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HomeMy WebLinkAboutBuilding Permit #1239-2016 - 34 ELM STREET 5/27/2016 BUILDING PERMIT of NURTN q t6, �o TOWN OF NORTH ANDOVER ,�� h .. ,::•�.: APPLICATION FOR PLAN EXAMINATION 70 Z 2A Date Received �4"°RATE° ""c5 Permit No#: / 21 LUI Date Issued: 1 gSSACH I PORTANT: Applicant must complete all items on this page LOCATION h_ eq^jove r^ Print PROPS TY OWNER fbectiq h at T-TttTO PI r Print 100 Year Structure yes no MAP PARCEL: I ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no 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 ?r Others: ❑ Demolition ❑ Other L7oSV/4r/0 " ❑ Septic []Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ���' Seali✓14 ,�I T'1 .C i hS�JaTiOv, Ta - ys Zjr1,1;IaTi�o6? Identification- Please Type or Print Clearly OWNER: Name: fl-)t I"r^ v1 /)eT i I Yro v, Phone: �1�� 6S�SE3 0 Address: 34 Cjyy7 S /I. ?9r efd✓r r' Contractor Name: 7e-r P i l r 6/a v1C Phone: y0 ?G3,` Email: Address: 2- r (F 67- ;o e 5 77 S iD r.✓ 0- Supervisor's Construction License: /vG o lExp. Date: u/ /,�g�r� Home Improvement License: >0A 2d- G Exp. Date: 7 Z A� 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: $ 3 3dO- 6 FEE: $ 4c) — Check No.: ]-7 I, Receipt No.: -�6%4 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ti Location No. — l Y' Date t • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ Check# Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body ody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE4DEPAR710-NT Temp�pumpster,oncsite ty"es_ Locatetl�at,12.4Main�Str•eetF ---- ---- -_- __._ Fire Departments_ignature/date,..,.. C®MMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pen nit 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 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 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 .� 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4 Building Permit Application Certified Proposed Plot Plan �. Photo of H.I.C. And C.S.L. Licenses .� Workers Comp Affidavit ,a< 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 OTE: 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 NORTH ` E � Town of _ Andover O �` 0 2 T �. h �, ver MassC46t - 0.1 26(�r c0c.41c"IWIC �1 �qs RATED U BOARD OF HEALTH Food/Kitchen PERFI LD Septic System THIS CERTIFIES THAT Q BUILDING INSPECTOR ................... r.. .. ... ......................... ............ . ................... ....................... haspermission to erect ........ buildingson ...... ..,, ,,,,,,, „ ' Foundation p ................ � ...... ....... ... .... v Rough to be occupied as � 1 Chimney provided that the person accepting this permit s5 every respect conform to the erms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ..'..•....,. Service r ..................... .... .. .. l....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. O to fioa RISE Engineering Federal ISEA division ofTbidscb Engiueering MA Contractor ReglotraOaM Na 120979 ENGINEERING' G9 nossrent unit 7r7, 9'A2T C��TIV'9CT 339542 FAX 339.502-6345 'Page 1 „- PROGRAM THSCOMMIMISENIERADom d0U CMA-HESAANDnmcu$roolmusamm=AsAs VKWM wan: guars mmnrotxEa Meehan Nettleton (978)655-3193 0325/2016 431843 00003 aFavxM aTAi=ttr � era:sir _. _- _ -- _ •-- -.--- 34 Elm Street 2QDESCREMON t� 34 Elm Street 2 6W=8 CrMSTAMW ._. . .