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HomeMy WebLinkAboutBuilding Permit #1125-2016 - 48 COTUIT STREET 4/26/2016 BUILDING PERMIT of NoEoT bq�o TOWN OF NORTH ANDOVER 32 5 APPLICATION FOR PLAN EXAMINATION [o Date Received * 4 ' Permit No#: T 1��OOR^TED SSHCHUSfc Date Issued: 4 IMPORTANT: Applicant must complete all items on this page LOCATION W3 Print PROPERTY OWNER IV(�.(��(1� ���h Y-\.S O fI Print 100 Year Structure yesOno MAP 073 PARCEL ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 q Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: i(- S4-0.1 t t%J L i r\0- �z- (L ov Identification- Please Type or Print Clearly OWNER: Name: N Phone:gTb`V" 310 I kO Address: y (.y1'U► S N o(1'h 1°sYt /G� ��' Contractor Name: C.0/�- �' o {'11i -� Phone: Email: v\cj.iiOn (t) !1VVLCkt i Address: Pot3\k 34N p&,L)tth r1 n1Q 78 Supervisor's Construction License: Exp. Date: I ZI I Home Improvement License: 3`� i o Exp. Date-.- ARCH ITECT/ENGINEER ate-.ARCHITECT/ENGINEER Phone: Address: Reg. No. ; FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ _� .y�D FEE: $ --30— Check No.: Receipt No.: -!:�Zei+ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location i. { No. ] . _ ? c l Date • - TOWN OF NORTH ANDOVER F . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL 1a Check Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r 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 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 !pi later& Sewer Connection/signature& Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street FIREDEPARSTMENT Temp�Dumpsfer on;srte, ,yes s �.�° ,trios , Locatediat-.1,24i Maih.,8treet• FireaDepartment signature/date r _ _..__. ._... _. COMMENTS 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name 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. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit 4. 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 :ro 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) ,a< 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 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 Doc:Building Permit Revised 2014 NORTH f own of 3? L ndover . o � .�r � � No. � * = - _ y ' h , ver, Mass, #2(0 26 T O LAN( A- COCNIC NEwKK V RATEo U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ....PEROT ►....�T..� . !�l�... ......�............... ............................ BUILDING INSPECTOR Foundation has permission to erect .................. buildings on ... �,l ... .. : Rough to be occupied as ........... .�.. .. i... k!►0 ....1r~!... . . o application r� :. . . . Chimney provided that the person accepting this permit in every respect conform to the terms of tFinal 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 STARTS Rough Service ,1.�..//.�/.��f ................ 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. Federal ID 9 0"405629 R RISE Engineering RI Contractor atio No 8106 MA Contractorr Registration No 120.979 A division of Thicisch Engineering CT Contractor Registration No 620120 ENGINEERING' 60 Shawmuf.Canton.31A 02021 CONTRACT 339-502-5197 FAX 339-502-6345 Page 7 PROGRA,\1 TJILS CONTRACT R ENTERED INTO BETWEEN RISE CNIA-HES ENGn1EERVISAND TIM CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOLIER i ��,`. ' ALONE DATE Cum# VXM ORDER Nadine Johnson ` (978)979-7616 04/02/2016 429428 00004 x SERVICE STREET t ,` BRtR10 STREET 48 Cotuit Street 48 Cotuit Street SERVICE CriY.3TATE.ZIP BnlFM CITY.STATE.77P North Andover.MA 0184\"',� North Andover,MA 01845 JOB DESCRIPTION AIR SErUJNG:Provide labor and materials to scat areas of your home against wasteful.excess air leak:gtc this work will be performed in concert with ile rise ofspecial took and diagnostic tests to assure that your home will be hat with a healthful level of air exchange and indoor air quality.Materials to be used to stat your Imre can include caulks,foams and other products. Primary arca.;for Scaling include