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Home My WebLink AboutBuilding Permit #787-2016 - 31 WOOD AVENUE 1/7/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#; –77 / Date Received Date Issued:/1'711Z IMPORTANT: Applicant must complete all items on this 164 /o ®�4SfLE� res - no Ks) tno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other Others: 21n5vlarf o h '1111-'{Wea Water/:Q- r ®isSepc®Wehctr ct .:<.. DESCRIPTION Oh VVOKK i c) tst r1=K1-UK1V11=U: A` fS�g I��hA—�TT►�C TNS 14rr"0 h i o d =K Identification - Please Type or Print Clearly OWNER: Name: ^otY 04bbOfY Phone: yis= �►3�-�nSl Address: I Woo d Ave.,n t/ � t d .,, .t u � ,,- , • _ , of � , /. � t�,.: a n �. �i� / - Supervisors Co Sn tr�uc on Laic e?_ ld E off? E p,, ®fe ��& L > � m�Imri rr_,omoni'� ,roncCbd' a'l /i i.%�--� kt, IFxM, II►/atf?r. - �..- -�� _ __- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ dP'00 • D 0 FEE: $ �''-- Check No.: ��oReceipt No.: o2 9 rf // NOTE: Persons contracting with unregistered contractors do not have access to the guaranty.fund tiignature'of'Agent/Owner Signafiure'ofrcontracto_ _ Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swiimlmg Pools ❑ wen ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature, CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comme Water & Sewer Connectionisignature & Date Driveway Permit DP r' Town Engineer: Signature: 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) I ❑ Notified for pickup Call Email I Date Time Contact Name Doc.Building Pennit 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 a Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract a Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products ®TE: 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 µ~ ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products ATE: 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 Location No. 't s E { 1� Check Date t i TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $30" I Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ � Building Inspector WF- _ LL O D Q O m u Y -O O LL E N v+' In U Y O_ f%I c Z Z m C O Y "O C 7 LL L Oq" 7 w i G U — C LL � � y ? Vr Z m J d L WUO 3 CC I..L � O N Z J u � W L 7o d' u i V) N LL O V W N Q t7 L -3' c0 LL W D: Q w W LU Il i m Z `1 (y } Q Y O (n O ea 0 CcU _ O O U •• Q L a �a :CO cc cF) pow - z E * o ,� o y�A E of ~� . s _ Y= O v'^ / _ p d "Q0 o = H Q `NGS f�P a v . i O 10 *# "3 L Z N JCc �O zv _ d `' A W omAalg=m> �F— o� > cri c ::.••=n c� = v�CLZ • } s C LLJ C) -� Eoo F -v t� Noo a �� _ W ® (/� .y �/ 1 a, > o c W J Z d vcu w c 0 1 O -ac c 2 a� Q (D •� N ujco W O '� +�+ O O LL .n Q N O O V •a = V O OLW i 0 Q.— F� N U) L. 0_ F- 2 CLO 0 > O �L.: Z �. 0 0 � A' O W Q N d � Elm m • CD ams°, o �+ v O CL 0 CL a) Q o c v_ J 0-0 Z 0 0 cn W— Faftral m 0050405829 RISE Engineering w nolle A dlvWou of lUdwh Eagiaeming CrContractorReglatradoriftQW120 RISE ENGINEERING 60Sbmn=Uok02,C'auten,MAmn CONTRACT s39 -M 6,13 39.Saz" AMP f 757575 PROGRAM Lu".J nuscownv=mmr oaosoumPosn CMA -MS us aiermane aRFORmAs Ln Cliarn UM N PHOrta RAM cum* Wmanflen Sway Abbay tri (415)130-8054 10/0V2015 424645 00004 arRuaca ammr 31 Wood Avenue ening nurser 31 Wood Avenue sinince am arAIMM 75�75�75n Balain art;arAMZP North Andover, MA 01845 Lu_1 North Andover, MA 01845 OB DESCRIPTION AM SEAMM. Provide laborand materials to seal areas ofyo Thome sgainstwmstefol, guess