HomeMy WebLinkAboutBuilding Permit #927-2016 - 213 HIGH STREET 3/1/2016PermitNo#:
Date Issued
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TANT: Applicant must complete all items on this pal
LOCATION 1 1-3 L7/) A 5 7—
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V%ORT
616
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PROPERTY OWNER ,�71e471,
MAP 0 PARCEL:
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ZONING DISTRICT:
lob Year Structure
Historic District
0 New Building
El One family
Machine Shop Village
ye
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
El One family
0 Addition
El Two or more family
0 Industrial
0 Alteration
No. of units:
0 Commercial
El Repair, replacement
0 Assessory Bldg
Others:
El Demolition
El Other
0 Septic 0 Well
0 Floodplain El Wetlands
El Watershed District
0 Water/Sewer
Uhb(;KIPTION OF WORK TO BE PERFORMED:
"7 0 Y2
ei -rt'o tA
Identification - Please Type or Print Clearly
OWNER: Name:. e r- u) oyle Phone: F- '.2 ;;00
Address: d 13 ///'q /1 57- /7 , 4A Ja &,,e r -
Contractor Name: Z?,r 6o6*tPhone-. q ")IF- /01
Address: z- c? 5 r"-
�t4, , 5 �-a t,,,/
Supervisor's Construction License: Exp. Date:
Home Improvement License:
ARCHITECT/ENGINEER
EXD. Date: ;"/-�-b
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost:$ �-;F0000 FEE: $ q —
Check No.: -I -I r�>Z- - Receipt No.: -3.-.60V-L
NOTE: Persons contractil *th registeread contractors do not have access to the guarantyfund
_; un
Sig '6�fu-re- -of c6i�t-ra-ct
or
Plans Submitted El Plans Waived El Certified Plot Plan El Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art F]
Swimming Pools 11
Well
Tobacco Sales
Food Packaging/Sales 11
Private (septic tank, etc.
Permanent Dumpster on Site [I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
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
Conservation Decision: Comments
Water & Sewer Con nection/sig nature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main 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 tb and UA I A - (For department use
LJ Notified for pickup Call Emai
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
• Photo Copy Of H. 1. C. And/Or C. S. L. Licenses
Li 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
ci Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
ci 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)
Ei Building Permit Application
Li Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
Ei Workers Comp Affidavit
ij Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Copy of Contract
Li Mass check Energy Compliance Report
Ei 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 .2 1 -!�) -- - - �- � � -�-
No. Date
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $3!i—
Foundation Permit Fee
Other Permit Fee
TOTAL
/ Building Inspector
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Federal ID #
PJSE Engineering RI Contractor Registration No
MA Contractor Registration No
A division ofThiclsch Engineering CT Contractor Registration No
60 Shawmut Unit #2, Canton, NIA 02021
CONTRACT
339-502-6335 -AX 339-502-6345
r
R I S'E PROGRAM Page I
THIS cONTRACr is BiTERED iwo BEwAmm fuse
CMA -HES ENGMEERING AND Tw- CUSTOMER FOR WORK AS
ENCINEERINC
DESCRIBED DELM
CUSTOMER PRONE DATE CUMTO
Heather Doyle (978)270-7839 09/1742015 ,--,418155
0-011n
00 -
SEWCE STREET GWNO STREET
213 High Street 213 High Street
SEWCE CITY. STATE, BP GILUNG CnY.STATE.VP L
North Andover, MA 0 1845 North Andover, MA 0 1845
U
JOB DESCMPTION
BARRIER: A Blower Door TcstwiiI not be conducted at your home, due to the presenscofasbcstos.
$0.00
BARRIER- The following contract is not valid unless accompanied by the Pre-Weatherization Barrier Incentive form, signed by
your licensed electrician. Work will not proceed with thiswork until --ve receive a copy ofthe form.
$0.00
BARRIER:We have identified a moisture issue in your home that needs to be addressed. Homeowner is rcsponsibic for correcting this
moisture concern, prior to the installation ofany weatherization' work.B.DRY SYSTEM GOING IN OCT. 3RD. SHOULD SOLVE
PROBLEM
$0.00
AIR SEALING: Provide labor and materials to seal areas ofyour home against wasteful, excess air leak -age. This work will be
performed in concert with the use ofspecial tools and diagnostic tests to assure that your home Vill 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 aitics, basements, attached garages and other unheated areas (windows are not gene N'ly
addressed.) This will require (8) working hours. A reduction in cubic feet per minute (cfm) ofair infiltration will occur, but the actual
number of cfm is not guaranteed.