air kakage to attics,basements.attached aara;cs and other unheated areas(windows are not generally addnsscd.) -17his kilt require(6)working hours. A reduction in cubic feet per minute(cfm)of air infiltration%till occur,but the actual number of efm is not guaranteed. At the completion of lite weatherization work,and at no additional cost to the homeowner,a final blo cr door and/or combustion surety analysis%till he conducted by the sub-coutructor to ensure the safety of the indoor air quality_ S510.00 DAMMING:Provide labor and materials to install a 12"laver of R-38 unlaced fiberglass baits to(66)square feet for drumming purposes. S135.30 xrric FLAT:Provide labor and materials to install a I(r luyvr of R-35 Class I Cellulose added to MR)square feet of open attic space. S370.36 AMC ACCESS:Provide labor and materials to install(1)easily moved.insttlating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic. This will allow the cover's,�jmcgral%%lather-stripping to restrict air leakage. $'_37.65 VL•`NTILATION:Provide Jabot and materials to install(1)insulated exhaust horse vvith roof moumed flapper vent to exhaust existing bathroom fan(s). 5118.75 VENTILATION:Provide labor and materials to install ventilation chutes in(42)rafter bags to maintain air flow. 584.00 RISE Engineering will apply all applicable.eligible incentives to this Contract. You will only be Milled die Net amount. Currently.for eligible measures,Columbia Gas offers 75"6 incentive,not to exceed 52.000 per calendar year.and an incentive of 10096 for the Air Staling measures up to the first 5680 and an additional 5340 if savings roe justified by tor.auditor. For the safety and health of your home's indoor air quality,we will he wndu:ting a blower door diagnostic of the available air flow in your home both befiore[fie work is begun,and atter the weatherizatito work is complete.We will also conduct a fill assessment of the combustion safety of your heating system and water beater.This has a value of$90 and is at no cost to you. Total allowable vicathcrbation incentive is 53.110. 590.00 RISL Engineering will apply a credit of SI Oil towards this contract,in ackawledgenm:nt of the deposit you mule to Next Step Living towards your original wcathcrization contract. $11.00 Federal 10 0 054405629 RISE Engineering RI Contractor 8186 MA Contractor Registration No 120979 RISE A division of 7'ilicisch Engineering CT Contractor Registration No 620120 ENGINEERING GO ShRwnHIL(aotan.MA 1121121 CONTRACT 339-503-5I97 FAX 339-503-045 Page 2 PROGRAM THIS CONTRACT O ENTERED P...TO SOMEEN RISE CAL•-I!ES QIGRHEERIIG AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER --` PHONE DATE CUENT• WORK ORDER Nadine Johnson (978)979-7616 0410212016 429438 00004 SERVICE STREET SRIING STREET 48 Cotuit Street 48 Cotuit Street SERVICE CITY,STATE,ZIP DNLL=COKSTATE.ZIP North Andover.MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $1,746.06 Program incentive: $1,559.55 Customer Total: $186.51 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCOROATICE WITH ABOVE SPEOFICATIOHs.FOR THE SUR!OF "`One Hundred Eighty-Six&511100 Dollars $186.51 UPON ION AND APPROVAL DY RISEEHGINEEOW-CUSTOMER AGREES TO REWT AMOUNT DUE IV FULL-INTEREST OF I%VATL BE CHARGED HONHRY ON ANY UNPAID AFT30DAYS.SEEREVERSE MR NVORTAMT pYORMATIONOR GUARANTEGS.RICHTA OF RECE".SCREQUIUM.AVJ CONTRACTOR REGISTRATION. i NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AUTHORBED SIGNATURE='RISE Enplmenl�g CUSTOMER ACCEPTANCE ROTE:TFIS CONTRACT MAY BE WI71tDRAMNOY Us IF NOT EKECUIEONATHIT DATE OF ACCEPTANCE 2,12-0 1 ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,5PECIFICATIO14 AND CONDITIONS ARE 30 DAYS - SATISFACTORY TO US Aho ARE HEREBY ACCEPTED.YOU ARE AUTHORREO TO DO 711E W RK AS SPECIFIED.PAYMENT VALL DE MADE AS OUTLINED ABOVE F gm' �V F APPI ., 2016 OWNER AUTHORIZATION FORM I, (Owner's Name) owner of the property located at (Property Address) (Property Address) hereby