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HomeMy WebLinkAboutBuilding Permit #1238-2016 - 22 BUCKINGHAM ROAD 5/21/2016 Q 4o 1Yof"°oT 6'�tio BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 9q Permit No#' °RZED SSACHUS� Date Issued: IM ORTANT: Applicant must complete all items on this page r LOCATIONS �.oGxr✓Iy Lj9liY1 Pd Print PROPERTY OWNER Cd�a vl Print 100 Year structure yes rio MAP '"1 PARCEL 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: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other ��� NPtift- , ell I -r ®tFl©od I}ai�n�:3®Wet an=tlgse _ O Watershed District - 4,r`C t;.Y: `tt _ .�. ._. DESCRIPTION OF WORK TO BE PERFORMED: re/��/ySc -ro ,�/vw,;nu tM Identification- Please Type or Print Clearly �G1 l y46 OWNER: Name: 5/A(-o v\ �Cx 170 Vk Phone: r/� 5 Address: 44L- g✓Ct 1,nq/1407 Contractor Name: ?r rr t e Phone: Email: Address: eQS i e�v1 -e ?,/ P9 Supervisor's Construction License: ro 6 a/ 7 Exp. Date: L/ Home Improvement Licenser lob-7a-Co Exp. Date: 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: $ a- 10o. o c) FEE: $ Check No.: 1-7-1 1 Receipt No.: L�� NOTE: Persons contracting with unregistered contractors do not have acc to the guaranty fund ._ qg.'r"'.' ,,�+'vVa,-rte..'.Y^"`. —�'r` w. -E i S "s*'w#s 1.g t ] fit` i _P _ i Location No. - 4_ t U %° Date 6 P j. i • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ y" Foundation Permit Fee $ Other Permit Fee $ 4 7 l TOTAL $ f Check# 30431 Building Inspector j l _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL, r Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I � Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: d 384 Osgood sgood Street "�i ''"A "M1a S:`r'ryf`".sl° S$�' •A^'. ' p w� �r'1 '!I`T' 345�,. FIRE DEPARTMENT Temp Dumpsterr oYns teyesy � �ho Located at 12`4 Main Street � � z 11 a Fir�e Department signature/date: � ' �" � �� � L ;.��� $ ��t 4s-.. ", t sr��-• a'- .� }� � +'tea.`3 �3 _ _ ;�,. `� _�.._�`^C��"` :.n-moi,t.r.:r: .sn-•��t�.`.��t*� i�.., ..�y..wrt �sr&t�a:t�` S ...,.�� .,fin':-c 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 NOTES and DATA— (For department ease) ® Notified for pickup Call Email 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.I.C. And/Or C.S.L. Licenses 4, 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 4. 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) 4 Building Permit Application 4. 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 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doc:Building Permit Revised 2014 F NORTH E � Town of �� _ 1r1. ndover r K al :2, ?til h ver, Mass o > > �y coc.ucHewrcK y1. I.ps' 'ATEA J"" V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 5 . . f/�. .... . THIS CERTIFIES THAT ���.�..... ,.,.. BUILDING INSPECTOR , Foundation has permission to erect ...... ................... buildings on . ....... ... ..... .,, Rough to be occupied as ..e .... .... *Av.....L . .�� �... �..... . .. . Chimney provided that the person accepting this permit shall in every respect conform to the terms of the plication Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection Iteration and Construction of Buildings in the Town of North Andover. c PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS Rough Service ........................................... ..... ......... .................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT .Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. h r Federal lD.#05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No.120979_ RISENA dhisian of7hirlsch F.rigincering " ¢€ NG' Company Address,Cilv,.NLA00000 !fit h ppb+ ENGINEERICONTRACT 401-123-1234 EAX401;123-1234 Page 1 PROGRAM '." THIS COMAC M EUMMEDPOIDBEMENRISE CMA-HES ENWEER010 AM 1HE CUSXVER FOR WORK AS DESCRwo REUM CUSIMER 1 _. % PHw_- WE cusn'd WORKORDER. Sharon ConanC/14-4 G l ko 05/12/2016 422289 r SERVICE SWET - BWNG STREET 22 Buckingham Road 22 Buckingham Road SERVICE CoY.SVO M BmLm CnY.STATE,BP North Andover,MA 01$45 North Andover,MA 01845 JOB DESCRWnON WALES.Provide labor and materials to install blown in Class Cellulose to(1008)square feat of aluminum-sided exteriorwift Touch-up paroling,if'nerded,%vill bathe customces responsibility_iiomeov+ner has received a copy of the EPA's Renovate Right Lcad-Safe information guide explaining the potential riSl of the lead hazard exposure From the meatherimtion work to be performed.Your signature is your acknot%edgement of receipt and agreement to proceed $2.016.00 RM Engineering mll apply all applicable;eligible incentives to this contract. Yournll only be billed the Net amount. Ctvrently; for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the. Air Seating measures WF to the first.