At the completion ofthe wcadicrization wotk, 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.
$680.00
DAMMING: Provide labor and materials to install a 12" layer of R-38 unlaced fiberglass batts to (120) square feet for damming
purposes.
$246.00
ATTIC FLAT. Provide labor and materials to install an 8" layer of R-28 Class I Cellulose added to (696) square feet ofopcn attic
space.[ COULD NOT ACCESS OVER REAR I ST. FL. BUMPOUT ASSUMMED SAME AS MAIN ATTIC.
$953.52
ATTIC ACCESS: Provide labor and materials to insulate the back of (1) attic hatch with 2" rigid Thermax board. Weatherstrip the
perimeter.
$60.00
ATTIC ACCESS: Provide labor and materials to make (1) temporary access to an attic area. 'Me opening will be closed with a
permanent roofvent.
$92.42
VENTILATION: Provide labor and materials to install ( 3 ) S' diameter Toofvcnt(s) to increase ventilation in attic areas. The vent
can be supplied in (circle color) black brown, gray or mill I'mish.
$256.50
VEI�ITILATION: Provide labor and materials to install (1) insulated exhaust hosc with roofmounted flapper vent to exhaust
existing bathroom ran(s).
$118.75
VENTILKRON: Provide labor and materials to install ventilation chutes in (56) rafter buys to maintain air flow.
$112.00
Federal 10 #
PJSE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of"Ilicisch Engineering CT Contractor Registration No
60 Shawrout Unit N2, Canton, MA 02021
CONTRACT
339-502-6335 M 339-502-6345
S E PROGRAM Page 2
VIS CONTRACT IS ENTERED INTO BETWEEN RISE
ENGINEERING CMA -HES ENGINEERING AND THE CUSTOMER FOR WORK AS
012SCRIBEDSELOW
CUSTOMER PHONE DATE CUIENTO WORK ORDER
Heather Doyle (978)270-7839 09/17/2015 418255 00003
SERVICE STREET OWNG STREET
213 High Street 213 High Street
SERVICE CITY.STAMBP BILLING CITY. STAM NP
North Andover, MA 0 1845 North Andover, MA 0 1845
JOB DESCIUTION
VENTILATION: Provide labor and materials to install (6) 6" X 16" rectangular aluminum soffit vents to increase ventilation in
attic areas. Specify color White or Gray.
$150.00
BASEMENT CEILING: Provide labor and materials to install (86) linear feet ofR-1 9 unlaced fiberglass insulation to the perimeter
ofthe basement ceiling at the house sill.
$150.50
f
Total: $2,819.69
Program Incentive: $2,284.77
Customer Total: $534.92
WEAGREENEREBYTO FURNISHSERVICES -COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF
**'Five Hundred Thirty -Four & 921100 Dollars $534.92
UPON FINAL INSPECTION AM APPROVAL By ME ENG(NEEMNG- CUSTOMER AGREES TO REMITAMOUNT DUE IN FULL I A
UNPAID BALANCE AFTER 30 DAYS. SEE REVERSE FOR OF 1% WILL BE CHARGED MONTHLY ON ANY
UPORTAUTV'FORMATIONONGUMMTMS-MGKMOFPZCISI SCHEDUUNG. AND CONTRACTOR REGISTRATtOtL,
NOT SIGN ITHIS CON7RACT IF THBM ARE BLANK SPACES z
AUTHORMED SIGNATURE - _PJSE En`:i_!�
NOTF-'THIS CONTRACT MAY BE WTHORAWN BY US IF NOT EXECUTED VRTWN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT - THE ABOVE PRICES. SPECIFICATIONS AND CONDITIONS ARE
30 DAYS. SATISFACTORY TO USS AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK
AS SPECIFIED. PAYMENT INU BE MADE AS OUITUNED ABOVE
v
It
OWNER AUTHORIzATION Fogm
/1-e .0 -rhepe 0,
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13 1*9A apf -
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Data
The Commourveirith ofMassachuseffs
Department qfl
I ndustrialAccLdents
I COngr= Sfree4 Sufte 10 0
Boston, MA_ 02-1-74-20.7 7
Www.MaS&gov1d1a
Workers' Compensation Insurance Affidavit; lauflders/Contmclor Ric cl2ns lumbers-
