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HomeMy WebLinkAboutBuilding Permit #860-2016 - 22 IRVING ROAD 2/3/2016BUILDING PERMIT p10RTM w- o��q LES abq-rC TOWN OF NORTH ANDOVER 32 APPLICATION FOR PLAN EXAMINATION~ _ n� _ �1 * SOF Permit No#: `� Date Received �gSSgcHIJO Date Issued: IMP RTANT: Applicant must complete all items on this page LOCATION R.� Prir PROPERTY OWNER %w e Pnr MAP PARCEL: Z- ZONING DI,. 100 Year Structure yes no RIOT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential- Non- Residential ❑ New Building ❑ One family El Addition El Two or more family El Industrial ❑ Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑ Assessory Bldg Others: ❑ Demolition ❑ Other T/7 S v 14 %/ d N O. Septic eW II t ®' F,I®`ao p in Wetla: tls, , n 'U1/at�e sl ed D tact ��Wate�/Sewer• -- t �--- - _�-� DESGRIPI IUN UI- VVUMM I U or rr-mrumrviw. i�'S�y1;H �rric ih5vlq;;''Q14 Tm %Z'`f9 ; IGir�Do Identification - Please Type or Print Clearly OWNER: Name: S o n d tro COul'ru S Phone: Address Contractor Name: V Y>trr Pe6 lgAc Phone: 7163 F Email. Supervisor's:Corlstruction Licerse /yGai� .:,,...:.,.. Exp: Date Home Improvement License: Exp. Date: ARCHITECT/ENGINEER, Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ />©o. o v FEE: $ 7?;'� Check No.: .1 Receipt No.: '-A7 9 b6 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund °L 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 ,;6 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 TOTE: 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 IECC 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 Doc: Building Permit Revised 2014 J Plans Subrnitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swfimning P0013 ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes � r ,Planning Board Decision: Comments v Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street °A RTMENT , Ternp Dumpster on site yes' no �, 24 Main S reet F -�->z rfinen 0i.g fiure/date , .,.�; , �,"�° ; tSi f f i a 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 use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Bnilding Permit Revised 2014 2-Z- avvc Location -A' �YN-e- 6W -z- Q No. Date -.2 21,11 13� 'A S(P(0 1( a TOWN OF NORTH ANDOVER Certificate of Occupancy Building/ Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL C e h bk # 29,9B5 Building' Inspector Oi� O � c 0 S —-� o =_ x_ O to < CD 0 N O CD O � n p Q-0 Z O E N a=i Ln. V, -1 O O .. CL m . �+S h CD00 0 m y O0 CD Cl) L A) c 2) O N c� y � co CD oo CD / CD O-0 ZZ Z-0 a O < ��—crm to :ENrt •3: cn -� N A� -� o 0 a v E -L nr�`1 Z� < roe' cc 0 v CD Cl) 0 �• N —�� Q <N o CD � O Z Tom cn ��,I = Qt�� �' Com. Q� co �� S �Z -0CD- CD CD 0 CD w� cDO O y *♦"♦` 0 CD 1-4 00 0, 0 CD fi Z U) rz= o y a ;C 0 O N = ;t► > cn CD CD � O 7 m v( C N �� O a @"a: C 0 O n CD --i : 0: 2) o C 0 c (A_T 70 T r) W T N T 3 c 60 O _T O CD O O 5' S O O N O O N j N �'• N � r_ N N 'O 77 0, LO W �' OqC 7 Q K K m s o N a Z z ° m z D H O m m O n n M z 0 0 0 _ 0 c 19 1�1 / � 9 �� Federal ID # 0S-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 Adivisionofnieisch'Engineering CT Contractor Registration No 620120 RISEQE ENGINEERING 60 Shawmul, Canlon, MA.02621 CONTRACT 339-502-51197 FAX 339-502-6345 Page 1 PICOGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA -HES ENGWEEMO AND THE CUSTOMER FOR YJCRK AS DESCRIBED BELOW CUSTOWR PHONE DATE CUENT0 WORK ORDER Sandro Quiros (617)955-9268 12!08/2015 426693 00002 SERVICE STREET MUM STREET 22 Irving Road 22 Irving Road SERVICE CITY. STATE, ZIP MUNG CITY,STATE. ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This work will be performed in concert with the use ofspccial tools and diagnostic tests to assure that your home will be left with a healthful levet of air exchange and indoor air quality. Materials to he used to seal your home can include caulks, foams and other products. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (tivindows are not generally addressed.) This will require (4) working hours. A reduction in cubic :feet per minute (efm) of air infiltration will occur, but the actual number of efm is not guaraniced. At the completion ofthe %veatheriration work, and at no additional cost to the homeowner, a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety ofthe indoor air quality. $340.00 ATI'IC FIAT. Provide labor and materials to install a 12" layer of R42 Class I Cellulose added to (312) square feet ofopen attic space. 5499.20 SLOPES: Provide labor and materials to install a 8" layer of R-28 Class I Cellulose added to (260) square feet of slope area Wltcmvcr possible battles will be installed to the entire length ofench bay to maintain ventilation space. $496.60 ATTIC ACCESS: Provide labor and materials to insulate the back of (1) attic hatch with 2" rigid 7'hermax board. Weatherstrip the perimeter. $60.00 VENTILATION: Provide labor and materials to install ventilation chutes in (36) rafter bays to maintain air flow. 572.00 BASEMENT CEILING: Provide labor and materials to install (I 18) linear feet of R-19 unfaccd fiberglass insulation to the perimeter ofthe basement ceiling at the house sill. $206.50 RISE Engineering will apply all applicable, elieible .incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures, Columbia Gas otl'ers 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 5340 if savings are justified by the auditor. For the safety and health ofyour home's indoor air quality, we will be conducting a blower door diagnostic ofthe available air flow in your home both before the work is begun, and after the weathcriiation work is complete. We will also conduct a full assessment of dic combustion safety or your heating system and water heater. This has a value of $90 and is at no cost to you. Total allowable wcalhcri;ation incentive is $3.110. $90.00 2d15 1 � ptl� � i1 Federal 10 # 05.0405629 RUSE RI Contractor Registration No 8186 Q� MA Contractor Registration No 120979 RISEngineering 5=°.o A division ot7lficisch Engineering CT Contractor Registration No 620120 ENGINEERING 60 Shawrnut, Canton, NIA 02021 CONTRACT 339-.502.5197 FAX 339-502-6345 Page 2 PROGRAM �+ LMA-HES TILS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BEIMI CUSTOMER PHONE DATE CLIEIITII WORK ORDER Sandro Quiros (617)955-9268 12/08/2015 426693 00002 SERVICE STREET BILLING STREET 22 InNing Road 22 Irving Road SERVICE CITY, STATE, ZIP BILLING Cn Y,STATE,ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $1,764.30 Program Incentive: $1,430.72 Customer Total: $333.57 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ""Three Hundred Thirty -Three & 57100 Dollars $333.57 U LULL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OFt% MONTHLY Ot U BALANCE AFTER 30 DAYS.SE£ REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,WGKTSOFRECl5R01{SCHWUI7NG, COClIIIRGFD NTRACTORREGt9TRA N. 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY 8 PACES/ AUTNb S TURE-RISE E.94-dnR CUSTOMER ACCEPTANCE (J1 NOTE: THIS CONTRACT MAY BE MMORAV I BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT -THE ABOVE PRICES, SPECIFICATIONS AND CONDITIONS ARE 30 SATISFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORED TO 00 THE WORK DAYS. - AS SPECIFIED. PAYMENT WALL BE MADE AS OUTLINED ABOVE I ��n OWNER AUTHORIZATION FORM Sandro Quiros ,(Owner's Name) owner of the property located at 22 Irving Road North Andover MA (Property Address) 22 Irving Road North Andover MA (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering, WOO on my behalf to obtain a building permit and to perform work on my property. /.2-/0 Date IV The Commonwealth ofMassachusem Departmeni of ndaestrzalAeeadents I Congress stree4 S aite 100 Boston, llL4- 02114-2 017 www.mass g®v/dna 'Workers' Compensation Insurance Affidavit: IBuilders/Contractor/Eleca iebus/Pluinbers. Name (Business/Orpniz:ationfindividual): K0 bk l 1 "6 -re, t' Address:-- Cit3r/State/217-- Phone #: Art: yoto nu employer? OwxiL die nppmpdntc boa: am a employer with 1T c,,pWees (full and/or part-time)' 2.0 I am a sola proprietor or Partnership and bave no employees working tnr me in any eap-ity- We workers' ootnp. innaancz required_) 3.0 I am a homcawner doing all work myself- [No workers' comp- insurance required.] t 4_® I am a homeowner and will be hiring Contractom to conduct 811 work on MY property- I will ensure that all conmxiors atha• have workers' compensation insurance or are sol` prttpriaors with no ®ployees- 5.01 am a general coca -actor and I have hind tbz subconazaars listed on the attached shad_ These sub•couazctoa have employees and have workers' comp. iasis ancc r 6_ We are a corporatioo and its officers have exercised their right of ccesapdm per MGL C- 152, 152, § I (4), and we have no employees. [No workers comp- insurance rcquitc(L] Type of project (required) -- 7- New construction S_ Remodeling 4_ Demolition 10 0 Building addition 11_E] Electrical repairs or additions 12. n Plumbing repairs or additions 13.E]Roof repairs 14. lOther -Any applicant that checks box #I mist also 61l out thesection Mow showing their workers' compensation policy information t I-lomcownars who submit this affidavu mdi®ting they art: doing all work and thea hire outside contractors must submit a new afs&vit indicating stub tCoonsaors that check this box mast atumb d ffi additional sha=t showing the name of the sab-conaacums.and state wbetbe or oot those --otitic:+ have employees_ If the stub -contactors have employees, they must provide their work._, cvmp_ polity number. I am an employer that is provuding workers' corsaperrsataon insurance�or tray eneployees Bdlow es the policy anal job site irdfosrrrafion. 1 9 insurance Company Name:11"10 Policy # or Self -ins. Lic. #: ;� i�JG 7%-' , J Expiration Date Job Site Address: a2 `t:Q: tng City/State/Zip- ,r . _pO hdl Utacb a copy of the workers, conapensadon poUcy dedaratiEon page (showing the policy number 2eytpimfloa date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1.500-0 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fills of up to $250.00 a Jay against the violator_ A copy of this statement may be forwarded to the Office of investigations ofthe DIA for :,,nuance :overage verification. da hereby cerYi• jar under the pains and penaltites oppeigFury that t ke inform a&n provided above is true aid eorlrect - iimature: �Z T ``,z l ;(. 1 - Date- r 'hone _7 #: G�k ` ='� , ®6rw,aal use only. Do not rural.-- are ilei_ area;. to be completed lay city or town ofie€aZ City or Town_ Permit/Lkense t`# Issuing Authority (circle one): 1_ Board of Health 2. Building DVErtsllent 3. City/Town Clerk 4. Electrical inspector 6: PIunribing Inspector b_ Other Contact Persom Phone #:• 1/4/2016 Preview: Certificates of Insurance ° ., CERTIFICATE OF LIABILITY INSURANCE DATE(r.1?XDD;YYYY) 0110412016 THI�RTIFICATE 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. It 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: PHOUE AY la c. No. Enl: to+c. nal Automatic Data Processing Insurance Agency, Inc. 1 Adp Boulevard t• .,AIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC9 Roseland, NJ 07068 I IIISURER A: NorGUARD Insurance Company 1 31470 INSURED INSURER 8: INSURER C: I POLAR BEAR INSULATION CO INC PO BOX 958 Andover, MA 01810 INSURER D: INSURER E: INSURER F: nt-C /`CUTICIr`ATF NIIMRFL.`• YLY/11.8 REV1JiLJIV NIJIVinmm. v THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO:: HAVE BEEN ISSUED TO THE INSURED NAT:;ED ABOVE FOR THE POLICY PERIOD INDICATED. NOTI. ITHSTANDING ANY REOU;RESENT. TERI OR CONDITION OF ANY CONTRACT OR OTHER DOCUt.SENT'rl:iTH RESPECT TO WHICH THIS CEP.TIF:CATE (SAY BE ISSUED OR 1.1A1' PEPTAiN. THE INSURANCE AFFORDED BY THE POL'.CiES DESCRIBED HEREN :S SUBJECT TO ALL THE TERLIS. EXCLUSIONS AND CONDiTiONS OF SUCH POLCIES LIf61TS SHOWN LIAY HAVE BEEN REDUCED BY PWD CLA:L'S uT R LTR TYPE OF INSUPVICE It7trJ VIVO POLICY NULIBER (r,"IXDD YYYY) { 1G7D D'YYYYi I LCd1TS AUTHORLED REPRESENTATIVE COMMERCIAL GENERAL LIABILITY I CL.i1Llj �L1:.L :c ❑ ..,.L I, i ( I t,::r GCE:Uta:Ehl'E > 1'Iif:f.11�t�tlt.'