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HomeMy WebLinkAboutBuilding Permit #750-2016 - 206 OLYMPIC LANE 12/21/2015JaWtS MM41�- Permit No#: Date Issued: MMOZ BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page -e A-1 (1) N I Q11111 L9, I -bi I I Kc 11 VtORTH 0 resf -t (M 0 1 no TYPE OF IMPROVEMENT PROPOSED USE 111�1 I Oil; Residential Non- Residential El New Building [] One family , U Addition [I Two or more family 11 Industrial 0 Alteration No. of units: 0 Commercial 0 Repair, replacement 0 Assessory Bldg Others: 0 Demolition 0 Other Seo MW 0 i *&Me Wetlands W, NI OWNER: Name: AddrPq.-,- DESCRIPTION OF WORK TO BE PF=K[-UKML:U: Identification - Please Type or Print Clearly �0t -YYN& 4'r,"Of-elf -)o � 0 fyytl A "C 1,4A) -( ne:,6->F 3?5--73 � n, Un —P, Rim all. 111�1 I Oil; 6ffle-EX M- ae- .: , Home Improvement,,-jffiee�s:e:K. Exp., MR) I D ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ &I o b- o a FEE: $ Check No.: CQ 0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund --A-7�, 7 nature '6.Q o,n L-1 - - VI-, M -- �, Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming fools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments `Conservation Decision: Comments r ater & Sewer Connection/Signature &Date Driveway Permit ]PBV Town Engineer: Signature: Locaiea do/4 usgooa Street M, ®umpster�onxsite��,yes `;�M;`' F `� F F ; , s � �s►lia si � n � _ -5 .i,, -s F _rte.7,, Du erasion 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) w I ® Notified for pickup Call Email I Date Time Contact Name Doe.Building Permit Revised 2014 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 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 DTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Perm it'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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 3TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit fn all cases if a variance or special permit was required the Town Clerics 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 CA A11PQ— G-,� Loca"t'i"ojn�i��!'` No. Date 4A 7 Check # 2.9846 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $`'S Other Permit Fee $ ,� TOTAL $ ` Building Inspector 0 G 0 r < `D N c CL m t/1 z p -22 N' -h O O r+ Q m —++ C• N `C CD 00 CD vi p N �CD =-0 a) n CD 0 co a = .�+ ^ n N I O CD W '"F COD �i Z N C C• CD -0.rt rF Q cam' CL Fm ca � N. `- � � z 'COD �CA��N c�� 0.� M S O' : _ •� Q O �.X N D :G 00 z cm �� <cDD m ;, cD 4. Q cn C C7 N WCr CD �' CD CD FL ZCD � N ca cn Z 0) E !•� — U) O G CL CD Cl) y + .-� O (� =r S C 0 N. CD ti CD CD O oo ; �, �D Z n NOOL v. G): nC N : CD '0 a: n : c 0. CD 0: a, O C N 3 O (D 0 (D 0O W c •n m m T j ;'D O S D Z m p T 7 N < fDD .Z1 pCq S m m DLA Z LA A 0 T 3 .Z7 O D�q 3 •o C W Z A 0 T 3 _S 7 (D O OCO S O 7 C O G1 vzi nm a n 0 N n (n m O Q � m OW > p S _ O 0 c v � SI DO I UFederal to # 05-0405629 RISE Engineering Contractor Registration No 0106 MA Contractor Registration No 120979 M RISE A division orrhicisch Engineering ENGINEERING- 60 Shawmut Unit #2, Canton, MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 1 PROGRAM THIS COMMACT IS ENTERFA Wro BETWEEN RISE CMA -NES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE .. DATE --- _. CLIENT 0~ WORK ORDER Doreen Side11 (978)375-7363 09/29/2015 419414 00002 SERVICE STREET BILLRIG STREET I —x-- 206 Olympic Lane 206 Olympic Lane SERVICE CITY. STATE. LP