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HomeMy WebLinkAboutBuilding Permit #819-2017 - 31 MAPLE AVENUE 3/2/2017- m �UANW4 V�dv Permit No#:I 1 Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION" Date Received O/ X9,4 �A.tren POP SSACHUS, 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 AL Others: ❑ Demolition ❑ Other fF 2 07 - u Septic `Dwe - E!. Floodplain 0 Wetlands Ullaterslii=d District , . --- DESCRIPTION 01- VVUKK. I u Int t'1:-K1-UK1u11=u: e'jeT r r,10 ✓' L^/A /l r: IN s u 1a?,`o •i ' D ryns e Identification - Please Type or Print Clearly OWNER: Name: ,( v� kJ ► N 4 Z Phone: Address: 33 Mci Ple Inc.- Ph0 � eter L la Contractor Name::_. _ ___ ____.-Facet,xa Maw, -r: Ex" D ateK 5 . Su eI rvisor-s Construction Licen ,se::.._ _ _ p ... Home liri .%ovee°ient: License: J6 -_Exp,. Qateq-- p. - ARCHITECT/ENGINEER Address: Phone: Reg. Nb.—,- FEE O._ FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. f. _.Total Project C®St: $ �(6ni - DD FEE: $ Check No.: Receipt No.,: NOTE: Persons contracting- with unregistered contractors do not have: ee toothgu,a�ca�zty fund Ili Plans SubmittedEl Plans Waived 5 Certified Plot Plan ❑ Stamped Plans ❑ -TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tmiring/Massage[Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales - ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS Reviewed On Signature_ Reviewed on Signature HEALTH Reviewed on Signature COMMENTS i; It'd Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: (I, Comments Conservation Decision: Comments Water & Sewer Con nection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT' -.Temp Dumpster on site yes Located at 124 Main Street Fire Department signatureldate Located 384 Osqood Street no I `dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ==r ELECTRICAL: Movement of Meter Iocation, mast or service drop requires approval of Electrical Inspector lies No DANC=ER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine 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. r - 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 N®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o 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 140TE: 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 act Ei Mass check Energy Compliance Report o Engineering Affidavits for Engineered products (®TE: 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: BUdingPermif Revised 2014 ,60 , cl� C& W x a 0 cov u s� n T cl Om C"% cr UWWc d Z Z °° d N Z —i u W W O w O Wa z a Z G cr. a D w LL y O Z y ❑ W x a 0 cov u s� n T 0 d H z Z o m Om cr UWWc d Z Z °° d N Z —i u W W w O Wa z a Z G cr. a D w LL O Z y ❑ a O LL u �. a V) a c O � � Ot Ku c E io O LL t °b° O w m C iz t 00 O OC > N m c LL Lao b O W — ca c LL ` c 7 [D v � ++ V1 Y O E V1 r�O I� � o a� CL as Z C a !•-••. O �■ c o E Q. L CD E cm 0 ci L " 3 °' ca a� .r �` N m � m _ > O i O _ -0 0 d10 -a t V C N Q —o Boz 0.r� 0 > = oo� Q CL • m �. c r� F- v y O O Q L L f— o w 0- cn v�� m W C •0 *, O O C N N C .N LU E0 d — U m O m .. U) -0 > y= c 2 tv o o C O �-- t .,- O. O U I- CD 0- U) U) O (n tm cc cm m 0 CD O N a) t O Z O Q J O I- 0 VI 0 a U) Z 0 •m I E w O � mo O CL Q �a s � J O d Z v CL N C O,j5Ao7� Federal ID * OS-W5629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Re No 120979 CT Contractor Registration No620120 RISE 60 ShawmutRoad, Canton, IVIA 02021 CONTRACT E GINEERING 339-.502-6335 FAX 339-502-6345 Page PROGRAM THIS CONTRACT 0 fit rER£O INTO BETWEEN RISE CMA-HES ENGINEERING ANOTHEWSTOME11FOR 'WORKAB DESCRIBED BELOW FCMONER PHONE .� DATE CtIEHTS. WORK ORDER Franklin Diaz (978)6974039 02/21/2017 446254 23902 SERVICE STREET _ aM1LRJO STREET 33 Maple Avenue 33 Maple Avenue SERVICE CRY, STAMnP VUJAO CnY,6TATE,ZIP North Andover, MA 01845 North Andover, MA 01845 ,BOE I)ESCWTION BARRIER: A Blower DoorTest wilt not be conducted at_gour home, due to the prescnse of asbestos. S0.06 AIR SEALiNG: Provide labor and materials to seal areas of your home against wvasteful, excess air leakage. This work will be performed in concert with the use ofspecial tools and diagnostic tests to assure 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 at= for sealing include air Icakage to attics, basements, attached garages and other unheated areas (windows ars not generally addressed.) This will require (3) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number ofefm is not guaranteed, At the completion ofthe weatherization work:, and at no additional cost to the homeowner; a final blower door andlorcombustion safety analysis will be conducted by sub-contractor to ensure the safety ofthe indoorair quality, $255.00 AIR SEALING: Provide labor and materials to install Q-ton weatherstripping and a doorsweep to (I) door(s) to restrict air leakage. 