HomeMy WebLinkAboutBuilding Permit #928-2016 - 196 WAVERLY ROAD 3/1/2016Ay �y OLA -�v Lr ,'UILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:
Date Received
0-1.
0 .. ...
Date Issued: 1� I � 14
1IMPORTANT: Applicant must complete all items on this page
LOCATION
Pdht
PROPERTY OWNER 6-'VyGoC V, 14-vir!
'000r
Pdht 1 60Y�ar Siw6tuh6__'__ 0
MAP PARCE-Q�W2__-, ZONING DISTRICT Historic District ye no
T s
Machine Shop Villaqe ves/ no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
0 Addition
El Two or more family
El Industrial
0 Alteration
No. of units:
El Commercial
El Repair, replacement
0 Assessory Bldg
kOthers:
0 Demolition
Other
El Septic El Well:
-
El Floodplain El Wetlands
El Watershe.0 District
0 Water/Sewer I
L
DESCRIPTION OF WORK TO BE PERFORMED:
5-00 0 4 .4 7-7-1-C /0, --;/1117 -/-z2
pi -71 16L 71, 0 0
Identification - Please Type or Print Clearly
OWNER: Name: 6ty3of-Y rPv iv7 q Phone: Cr >9- Y
-11 -
Address:
ML-LOV�A_ P e te r Leblanc -
Contractor Name:- 2 East Tine -Street
.W_--UC'V Ax ix
Address: Jaujs autcl JS821 Z Plaistow, N.H. 03865
juvitlaq 97' 118-4V07 7638
Supervisor's Construction License: /eq __Exp- Date:
Home Improvement License:,____,_,_J EXrp. Date:
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEESCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00PER S.F.
TotAl Project Cost: $ Y90 - a 0 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acces&to the guarantyfund
A
nature of Agent/Owner Y,,Mff
',L4�� Sicinature of contractor
Plans Submitted 11 Plans Waived [I Certified Plot Plan 11 Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales 11
Private (septic tank, etc.
Permanent Dumpster on Site F1
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 Sianature
COMMENTS
'Z Y 7
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
1. Planning Board Decision:
Conservation Decision:
Comme
Comments
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 124 iMain Street
Fire'Department signature/date
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.$100-$1000 fine
NU I t:bana UA I A — wor cieDartment use
U Notified for pickup Call —Ema
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
• Building Permit Application
• Workers Comp Affidavit
Ei 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
NOTE: 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
Li Photo Copy of H.I.C. And C.S.L. Licenses
a Copy Of Contract
Lj 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
NOTE: 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. 1. C. And C. S. L. Licenses
Lj Workers Comp Affidavit
Lj Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
Mass check Energy Compliance Report
Engineering Affidavits for Engineered products
NOTE: 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 (-'o
No. 9 — 2—C)
Check
U
v-, J, .
Date -7, 0\ ��-
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL
Building Inspector
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Federal ID
WSE En&ftlilw
I" contractor "Istration No
A division Of'MFAsa fteneedug CT Commaorit"Istration NO
RISE
ENGINEERING 60 Showinut Unit #2, Cauton, MA CONTRACT
(401) 7"3700 FAX (401) 7"10
Page 1
PROGRAM
THOCONT&MIS -XIOSETINEEMRSE
CMA-E[ES ENMEERINIONU)THECUSTOMERRMWOMAS
SMAIN
CUSTOIKER PHONE OM cuent WORK
OHM
Gregory Irving (978)857-7924 02/01/2016 428660
00002
SERME STICEEr 611AING STREET
196 Waverley Road 196 Waverley Road
SEWCE CnY.VrATkZP MLM aMWATMEP
North Andover, MA 0 1845 North Andover, MA 01845
F E8 2016
JOB DESCRIPTION
AM SEAMG: Provide labor and materials to seal areas Ofyow home against wastft cow air jeajaq�& This work will
Perforated in concert with the use of special tools and diagnostic tests to assure dud your home will be ldt with a healthfil lad of
air exchange and indoor air quality. Materials to be used to seal your home can include caulks, towns and other products: -PrVW
areas for smfing include air leakage to attics, basenzcnts� attached garages and other unheated areas (windows am not generally
addressed.) This will require (6) wodft bours. A reduction in cubic feet Per minute (0m) of air inffitration will occur, but the actual
number of cfin is not guaranteed.
At the completion of the weatherization work, and at no additional cost to the homeowner, a final blower door and/or combustion
safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality.
S510.0D
HOMEOWNER SHOULD RB40VE ROORING IN ATTIC PRIOR TO INSULATION AND AIR SEAUNG
$0.00
AIR SEALJNG: Provide labor and materials to install Q-lon weatherstripping to (1) door(s) to restrict air leakage.