BILLING CITY, STATE, ZIP North Andover. MA 01845 North Andover, MA 0 184 t , OCT —7 2015 JOB DESCRIPTION I ` AIR SEALING: Provide labor and materials to seal areas oryour home against wasleiul, excess air leakage. This work will performed in concert with the use of special tools and diagnostic tests to wssure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products Primary areas for scaling include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally addressed.) This will require (8) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cftn is not guaranteed. At the completion of the wcalherization York, and at no additional cast to the homcoi-mer, 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. $680.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass batts to (138) square feet for damming purposes. $282.90 ATTIC FLAT: Provide labor and materials to install a 7" layer of R-25 Class I Cellulose added to (842) square feet of open attic spacc.KEEP DESIGNATED FLOOD/ LIGHT CANS ARE LED. $1,094.60 ATTIC ACCESS: Provide labor and materials to install (1) easily moved. insulating cover for the attic access folding stair. The cover has integral weather-stripping to restrict air leakage. $200.00 VENTILATION: Provide labor and materials to install ventilation chutes in (52) mflcr bays to maintain air flow. 5104.00 RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures. Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the Air Scaling measures up to the first $680 and an additional $340 it'savings are justified by the auditor. For the safety and health of your home's indoor air quality, we will be conducting a blower door diagnostic of the available air now in your home both before the work is begun, and after the weatherization work is complete- We will also conduct a full assessment of the combustion safety of your healing system and water heater.111is has a value of $90 and is at no cost to you. Total allowable weathsrizzion incentive is $3.110. $90.00 JOB DESCRIPTION Total: $2,451.50 Program Incentive: $1,963.13 Customer Total: $498.38 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF 'Four Hundred Ninety -Eight & 381100 Dollars UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1% WIL UNPAIDBALANCE AFTER 70 DAYS. SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES. RIGHTS OF RECISION. SCHEDULING. _ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLAN S AUTHORDEOSIGNATU -RIS Engineering.— NOTE: THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN 30 DAYS. $498.38 ON ANY C., �BER ACCEPTANC —_• �� OA OF CE PTANCE-- ACCEPTANCE OF CONTRACT -THE ABOVE PRICES. SPECIFICATIONS AND CONDRIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED, PAYMENT WILL BE MADE AS OUTLINED ABOVE +`� Federal ID # 05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 RISEI A division of'rhictsch Engineering 60 Shawmut knit 92, Canton. MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 2 PROGRAM CMA -HES THIS CONTRACT 6 ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER _- PHONE DATE CLIEUTO WORK ORDER Doreen Sidell (978)375-7363 09/29/2015 419414 00002 SERVICE STREET BILLING STREET 206 Olympic Lane 206 Olympic Lane SERVICE CITY. STATE. ZIP — ..—.-AA BILLING CITY. STATE. ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $2,451.50 Program Incentive: $1,963.13 Customer Total: $498.38 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF 'Four Hundred Ninety -Eight & 381100 Dollars UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1% WIL UNPAIDBALANCE AFTER 70 DAYS. SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES. RIGHTS OF RECISION. SCHEDULING. _ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLAN S AUTHORDEOSIGNATU -RIS Engineering.— NOTE: THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN 30 DAYS. $498.38 ON ANY C., �BER ACCEPTANC —_• �� OA OF CE PTANCE-- ACCEPTANCE OF CONTRACT -THE ABOVE PRICES. SPECIFICATIONS AND CONDRIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED, PAYMENT WILL BE MADE AS OUTLINED ABOVE +`� I OWNER AUTHORIZATION FORM (Owner's Name) owner of the ,property located at C7 6 vk 0 it kms W. /J . i4 N /00'Y-,v,yh Q . v t 5" (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my nronerty. Date ��? ��=`' iV'14.�1U.112fiSS 9 t31r�f>'lf( Woi-kei"s' CmzipeElsation Inst?r'ance A—Ifidavit: Ruilders�Cont actors/y?e 1,ici,1L s/TIQ?mb�r+i rte. CI C7 i 1 Kamm (Business=Oreaniaatio)illndividtta(): L (P2t, r eQ n J'—T! � a V il- 7`7 „ Gg n :a ddress: o f `;M Phone':: Q7 Are }ou an emplovet? Check the appropriate box: 1. �3 I am a employer tirith` L/ _ 1 ❑ I am a ge neral contractor and I empIoYees (AIll andior part-time)." have hired the subcontractors ? ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no emploe•ees These sub -contractors have working forme in any capacity - [No and have »orkers [;;o workers comp_ insurance comp_ insurance required_] S- ❑ We are a corporation and its 1 ❑ I a1n a homeotic-ner loin. all work officers have eYzrcised their myself. [-o workere comp. right of exemption per VIGL insurance required_]c- l 52. t 1(4)_ and we have no enpiovees. [\%-o workers- comp_ insurance required] Type of project (required): b. ❑ heti• construction 7. ❑ Remodeling S. [] Demolition 9- ❑ Building addition 10.0 Electrical repairs or additions 11 .0 plumbing repairs or additions ❑ Roof repairs l S1ROther9 7,_'6'J 'am a;tplicant Lila[ chfcks box = i mttit also tilt out the section 11CIOW sttotcin_ dreir xrorkrS cortpcnsarion policy inror_natinn. I torueoiuwzrs echo submit this affidavit indicating they arc coir.=_ ail nvor's and then hire outside contractors must subunit a nen- afitdalll i'dieatinE Sutcit- =Contractor thar clic--1-- this bog nuwi auached an additional sheet shoring the name of ilte sub -contractors avid state -hetheror not those et►titics have cmniov ecs. If iltc sub -contractors fiat, eniplavees- they ntttit provide their worL_rs' uornp_ policy number. I tali an en plorer that is provi(ling workers' colupe(1.sf(t101,111sitralicept.111,- enlplot:ees: BL710itr iS file polirt' [!n(I jab .sae information. Insurance Company Name: police = or Self -ins- Lie.; E itt��.- � Cep Expiration Date: Job Sitc Address:1 Y► \'P1"' ' t'.Io'e CitviState0o: 11 o9tn1,(D n( Attach a copy of the czorl ers' compensation policy declaration pane (showing the policy' number and e-Piratlon date). Failure to secure coverage as required under Section 25th of VIGL c-1?? can lead to the imposition of criminal penalties of a fine up to Sl -500-00 and,'or one Fear imprisonment; aswell •ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to SZSo_Oo a dad againstthe violator_ Be 2dvised that a copy of this statement may be forwarded to the Office of Investigations of die DIA for insurance coverage verification. 