HomeMy WebLinkAboutBuilding Permit #718-11 - 296 MIDDLESEX STREET 4/26/2011Permit NO;
Date
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
0
IWORT.ANT:
Date Received
must complete all items on this
_LOCATION 99 (a 1�1,'el l
Xk t� 5
Print
_PROPERTY OWNER 4L ,'
Print
MAP NO: �__PARCEL ZONING DISTRICT: Historic District yes . no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
/Yd"L� l4
Residential Non- Residential
❑ New Building
❑ Addition
❑ Alteration
p30ne family
❑ Two or more family ❑ Industrial
No. of units: ❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg ❑ Others:
they
❑Sephc� "®1We11 *�
`� Floodplavi,®Wetlat, s atershedDistr`ict
DESCRIPTION
OF WORK TO BE PERFORMED:
If- 1"Z''�
s��! •�`� CYllyl®S[� f�2
.5 C/L-Gc���i't _ .s. _
/Yd"L� l4
/�'i%.//� �E`��tC.T �_
/e�
Identification Please Type or Print Clearly)
OWNER: Name: /n?%s5��
GcJi/lam �J/
Phond• tZ?- •73 P. Of(d-y
Address:—,-;-) 9L,
CONTRACTOR Name:
Lz_Phone: .7,P/•
Address : 7�� %�1.�. ` 1��--, .-,
/err /2 e
6�
Supervisor's Construction License:
'�i"a ;�� a
Exp. Date:
p
f /z /Z-. ;
Home Improvement License:
Exp. Date:
l .Q -
ARCHITECT/ENGINEER Phon
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: $ ;� 1 " 7 ' 9 '� FEE: $. bd' _
Check No.: n1 �� Receipt No.: 7 �oZ_
NOTE: Persons contacting with unregisteYeci contlacto�s tlo not have acres to he guaYan fun
Si nat%ire o co``
'��ner;�
�Sianature.ofi�Agen ............. ------------ ............ -- %Ow
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
o 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
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
❑ Photo Copy of H.1.C. And C.S.L. Licenses
❑ . Copy Of Contract
❑ Floor/Crossection/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.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
aL the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
ist be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ swimming Pools ❑
We11 ❑ Tobacco Sales ❑
Foodpackaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
R
Reviewed on Signature
Reviewed on Signature
Zon-.ng Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature &Date D'riveway 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
COA4MENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. t.:
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.$10041000 fine
Doc:.Suilding Permit Revised 2008
Locations
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Buirding/Frame Permit Fee $ '�✓
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1
4447
24052
Building Inspector
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The Commonwealth of Massachusetts
s = Department of Industrial Accidents
Office of Investigations
c
600 Washington Street
Boston MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintLegib
Name (Business/Organization/Individual): 1441ccrr e -,c
Address: Z 6
City/State/Zip: �e �,�< <, ,_tom �l�y Phone #: ��'! 7S - Zv%s
Are on an employer? Check the appropriate box:
1. I am a employer wither
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ElI atm a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
officers have exercised their
required.]
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowns who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
er
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. %4
Insurance Company Name:
Policy # or Self -ins. Lic. #: C> d6 7 �`��/S— ! Expiration Date:
Job Site Address: �� Li'l%Gv�� f"� City/State/Zip: 61
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Se6tion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn 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 DIA for insurance 'coverage verification.
I do hereby certify under the pains anti penalties of perjury that the information provided above is true and correct.
.u. -7,P/. U 7�-- 219' c'"
Official use only. Do not write in this area, to be completed by city or town offciaC.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sur&that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.govldia
Nouse .Type: Cape Ranch . Split
1 fam 2 fam 3 faro duplex 4 family Victorians a Tenement
Siding Type.:
oboVinyl. Alumn_ Asb Single Asb Dble Condition Good Fair Poor
Vin y1 over Asb T111 _ Brick / Stucco Asphalt Comments:
r oof Type
Roof Material
CS-ip Flat Gambrel
Asphalt Slate Rubber Tar & Gravel
Condition Good Fair Poor
Heating System
Print out
Manufacturer.:
Efficiency S e
Excess.Air,$
BACMACH, INC.
