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HomeMy WebLinkAboutBuilding Permit #885-15 - 33 PILGRIM STREET 5/6/2015Permit No#: Date Issued: —✓ J BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER v-4 So k S T �YGI,ckJ' I Print 100 Year Structure ba� MAP ` PARCEL: ZONING DISTRICT: Historic District Machine Shop Village ye: 32 y� `�`- •' 6 1 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 Fv /��` �eoi ❑Septic. D Well D floodplain D Wetlands ❑ 'Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PEKI-UKMLU: Identification - Please Type or Print Clearly OWNER: Name: r - A4 e vi S?t %hP0L-5 Phone: 4,-'Ff Address: 33ST— Contractor Name: r l ea tQ pk-e Phone: f �JF!77 V o �-718 8 Email: Address: 2 efy- L'Kr- -rT I teeS'�1,✓ .411%1- Supervisor's 41NSupervisor's Construction License: IO G oZ;" Exp. Date: Home Improvement License: GoA 7� Exp. Date: G 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: $ LI FEE: $ 5 a bo Check No.: -� (aal7- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund A i 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 4, Building Permit Application 4. 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 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) 4, Mass check Energy Compliance Report (If Applicable) 4. 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) 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 Doe: Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS il Reviewed on Signature t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i' conservation Decision: Comments a Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp DumpUp on sif es ` no • y Lo ted at 124 !97in Street d M r•'l�F�^��� � ° k� ' • la %., : J s `r 7 �y �' r»wr'i ^7"fi^^R �,i'�e ��^"f `+R :� C-.s',� '� ' •s,L� k k` 3'b. t�� � � � �(� ,� ' tum tl � �� � � � � � ., Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and LDATA— (For department use ® Notified for pickup Call Emai Date Time Contact Name Doc.Bnilding Permit Revised 2014 No �.Location ':�%No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $5��- Foundation Permit Fee Other Permit Fee $ TOTAL $ Check #1 2 8. 3 E) Building Inspector y CD 0 z C � r sv ;, > co � o CD CL cr 2) CD O CD o cam. CD N 0 CD 0 r -r O LWA O Cl) -v n CD r•F CD CD cn' CD N v z CD O CD Q (n r+ (p — C •n m 0 D Z T N .ZJ 0 C 3 H y m � M—nj T S. N (n M :)oT 0 C S m C m n v m m =3 N ;m 0 C 7' C W z -� A T D p� m .Z7 0 G 3' T 0 C CL N 0 M M V1 m -0 = n Ln 3 T 0 O � n ro WO p O 2 m 2 cn - c� cn C) M zX m cn � � z o � Cn r4 � z z m A� C D O z h CD N CL s ca C 2. y E; N -o CD O O n 0 D) __ O rt �D 0.0 �D • CD -1 0 7 CL 0 O 2:=-oy O N rt CD �_ O O •+ CL Fri N W N O `D = <D n QW N O' = O C7 CQ Q. O rt N rt O O C1 S . 3 O � O O O C CQ 0 sCo ' e O ��-:- - Z. D CD �- O 0to =' CLQ U) < CD O CD W ` rD 'V_ c' 60, co CD cc Ear E l rt c CD �. U) CDCDCD C� 0 O DCD CD -0 � o CL y 0 VI 3 0 m (DO (n r+ (p — OJ _ N •n m 0 D Z T N .ZJ 0 C 3 H y m � M—nj T S. N (n M :)oT 0 C S m C m n v m m =3 N ;m 0 C 7' C W z -� A T D p� (� 7 rD .Z7 0 G 3' T 0 C CL N 0 M p z G) O V1 m -0 = n Ln 3 T 0 O � n ro WO p O 2 m 2 O C sTZ-- :2-04� Fedorallo us RISE Engineering w Contractor mon No AAA Contractor Regisbatlon No A divlsloo ofThhehsch Enghaeering CTContraeiorRoglstrath n tto 60 Shmvmot Unh t12, Canton. MA 02021 CONTRACT 33945026335 FAX 339-5026345 Page 1 PROGRAM twscoNraAeraOft asmWaaRISE CMA -HES n ea AM MEarsrou>?xrouvroracas CUSTOM MUM am culme WORK ORDEA Jason Stephens (978)9944707 03/18/2015 400157 00004 ' 33 Pilgrim Street 33 Pilgrim Street V North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION MAH 2 3 2015 I fill BARRIER: A Blower Door Test will not be conducted at your home, due to the presense of asbestos. & .00 PHASE ONE - Proposal for this calendar year. $0.00 AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, a air leakage. This work will be performed in concert with the use of special 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 areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally addressed.) (8) working hours. At the completion oftbe weaderiration work, and at no additional cost to the homeowner, a final blower door anftr combustion safety analysis will be conducted by the