680.00 WALLS: Provide labor and materials to install blown in Glass Cellulose to (1068) square feet of asbestos-sided exterior walls. Touch-up painting, if needed, will be the customer's responsibility. Homeowner has received a copy of the EPA's Renovate Right Lead-Salic information guide explaining the potential risk of the lead hazard exposure from the wveathcrization work to be performed. Your signature is your acknowedgemcnt of receipt and agreement to proceed. $2,799.76 BASEMENT SILLS: Provide labor and materials to install (154)-linear feet of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill,. $300.30 BASEMENT DOOR: Provide labor and materials to insulate the back of basement door leading to the bulkhead with rigid board at R•10 or greater with the required fire rating that meets the scctions.R-315.5.4 and 316.6 requirements of truilding code. Seal all edges and scams with PSK tape. $110.00 ;t U { L2j, , Federal ID # 05-0405628 RISE Engineering RI Contractor Registration No 8186 IJU MA Contractor Registration No 120979 RISE V, CT Contractor Registration No6Z01Z0 r..60 Shawmut Road, Canton, :11A 02021 CONTRACT ENGINEERING" 339-502-6335 FAX 339-50E-6345 C Page 2 PROGRAM THIS CONTRACT Is ENTERED INTO BETWEEN RISE CMA-HES ERGINEERWDANOTHECUSTOMISR FOR WORK AS DESCRIBED BELOW CUSTOMER PRO" DATE CLIA WMORDER Franklin Diaz (978)6974039 02121/2017 446254 23902 SERVICE. STREET BILLING STREET 33 Maple Avenue 33 Maple Avenue SERVICE Cm,sTA-MBP BILLING CITY,STAMZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION 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 if savings are justified by the auditor. For the safety and health of your home's indoor air quality, we will be conducting a blostrer door diagnostic orthc available air f1oly in your home both before the work is begun, and niter the Aveatheri7.atioawork is complete. We will also conduct a full assessment of the combustion safetyof your heating system and a>.;atcr heater. This has a value of $90 and is at no cost to you. The Permit will be secured by the insulation contractor. This has a value of $75 and is at no cost to you. It is the homeo%mces responsibility to close out this permit by contacting their municipality at the completion of this work. Total allowable weathcri»ttion incentive is $3,185. $165.00 Total: $3,655.06 Program Incentive: $2,500.00 Customer Total: $1,155.06 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE VMH ABOVE SPECIFICATIONS. FOR THE SUM OF ***One Thousand One Hundred Fifty-Five & 061100 Dollars $1,155.06 UPON FINALINSPECTIONANDAPPROVALBY EEHDINEERINO. CUSTOMER AGREES TO REMIT AMOUNT DUE II FULLtuTEncst OF I%VALLBE CHARGED MONTHLYON ANY UNPAID BALANCE AFTER IS DAYS. SEER E FOR IMPORTANT INFORMATION ON OVARAHTEES, RIGHTS OF RECISION, SCHEDULING, AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AUri1 SIGNATURE • RIS SlnnAnq _ ' ^ )iGZ..R ACCEPTANCE Jj NOTE: THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES. SPECIFICATIONS AND CONDMONS ARE 30SATISFACTORY TO US ANO ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK DAYS. AS SPECIFIED. PAYMENT WILL BE MADE AS OUTLINED ABOVE RISS ENGINEERING 60 Shawmut Road, Unit 21 Canton, MA 020211339-502-6335 www.RISEengineering.com OWNER AUTHORIZATION FORM ct (Owner's Name) ' owner of the property located at: 33 P11 At - (Property Address) Address) hereby authorize _J�d (a T 6 rt, J- 5, IIsi r LA (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 form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Owner's Signature Date 20P s 6.2016 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly POLAR BEAR INSULAMON Name (Business/Organization/Individual): PO BOA! 958 ANDOVER, NIA 01810 Address: City/State/Zip: Phone #: 57 CT b - Are you an employer? Check the appropriate box: Type of project (required): 1. N I am a employer with (!!7 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. Y P tY• employees and have workers' comp. insurance.$ 9. ❑Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10. [1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' come. insurance reauired.