. ` Fyrite Insight
CAZ Base Reading : Pre Post:
Stack Temp
SN; QQ1154
CAZ Worst Reading : Pre Post:
Ptimary TempTime:
FHW Steam A Space Heater
Oxygen. Q,
CO 2.
10: 16:12 AM
Date: 04/14/11
Oil Ga Electric
CO P4 a
Fuel
Wood Pellet Coal
CO Air Free
Nat Gas
Flame Color L j —
Treated Ducts : Yes NoAge
Z
02 10.4%
c0 14 ppm
Ambient CO 8 .: Eff 75.0%
Domestic Hot Water Tank
Smoke Reading 0
� F
Oil Electric Tank less
Referred to HWAP
T STK
Ga
Y T -AIR 48.8 °F
Gallons _ q0 Temp Setting. WAkA
Date referred ...
EA 88.3 %
DraftSpillage Yes ��N
Smoke Reading
co (o) 28 ppm
Amb CO: 0_ Stack CO:.
Draft - p< of
Add.:6 Feet of pipe wrap ✓ NO
Spillage
Differential Pressure
Comments:
-0.01 inwe
r
Ambient CO Readings: Stove ,E ' Oven
Broiler '
Dryer
1.WEATHERSTRIPPING/CAULKING
Door M Q -Lon or Equiv.
Door Sweeps (Regular)
Door Sweeps (Automatic)
Reglaze Windows An.inch
Window.Weathstr Schlegel per side
Agent bypass sealing manthr
Attic seating with 2 -part foam man/hr
SUBTOTALS
2A.INFILTRATION I INSULATION
Domestic pipe Hot Water Tank 1st 5
Sill Insulation R-19 CF
Sill Two Part Foam wt Fiberglass Batt
Drape Perimeter R-5 Anch. Sq. ft.
Drape DOOR R5 Anch.
Tape Joints (Aluma Grip only) per hr.
Duct Insulation & Tape In. ft.
Rigid Foam Board Anch. 1"
Hydronlc pipe insulation to 1" R-5
Hydronic pipe ins.1.25"-1.5" R-5
Steampipe Ins. to1.25" Iron pipe R-5
Steampipe Ins. 1.5"- 2" iron pipe R-5
Steampipe Ins. 3" iron pipe R5
Air Conditioner Meeting Rail
Air Conditioner Cover
Air Conditioner Cover Special Order
SUBTOTALS
2B. INSULATION
Open Unrestricted R 49
Open Unrestricted R 38
Open Unrestricted R 30
Open Unrestricted R 20
Open Unrestricted R 10
Restrict FUSioped R 30
Restrict FUSloped R 20
Restrict FUSioped R 10
R-19 FGB open raftershvapsAareewaHs
R-11 FGB open rafterstwallwkneewalis
Attic Stairs(stakwell & common wall)
Cover Pull Down Stairs Thermadome
Site built pull datum stairs 2" foam tux
Job Number 3896
Client
address
city/ town
contractor
QUANTITY
4
2
0
0
0
1.5
2
1
0
106
0
2
0
0
0
50
0
0
0
0
0
0
0
0
0
0
0
0
0
42
702
0
0
0
0
0
DATE MARCH 15,201 '1
MELISSA WILLARD
296 MIDDLESEX STREET
NORTH ANDOVER MA 01845
ADVANCED ENERGY SOLUTIONS
TOTAL
172.00
30.00
0.00
0.00
0.00
90.00
150.00
442.00
15.00
0.00
212.00
0.00
88.00
0.00
0.00
0.00
162.50
0.00
0.00
0.00
0.00
0.00
0.00
0.00
477.50
0.00
0.00
0.00
0.00
0.00
0.00
56.70
870.48
0.00
0.00
0.00
0.00
0.00
AUDITOR NOTES
IDAM SOFFIT BAYS
AUDITOR NOTES I