TOBE:�641LEDvvlj—H7-iiE?ERAgTnNGAUTHORIT-y- �
Nairie (Busincssiorpnizatiowhdividuai):
Address:
City/State/Zip:_
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[�'Jl �7_ Phone 19:
Are you nis cmpkycr? Cbech the nppmprbtc bos:
1.Q-1 am . employr witb (full andtor part-fimc)_-
20 1 am a sole: proprietor or parm=-Sbip wd bayc no cmployccs working for rac in
any capadty- (No work—'comp, io==- requirmLl
301 am a homcowncr doing nil work my=IE [No workers' coov- ins=anccrcquj,,d_] t
I am a hommwncr nnd will be hiring coo- uactom to conduct nit work on may popcly- twill
ensure: thm all connmctocscitbcrbavrworkcrs'compcasation insuramxoram sole
IN01H C10rSWiEhnoCmpJ0y=_S_
.5-0 1 am a general c0uQ`BMr aud I L,, bb'd t1r- sub -contractors listed on tb-- anachcd sb=L
These sub-catimciars bavc employcm and [Lwc workess'comp- insut-ancrr
6-0 We a= R cDTP0fa6Do and its officczs bavc exerciscd tbcir right OF—cmPtion per MGL c-
- 152, § 1 (4)� and we have no cmployom [No workcrs' comp- inmvance rcquircd.1
Type oTproject (equired)_-
7- New construction
8. Remodeling
9- Demolition
10 F1 Building addition
I I -E] Elctlic;al repairs or additions
12-f-1 Plumbig,,;pairs or additions
13.E)R<)of repails
14.EjOther
-Any applicant tbal cbccks box #1 mug atso fill out tbnsection bclow sbowing their workers'oompensation policy information -
t Howcowncas who submit this affidavit indiegiing thcy am doing all work and tbm bire outside coutz-actors must submit a new afEdavij jo&cating sueb-
tCoo tors &w check this box n==aru=bcd= addhkoal sheer sbowing the nzmcoftb�csub-coGu7=om and stmewbabcr or nol jb050cat_AN*b"vC`
employees- Iftbc sub -contractors; have c. provide their workers, comp. policy numb=r-
_;Oyces� fl;cy
1 ain an employer that Isproviding worke7s'CompenSadon insurancefor 1"y employees. Edow is &,policy andjob site
Lasurance Company Name:
Policy M or Self -ins- Lic- #: 1 0 (/_/z� Expiration Date:
lob Site Address: - f,
city/Statalzip:
--Jn -
.,kttach 2 cDpy of the workers' compeDsation policy declaration page (showing the poricy nu
InbeF 2nd eyip
Failure to secure covcrage as required undcr MGL c. 152, §25A is a criminal violation Punishable by a fine up to S1.500-00
md/or one-year unprisomment, as well as Civil perialties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
lay agai= the violator- A copy of this statement may be forwarded to the office of investigations fth, DL&, for ir�ncc
�ovcrage vcrification.
I doh—eby cerVfyundej-dwPainsandpencdtFd:scpfjpcdlwlyjt"#BefnformadonPjloy&eiialmeis&ue andeorrect
;igmature: �/c Date:
"hone V;
-7
Off w_ial use OtIlY. Do not write & M& arez�, robe complef,,_d by cify or town offidal.
City or Townt
Permit/j:,,ense iff.
Issuing Authority (circle one):
I - Board of Health 2- Building DVartment 3- City/Town Clerk
6. Other
CoDt2ct Persom
4. Electric2l Anspecadr 5-- Plumbing InsPedOr
Phone
POLABEA-01 JONEILL
CERTIFICATE OF LIABILITY INSURANCE
DATE(M=D1YYYY)
1
OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
1/6/2016
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
Durso & Jankowski Insurance Agency
11 Saunders Street
PHONE
_j(XC_Nj)�(978�
_LAIC. No. (978) 688-7000 6 8-7001
North Andover, MA 01845
.8----.
E-MAIL
ADDRESS:
POLICY 1 JECT 1 LOC I
INSURER(S) AFFORDING COVERAGE NAIC#
OTHER:
INSURER A: Nautilus Insurance Co. IL7370
INSURED
INSURER 13: SafetY Insurance Companv
Polar Bear Insulation Co. Inc-
INSI. 1`111�11C -
U
Peter Leblanc & Steven Leblanc
_r�618
P 0 Box 958
INSURER D:
Andover, MA 01810
-INSURER-E.