+. Bum CITTATATEIIPNorth Andover.MA 01845North Andover,MA 01845 PHASEONE-Prapasrd for k saleadaryata. S0.00 BARRIER:A Blo w Door Ten wnl not be conducted at your hoax.doe to the p=cm ofeubca a. 4 $0.00 HAZARD BARRIER:1Ve have idemified that dxre are mteoaeted clectnat juncIft n bom prem to)varhoax.Ttaxeaeed to be covered prior to the start ofyour bounds weatherhotlo n wort,and are the why ofthc homemmu: S0.0D AIR SEALING:Provide haw and Materials to sal areas of)var home opho wMeril.excess drkalangt M utak mill bs pafotntedin concert s'eib the use ofspeeiol.Umb and dnuoWte tests to risme am)Tau hotue will be left with a beattlM Ievel of oil ettctraage wad andoor air gaaldy.Ivlazaiais to lx used to sea!yowl loax txa include c uRs,ibe ns mrd oUtei poduaL Pe6nmy areas rat slaftlndadea)rt*d6 toanks,basauerns,anotdudga%sawadatitermdnertroderas(windowsarentagaaWy ads cm&)This VIM regWM(8)umft bums.A redaction in cubic fat per ru' (efm)ofair in station silt actor:but dMAM t mmiber ofelin is not guatmowd. . At the cm*ton of the wathefmian work,and at Moadd hwal cost to the hooteoumr,a fuel blo ver dew mtdtor combustion safety analysis will be condactrd by ftnb-�to ermtrc the sofsy ofthe iadoorair gtu ty. S680.0D ATTIC FLAT Provide lo6w and materials to kwop a 6'Iqu oiR 21 Class 1 Cellulose added to(630)square Cat of Romod 2* Spam i $1.12140 DAMMING:-Provide labor and materials to irnslail a IP layer of R•38 anihoed jtbe*s bits to(40)slime feet fardatnuft purposm ATTIC FLAT:Provide labor and materiels to install a 10'toyer of R 3S Chns 1 Cdlatose added to(336)s,I feat ofopan WA b493.92 STORAGE BARRIER:homeowner is respm ble for the reooval of the$total items blocking the itatallafm of wcn*c im m wort in the autc. Removal muss occur prior to dw schedalod work sort. $0.00 ATTIC ACCESS:Prmido labor mrd materials to inset w the buk of ahc attic door whh Y rigid Mmumx baord wad$sal rix door's - edge wUh ttrathcMdpping to restrict air fie. 573.91 VENTILATION:Provide labor and fadaWs to isrstall%vmWwn dates In(481 after bays to umintain air Raw. 596.00 VEM I TION:Provide tabor and aaaerials to install(10)4'X ib'mctangabu abuWnmr sotrrt vents to; veouludon in allic Mem.Specify color Whitc or Cagy. 5250.00 t 0 w Federal to C 054405W R' RISE Engineering RI ContrmcWRegistration No 8186 MA Contractor Iteg�ralla No 120879 A division afTbieiscb Eogineerimdp Et`r4tREER1MC' 65 Simwmdu Coit 0t.Canton.MA 0=1 CONTRACT339-302.6335 FAX339-5n-045 CONTRACT Page 2 PROGRAM UMBAMMUFM CMA-HES NOTec FORMMAS aeDaoosoow coalman PRM :dN<TE suorre tTaExottuEa Meghan Nettleton (978)655-3193 03!..512016 431843 00003 34 Elm Street 2 34 Elm Street 2 arATed�CITY.aTATL;aP _ cmu=ary.sumnv — North Andover,MA 01845 North Andover.MA 01845 JOB DESCRIPTION COMMON WAM.-Provide labor and materials to h=23.S"R-13 faced fibaglass bat insddmiort lo(24)Weare rest of eomam =8 aren.2'd9id nbaglas inwImion wil be itwtotkd overthe mrfam 587.60 CRAWILSPAM Provide kborand materials job"(448)sdpmae rat of 6 ml poby%iryhadc w=open gWW in designated basomc n mos UNDER MAIN HOUSE.IFOVER MAIN HOUSE GEIS ATTIC INS. $344.96 RISE Enffincering will apply art 210cft d4ft inarnins to this cattraa You wilt oolybe bMal Melia moatau.Comnatly. fordigt3k>m ra.CohmthtaCasoRas75%bwcmivt;Amto0zaodSZ0oprenkoftyMandaoiuoautv0or100!6forthe Air Sailing mdxmerrs up to the bat S680 and an addhtaaal 5340 irsavings arc jodreed by the auditor. For the aft dad hdxlth ofytNtrhomes indtow air der t.we will be orndang a blower door'dmg twL-orthe avand teair now in your home bah berate on wort Is begun,oAd ofler lhe md=b2goa vm&is oomplft we w81 d w dm &m a rap me==of 1110ownb051ion SaBdy ofyvduftWi29system dad wamhealer.This has nVabm 017590 and is m no cost toym Total altowable malbuiaation ineemin b9.110. 590.00 �s Total: $3,318.79 Program Incentive: $2,592.34 Customer Total: $727.45 WEAMMMEW VTOt4RtMSt PJM.CMWLMMACCORDANCEWOMAMMSPECWA3tMMFORMMSUNOF *-Sever[Hundred Twenty-Seven S 481100 Dollars $7VAS tWdlFilgLaBt�iWWAriDATPRa1MttiYPKEa1310i1titA�TOtiFJIRAitala7ralK alilnL Wr6RESTOF t%w11L BS QWI6EOMOIRIILYONAftlt _ dncvruaewa�47 - r0moaowrn�eata_aoaaan,�u�aa.waxrsocAra�u,sdxadua+¢.amooxmw�_eTowaemmeAnaec UN SMTM1.RCONTPACTIFTHEMMEANY IANKSPACE3 dmrE Trm dANraJIeTWY mmmw.rmdmrus4Naromco1BDmol= aATEOPMU"ANCS /213 j 2016.._... _. ACCfArAMEWCORIPA r-TNEAtiOV-MOMBtECIFIC►TUMANDCONW10min °"Y8 uave w�inar�NrieerAsoOnnrto wnmoornEnedaot RISEr 60 Shawmut Road,Unit 2 1 Canton,MA 020211339-602-6336 ENGINEERING www.RI$Eongineoring.com