sub-contrector to ensure the safety of the indoor air quality. $680.00 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 of special 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 areas rot sealing include air leakage to attics, basements, attached garages and other unheated ureas (windows are not generally addressed.) (4) working hours. At the completion of the weatherimtion work, and at no additional cwt to the homeowner, a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. $340.00 AIR SEALING ADDER: (4) working hours. $340.00 DAMMING: Provide labor and materials to install a 12' layer of R-38 unfused fiberglass bans to (30) square feet for damming per• $61.50 ATTIC FIAT: Provide labor and materials to install a 1 t' layer of R-38 Class 1 Cellulose added to (600) square feet of open attic ?PM $906.00 SLOPES: Provide labor and materials to install a r layer of R-25 Class 1 Cellulase added to (16) square feet of slope arcaWhenwer possible baffles will be installed to the entire length of each bay to maintain ventilation space. $30.08 KNEEWALLS: Provide labor and materials to install 1- FSK faced semi-rigid fiberglass or similar rigid board insulation to (280) square feet of knwwall area $798.00 Federal In # RISE Engineering RI Contractor tteptatrafton No MA Contractor Reoleftatioo No A division of Thldseb Engtam ing CT Contractor Reolawatlon No 60 Sl awmat Unit IM Canton, MA OMI CONTRACT 339-501.6335 FAX 339-502-6345 Page 2 PROGRAM rreseoeunnerm>:arERED,hrrottETWEEnuoa CMA-HES 6e p rnffiCUINTO nrearrOmr AS CUSTOMER PHONE we CLLMN WORK Jason Stephens (978)994-4707 03118/2015 400157 ORDER 00004 WIWI[ SIRM -11 65W 33 Pilgrim Street 33 Pilgrim Street North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION STORAGE BARRIER: Homeowner is responsible for the removal of the stood items blocking the Installation of weather®tion work in the knwwWl arias. Removal must occur prior to the scheduled work start. SO.Oo KNEEWALL FLOOR: Provide laborand materials to install an 9" layerofdense packed R-30 Class 1 Cellulase added to (360) square feet ofkneewall floor. $648.00 ATTIC ACCESS: Provide labor and materiels to insulate the back of (2) attic hatch with r rigid Thermax board Weatherstrip the perimeter. $120.00 ATTIC ACCESS: Provide labor and materials to insulate the back of the attic door with 2' rigid 7hermax board and seat the door's edge with weatherstripping to stria air leakage. $73.91 ATTIC ACCESS: Provide labor and materials to make (2) temporary so= to an attic area The opening will be closed with materials similar to those existing. Finish sanding and painting is not included. $170.00 VENTILATION: Provide labor and materials to install ventilation chutes in (30) rafter bays to maintain air flow. $60.00 RISE Engineering will apply all applicable, eligible imxmives 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 calendaryear, and an incentive of 100% for the Air Sealing measures up to the fust WO 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 blower door diagnostic of the available air flow in your home both before the work is begun, and atter the weatheriration work is complete. We will also conduct a full assessment of the combustion safety of your heating system and water heater. This has a value of 590 and is at no cost to you Total allowable weatheriaatou incentive is 53,110. 990.00 MAF 2 3 2015 , Federai 10 # RISE Engineering RI Contractor Registration No MA Contractor Registration No A division ofThielsch Engineering CT Contractor Regtstration No 60 Shaµmut Unit 102, Canton, MA 02021 N CONTRRA CT (,► 339-502-6335 FAX 339-502-6345 Page 3 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBEDRELMY CUBO ER PHONE TE CLIENT• WORK ORDER Jason Stephens (978)994-4707 03/18/2015 400157 00004 SERV#C6 STREET BILLING STREET 33 Pilgrim Street 33 Pilgrim Street SERVCCE CITY.SIATE.ZW BIU.IJO CffY.SIATCZW North Andover. MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $4,317.49 Program Incentive: $3,110.00 Customer Total: $1,207.49 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF **'One Thousand Two Hundred Seven & 491100 Dollars $1,207.49 UPON FINAL VrZPECTKRJ AND APPROVAL BY RISE EUGIJEERMG. CUSTOMER AGREES TO REOR AMOUNT DUE IN FULL INTEREST OF 1%Y41LL DE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 300AYS. SEE REVERIf FOR tMPORTANr INFORMATION ON GUARANTEES. RIOHTS OF RECWON. SCHEOULOIO AND CONTRACTOR REGISTRATION. 