111, herehr certif • ander the harms and penalties ofperjt[r1- tJlat the infunizarian proaicle(d above is trite '111,61 correc,. r t I / Signature: a � ; r - Date: l a /d fJ15 Phone: 4 a V g > - � _ 1-, D fficial r(se orti: .(gyp hat trrltr ill tflis arca, to bt: co111pleterl Gt' vitt ar it7lttt nffcirl!_ Citi' or Town- PermittLicense g Issuing Authority (circle one): 1- Board of Health Z_ Building Department 3_ CitvfTotrrt Cierl�z -l. Electrical Inspector- Plumbing Inspector 6. Other contact Person: PhoncT: The C011IMon1i-'L[1jt%1 of Mr1SSUCIII(SettS Depitl'ts17Ient of fYid iistrial Accidents 00 tce ofInvestig ation.5 I - 600 T-Tia5J1in ton Streef Boston, 1111,14- 03 f i i ��? ��=`' iV'14.�1U.112fiSS 9 t31r�f>'lf( Woi-kei"s' CmzipeElsation Inst?r'ance A—Ifidavit: Ruilders�Cont actors/y?e 1,ici,1L s/TIQ?mb�r+i rte. CI C7 i 1 Kamm (Business=Oreaniaatio)illndividtta(): L (P2t, r eQ n J'—T! � a V il- 7`7 „ Gg n :a ddress: o f `;M Phone':: Q7 Are }ou an emplovet? Check the appropriate box: 1. �3 I am a employer tirith` L/ _ 1 ❑ I am a ge neral contractor and I empIoYees (AIll andior part-time)." have hired the subcontractors ? ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no emploe•ees These sub -contractors have working forme in any capacity - [No and have »orkers [;;o workers comp_ insurance comp_ insurance required_] S- ❑ We are a corporation and its 1 ❑ I a1n a homeotic-ner loin. all work officers have eYzrcised their myself. [-o workere comp. right of exemption per VIGL insurance required_]c- l 52. t 1(4)_ and we have no enpiovees. [\%-o workers- comp_ insurance required] Type of project (required): b. ❑ heti• construction 7. ❑ Remodeling S. [] Demolition 9- ❑ Building addition 10.0 Electrical repairs or additions 11 .0 plumbing repairs or additions ❑ Roof repairs l S1ROther9 7,_'6'J 'am a;tplicant Lila[ chfcks box = i mttit also tilt out the section 11CIOW sttotcin_ dreir xrorkrS cortpcnsarion policy inror_natinn. I torueoiuwzrs echo submit this affidavit indicating they arc coir.=_ ail nvor's and then hire outside contractors must subunit a nen- afitdalll i'dieatinE Sutcit- =Contractor thar clic--1-- this bog nuwi auached an additional sheet shoring the name of ilte sub -contractors avid state -hetheror not those et►titics have cmniov ecs. If iltc sub -contractors fiat, eniplavees- they ntttit provide their worL_rs' uornp_ policy number. I tali an en plorer that is provi(ling workers' colupe(1.sf(t101,111sitralicept.111,- enlplot:ees: BL710itr iS file polirt' [!n(I jab .sae information. Insurance Company Name: police = or Self -ins- Lie.; E itt��.- � Cep Expiration Date: Job Sitc Address:1 Y► \'P1"' ' t'.Io'e CitviState0o: 11 o9tn1,(D n( Attach a copy of the czorl ers' compensation policy declaration pane (showing the policy' number and e-Piratlon date). Failure to secure coverage as required under Section 25th of VIGL c-1?? can lead to the imposition of criminal penalties of a fine up to Sl -500-00 and,'or one Fear imprisonment; aswell •ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to SZSo_Oo a dad againstthe violator_ Be 2dvised that a copy of this statement may be forwarded to the Office of Investigations of die DIA for insurance coverage verification. 111, herehr certif • ander the harms and penalties ofperjt[r1- tJlat the infunizarian proaicle(d above is trite '111,61 correc,. r t I / Signature: a � ; r - Date: l a /d fJ15 Phone: 4 a V g > - � _ 1-, D fficial r(se orti: .