$58.00
DAMMNG: Provide labor and materials to install a 12* lam of R-38 un&ccd fibeWass batts to (126) square feet for damming
purposes -
$25930
ATI1C FLAT- Provide labor and materials to install an go layer of R-28 Class I Collulose added to (600) square feet ofopen attic
space.
SM.00
ATIIC ACCESS: Provide labor and materials to install (1) easily moved, insulating cover for die attic access Miling stair. The
cover has integral weather-stripping to restrict air lealoap.
S200.00
VENTILATION: Provide labor and materials to install (1) insulated exhaust hose with soffit mounted Ilona vent to eKbaust
existing bathroom fim(s).
$119.75
VENTILATION: Provide labor and materials to install ventilation chutes in (37) raftcr bays to maintain air flow.
$74.00
VENTILATION: Provide labor and materials to install (4) 6" X 16" rectangular aluminum soffit vents to incvem ventilation in
attic areas. Specify color White or Gmy.
$100.00
BASEMENT CEIIINQ Provide labor and materials to in;Wl (114) linev fed of R-19 unlaced fiberglass insulation to die perimeter
ofthe basement ceiling at the house sill.
$199.50
RISE Engineering will apply all applicable, eligible inceritives to this contract. You will only be billed the Net amount Currently,
for eligible measures, Columbia Gas offiers 75% incentive, not to exceed $2,000 per calendar yea4 and an incentive of 100yo for the
Air Sealing measures up to the first $680 and an additional $340 if savings arejustified by the auditor.
For die safety and health of your homes indoor air quality, we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is begun, and after the weatherization work is complete. We will also conduct a full assessment of
W,
Q Federal ID #
RISF, ]Engineering RI Contractor Regletraflon No
MA Contractor Registration No
RISE A dWon of Thlelsch Engineering CT Contractor Registration No
ENGINERING 60 Sbawmut Unit 02, Canton, MA CONTRACT
(401) 7"00 FAX (401) 784-3710
page 2
PROGRAM
YMCONTRACTISENTEREDUMBETWESNIUSE
CKA-10ES ENGINIUMING AM TICE CUSTOM FOR WORK AS
DESCAMEDSELVIN
CUSTOM PHONE CATE CLtENT# WORKORM
Gregory Irving (978)857-7924 02/01/2016 428660 00002
SERVICE 9IRM
196 Waverley Road 196 Waverley Road
SERVICE env. STAM ZP MLM CUY. WAM ZIP
North Andover, MA 01945 North Andover, MA 01945
JOB DESCREMON
the cornbustion sdLty of your heating systern and water heater. This has a value of $90 and is at no cost to you. Total allowable
weatherization incentive is S3.1 10.
$90.00
2OA6
Total: $2,430.65
Program Incentive: $1,987.41
Customer Total: $443.14
WE AGRM HEFMW TO FURNISH SERVKM - CONIKEM W ACWRMNOE VON ASM SPEaFICAT[ObM MR ME SUM OF
***Four Hundred Fofty-Three & 141100 Dollars $443.14
UMN FINAL WPECTION AND APPROVAL BY RISE EMINEERING. CUSTOM AGREES TO RIMIT AWUNT DUE N RML WEREST OF 1% VML BE CRARGED KONMY ON ANY
UNPAID BALANCE AFTER SO DAYS. GEE GUARANIM.RMMCFR=ICKSCHEOULMXWCONTRACMRSMM?Kft
00 NOT SIGN THIS CONTRACT IF THERE ARE ANY 13LANK SPACES
A -11V; I
AMORICEDGIGNATURE-RISEEngirmeftp CUSTOM
NOTF-' TWO CONTRACT MAY BE WITHDRAWN BY US (F NOT EXECUTED WITION
ACCEPTANCE OF CONTRACT - 71M ABOVE PRICES, SPECIRCATIONS AND COWDTrtONS ARE
DAY& SATMACTORY TO US AND ARE HEREBY ACCEPTED. TOD ARE AUTHORIZED TO 00 TKE WORK
AS SPECWW. PAWMENT VML Sa MOB AS OUTLINED ADM
R I S E
ENGINEERIN
60 Shawmut Road, Unit 21 Canton, MA 020211339-602-6335
www.RISEengineering.com
OWNER AUTHORIZATION FORM
(Owner's Nagle)
owner of the property located at:
/ q ( wavert6v (Zd
(Propetty Address)
IV, 449ve'r M 1 0 1'9 4 5'
(Property Address)
hereby authodze (Subcontractor) —1
an authorized subcontractor for RISE Engineedng, 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..:
Owneesi%"?r Y ......
Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
jvwiv. nuiss. ao v1dia
NVorkers' Compensation Insurance Affida-vit: Builders/Contractors/Electricians/Plunibers-
TO BE FILED NVITHTHE PERMITTING AUTHORITN'.
Applicant Information Please Print Legiblv
NalTle (Bus i nessiorganizat i on/l nd iv idual) (A f- b 14 V 94
Address: P.O. 9 0 X P -5-F
CIty/State/ZIp:__9),xdot/-er, mpq, olile Phone#
Are you an employer? Check the appropriate box:
110 1 am a employer wilh 0 -time)
_employees (full and/ r part
I am a sole proprietor or parinership and have no employees working for me in
any capacity [No workers' comp insurance required 1
3 [] I am a hornewwrier doin- all work myself lNo,�%orkcrs' comp insurance required
4 0 1 am a homeowner and will be hiring contractors to conduct 311 work on my property I ,vill
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees
5.M I am a general contractor and I have hired the sub-contraciors listed on the attached sheet
These sub -contractors have cinployecs and ha\ e workers' comp insurance,"
6 n We are a corporation and its officers have exercised their right cifexemption per MGL c
152. § IM. and %vc have no employces [No workers' conip insurance required j
Type of project (required)�
7. F1 New construction
8. F1 Remodelina
9 El Demolition
10E] Building addition
I Ln Electrical repairs or additions
12. n Plumbing repairs or additions
13.F]Roof repairs
14. E] Other
*Anv applicant that checks box 91 must also fill out the section below sho%virn,. their workers corriperisation policy infurination
I lonicomners -who submit this affidavit indicatiniz they are doing all work and then hire outside contractors must submit a new alfidavit indicating such
'Contractors that check this box must attached in additional sheet sh(m ing the n3nie of -the suh-contracmis and state whether or not those entities have
employees If the sub -contractors have employees. they must pro\ ide thell %VOikers' cornp policy number
I ain an enWlojvr that isprovidinv, workers'compensation insuranceformij., emplqvees. Belotiv is thepolh�j? andjob site
inforinatiotif.
Insurance Company Naniei 11 6: j q
Policy 4 or Self -ins Lic. 4 Li Ca 7 ;k Expiration Date: 47,0 /V/ 00
Job Site Address— 14 iz. W 4 L -r t 1. �- - C 1 ty/State/Z i p:_ 14 – rl� 1"'A V-,_ /—
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fail ure to secure coverage as required under MGL c. I 52L §25A is a criminal violation punishable by a fine Lip to $1,500.00
and!or one-year imprisonment, as we] I as civil penalties in tile forin of a STOP WORK ORDER and a fine of up to $250.00 a
dav ap-ainst tile violator. A copy of this statement inay be forwarded to tile Office of Investigations ofthe DIA for insurance
COVerage \-erification,
I do hereky certifj- under thepains andpenalties qfperjuty that the hif6rinationprovidedabove is true and correct
Date -
Phone 4. 91 '),F- %10 2
Official use onty. Do not ivrite in this area, to be completed kil cio, or town officiaL
City or Town: Permil/License 9
Issuing Authority (circle one):
1. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone fl:
POLASEA-01 JONEILL
"ICA 9— 9—offir "
411.� CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD1YYYY)
1
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
116/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T� "TE 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 bolder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SLIBROGATION 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
11 Saunders Street
PHONE
AIC No E;?M- (978) 688-700D I AcAo): (978� 6588-7001
_L — ___ __ , -
North Andover, MA 01845
E-MAIL
ADDRESS:
i GEN*L AGGREGATE LIMIT APPLIES PER: i
INSURER(S) AFFORDING COVERAGE NAIC#
X [—I PRO -
INSURER A: Nautilus Insurance Co. IL73TO
INSURED
INSURER 8: WetY InSurance CpIllpany
Polar Bear Insulation Co. Inc.
C:
Peter Leblanc & Steven Leblanc
-INSURER
P 0 Box 958
_INSURER D:
INSURER E:
BODILY INJURY (Per acciden t S
Andover, MA 01810
1_P_R_0PERTYf)7AM_A__G_E_____ — ------- I
:S
INSURER F:
GUVEHIAUES rFRTIFICATE NUMBER- RIP-11lizinki PJI IIVIRFR-
-------- Z�
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIEY —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.