airkxlmge. This wank will be performed in concert with the ase of apxid tock and diagnostic wow risme that your houte willhe kft wbb s healmd levo] of air cwtm ge and indoor air q=Uty. Abftiah to be used to seal yawn homecan ischrdo omdk% foams and o*wpm&wtL Primary areas forWdi8g=Wt *huge to attics, bri==e aunhad garages and otherwteated areas (windows are not generally addressed.) This will require (8) waking hours. A redaction in cubic fact per mimrte (cf n) of air infiltration writ cow. but the actual number of cf n is not gnammead. ALL AIR SEALING 13 FOR EXT KNEEWALL TRANSnmNS AND ATnC At the completion ofthe wee&erimtion work, and at no additional cog to the komeown=, a final blow= door and/or combustion safety analysis will be conducted by the sub -contractor to ensure tee safety ofthe indoor airgm ty. $680.00 AIR SEALING ADDER: (3) working hams $255.00 AIR SEALING: Provide labor and materials to install Q4an weatheratr4Viog and a doorswaep to (1) door(s) to restrict air leakage FRONT DOOR $75.00 Ant SEALING: Provide labor and materiels to install Qdou wesihmstripping and a domaweep to (1) door(s) to restrict air ledmge. SIDE DOOR $75.00 KNEBWALL SLOPE: Provide labor ad materials to mst&U 2" FSR f zed semi-rigid fiberglass board insulation. to (282) squaw feet ofkneewoll uder am $987.00 STORAGE RARRIRR• Homeowner is responsible for the removal of the stated its usblwwmg the instalIshon of weath=iation work in the kneawall aces. Removal must cotta prior to the scheduled work sten $0.00 ATTIC ACCESS: Provide labor and materials to make (1) tempwayaccess to an attic area. The opening will be closed with matarals simila to those aaiernrg. Fniah sasdiag and l iodng is net included. GABLE VENT IS INSIDE THERMAL ENVELOPE, Iffle ACCESS INTOATTIC AND BLACK GABLE VENT WnH r FOAM BOARD $85.00 COMMON WALLS: Provide labor and materials to immn 2" FSK faced semi-rigid maglass board msuletion to (4) mwe fees of commonwallares $14.00 RISE Engineering vrill applyail applicable, eligible incentives to this cwubact Yon will only bebilled the Net amount Cmready, foreiigtble measmc%Columbia Gas offers 75% incentive. notto arceod 51,000 per calendar yew. and am incentive of 100%forthe Air Sealing measuresnp to the fast $680 and an additional $340 if savings ate justified by the auditor. For the safety and heft of your homes indoor air quality, vie will be conducting ablower door diagnostic ofthe available air flow in yaw home both before the work is begun, and a@er the weeacrization work is complete. We vA also cnadact a full assessmantof the combustim safietyofymwheating system andwaterheater. This has a value ofS90and is at no cost to yam Total allowable weathuiratian incmtivc is $3,110. $90.00 Fedwd ID S 85a405W RISE RISE Engineering RI C ordmd Reodr ton No 120 A diviaEDn otlbtetsch � CaltracmTRa�OnNo 120978 s8 CTCm0actorReodmUentooO M20 ENGINEERING 60 Shswmui Unk til, cent mk MA 02021 339-5024335 FAX339-56345 CONTRACT Page 2 PROGRAM "mc0Nmacrm6ffn mw0BETVPeiR= CMA-HES EKGWM [eA WUMCUffM�FWV1 PKAs e smaw amIW m PNM@ DATE werte TIMOCerAm Senay AbbaY (415)430-8054 10!07/2015 424645 00004 sues STRU BBLan WNW 31 Wood Avenue 31 Wood Avenue BERM CRY,BTmzp WIM GfMffrAMZP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $2,261.80 Program Incentive: $1,970.75 Customer Total: $29025 WEAGM HERMTOFUMM SEWCM-COMMM IN AC0GRnFJ=VM ABOVE8PWWATIDWFORTHESUMOF ""Two Hundred Ninety & 25h00 Dollars V $290.25 UPONFDIALRMWeM bANDAPPAOVALBVFMB SDCEEPA`4CUSM H AMMTOR=rAMWMMMFULLMTm=cP1%vILLOCOVismo mILYONANY IMPAR DALA[pX+AFTBiS0OA18BF8R>xY FORe6ORTAM OWN11f4=00 OUARWFM%WMn80F1MCMOKBMMMB NDCOMFPACfDRRBIimfRA7KML Do NOT SIGN TNS COMRACT W THERE ARE ANY AnH0N=X0NATURE•RI88B rr4to //1 (/ IUM- IMCMIIRACfMYWWffKWA=BVUSWNWBMCUMVMM V/-0FA�fMKE - f I,) ADesvraNee OF OCNTDACT • liR: ABOVE P100B3, BPBCBTGTBDlm Al0) OMMIROlOI AIM 30 DAY& AB PAT�tAIL�88Y AB �A�BM1�E AUIFIDIt®TO DDTNFNmOC a OWNER AUTHORIZATION FORS!! !, oVfiW Of OW ► ,id ,77 .: an mdw&W mtcmtrac W for RISE En g, to act an my btu to obWM a bd t&g P and to ptnftnm wa* cn my . D 1.6h,:L tea Name The Commonwealth of Massachusetts Department of IndustrialAc6dents e I Congress Street, Suite 100 Boston, MA 02114-2017 wwnsmass.gov/dia Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. o//A1 5Y rttr j. it5,,Ai'/'oo !U_ Address: 1,,'_ 0, Y_ Ci j City/State/Zip _ M)(; /970 Phone #: S'7�''- 4= ��_ `S/f-.s`- Arc you an employe,? Check tie apprvpdate box: Type of project (required): )-jai am a employer wide 3 _employees (fun and/or pan -time) • 7- ❑ New construction 2.❑ I am a sole proprietor or partnc9hip and have no employees working for me in S. Remodeling any amity. [No workers comp. insurance require&] 3.01 am a homeowner doing ale worst myself [No workers' comp. insurance required.] t 9. Demolition Q4.[:]] am a homeowner sod will be hiring ewatractors to conduct all work on my property_ 1 will 10 Building addition eamm that all contractors citbcr have workers- compensation insurance or are sok 11.0 Electrical repairs or additions proprietors with no empbyar 5� 12-[] Plumbing rCpairs or additions I am a geaesal eootraetor and t have hired the mra b-contctors d listed on theanached shad These sub -contractors have employe = turd have workers' comp. ittsuraocr-t 13.❑Roof repairs 611 we arc a corpo=6— and its officers have exercisod their right of aranption per MGL c 14. D Other 152, § 1(4). and we have so employees [No workers' comp, insurance, tcqui c&j 'Any applicant that cheeks box #1 mast also tial out the section below ers showing their work` compensationpolicy >afOnII8t1011 t Homcowoers who submit this affidavit indicating they are doing all work and then birc outride 000tractors must submit a stew alitdavit indicating such_ 'Coovaaom that check ibis box mast attarbed an additional shoot showing the name of the subcontractors and sate wbether or not those eotities have employees. If the sub -contractors have cmploye6, they mast provide their workers' comp. policy number. l am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. j Insurance Company Name: p `6G v 11� Policy # or Self -ins. Lie. #: c� (,JG ��-� �b t� Expiration Date: d/x,11_20 /2 Job Site Address:25 � w0 $ a _ V -L City/State/Lip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00 ind/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 Jay against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for ins;uranoe ;overage verification. t do hereby certify under erre pains r' I -- el(- penalties of perjury that dee information provided above is true a Date: Y � 'lone #: �� —% J d correct 4 08kial use only. Do not write in this area, to be completed by city or town o ffiew City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5 Plumbing Inspector 6. Other Contact Person- Phone #: 1/4/2016 Preview: Certificates