$680 and an additional$340 if savings arc just Mad by the auditor. For the safety and health of your homes indoor air quality,%te%till be conducting a blotter door diagnostic of the available air flow in your home both before the stork is bcg n.and ager the%teatherization stork is complete.We till all^duct a fish assessment of the comb=ion safety ofyour heating system and Mater.heater.Thishas a value ofS90 and is you Total allottable tteatherization incentive is$3.110. $90.00 Total,: $2,106.00 Program Incentive, $1,60100 Customer Total $504.00 W EAGREE HEREBY TO FURNISH SEMCE$-COMM Of ACCORDANCE W ITH ABOVESPWFICAMONS..FOR THE SUM OF *'*Five Hundred Four 8i 001100 Dollars $504.00 WON FOOLUMPECUMAND APPROVALBY RISE ENOMEERIM CUSXMER AGREED DREUTAMMMUE IN RRL WMRESTW'1%WUBECHAROMMMMY04ANY UNPAID 13MAI R DAYS.SEE REVEFME FOR W01MWUQRXr V=ON ODUWMES.RICHS CFRXCniMSQeWU1nAND WMACIORREGMIRA"L O NOT GN THIS CONTRACT IF`7}IERE ARE ANY BLANK SPACES AUJp uxu nlaF Ek.,ma a aTa En accEenNCE rtor:TNA CONYtAartA r eE Wrr taRAwx eY US tF#=EXECUrrDVn1H N DATe OF ACCEPWNM Jam` �L ld ACCEPTLKCE OF CONTRACT-'WE ARM PRUMS.SPECIRCABCNS AND CONDIEOM ARE .. 30 DAYS. SAI.W=«AanT r PAUS AND AAE YYh BE M1DDEE AAS O PUWMD ABOVEAU110it1>Eo W DpLtE WORK- RISE60 Shawmut Road,Unit 2 1 Canton,MA 02021 (339-502-6335 ENGINEERING www•RiSEengineering.com OWNER_AUTHORIZATION FORM I, . v-mom C oV-avz (Owner's Name) owner of the property located at: C (Prop Address) Zp16 3 (Property Address) hereby authorize a (a -ea f , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property.This forms only valid with a signed contract. Owner's Signature Date The Commonwealth ofMassachusetts Department ofl'ndustrialAccidents Office of Invesilgaflong 600 Washington Street Boston,MA 02111 www m7vv gov/c?aa Workers' Compensation Insurance Affidavit:guilders/Contractors/Electriciam)Piumbers Avylicant Information . .'lease Print Le 'bl Name(Businessiorganization/rndividual): Address: PO Bpi M City/State/Zip: Phone#: Lo-meowiler gou an employer?Check the appropriate box: a employer with 4. 0 I am a general contractor and I �e of project(required): - loyees(full and(or part-time).* have hired the sub-contractors 6• ❑New construction a sole proprietor or partner- listed on the attached sheget.1 7. 0 Remodeling and have no employees These sub-contractors have ing for me in any capacity, workers'comp,insurance. S' I?emblition workers'comp.insurance 5. ❑ We are a corporation and its 9. 0 Building addition red.] officers have exercised their 10.0 EIectrical repairs or additions a homeowner doing all work right of exemption per M(3L1L[]Plumbing repairs or udditions lf[No workers'comp. c.152, §1(4),and we have no nce required]r employees. 12.0 Roof repairs [No workers' comp,insurance required] 13.0 Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information; Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a neer 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. am an em I to er that is P Y pYovidzng workers compensation Insurance f"my employees Below is tliepolicy and job site informatio>r, Insurance Company Name:_ r Policy#or Self-ins.Lie.#_?D W'C -7 City/Sfate/ZiExpiration Date: 101> J-ob Site Address:__ l� or/t;rn�Aq LA1 & /J , 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 cart lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage veri.$cation. I do Izereb. ce fp J r y ` Y hilar Elie pain and penalties o er'u that the Wfor�mtion pr ovided above is trice and coTrec Si afore: G Date: S7/2_ 'none#: > y��—;>fo 3 a Official use only. Do not write in this area,Yoke completed by city or town official: City or Town: Permit/License# Issuing Authority(circle one): , • I.Board of Health 2.Building Department 3. C14/T9" 6 Other t9 wn Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: ACo CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) �.•�� 3/23/2016 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 endorsemen s. PRODUCER CONTACT Linda BO daaowicz NAME: g Insurance Solutions Corporation PHONE(A/c NO (603)382-4600 Fac No):(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.aom INSURER AFFORDING COVERAGE NAIC(k Plaistow NH 03865 INSURER A Western World INSURED INSURER S NautiluS Insurance Group Polar Bear Insulation Company Inc INSURER C: PO Bos 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1632326134 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. INSR TYPE OF INSURANCE DL SUBR POLICY EFF POLICY EXP L POLICY NUMBER WDD/YYY M D/Y Y LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 A CLAIMS-MADE ❑R PREMISES Ea occurOCCUR DAMAGES( RENTED rence $ 100,000 A NPP8274967 3/24/2016 3/24/2017 MED EXP(Any oneperson) $ 5,000 