00 NOT SI S CONTRACT 1F THERE ARE ANY BLANK SPACES 7,zv Bre .eNs .Bre e.Ls -Jay ..tvtlhcm ix2(1,20t5) aySlephms Nw20,2015) e• mg NOTE: PUS CONTRACT MAYBE TJRHORAWN BYUSIFITE%ECUTEDWITION DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT • TRE ABOVE PRICES, SPECIFICATIONS ANDCONORIO.NS ARE SATISFACTORY 30 DAYS. ASSPECIF7ED PAYMENT WI BEEMAADDEYASO�UTLI ED ABOVE AUi1fORIrFATODOTHEYloax L./ MAn 2 3 2015 M OWNER AUTHORIZATION FORM hens owner of the property looted at 33 Pilgrim Street North Andover, MA 01845 hereby authorize (subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. ��elt8 ir2D.201 Owners signature 03/20/2015 Date Signature.;Mm n Given Pv20,2015) Email: rgiven@thfelsch.c= liJi LL— an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. ��elt8 ir2D.201 Owners signature 03/20/2015 Date Signature.;Mm n Given Pv20,2015) Email: rgiven@thfelsch.c= s wwminass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Marne (Business%Organizationtindiyidual): 1 o. rQi & e4 r ry\5 J IQ r,sQ 111 O ?'he _ Address:. p_ ,� O X Phone #: Q? Are you an employer? Check the appropriate box: The Common ivealth of Massachitsetts _ Department of Industrial Accidents have hired the sub -contractors Office of litvestigations listed on the attached_ sheet. 600 Washington Street These sub -contractors have Boston, MA 02111 s wwminass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Marne (Business%Organizationtindiyidual): 1 o. rQi & e4 r ry\5 J IQ r,sQ 111 O ?'he _ Address:. p_ ,� O X Phone #: Q? Are you an employer? Check the appropriate box: 1. Z I am a employer with –7 4• ❑ I am a general contractor and I employees (hill and/or part-time).* have hired the sub -contractors 2. ❑ I am 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. employees and have workers' [\o workers' comp. insurance comp. insurance. '• required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their mvself. [\o workers' comp. right of exemption per MGL insurance required.] c.152, §1(4), and we have no employees. [No workers' comp. insurance reouired.) Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions i2.❑ Roof repairs 13.&Other r 5,JLCA6 ✓1 *An% applicant that checks box +I must also fill out the section below shoeing their workers' compensation police infornnation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must. a new affidavit indicating such. =Contractors that check this box must attached an additional sheet shoring 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- connp. police number. I ain an eniphorer that is providing workers' compensation insurance for mi• emphlves. Below is the pol%f ant/ job site information. Insurance Company Nam Police # or Self -ins. Lic. #: �0 SIG- $-5—/Ocp & 5 Expiration Date: Job Site Address: 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 Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a fine up to S 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 S250.00 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 berebr certify under lite pains cool penalties of perjtity that the information provided above is true and correct. Official use only. Do not write nt t/tis area, to be completed bi' citr or totvn officirtl. City or'fown: 11'ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: o® CERTIFICATE OF LIABILITY INSURANCE °�'�'""�°°'" 04128/20155 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 terns 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 Automatic Data Processing Insurance Agency, Inc. PHONE o Ext : No 1 Adp BoulevardADDRESS: INSURER(S) AFFORDING COVERAGE MAIC 9 Roseland, NJ 07068 INSURERA: NorGUARD Insurance Company 31470 MED EXP (Any one Person) $ INSURED INSURERS: POLAR BEAR INSULATION CO INC PO BOX 858 INSUMC: $ Andover, MA 01810 INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUM6ER: "0711114 KCVlblUN NUMLICK: 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICE GROUPS POLICY NUMBER MMID LIMITS Westborough, MA 01581 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $DAMAGE _ TO