[ATTIC AND BASEMENT TO OUT I
I AUDITOR NOTES I
IN DAUGHTERS CLOSET
USE CAUTION THE FLOORBOARDS NEW
Page 2
Attic / Kneewal Floor Transition. Dense pack cellulose
0
0.00
W.S. & bat Hatch R-19 /Q -Lon or =
0
0.00
W.S. & bat Hatch R-30 /0 -Lon or =
0
0.00
Krmwail R-12 cell behind Per.Memb
0
0.00
Open Rafter R-20 Cell. /w poly
0
0.00
Open Rafter R-30 Cell. /w poly
0
0.00
Basement Overhead R-19 fiberglass
0
0.00
Basement Overhead R-30 fiberglass
0
0.00
CraWpace Overhead < 4' high R19
0
0.00
Crawlpace Overhead < 4' high R30
0
0.00
Garage Ceiling cavity filled w/ cellulose
0
0.00
Wood,Shake,Clapboard,Shingles Vinyl
1744
2964.80
Asbestos (single naiq / Asphalt
0
0.00
Asbestos (doub. Nail) / Aluminum
0
0.00
Bricidstucoo
0
0.00
Vinyl over Asbestos
0
0.00
Muftl-Layered 3 or more layers
0
0.00
Drill rough plaster or finish wood plug
0
0.00
Drill finish plaster
0
0.00
Test Drill Wails (all 4)
1
60.00
SUBTOTALS
3851.98
2. INSULATION TOTAL 2A.+2B.
4429.48
3. STORM WINDOWS l DEADLITES
Plexiglass up to 88 u.i_
0
0.00
Addlfional per UI over 88"
0
0.00
Other (Negotiated Price)
0
0.00
SUBTOTALS
0.00
S. OTHER MATERIAL
Ridge vent In ft.
0
0.00
Vents Gable rectangular
0
0.00
Varipitch Vent
0
0.00
Vent Roof 135 (1 sq ft NFV) Large
0
0.00
Vent Roof 865 (.4 sq ft NFV) Small
0
0.00
Vent Soffit Round
0
0.00
Vert Soffit Rectangular
6
156.00
Turbine Vents All
0
0.00
Stack Vent
0
0.00
Propa Vent
6
22.50
Permable House Wrap
0
0.00
Vapor barrier
0
0.00
Energy Star R-4 Rigid Vinyl Rept to 73" U.I.
0
0.00
Energy Star R-4 Rigid Vinyl Rept 74.84" U.I.
0
0.00
Energy Star R-4 ftid Vinyl Rept 84-93" U.I.
0
0.00
Energy Star R-4 Rigid Vinyl Reps 94-101 U.I.
0
0.00
SUBTOTALS
17$•50
6.R. E.C. MATERIALn ABOR
5048.98
I- AUDITOR NOTES I
X16
AUDITOR NOTES
AUDITOR NOTES I
Page 3
8a. HEALTH & SAFETY
Vent Bade / Kitchen Fan
0
0.00
Dryer vent w/ exhaust duct Heartland
0
0.00
Dryer Transition Duct only
1
38.00
Blower Door Test Pre Post
0
0.00
SUBTOTALS
58.00
8b. REPAIR MATERIAIJLABOR
Basement outside door only
0
0.00
Basement outside door w/ iambs
0
0.00
Door Rep] pre hung 32-W Steel*
0
0.00
Door Repl Interior solid core 28-32"
0
0.00
Door Rept pre hung 32-W wood`*
0
0.00
Window Replacement w/ SIR less than 1
0
0.00
Basement Window Repl. Awning/ hopper
0
0.00
Basement Window Rep]. With a frame
0
0.00
Lockset ( door) Schlage or equal
1
70.00
Repair / Refit Door
0
0.00
Replace Side Stop
0
0.00
Replace Casing
0
0.00
Glass Replacement to 64 u.i.