of Insurance -�1 At-t-CIRL® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD YYYY) I` _i' nimu7niR 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 policyfies) 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 NI*.: Automatic Data Processing Insurance Agency, Inc. A!C. No. Ext): INC. No : ADDRESS: 1 Adp Boulevard Roseland, NJ 07068 INSURER(5) AFFORDING COVERAGE NAIC C INSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B: INSURER C: PO BOX 958 INSURER D: Andover, MA 01810 INSURER E: PRODUCTS - COMVCP AGG S INSURER F: 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 REOUIRENIENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUNIENT 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 CLAIMIS- INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ICY EFF MNRJ VDDIYYYY) POLICY 13�1`t LIMITS (MMIDDIYYYY' Cranston, RI 02910 COMMERCIAL GENERAL LIABILITY CLAIMS-MAUE ❑ OCCUR El.CFtOCCURHENCE s PIiEN115ES IEa n-rlc ce) S MED EXP (An: one person) S PERSORIAL S ADV INJURY 5 GEHL AGGREGnl E LILII I APPLIES PER: POLICY ❑ PRO- JECTJECT❑ LOC OTHER: GENERAL AGGREGAI E S PRODUCTS - COMVCP AGG S S AUTOMOBILE UABWTY ANY AUTO ALL &W.'EU SCHEDULED Autos nUfOS NON 0,A'NED HIRED AUTOS nU105 C :I U SI ' °L ;I S IE. _C_11 BODILY INJURY (Pc persom S BODILY INJURY (Per acadenl S I ' U'E S 1: Al: IP acfdm1) S UMBRELLAUAB EXCESS UAB OCCUR CLAIFJS-F.IADE EACH OCCURRENCE AGGREGATE S DELI I I RETENTIONS S A WORKERS COMPENSATION AND EFAPLOYERS'LIABILnY YIN ANYPROFFICER:T-EMBER Y❑NIA (Mandatary in NH) If YCS. desmbe under DESCRIPTION OF OPERATIONS N POWC772258 011D1/2016 01/01/2017 U H X SIATUIE ER �LEACHACCIDENr s 11,00,000 EL DISEASE - EA EMPLOYEE S 1.000,000 E.L. DISEASE -PCUCY UId1T I S 1,800,000 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101• Additional Remarks Schedule. may be attached it—I space is required) varv.w' "I". MIT ngms 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 Cranston, RI 02910 AUTHORIZED REPRESENTATIVE varv.w' "I". MIT ngms reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL ACORO CERTIFICATE OF LIABILITY INSURANCE ATE (MMIDDNYM P TYPE OF INSURANCE 116!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 WANED, 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 g y PHONE — -- FAX ac' No gip); 978) 688-7000 —_ a_c,, No): 978)6-7001 11 Saunders Street North Andover, MA 01845 ADDRESS: EACH OCCURRENCE _ Is PREM SESO(Ea occurreR NTEE)nce MED EXP (Any I _ _ INSURER(S) AFFORDING COVERAGE _ _ _ NAIC S INSURER A: Nautilus Insurance Co. 17370 INSURED INSURERB:Safety Insurance Company 33618 Polar Bear Insulation CO. Inc. INSURER Peter Leblanc & Steven Leblanc $ P O Box 958 INSURER D: --- - ------ -- _ _" Andover, MA 01810 INSURER E INSURER F : 01/04/2016 , envcoAnpc rGQTICIrATF NUIUIRFR- RFVIQinm NtIMRFR, 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.AD-DOv ILTR TYPE OF INSURANCE NSD HND I POLICY NUMBER MWD Y E� POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE N OCCUR NN538691 03/24!2015 I I 03/24/2016 EACH OCCURRENCE _ Is PREM SESO(Ea occurreR NTEE)nce MED EXP (Any I 1,000,000 $ _ _ _ 50,000 $ 5,000 J GEN'L PERSONAL & ADV INJURY GENERAL AGGREGATE is PRODUCTS-COMP/OPAGGI $ 1,000,000 2,000,000 $ 1,000,000 _ AGGREGATE LIMIT APPLIES PER: POLICY JET F --]LOC OTHER: I $ BHAUTO AUTOMOBILE LIABILITY ALL OWNED ^ SCHEDULED AUTOS X II NON -OWNED AUTOS X I HIRED AUTOS �X AUTOS 1( I I 2100926 01/04/2016 , 