1ADD`[1!19UBFf_'
WVD POLICY NU1M__
ITR TYPE OF INSURANCE INSD BER
FIMPWIM LIMITS
A X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE s 1,000,000
CLAIMS -MADE OCCUR INN538691
)__R-_NTEO
i DAMAGE TO EN
03124/2015 03124/2016 50,000
PREMIS�S (Eq
MED EXP (Any one person) S 5,000
r
— ---- -
ADV INJURY S 1,000,000
i GEN*L AGGREGATE LIMIT APPLIES PER: i
GENERAL.AGGREGATE 2,000,000
X [—I PRO -
POLICY IECT LOC
PRODUCTS -COMPIOPAGG s I'mo,ow)
OTHER�
S
I AUTOMOBILE LIABILITY
COMBIN D SINGLE LIMIT S
ki 1,000,000
B ANY AUTO ;2100926
0110412016 01/0412017 BODILY INJURY (Perperson) S
f
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per acciden t S
___J
X NON -OWNED
HIRED AUTOS
1_P_R_0PERTYf)7AM_A__G_E_____ — ------- I
:S
.AUTOS
:$
UMBRELLA LIAR x OCCUR
s
EACH OCCURRENCE. i--- 1,000,000
A EXCESS UAB CLAIMS -MADE i ANO19284
03/2412015 i 03/24/2016 7 AGGREGATE is
DED RETENTION S
is
WORKERS COMPENSATION
PEI� OTHI-
AND EMPLOYERS' LIABILITY Y/N'
t �Elk
ISTA`RgE�_!
ANY PROPRIETOPJPARTNERI EXECUTIVE i
OFF] CER/MEMBER EXCLUDED? IN/Ai
E.L EACH ACCIDENT is
(Mandatory in NH)
i E.L. DISEASE - EA EMPLOYEE $
If yes. describe under
DESCRIPTION OF OPERATIONS below
E.L DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Insulation Work - Mineral
insulation Work - Mineral; Additional insured for general liability per blanket additional insured endorsement with respeas to work performed on their behalf
by the above insured is Thielsch Engineering
CERTIFICATE HOLDER CANCELLATION
,P, nn,in Atlr%Mr% All -E,.-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thielsch Engineering Columbia Gas
195 Francis Ave
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Cranston, RI 02910
AUTHORIZED REPRESENTATIVE
,P, nn,in Atlr%Mr% All -E,.-
1/4/2016
Preview : Certificates of Insurance
-- '1 9
'CERTIFICATE OF LIABILITY INSURANCE
IWIE (-,.I'.I;DD--"YY)
F
TYPE OF INSURANCE
011041Z016
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 endorsemenL A statement on this certificate does not confer rights to the
certificate holder in iieu of such endorsement(s)-
PRODUCER
CONI'ACT
NA'.JE
Automatic Data Processing Insurance Agency, Inc.
PHONE
IA;C- He. E.N:
I Adp Boulevard
E-f4AIL
ADDRESS:
Roseland, NJ 07068
InSURERIS) AFFORDING COVERAGE HAIC Pt
INSURER A: NorGUARD)nsurance Company 31470
GEI;L AC-C-F.EUAIELVAII AITLIF�il-Efz-
PULIC' Ll�c
INSURED
INSURER 8:
POLAR BEAR INSULATION CO INC
PO BOX 958
INSUR R C �
INSURER D.
Andover, MA 01810
INSURER E:
INSURER F:
-INLIJEL11.11t
COVERAGES CERTIFICATE NUMBER: 4LJfU3 REVISION NUMBER:
THIS IS TO CERTIFY THAT THIE-POUCIES OF INSURANCE LISTED BELO��.' HAVE BEEN ISSUED TO THE INSURED NArorD ABOVE FOR THE POLICY PERIOD
INDICATED. NOTV!ITHSTANDING ANY REOU;REIAENT- TERM OR COND:T!Of-I OFANY CONTRACT OR OT HER DOCUIAENT'V�."'TH RESPECT TO 'NHiCH THIS
CERTIF:CATE N.AY 13E ISSUED OR i.iAv r-rRTAJ-I. THE iNSUPANCE AFFORDED BY THE POL!CiES DESCRIBED HERE:N 1S SUBJECT TOALL THE TERLIS.
EXCLUSIONS AND CONDJTION�S OF SUCH POLICIES LILPTS SHOVJN LIAY HAVE BEEII REDUCED BY PAID CLA:,4�S
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DESCRIPI ION OF OPERATIONS i LOCATIONS I VEHiCLES (ACORO 101. Addftio.M Re—ks S.hlduic. m.TJ be alle,ched if mwe spa= is req,ned)
CERTIFICATE HOLDER CANCELLATION
AQ- 1988-2014 ACORD CORPORATION. All rights reserved.
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
Theiisch Engineering, Inc.
ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave
AUTHORIZZED REPRESENTATIVE
Cranston, RI 02910
AQ- 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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