0
0.00
Glass Replacement per u.i. over 64
0
0.00
Sash Sidelock trop Replacement
0
0.00
Threshold (Wood)
0
0.00
Threshold (Aluminum)
0
0.01)
Slide Bolts
0
0.00
Plug Plate Cover
0
0.00
Cut / finish adialmeewall access
0
0.00
Cut / close afdakneewali access
0
0.00
Labor Rate Hours
0
0.00
Permits / Fees (Wap only)
0
0.00
SUBTOTALS
70.00
TOTAL REPAIR + HEALTH & SAFETY
108.00
GRAND TOTAL WORK ORDER # (A) 3896 5157.98
Any alterations or deviations from the above specifications involving
extra costs must be cleared in writing before installation.
The Work Order must be complete within 15 woridng days from acceptance
date below.
I AUDITOR NOTES I
GAS LEAK WILL DO DAY OF AUDIT I
I AUDITOR NOTES I
ILOCK SET WITH DEAD BOLT I
CONTRACTOR/COMPANY. ADVANCED ENERGY SOLUTIONS
ACCEPTANCE.Company/Contractor
AUTHORIZED SIGNATURE: Date
AGENCY APPROVALS:
CTI Authorized Signature: Date
GLCAC Authorized Signature: Date
A� O CERTIFICATE OF LIABILITY INSURANCE
°A�` 3�,°" '
/11
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 endorsemengs).
PRODUCER
Paul T. Murphy Insurance Agenc
16 Lebanon St
Malden, MA 02148
CONTACT
NAME:
PHONE FAX N
E-MAIL
ADDRESS:
PRODUCER 7064
INSURE S AFFORDING COVERAGE NAIC #
40 Washington St
INSURED
INSURERA: Scottsdale Ins
INSURER B: Peerless Ins
Advanced Energy Solutions LLC
INSURERC:AIG
28 Hamilton Rd.
INSURER D:
Peabody, MA 01960
INSURER E:
INSURER F:
CPS1014919
COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR!
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 LTR
TYPE OF INSURANCE
ADDL
UBR
POUCY NUMBER
POLICY EFF
M/DD/Y
POLICY EXP
MM/DD/YYYY
LIMITS
40 Washington St
GENERALLIABILITY
Westborough, MA 01581
EACH OCCURRENCE $ 11000,000
A
X COMMERCIAL GENERALLIABIUTY
CPS1014919
5/7/10
5/7/11ance
DAMAGE TO RENTED
$ 100,000
MED EXP (Ary one persm) $ 51000
CLANS -MADE a OCCUR
PERSONAL &ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATELIMITAPPLIESPER
PRODUCTS-COMP/OPAGG $ 2,000,000
POLICY PRO- LOC
$
AUTOMOBILE LIABILITY
COMBINEDSINGLE LIMIT $ 1,000,000
(Ea accident)
13
ANYAU10
ALLOWNEDAUTOS
X SCHEDULED AUTOS
X HIREDAUTOS
8633314
3/19/10
3/19/11
3/19/11
3/19/12
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
(PeraccIden) $
X NONOWNEDAUTOS
$
$
UNBRELLALIABOOCUR
FCLAIMS-MADE
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
DEDUCTIBLE
$
$
RETENTION $
C
WORKERSCOMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIEMRIPARTNERIEXECUTiVE
OFFICERMIEMBER EXCLUDED?
(Mandatory in NH)
Ityes describe under
DESCRIPTION OF OPERATIONS below
N/A
006789459
5/14/10
5/14/11
WCSTATU- OTH-
ER-
E.L. EACH ACCIDENr $ 1,000,000
E -L. DISEASE -EA EMPLOYE $ 1 000,000
E.L. DISEASE-POLICYLIMR Is 1,000,00o
-7
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (Attach ACORD 101, Additional RenerRs Schodule, If more apace isrequlred)
Insulation -Coverage subject to policy terms conditions and exclusions.
NSTAR Gas Co are listed as additional insured on GL policyper form CG20330704
CERTIFICATE HOLDER CANCELLATION
G4,1 a* L-cu3c,(A
�5r- w' dip, do
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NSTAR Gas CO
ACCORDANCE WITH THE POLICY PROVISIONS.
EFI
AUTHORIZED RE PRESENTATIVE
Attn: Rosemary
40 Washington St
Westborough, MA 01581
/ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The AC ORD name and logo are registered arks of ACORD