RENTED PREMISES Ocamence $ MED EXP (Any one Person) $ PERSONAL & ADV INJURY $ GEITL AGGREGATE LIMIT APPLIES PER: POLICY ERCTT LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO AILILO ED SCHEDULED ATOS OS NON -OWNED HIREDAUTOS AUTOS(Par COMBINED accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per aatident) $ PROPERTY E $ $ UMBRELLA UAB EXCESS LAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If Yes, describe DESCRIPTION OF OPERATIONS below N I A N POWCM990 01/0112015 01/0112016 X P UTE I ER STAT E L EACH ACCIDENT $ 1,000,000 EL DISEASE - EA EMPLOYE 1,000 S .000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remalo; Schedule, may be attached H more space is required) CERTIFICATE HOLDER CANCELLATION A©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (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 CONSERVATION SERVICE GROUPS ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET AUTHORIZED REPRESENTATIVE Westborough, MA 01581 A©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD OP 01. SS CERTIFICATE OF LIABILITY INSURANCE ON131201 " 03fi3R015 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 REPRESENTATME OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the pollIcy(les) must be endorsed. If SU13ROGATM IS WANED, subject to the terms and conditions of the policy, /fin policies nmy require an endorsement. A statement on this certificate does not coater rights to the certificate holder In lieu of such endorsement(S PRODUCER Durso & Jankowski Ins Agcy LLCPHONE 198 Massachusetts Avenue North Andover, MA 01845 Durso & JaNmwsid Ins. Agcy. ACT FAX : POLAR -1 INSURMS)AFFOREIING COVERAGE N=# INSURED, oar Bear ns n Co. Inc. P O Box 958 Andover, MA 01810 I A,Penn America32859 HIsum s:Solety insurance Co. 33618 DrsuRlal c : D(SUREt O INSUM tE graum F: rYfvFRAPPIL Cir_ATF 1g1kIYRFR- REVISI13M NUMBEK: 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. EXCLUSION AND CONDMONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. TYPEOFR�ANCE ThtelSCh Ineeri ng THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN POLICY POLLRVOT -POLICY YM OwUNITSGENERALLIABILITY AOppEPpAT1VE Cranston, R102910 EACH OCCURRENCE i 1,000,000 PREMISES E solo" rA X COMMER mi GENERAL UAwuTY CLAIMSAWE XQ OCCUR AC7052023 032/05 03?A2016 MED EXP (Any are Person S 5.00 PERSONAL &ADV INJURY E 1,000'and GENERALAGGREGAfE E 2,000, GEN9.AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOPAGG S 1,000, i POUCY PRO- LOC B AUTOMOBILE LIABILITY ANYAUTO 210090 01/0412015 01/04=6 COMBINED SINGLE UMIT i 11000,00 (EG ) BODILY INJURY (Par P—) E ALLOWNED AUTOS X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY (Per aaiderd) i PROPERTY DAMAGE E (PER ACCIDENT) i X NON.OWNED AUTOS S UMBRELIA LUUT X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE E A EXCESS I C JMS 1ADE AC6906385 0324/2015 0312412016 DEDUCTIBLE E E RETENTION S WORIMPS COMPENSATION WC STATU AND EMPLOYERS' LIABILITY ANY PROPRIETORIP� Y/N OFRCERIMEMBEREXCLUDED? ED (iTow"Istary In NN) DESCRID PTIOunder N OF OPERATIONS Wy, N/A I EL EACH ACCIDENT E EL DISEASE- EA EM E EL DISEASE- POLICY LIMIT S OEw4wmKM OPERA111Ior - 1"ma"all; qdd / 1 inpu gra 10I.� it� With D,�ro ol.ra Insu on or � nalr o rr! tIti1ee rte! i Th s Wo perforTned on the r be y thsiabove nsu s lelsch 9 CERTIFICATE HOLDER CANCELlA'TIAN THIELS2 - SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE ThtelSCh Ineeri ng THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave AOppEPpAT1VE Cranston, R102910 ®1988-2009 ACORD CORPORATION. All rignts reserved. ACORD 25.(2008109) The ACORD name and logo are registered matt of ACORD JX , Consumer s and usiness Regulation Office of 10ParkPite 5170 • Boston, Massachusetts 02116 improvement Contractor Registration Home imp - Registration: 102726 -- Type: DBA Tr# 252249 Expiration: 71212016 POLAR BEAR INSULATION CO. - Vincent LeBlanc—"-- p,p. BOX 958 - ANDOVER, MA 0181 Update Address and return �►� Mark reason for change. al Employment [] Lost Card Address Renew OPS-CAI a soM-04M-GIo1216 1 Massachusetts =Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialt% License: C.RSL-106017 tip• `''.. PETER A LERLAN1C , - '- 2 EAST PINE STREETt Plaistow NH 0386-5 ,t Expiration 04/2812018 commissioner