INSURER F
UUVIMHAUtb CERTIFICATE NUMBER- Rpincinm KII IURFP-
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 -
TYPE OF INSURANCE _P0
LTR 1 _ZINSD ItWD I LICY NUMBER
I �MPW i LIMITS
A X COMMERCIAL GENERAL LIABILITY
X INN538691
EACH OCCURRENCE S 1,!000)000
DAMAGE TO"REWTED
CLAIMS -MADE I OCCUR
03/2412015; 0312412016 PREMISE ccurmeTol 41
_UE2 0 50,000
1 MED EXP (Any one person) S 5,000
PERSONAL& ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
1—i PRO -
X
GENERAL AGGREGATE 2,000,000
POLICY 1 JECT 1 LOC I
PRODUCTS - COMPIOP AGG 1,000,000
OTHER:
S
I AUTOMOBILE LIABILITY
B
COMBIN D SINGLE LIMIT
$ 1,000,000
[JEa accident) -
ANY AUTO 12100926
0110412016 01104/2017 !BODILY INJURY (Per person)
ALL OWNED SCHEDULED
AUTOS IAUTOS
BODILY INJURY (Per accident)' S
NON -OWNED
X HIRED AUTOS
-fiR—OPERTY 6—AMAGE ;S
'AUTOS
ff!traccidenji
UMBRELLA LIAB X
OCCUR
I EACH OCCURRENCE is 1,000,000
A EXCESS LIAB CLAIMS -MADE AN01 9284
03124/2015 i 03124/2016 AGGREGATE :s
DED RETENTION$
IS
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY
YfN1
!PER OTH-
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-RUE
ANY PROPRIETORUIPARTNERtEXECUTIVE
'OF DIN/A!
FICER/h4EfABCR EXCLUDED?
E.L. EACH ACCIDENT
(Mandatory In NH)
EA EMPLOYEE! $
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT i S
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is "uired)
insulation Work - Mineral
insulation Work - Mineral; Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf
by the above insured is Thietsch Engineering
L,=t'i 1 H- KfA I t r1ULUt:K I fiTInM
f- 4000 -'It%4A A^f%nr% f%1%Mnf%C2A-r1f%10 All .;.6*. -_A
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thielsch Engineering Columbia Gas
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 Francis Ave
ACCORDANCE WITH THE POLICY PROVISIONS -
Cranston, Ri 02910
AUTHORIZED REPREsENTAnvF_
f- 4000 -'It%4A A^f%nr% f%1%Mnf%C2A-r1f%10 All .;.6*. -_A
11412016 Preview : Certificates of Insurance
DATE I.'.1!XDD--YYYY)
CERTIFICATE OF LIABILITY INSURANCE
I 011041ZO16
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 T14E 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 endorsomenL A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PROOLICER
CONFACr
NAME:
Automatic Data Processing Insurance Agency, Inc-
PHONEE A
IA:C- No. E.H: JAIC. No"
I Adp Boulevard
E-MIWL
AODRESS:
Roseland, NJ 07068
INSURERJS)AFFOROUIG COVERAGE HAIC;9
INSURERA: NorGUARD Insurance Company 31470
INSURED
INSURER B:
POLAR BEAR INSULATION CO INC
PO Box 958
INSURER C:
INSURER 0:
Andover, MA 01810
INSURER E:
INSURER F.
t A IV 1- Hutll-N t -�w I Ii -11 a 1 1- N1 IMIKI-W. 4�11 r UA wi-vl�-Itlm mllmiA�w-
THIS 15 TO CCRT 1FY TH.zJ THE PQL.'CiFS OF INSURANCE LISTED SELOV,HAVE TO THE 41SURED NALILD'�.SOVE FOR THE rOUCVP=—RIOD
INDICATED NOTIWITHSTANDING ANY REOU:RE,�'.EHT. TERI,: OR CONDMON OF ANY CONTRACT OR OTHER DOCU-4ENT V. -M-1 nESPECT TO 'NHICH THIS
CERT!F:C;.TE LIAY BE ISSUED OR I.;A7PCrTAi(-I- THE iNSUFANCE AFFORDED BY THE POLIOES DEScn;BED HERE:N :S SLIBiECT TO ALL THE TERLIS.
EXCLUS:ONS AIND COND5TiO:,'S OF SUCH POLIC!ES LIMPTS SHOt!N ?..IAY HAVE BEEN nCOUCED BY PAO CLA'11�ls
INA" I
L
TYPE OF INSURANCE
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OESCRIPTION OF OPERATIONS ; LOCATIOrIS F VEHICLES (ACORO 101. Addiflo=1 R—MIei Schedute. -TJ be atacbcd il mo—p2ce Is rcq,irecl)
SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
E EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Theiisch Engineering, Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
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Cranston, R1 02910 AUTHORQED REPRESEnTATwE
A9 1988-2014 ACORD CORPORATION- All riolits rp-pnipri
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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