rC Awn f AwnwWwANC &'"VWAR AM Irmw ilpwwF.RCF. 1)1)11/ 1) 1/11; mass save 5WW1% tt>ns0.R,W0ftM c,, PERMIT AUTHORIZATION FORM I, NATHAN SMITH , owner of the property located at: (Owner's Name, printed) 192 Lacy St NORTH ANDOVER (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my prod Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date D�rO �I For Office use onty Rev. 12132011 \ The Common ivealth of Massachusetts Departinent of Industrial Accidents • - '+ Office of lit vestigations 600 Washington Street `r %ir Boston, MA 02111 X ivivtv.inass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADnli blv atne (BLIS iness/0reanization!1ndiv idual): 1 0 Ntf— A ea r` Address: P-1 D_ O X Phone #: Q Are you an employer? Check the appropriate box: AI am a employer with -- 4• ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am a sole proprietor or partner- listed on the attached. sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.= required.] 5. ❑ We are a corporation and its �. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] c. 152, 51(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.0 Roof repairs 13.&0ther =A1;1J 4 l h h •Any applicant that checks box =1 must also till out the section belo%% showing their workers' compensation poliey information. — Itomeoeners %cho submit this aflidav it indicative they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. `Contractors that check this box most attached an additional sheet shoe ine the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees. they Hurst provide their workers comp. policy number. am an entplrtper that is providing ►vorkeas' compensation insurance for nth' employees. Below is the police roar/ job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: p tl✓�— $—�—(meq Co �J Expiration Date: .lob Site Address: City/State/Zip: 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. I do hereby cerif , [,aider the pains and penalties of perjtn}, that thein%rmation provided above is true and correct. Phone-!'-': Oficial use only. Do not write in this area, to be completed 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: OP ID: SS CERTIFICATE OF LIABILITY INSURANCE NSR Im THIS CERTIFICATE 18 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. H the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the tenns and Conditions of the Policy, Certain policies may require an endorsement. A sudmient on this cartirmate does not confer rights to the certificate holder in lieu of such endo s PRODUCER Durso A Jankowsld fns Agcy LLC 198 Massachusetts Avenue Nort_ Durso&�Jao�kowssW ins. Agcy. A p FAX AeOnsss POLAP,1 UNURERM aFFOROO/G COVERAGE NAIL # INSURE Polar Bear nsu Co. I= P O BOX 958 Andover, MA 01810 e>SURERA:Penn Arnerica 52859 MMER a:Safety htsurance Co. 33618 09RMMC: PISURER O MUREi E : nounmr.: COVERAGES CERTIFICATE NUMBER: AF!VLCIHIU "UMBER: 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. NSR Im TY?EOFWSURA EI mmmvvl POLICYEFFESP Lnm A GENERAL LUMIUM X CDMMEmAL GENERAL LIABILTIY CLAIMS -MADE a OCCUR PAC7052023 03124=5 OSM4I2016 EACH OCCURRENCE $ 11000, pSEy� � � � s 50,0001 MED EXP QUw arre $ 5,90 PERSONAL&ADV INJURY $ 110001 GENERAL AGGREGATE $ 2,0OO, GEML AGGREGATE LIMIT APPLIES PER POLICY F1 JECT F-1 PRO LOC PRODIIM-COMPIOP AGG S 11000, $ 8 AUrOMOSI E LJABILI Y ANYAUTO ALL ONMED AUTOS X SCHEDULED AUTOS X HIREDAuros X NON -O MEDALROS 2100926 ("/0412015 01AM M6 COMBINED SINGLE LIMIT S 11000, 000 me: ) - BODILY INJURY (P- Pmm) S •- BODILY INJURY ow mcidwm S PROPERTY DAMAGE $ (PERACCIDEiJ'O $ $ A UMBRELLA Line EXCESS LIAR I X OCCUR q giMS MgpE PAC6906385 030MI5 03M4=6 EACH OCCURRENCE $ 1,000, AGGREGATE $ DEDUCTIBLE RETENTION s $ $ VAN"amCOMPENSATION AND EMPLOYEISLIASUM YIN ANY PROPRIETORR'A�IE ( � EXCLUDED? Nm yy3 DESCRIPTION OFPO ERATIONS blow N/A WCSTATU TH E.L EACH ACCIDENT s EL DISEASE - EA EMPLOYEE S EL DISEASE - POLICY UMIT S IONQ OPn orkERA HSI TIONS/VEIICLES(AfteechACORD �18I.A�ddWmWRem ftSdwdui%Bammgmein su al iity�poiicy- Coverege rtr ury and Mon o on ryfnsured Conservation Service Group Contractor Services Delft 50 Washington St Westborough, MA 01581 SHOULD ANY OF THE ABOVE DESMWED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD CORPORATION. All dahts reserved ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD A� " CERTIFICATE OF LIABILITY INSURANCE DATE'MI",D°'YY"r' 04/28/2015 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 NAME: Automatic Data Processing Insurance Agency, Inc. 1 Adp Boulevard PHONE F IAJC. No ExtI: AIC No): ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Roseland, NJ 07068 EACH OCCURRENCE $ INSURERA: NorGUARD Insurance Company 31470 INSURED INSURERS: POLAR BEAR INSULATION CO INC PO BOX 958 INSURERC: GENERAL AGGREGATE $ Andover, MA 01810 INSURER D: AUTOMOBILE LIABILITYD ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS q INSURER E: INSURER F : 1 COVERAGES CERTIFICATE NUMBER: 338194 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 IND Vivo POLICY NUMBER MMID Y F F POLICY P MM/D I LIMITS Westborough, MA 01581 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FlOCCUR EACH OCCURRENCE $ DAMAGE TO RENTE9_ PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ElJECOT- E-1 LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITYD ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS q 1 SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under1,000,000 DESCRIPTION OF OPERATIONS below N / A N POWC660990 01/01/2015 01/01/2016 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) nf•tlTrrr9% TC Uf11 MCO CANCtLLA I DUN M_ -1 Vo0_&w M /iVVRU %.wM . V 1 GaGSGV. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICE GROUP5 ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET AUTHORIZED REPRESENTATIVE Westborough, MA 01581 M_ -1 Vo0_&w M /iVVRU %.wM . V 1 GaGSGV. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD �l 0/ IOP and Business Regulation Office of consumer ��a _ Smote 5170 Boston, Massachusetts 02116s�ation ctor Reg Home Improvement Contra . _ Registration: 102726 Type: DBA Tr# 252249 = Ejviratiorr 7/212016 POLAR BEAR INSULATION CO Vincent LeBlanc P.O. BOX 958 - -- ANDOVER, MA 01810 _. `Update Address and return card* Mark reason forLO Card Address ❑ Renewal J EmPlOyment [] DPS -CAI 'V 50M_WG4-(101216 • Massachusetts =Department of 'Public Safety ' Board of Building Regulations and Standards Construction Supervisor Specialty T License: CSSL_106017 PETER A LEBLAINC J 2 EAST PINE STREET, Plaistow NH 03865 r Expiration 04/2812018 commissioner