(gyp hat trrltr ill tflis arca, to bt: co111pleterl Gt' vitt ar it7lttt nffcirl!_ Citi' or Town- PermittLicense g Issuing Authority (circle one): 1- Board of Health Z_ Building Department 3_ CitvfTotrrt Cierl�z -l. Electrical Inspector- Plumbing Inspector 6. Other contact Person: PhoncT: GAFF 11D.. DATE (rall!IDtuYY�^t) THIS CEWTIFICATE i5 ISSUED AS A M`170 OF INFORMATION ONLV dlNi2 CONFERS NO Ri�ai�iTS UPON THE CE"3p TIF€GATE HOLDER.a alis IES CEiB'�iFICATE DOES NOT AFFIRM WELLY OR MEGA-1WELY AMEND, EXf�f D OR AL ER EHE COVER&GE AFFORUEC 13V �AaH® HE ClcED 13&000 THIS CERTiFiCA7i_ OF INSURANCE ®DES NOT CONS_ ON en!! - A CO OT 8 ti iIEEN 11ir ia^�tAIN1s €NSUS�gsp, REPRESENTATIVE OR PRODUCER, AND eZ-lECERTIFdCAIVE HCL€BER. les ree�:sY 5e endorsvtM €f SIiBRE16A ®N IS Q1UAiiIM sv5ject to IMI.ORTANa: ii the cerldficate holder is are Aia)3iTI®NAi. €NSU , the lalicy4 ) the testis and cendidans Of the policy, car2ain policies nay Mquire an endocsen, 9M A SWmeml on Iiils cerli6' ica3te does na, Confer rights to the rereificate Folder in lien Of SuCle endorseMent{s)-_ - INSURED 3andwlrrsfd Ins Agcy I I C sachus¢c8s!,Avenue Edover, MA 09895 Jan[mvvasid Inas. Agcy. P 0 B0.. 958 Andover, MA 5196913 America Ir insurance Geo. merwemm all MnMEIR: COVERAAI:a THIS CER i IFiCsA IS TO CERTIFY THAT THE POLICIES OF 114SURANCE E imulvlprn: --------- * •--OD LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO RESPECT T iOUWHICH TH 5 OR OTHER DOCUMENT WITH INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN• THE INSURANCE AFFORDED BY THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ ItN.TH ow TYPEOFINSURAWCE 311111w POtSCYNUe38ER &49l1CDMl- Ctd091DCY� J0.5TiS 9,0DD ®D� EACH OCCURRENCE $ , IDAMAG 5D,0D0 GENER LUASILM' � PAC7052023 0312=15 O312W016 PREMISES Ea oc�+�Ce S P. COMFdERCIAL GENERAL LIABILITY CLA1MSdtiADE �� OCCUR 5 0D0 MED EXP (Any ane Person) S , PERSONALSAOVINJURY S I,OOD,ODO GENERALAGGRE GATE S 21000,000 PRODUCTS-COMPIOPAGG 1,ODDI000 GF�ILAGGREGATE LIMTTAPPUESPER 5 POLICY PRO- RC LOC F-11 COMBINEDSINGLELIMiT S 71000,006 AUTOFAOBILETIABILITt' eident) (EaeO1104f2075 $ ANYAUTO 01AMM016 BODILY OQS2S 80DILYlNdURY(per Person) S ALL OVMED AUTOS BODILY IN.IURY(Peracod-Q S LS SCHEDULEDAUTOS PROP ERTyDAMAGE S (PER ACCIDENT) HIREDAUTOS S NON4WNEDAUTOS S UMBRELLA LW8 OCCUR EACH OCCURRENCE S 7,ODD,01)D EXCESS UAS CLAIMS -MADE PACSSD& ' 03!24/2075 03124MU15 AGGREGATE S A s DEDUCTIBLE S RETENTION 5 VVC SAN_ WORi ERS COPAPEM710N TORY fi I E AND'EMPLOYERS LIASILi:Y PROPRIETORIPARTNERIEXECUTIVt' YIN EL EACH ACCIDENT S ANY OFRCERiMEMBER EXCLUDEo? ❑ NJAPLOY EL DISEASE -EA EM S (Mandatoriin NH) if yes. descibeunder E.LOISEASE-POUCYUMET 5 DESCRIPTION OF OPERATIONS belch, DESCRi MON OF OPERATtONSILOCATIORS/VEHICLES (Meh ACORD.01, AtTcOarsd Ren,lco Scl,cdulo, if mm cPaao io requirA Insulation Work - Mineral; Additional insured for general 1161biRty wi`h . resp s � rt-, performed ora their behalf by Me abOve irlsureb? es%felsall t Engieer THIE S2 5?jOULD ANY OF THE ABOVE DE.-t+$iS® POLICIES �� � OELIUFR® BEFORE !N HE IDIPI)7RT(ON DATE 3i�EREOF NOTICE Thleisch Engineeriu:g AcCORI?ANCE 1WH T HE POLICY PROVISIONS. colunk ble Gas 195 Francis Ave AfiT€tOROM REPAESENrAYIIlE 1sr8riS$dSri, RI 02996 ©7989-2r30:i ACRD CoRpORA"nCR4. Ali rights rweemed. ACORD 25 (2009109) Tine AICORD nafne and logo are rc-JIstered na Brlts of ACORD p,1TE (A1A7DD YYYY) AC(O O CER-HFIC 6L- OF LIAG EI.t-ll INSURANCE NCE 12/16,2014 �-� NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS COVERAGES CERTIFICATE NUMBER.. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND BETWEEN THE ISSUING INSURER(S). AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOTCONSTITUTE A CONTRACT REPRESEI7ITATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. be IfSUBROGATION 15 WAryED, Subject to IMPORTANT RIO:; certificate holder is an ADDITIONAL INSURED, the policy(IES) must endorsed. A statement on this certificate does not confer rights to the the terms and conditions of the policy, certain policies may require an endorsement certificate holder in lieu of such endorsement(s). PRODUCER NM�ALI Automatic Data Processing Insurance Agency, Inc. PHONEA (AJC Na EX& (A..0 nbk 1 Adp Boulevard ADOREss: VISURERIS) AFFORDMG COVERAGE NnIC:. 31470 Roseland, NJ 07068 INSURER A• NorGUARD Insurance Company 04SURED POLAR BEAR INS ULATION CO INC ENSURER 6. PRErtISFS rE cccwrcrce! S DBA: Polar Bear insulation CO Inc ENSURER C: NSURER D: PO BOX 956 LYSURER E Andover, MA 01810 L4SURER F: 291624 REVISION NUMBER: - poLICY PERIOD ISSUED TO THE INSURED NAMED ABOVE FOR TH- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN H THIS CONDITION ANY CONTRACTOR OTHER OOC` WENT 1TH RESPECT TO1'tHICH rHiS INDICATED- NOTLYtTHSTANDING ANY REQUIREMENT.TER6:Olt OF ALLTHE \TAY BE KAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is SUBJ ECT CERTIFICATE ISSUED OR EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. MUTS SHOti: N S'AY HAVE BEEN REDUCED BY ?IUD CLAUS. LTR TYPE OFMSURANCE MSD IWO POLICY N".1 ER (I-MOD.=1DOMM) LI511IS COMMERCIAL GENERALUABRnY EACH OCCUHREKCE '.------ WOIS-14ADE F� PRErtISFS rE cccwrcrce! S OCCUR aIED EXP 1 yPcre peucr•1 � ('EIISOKAL E Aff:' It:! UItY GENERAL ACCREGAIE GEA'L AGGREGATE LILUT APPUES PER - S 'n0_ ❑JIECT PRODUCTS-COriRCP AGG POLICY LOC ROTHER S LU46KtUbI.Ir 5 AUrormaiLE L1Anum IEa attlClRU BODILY INJURY leer peucn! S NY AUTO ALL C:9NED SCHEDULED ECDIU' IK; URY U'a ssi2err 5 AUTOS Wios f' UI't UY d.L s HUtED AU les nOn-01iTEU AUi 0_ mer atuderp i uraREuntL'iB occuR EACH OCCURREKCE E!(CESS LIARS CL.II;J5i•1,1DE ACCREGATE $ DED ItETE%Trio . $ J{ WORKEnS COSIPEABATIOx STATUTE ER 7.0001000 ANOMPLOYERS'LIABitiTy v IN ELEACH ACCIDSrcT s A N.rPnOPnIErOnPUttrEn.ExECI:TIt•'E �N,A OFFICEItAVASER EXCLU(reD, N POIVC660390 OltDiRQ75 OiUi(L016 EL.DISEASE-EAEAIPLOYEE S 7,000.000 Wmdatcry in toi)1,000,000 It rte. dexnbe me,r EL. DIS EAS E-POUCY LIMIT S Cf SCRU'ri0N OF OI'EIG1TIOi K Ltlucr DESCRIPTION OF OPERATION$ILCGITIONS?L'EFBCLES NCORD 101 AdrGlimvJ Rem�lo Sch, ,le. may ix attachedilmemspaw is regwndi Columbia Gas massachusetts SHOULD ANY OF THE ABOVE OESCRIR ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE LVILL BE DELIVERED IN Theitsch Engineering. Inc. ACCORDANCE wITH THE POLICY PROVISIONS- 195 ROVISIONS_195 Frances Ave AORIZED REPRESENTATIVE Cranston. RI 02910 -� ACORD 25 (2014M) The ACORD name and logo are registered marks of ACORD J046 Aff nid om of Cobs 1 _ 5�.e 5170 to PSP M U2116 Bos�o� 1Viass Cc L,We� =`�ctor Region �roveme 'Conte .� M ; mlww. iwo Dm`e ReS Type= DBA 252M T12iLQ�6 - POLAR BEAR lNSULAT[ON CC? -— Vincent LeBlancoxx P.Q. 80X 958 181 V� Adams and return EEE: �'�' Lost Card ANDO\/ER, MA 0 - _ Address � Renewal :' - - - OP�+A1 p4G101216 Site 9[Rf ?ia55aChSIS .. 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