PERSON AL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 j x POLICY 1-1JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED B (Per accident)) BODILY INJURY Pident $ AUTOS AUTOS NON-OWNED PROPERTY III DAMAGE HIREDAUTOS AUTOS Per acciden $ $ R UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVEEL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOY $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Thielsch Engineering is named as Additonal Insured on a Primary and Non-contributory basis on the Liability policy as per written contract for work performed on their behalf by the insured for insulation work-mineral. I I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(901401) POLASEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(Wmo"YYY) 1161201 s 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 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 PHONE — 11 Saunders Street ac,N0.x_(978)688 7000 _ 3 FAX,No ( }978 6588-7001 � North Andover,MA 01845 EMAIL — ADDRESS: INSURER(S)AFFORDING COVERAGE ; NAIC# _ INSURER A.Nautilus Insurance CO. 117370 INSUREDINSURER B:Safety Insurance Company— 0618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc INsuRER D• 1 P 0 Box 958 _— ----= —-- ----_ Andover,MA 01810 INSURER E,_ INSURER F• y COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: E 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF � POUCYEXP ; — - LTR; TYPE OF INSURANCE ?INSD I VfVD: POLICY NUMBER i MMID I MMIDD LIMITS A COMMERCIAL GENERAL LIABILITY S I EACH OCCURRENCE :S —_ CLAIMS-MADE OCCUR DAMAGE TO�tENTED --- -- !PREMISE�Ea occurtence) S i MED EXP(Any one person) S PE_R_SONA_L 8 ADV INJURY i S _ GEN'L AGGREGATE LIMIT APPLIES PER: ? GENERALA i GGREGATE i S x i POLICY jE ;LOC ! PROn i Tc_-- i - - _ -- - LC. COMPIOP AGG `S OTHER: i -- - --:S AU-TOP9 BlLE LIABILITY i O MC D SINGLE LIMIT i Eaaaciden0 �S 1,000,000 B '2100926 (Per ANY AUT 1/ 4 1 1/ 4 �BODILY J INJURY a person) i S O 0 0 /20 6.0 0 /2017 OD LY INJU ( P ) ALL 01ANED �� SCHEDULED !AUTOS ac INJURY BODILY DILY INJU (Per accident)!S —. . _ i NON-OWNED j I PROPERTY DAMADE--- HIRED AUTOS ��AUTOS ! PA :S UMBRELLA LIAB OCCUR EACH OCCURRENCE c A EXCESS LIAB CLAIMS-MADE I I` AGGREGATE _ _S i OED RETENTIONS WORKERS CONiPENSATION i PER OTH- :ANDEPAPLOYERS'LIABILITY Y/N';• `f STATUTE ER - ,ANY PROPRIEfORIPARTNERIEXECUTIVE r—�t 'OFRCERIIAEIABER EXCLUDED? I!N I A EL EACH ACCIDENT S ;(Mandatary inNK) E-LDISEASE-EAEMPLOYEt S If yes.describe under --- DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT 5 i I ! i f DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Insulation Work-Mineral i Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respectsto work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEIIED 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 AUTHORMED REPRESENTATIVE 'i n 4000'MAA AP%AOr1 nf100A0AT1AAl All 1/4/2016 Preview:Certificates of Insurance ® DATE(MMIDDNYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 01/04/2016 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 NAME: PHONE Automatic Data Processing Insurance Agency,Inc. Wo.Ext): I JAIC,No):, 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAICM INSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B: t DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429691 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. POLICY EFF P LICY EXP LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MMYDD MIDILYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F—I OCCUR PREMISES Ea occunence S MED EXP(Any one Person) $ PERSONAL 8 ADV INJURY $ GENL AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE $ POLICY JE T LOC PRODUCTS-COMPIOP AGG S OTHER: $ AUTOMOBILE LIABILITY $ Ea accident ANY AUTO BODILY INJURY(Per person) $ AUTOSAOWNED ICITH ULED BODILY INJURY(Per accident) S NOtJ-0WNED HIREDALITD$ AUTOS Per accident E S S i UMBRELLA LIAR HOOCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY YIN STATUTE I JER ANY A OFFICERRVIEMBER EXCWDEED7��1� NIA N POWC772258 01/01/2016 01/01/201] E.L.EACH ACCIDENT $ 1,400,060 (Mandatory In NH) E.L.DISEASE-FA EMPLOYE $ 1,000,000 H yes,describe under DESCRIPTION OFOPERATIONSbdow El.DISEASE-POUCY UMIT 1$ 1,000,000 FiT I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACTION INC ACCORDANCE WITH THE POLICY PROVISIONS. 47 WASHINGTON STREET + Gloucester,MA 01930 AUTHORIZED REPRESENTATIVE I I ©1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD I I I Office®fcoer �tl� IO pada- .W 510 _ Boston, 02116 `on ® bVr0VeMWtq0j4 �tc4� o� '1112726 - - _ Types- DSA T* 2MM eeraaw- 712016 POLAR BEAR INSUTAT'ON Co Vfficent LeBlanc p_C}_SOX 958 __ -- uaforcltanae. ANDOVER. MA 0 Aticleess L Renewal 09C rbTERAL 7 gt �HE 03M _