. J: _'t:•t_r:t�: � OtTa;+C-(FIiEC�•�lEULlli i.l°PLIE:i PEF.: � � L%- i'CLIC" J1'IiEC;I L::C +SEl:Eli4L;,GGkEG�1iE AUTOL:OBILELIABILITY r LLL' SLI-EDLLEO I "I.t 'P:tL•�II:Ltt Ll::ill 6CIJiL` IIJLV.'W_-S 8CUIL"' 1%K:10 IPS!:::a.eiJ; S i' UL RELLA LIAB EXCESS UAB L•LAILIS LIADE } ) EAL;r CCCUEN INCE: AGGI:EL •IE IS DEL. IiE1Eh IICi:j A WORKERS COMPENSATION AND E7IPLOYER5 lJABIU7Y yltl A.`iiz1-1VI l:I r_i: PAKI7 _I E;iECI;TI':E r FILEt:.it.16tKE J.LLc-G n jt.;andarory in NH) L--11� i+=ea:`1—!111 -"' L'•rS:_IiiPTICI; t�>-(;It�lii,Illl:S be �;: Ira R' � POt:/C772�J58 1011011201E 01101 ,2017 X EL E:,1:1-ACCIL+EI'.1 =-1,0OO,0DO EL. DISE,;Sc t%+ EI:II`L+J`'tE i 1,000,000 E.L. L'ISEi.SE �1`:;DL IJi.hl 1.000,000 DESCRIPTION OF OPERATIONS i LOCATIONS i VEMCLES tACORO 101. Addiiion3l Remmks Schxduto. m J be at..hed it mote sra� i, mq,aw) CERTIFICATE HOLDER CANCELLATION A„ 1980-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25 (2014101) 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 Theilsch Engineering, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave AUTHORLED REPRESENTATIVE Cranston. RI 02910 i A„ 1980-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL '4`c,,,oRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY)fl) 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 Durso & Jankowski Insurance Agency 11 Saunders Street North Andover, MA 01845 CONTACT NAME: PHONE- --- FAX A/C No Ext : (978) 688-7000 (ac. No): (978) 688-70.0_1 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 03/24/2016 j INSURER A: Nautilus Insurance CO. $ 17.370 INSURED INSURER 8: Safety Insurance Company 3.3618 Polar Bear Insulation Co. Inc. Peter Leblanc & Steven Leblanc _ INSURER C : PRODUCTS - COMP/0P AGG i $ 1,000,000 -" P O BOX 958 0: AUTOMOBILE F,(Ea _ X _INSURER INSURER E : ------ _INSURER Andover, MA 01810 INSURER F : 01/04/2016 01/04/2017 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLM1,000,000 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILNTR TYPE OF INSURANCE—� DDL— INSD— WVD POLICY NUMBER MM/DD YY POLICY EFF I MOM//DD LICY � UMC A X COMMERCIAL GENERAL LIABILITY - CLAIMS MADE OCCUR ❑X I NN538691 03/24/2015 i 1 03/24/2016 j EACH OCCURRENCE $ DAN)AG-E TO -RENTED __.._..___ PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE 5O OOO $ r $ 5,000 -- $ 1,000,000 _ — GEN'L AGGREGATE LIMIT APPLIES PER: POLICY (� JE0 LOC OTHER: $ 2,000,000 PRODUCTS - COMP/0P AGG i $ 1,000,000 $ B AUTOMOBILE F,(Ea _ X LIABILITY ANY AUTO ALL OWNED SCHEDULED FX— X AUTOS _n_ AUTOS NON -OWNED HIRED AUTOS X AUTOS 1 ! I 2100926 01/04/2016 01/04/2017 COMBINED SINGLE LIMIT accdent $ 1,000,000 -__ BODILY INJURY (Per person) $ BODILY INJURY (Per accident), $ _ PROPERTY DAMAGE _(Per accidence__.. 1. 1 $ — '$ A + j UMBRELLA LIAB X OCCURi EXCESS LIAB CLAIMS -MADE I DEDTI RETENTION $ AN019284 I 03/24/2015 103/24/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ i I Is WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y OFFICERIMEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below { N/A I I PER STATUTE E--..-H -- - $ -" - E.L. EACH ACCIDENT —` - E.L DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) 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 Thielsch Engineering CERTIFICATE HOLDER CANCELLATION n -4000 on -In Amnon 91noon0nr1nu1 An ....�...... .,. ,, a SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas 9 g 195 Francis Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE n -4000 on -In Amnon 91noon0nr1nu1 An ....�...... .,. ,, a FrIm lzegdofion MCC C°nsum� pa � - S�� 51�® iU park 02116 Bosto%assacht�se on 6uIl i or o '102726bapro _ Dme = Reg T DBA '[c# 7P1J2"6 252249 BEAR iNSUL'`ilo" Co- Vincent a- P�� t LeBlanc _ I BOX 958_== �� Vin _ - _ _- 0um,n g4P.OOVER, MA 01810 - _ = -_ _= U��,&AdrM cetum ent Lostcsatl D � �mptoy�u D AN f, Address `i�j Renewal Opg.CA1 u �,�ypq.�1G12t6 J� -73Si�])T3 si3polS 3). spit' &--y CSSi-406Qii pdstsRr NEI 03M *' _