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. I' Insurance Company Name: -D (' (� t1 IA :4� S v f 4 W e Ca kt N to 11 Policy # or Self -ins. Lic. #: Powe P'y 01 Expiration Date: of L-2 40 109 Job Site Address: 3 3— City/State/Zip: A 01' 1 k —0/5, 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 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 form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tliepaiM and penalties of perjury that the information provided above is true and correct. Phone #: q ? v-- y ob_ %r,_ pA Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # i Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A�, Rif CERTIFICATE OF LIABILITY INSURANCEF6J10�/2016Y) INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 Bogdanowicz NAME: Insurance Solutions Corporation PHONE (603)382-4600 FAX N _(603)382-2034 A� I lindab@isc-insurance.com 60 Westville Rd INSURER AFFORDING COVERAGE NAIC 4 INSURER A.Western World Plaistow N8 03865 INSURED INSURER B Nautilus Insurance Aron Polar Bear Insulation Company Inc INSURER C: PO Boli 958 INSURER D: INSURER E: Andover MA 01810 1INSURER F. CUVERAueh CERTIFICATE NUMRERCL1G3232G13Q 0P1/1NQIAAI M11U91r-0- 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. RLTR TYPE OF INSURANCE D B POLICY NUMBER POM y POLICY EXP LIMITS A X COMMERGAL GENERAL LIABILITY CLAIMS -MADE $ OCCUR EACH OCCURRENCE 5 1,000,000 DAMAGE TO RENTED PREMISES Eaoccurre ce S 100,000 MED EXP (Any one n) $ 5,000 UPP9274967 3/24/2016 3/24/2017 PERSONAL &ADV INJURY S 1,000,000 GENI AGGREGATE LIMITAPPLIESPER: % POLICY ❑ j� 0 LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident BODILY INJURY (Per person) $ ANY AUTO AUUTLL OWNED OS AUTOS BODILYBODILYINJURY(Peraccident) S NON -OWNED UT HIRED AUTOS AUTOS PROPERTY DAMAGE araccid S S $ UMBRELLA UAB OCCUR EACH OCCURRENCE S 1,000,000 AGGREGATE $ 1,000,000 B EXCESS LIAR CLAIMS -MADE DED I I RETENTIONS $ A0026107 3/24/2016 3/24/2017 WORKERS COMPENSATION PER OTH- ANDEMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTNE❑ OFFICERIMEMBER EXCLUDED? NSA STATUTE ER EL. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOY $ (Mandatory In NH) It yes, describe under EL. DISEASE - POLICY LIMIT I S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached M more space Is required) Town of North Andover 1600 Osgood St, Ste 2032 North Andover, IHA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Maglia/SJA�-- ©1988-2014 ACORD CORPORATION_ All rinhfim rrm . .I ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 rmtenn , 1/3/2017 Insurance Services AC40 V CERTIFICATE OF LIABILITY INSURANCE FDATE(MMlDD1YYYY) �� 01103/2017 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 CONTACT NAME: Automatic Data Processing insurance Agency, Inc. alco o. Ext):(,VC, No ADDRESS: 1 Adp Boulevard Roseland, NJ 07068 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: NorGUARD Insurance Company 31470 PERSONAL & ADV INJURY S INSURED INSURER B: POLAR BEAR INSULATION CO INC S PO BOX 958 INSURER C: INSURER D: Andover, MA 01810 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 59831U 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. LTR TYPE OF INSURANCE (NSD = POUCYNUMBER MwDD/YYYY MIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FIOCCUR EACH OCCURRENCE S PREMISES JEa occurrence) $ MED EXP (Any one person) S PERSONAL & ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECTF_� LOC OTHER: GENERAL AGGREGATE S PRODUCTS - COMNOP AGG a S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINM Ea accident SINGLE S BODILY INJURY (Per Person) S BODILY INJURY (Per accident) s (Per accident)S 5 UMBRELLALIABOCCUR EXCESS UAB CLAIMS•MADE EACH OCCURRENCE S AGGREGATE S DED RETENTIONS S A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/ EMBER EXCLUDED? Y❑ (Mandatory in NH) it yes, describe under DESCRIPTION OF OPERATIONS below NIA N POWC840361 01/01/2017 0110112018 xER STATUTE ER E.L. EACH ACCIDENT S 1,000,000 EL. DISEASE - EA EMPLOYE S 1,000,000 E.L. DISEASE - POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H morespace is required) Contractor License: CSL 106017 HIC 102726 Town of North Andover 120 Main st North Andover, MA 01845 ACORD 25 (2014101) VA17 V GLLA 11 Viz SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD https://adpia.adp.comlISExtemallapplindey.html?clientid=2037315&requestFrom=run#/home 1/1 Office of Consumer Affairs and Business Relation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C-bntractor Registration ReOstrAon: 102726 Typix. DBA Expiration: 7=18 Tri 419291 POLAR BEAR INSULATION Co. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Update Address and return card. Mark reason for change. SCA 1 0 20h5-05111[]Address F1 Renewal n Employment []Lost card gN OmecorconsumerAMfus&Business Regablion Ucense or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found reiata to.. Reglsireiicn-* 1027726 Type: Ofilice of Consumer Affairs and Business Reg intion Expiration- 7/212018 DBA 10 Park Plaza - suite 5170 Boston, IVIA 02116 POLAR BEAR INSULATION CO., Vincent LeBlanc 51 SO. CANAL STI 45A LAWRENCE, MA 018-41 Undersecretary IV N;tvalidwithout signature �Zul 1CIPIC, R'sa ula-H-.0 -7.3 znd n d�lmi CISSL406017 - nz-- PETER ALEBLANC 2 EAST PINE STREET Plaistow NH 0388 !7.21 -' -� 7 0412812018 Location � � "fir- r V` -t, i No. I �� Date 1 z 1 pj Check # I l TOWN OF NORTH ANDOVER Certificate of Occupancy $ �1 Building/Frame Permit Fee $ T "' Foundation Permit Fee $ Other Permit Fee $ TOTAL f Building Inspector