Efficiency Energized. OWNER AUTHORIZATION FORM ►, �r�NRns NFttLCToN (Owner's Name) ' owner of the property located at: LI ELM ST (Property Address) ' N6RT H RNl�oy� . M►� 0(814S; (Property Address) ' hereby authorize )d(C� i-Q ear TA Su fc -r'p 11 (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. r Owne ignature - 2016 Date The Commonwealth of Massachusetts Depa>tmefft oflnduMialAccidents Office of Invesagaflofts, 600 Washington Street Boston,MA 02111 s� www.mas. gov/dia Workers' Compensation Insurance Affidavit:guilders/Contractors/Electriciam/Piumbers Applicant Information 'lease Print Legibly Name(Business/Organization/fndividual): Address: PO BOX 958 City/State/Zip: Phone#: 17 [re an employer?Check the appropriate box: _ a em Io erwith� 4. Type of project(required):P Y ❑I am a general contractor and Xloyees(full and(or part time).* have hired the sub-contractors6 ❑New construction a sole proprietor or partner- listed on the attached sh9et 1 7. ❑Remodelingand have no employees These sub-contractors have 8. ❑Demblitioning for me in any capacity, workers'comp,insuranceorkers'comp,insurance 5. ❑ We ale a corporation and its 9. ❑Building additionred.] -Officers have exercised their10.❑Elecfrical repairs or additionsa homeowner doing all warp right of exemption per M(3L 11.❑Plumbing repairs or additionslf.[No workers'comp. c.152,§1(4),and we havens12•❑Roofrepaixs ance required.]i employees.[No workers' comp,insurance required.] 13.❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 their workers'comp,policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: d ok Policy#or Self ins.Lie.M. j W'C -7 Expiration Date: Job Site Address:_ _ 57- ,� City/State/Zip_Aer' Ja V r- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequired under Section 25A ofMGL c.152 can lead to the imposition of criminal penaltine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form es of a of a STOP WORK ORDER and a fine fi Of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of lrnvestigations of the DIA for insurance coverage verification. Ido here b ce 'y rider the pains and penalties ofperjury fliat the information provided above is true and correct+ Si ature: c Date: 'hone#: Official use only. Do not Write in Otis area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Tgwn Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other ContactPerson: Phone#: (MLVDDfYYY AC40RV CERTIFICATE OF LIABILITY INSURANCE D3/23/2016Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT Linda Bogdanowicz NAME: Insurance Solutions Corporation PHONE (603)382-4600 No:(603)382-2034 60 Westville Rd E-MAIL DDRESS:lindab@isc-insurance.com A INSURER AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A:Western World INSURED INSURER B Nautilus insurance Group Polar Bear Insulation Company Inc INSURER c: PO BOR 958 INSURER D: INSURER E: Andover MA 01810 INSURER F COVERAGES CERTIFICATE NUMBER:CL1632326134 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 WTH 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. ILSR L R TYPE OF INSURANCE POLICY NUMBER MM/DD/YLICY Y M LILY YYP LIMITS R COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE ❑$ OCCUR PREMIDAMASE,TO ED 100,000 PREMISES Ea occurrence $ � R MPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 R POLICY❑JELOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peracciden $ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000 000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTNE EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Thielsch Engineering is named as Additonal Insured on a Primary and Non-contributory basis on the Liability policy as per written contract for work performed on their behalf by the insured for insulation work-mineral. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r9n14on POLASEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE{61201 YYY) 1/612016 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 endorsement(s). PRODUCER CONTACT NAME_ __ Durso&Jankowski Insurance Agency PHONE g78 688_700D !FAX 978 68i-7001 11 Saunders Street Arc N`LEMI_� .. �.. a/c,Nowt ). North Andover,MA 01845 E-MAIL "— ADDRESS: INSURERS)AFFORDING COVERAGE ; NAICS INSURER A:Nautilus Insurance CO. _ 117370 INSURED INSURER B:SafetY Insurance Company— 13.3618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc DNSURER P O Box 958 INSURER ER D: __— Andover,MA 01810 INSURER E: INSURER F- COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRi — —' —'AEF60S0BR: - POLICY EFF POLICY EXP - LTR TYPE OF INSURANCE iNSO i WVD: POLICY NUMBER i MMlOD ! MM/D A LIM A COMMERCIALGENERALLIABILnY —_ 1 I .EACH OCCURRENCE S `- DAMAGE TOKEN TE - _CLAIMS-MADE OCCUR 'PREMISES{Eaocarrre .S -- _ _------ -- j MED EXP(Any one person) S PERSONAL&ADV INJURY i S GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE is _ i Y POLICY! JE _LOC PRODUCTS-COMPIOPAGG !S I OTHER: - -5 _.— AUTOMOBILE LIABILrfY 1 COMBINED SINGLE LIMIT S 1,000,000 i(Ea acciderto_ B ANY AUTO -2100926 01/04/2016'01/04/2017!BODILY INJURY(Per person) ;S ALL OWNED ?�'l SCHEDULED — AUTOS AUTOS y BODILY INJURY(Per accident):S ' n `HIRED AUTOS X : NON-OWNED - I PROPERTY DAMAGE S _AUTOS !_(PeraccidenJ — _._ _ . UMBRELLA LIAB OCCUR EACH OCCURRENCE S ) A ;EXCESS LIAR - CLAIMS MADE] i AGGREGATE _—_ I S — OED RETENTIONS I i$ WORKERS COMPENSATION 1 PER AND EMPLOYERS'LIABILITY $TAME _ ANY PROPRIETORIPARTNERIEXECUTIVE Y/N E.L..EACH ACCIDENT S ,OFFICERIMEIABEREXCLUDED? �IN/Ai i i (Mandatory in NH) E-L DISEASE-EA EMPLOYEE'S If yes•describe under 0 SCitIPTION OF OPERATIONS below t E.L.DISEASE-POLICY LIMIT i S j i j � I DESCRIPTION OF OPERATIONS/LOCA'noNS/VEHICLES(ACORD 101,Additional Remarics 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 Thielsch Engineering CER T IFICA T E HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE hThiielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS- Cranston,RI 02910 AUTHORIZED REPRESENTATIVE 4l 4000 nn-1A Af1f%n 1 nrlOnAOATlnal AH_:_t_4_..............i 1/4/2016 Preview:Certificates of Insurance ACORE® CERTIFICATE OF LIABILITY INSURANCE F�olTE ioarzols ) Iii . THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTAC NAME: FAX Automatic Data Processing Insurance Agency,Inc. iuc Mo Ext): A/C,No. 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIL 0 INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER a: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429705 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. tNSR LTR TYPE OFINSURANCE INSD rXDPOLICY NUMBER MWDDNM MIDd LIMITS �LKPOLICY EFF POLICY EXP COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE D OCCUR PREMISES Ea acarRnce S MED EXP(Anyone person) $ PERSONAL d AW INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PET �LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY $ Ea acridml ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident f AUTOS AUTOS ( } ND Per accident S HIRED AUTOS AUTOSUTOS S =--LLA I- OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION S WORKERS COMPENSATION X AND EMPLOYERS'LUIBILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUACG DENT E.L.EACH ACDENT $ 1,000,000 A OFFICERR.IEMBEREXCLUDED? M NIA N POWC772258 01/01/2016 01/01/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 1,000,000 tf yes describe under DESCRIPTION OF OPERATIONS bdow E.L.DISEASE-POLICY LIMIT f 1,000,000 DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H mon space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GLCAC ACCORDANCE WITH THE POLICY PROVISIONS. 350 ESSEX STREET Lawrence,MA 01840 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Regdodon office QfCOnsmer Af &S audB io Parkplm_Slnm 5170 BOstO%Maw=b- 0 02116 �OIl 4IIh.,rovemwtQW zc AQV26 Tjpw- DBATt# �9 - 7n aGIS - P0[�BEAR INSOLK Co Vincent LeBlanc -- p_Q_BOX 958 Address 1-11 Ieival OPS-CAt ct Yia�s�iK 03M _