01/04/2017 SINGLE LIMIT _(Ea- _(Ea accident) __ $ 1,000,000 r BODILY INJURY (Per person) s BODILY INJURY (Per accident) PROPERTY DAMAGE _(Peraccident---- $ -- $ A UMBRELLA LIAR EXCESS LIAR X I OCCUR CLAIMS MADE 'AN019284 I 03124!2015 03/24/2016 1 EACH OCCURRENCE AGGREGATE $ 1,000,000 $ DED RETENTION $ ( $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A _ I i AER DTH- STATUTE ER_�- E.L EACH ACCIDENT —" $ --- E.L. DISEASE - EA EMPLOYEEI E.L. DISEASE -POLICY LIMIT $ $ I 1 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORO 101, Additional Remarks Schedule, maybe attached if 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 Thieisch Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thlelsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston, RI 02910 AUTHORIZED REPRESENTATIVE L�y�� 1/412016 Preview : Certificates of Insurance AC`oR0® -CERTIFICATE OF LIABILITY INSURANCE GATE (MMiDDIYYYY) L / n11AA19MG 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 policyiies) 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 CON AC NAME: Automatic Data Processing Insurance Agency, Inc. PHONE A!C- Na. Ezl r (AIC. No. ADDRESS: 1 Adp Boulevard Roseland, NJ 07068 INSURER(S)AFFORDING COVERAGE NAICd _ INSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC PO BOX 958 INSURER B: INSURER C- INSURER D: Andover, MA 01810 INSURER E: GENL AGGREGATE LU -111 APPLIES PER: PRO- POLICY ❑ JECIPRG ❑ LOC OTr.ER: INSURER f: VRODUC Is - COMP -OP AGG 5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NANIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUiREMENT- 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 CLAIN-S. INSR LTR TYPE OFINSURANCE INSD YWD POLICY NUMBER IMtA DCY EFF DIYYYY POLICY EXP I (0.7MtDDJYYYY) LIMITS Cranston, RI 02910 COMMERCIAL GENERAL LIABILITY CLAILIS4.1ADE ❑ OCCUR EACHOCCURRENCE S n PRE1.1iSES"Eno'curlen[ei S LIED EXP iA-y one Person) S PERS01, L S ADV INJURY S GENL AGGREGATE LU -111 APPLIES PER: PRO- POLICY ❑ JECIPRG ❑ LOC OTr.ER: GENERALAGGREGAIE S VRODUC Is - COMP -OP AGG 5 S AUTOMOBILE LIABILITY ANY AUTO ALL Gi;aaED SCHEDULED AUTOS AUTOS NON-OVVNEU HIREOAUIGS AUTOS C :7 N U S IEn u"n^_lnll BODILY INJURY (Pt; pe Suri) S BODILY INJURY Wl acddenl S ) PRUPtch IP —d.dl r. .G S S UMBRELLALIAB EXCESS UAB OCCUR CLAIMS MADE EACHOCCURRENCE AGGREGATE $ CEO I I RETENTIONS 5 A WORKERS COMPENSATION ANDEMPLOYERS'LIABILIYY YIN OFFIICEf(AEEBEREXCLUDED>�UTIteE (Mandatoryb NH) II ves. describe under DcSCNIPTICNCFOPERA'nONSbtluw NIA N POVVC772258 01101120tH 01/01/2017 X t V M- STATUIE ER E.t..EACHACCIDENT 5 1,000.000 E.LUISEASE-EAELIPLOYE S 1,000,000 EL.OISFASE-POLICYUt.!!I S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule. may be avached H morespacc is required) nv woo-cU I-# /AwRU UUrcrILIKA IJUN- All 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 Cranston, RI 02910 AUTHORIZED REPRESENTATIVE nv woo-cU I-# /AwRU UUrcrILIKA IJUN- All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ((/uYifliil�°`m � " mess Reguiabon Office of �'Qo � and 10 pPlaza - SI&517p211b Boston,uo Nsachuse ion Home yprovement ContM_ : Rei cn: �02?26 DBA 48 T* 2522+ 7p2(ZO POLAR BEAR INSULATION Co Vincent LeBlanc P.O. BOX 958 _ _- -_ _-g for ctaur- ANDOVER, MA pq g10 _ ° Up�te Addrm and,retn�n cs O Last card Addres Renewal OPS-GA1 u 6 f ri-fii5 C„u*;rrucdun 5uprnigorLSlfpeci:t tv ` p lawALERLANC ZEAS'�pIINgS'�R��sT _ ptatstow 03865 042M2098 waxr-ussionef