authorize Lr �1�� 0�'1 �A— (Subcontractor)an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform:work on my property. Owner's Signature i gad Date U ,�., 20lb The Commonwealth of Slassachusetts _— Department of Industrial Accidents Office of Inrestigations i Congress Street.Suite /00 Roston,AIA 02114-2017 \Y T•�°e * ww%,,tttacc.gotldia Workers'Compensation Insurance AfSdaNit: Builders;iContractors Elect:ricians?Plumher% Applicant Information { ( Please Print Legihh• Name t Bj—, .s, Address: 6()t3ox 314 City State 7_i I nsw S now-; 9 fib 3 S L' 3`i S 3 Are you an employer:'Check the appropriate boy: j Fr pe of pr+)ject lrequired l M. Iain a cmploycr%ttlhl_ _ ❑ 1.un a hx t;hired the sub-cootraattr, rmplrnces t full andor}sae?-tori t' s a ❑ 1 am.t ,ole lsr,ipncutr ur parolee h,t,d on the at:aclic�,heel ®RcnwdchnL ship and ha-,c no :mPio\c,:, 1 l:c,t:';rh-culsu.tcfor,It"% . ❑Dctnc+lawn %torkinYt tiir me:n srs ::t 1a:tic etrtrloyce,.end ha%e%%rrker�, I 1 } ❑Ktttlditt addOwn [No u%'VT;er,'c%tinp. 111NUtJ1:C comp- :P.,ara:he. 11:arc e:.• rir.+uus.utd it, t 1t).❑i-lectrtial repairs or addowns rcilulretl; -` ❑ rF' i � % - 1,%I ama hwnU%rr duns, a!:%wfk I.❑Plumbing rtiralr,orau% Ithill, r r1_ht t clan lw t;er \3GL ❑Kort repatr, C t, in.,uran,%:rcqu:rvd I`', 114 t.:utd ue ha%r:1r Ctttpl%1.Ce, [ti%i.tri'%CI> 1�.❑[.)ihif� :%tittp- ttt,araill'i f %1Ulred-� ',%m s�11't_an'1tirtr:c„h„_{mi.t�',,. ,�tl,•at G.:,e.'trt ht,r.. ,�_. . '!r'arts:e, .,.:� ..,r.,t l• c. r• 11111 -N,me+:ane:•.u=•..ui+-r::.t:'o>a:.,i-��u:�•.t.ia'!'.z s.'t: .."J'4-2. .i V. yr,:...:T . .r «e,*.I.tc, •^•',,'.r.,T.t:,t nn,.t idi,v rdt.:t:•ap,;..i 41•:,t._. thiliwd'2 <,,+%Tir,-.t-v.t,e:n ah: t.3 r:.h.as;'.'e;wTx I*:%:I ......,te:».e,ireo ),t,1.,­Cdn'It C,,J" e c;•t. t,wh is.rirr;.^.t s:c_r^.tr e. ^.r:mcs:p r a L'tcr t,r-_t, ,,•t.1 rea.c:wtt'n: I um un employer that is providing workers'compen%ati n inturunce•for nrr emplrot'e•es. Belowit the polh)'and jots site information. ln,uramx t`ompam Naaw. I1 Pohc% =or ScIf-itis.1Ct7,t ^ 1+"{ l0�f JZP 30c'i L-1 - -- _._ _ [\Furxioi i C),itr J 101 Joh Site Addr:s, "l U wfv t� DY C tit State Lt1)._Iv t` `h vU n v`�4 ittach a cope of the t+orkers`compensation polic% declaration pa<<c Isho"in$the polis% number and expiration dote). Iallurc to K:ere icrirace as rc,iturcd r_ndcr ticetion_S•\ire M(it.c- 1 5_.an 1,::d fa the impu,titon v2 cr:ltural pen,llue�cf a fine up to`+LiVO tint utd or one-).c,tr ir1P'r),on-n.n1. -is%tell a;ces:l pcnaltt„to the forin of a S I(ll'\\ORK t)RD ER and.1 fie): of a1%w i250 00,1 d.rs against the%1~1:11.1-. lie ech l,cd theta ceps of 111,stat mwut inx, h4: lor%%arde%::o the f):Tice o 1n%eVlkatwn;z of the r)t\ for im_rare:cw.era:•c I tier herebs'certify under the pains and penalties of perjury that the information provided above is true and correct. ph,mi .,,.3 S_V- 31 Official u.se only. Do not write in this arca,to be compl€ted by city or to%n official Citi or Town: _ • PermitTirense# Issuing.iuthorits icircte one1: 1.board of health 2.Building Department 3.t•ils,' msn Clerk 4.Electrical Imst etor 4.Plumbing Inspect+tr 6.Other Contact Per%,ow Phone n: Massachusetts .Department of Public Safety Board of Building Rcgulatfons and Standards License.CSSL-102302 \I�, KURT R CAU7'ttl, ,y P.0.Sol 314 JPswich MA 01934 Expiration Corn"ss400tr 05/25/2017 r"t/'//�c <r.j:<i<�rr�f�fl.; Office of Consumer Affairs and Business Regulation ,.• 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA+ it 20M-0511 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: 'HOME IMPROVEMENT CONTRACTOR Registration: 173410 Type: Office of Consumer Affairs and Business Regulation 1�/ ''• Expiration: 10/1/2016 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 4.t 44 ESSEX RDIPSWICH,MA 01938 Undersecretary valid wi out signature AC"RE) CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF)'.FORMATIO'.CNLY Aho CONFERS NO RIGn"15 j'ON'^IE CERTNICATE HO-DER TH15 CERTIFICATE DOES NOT Af--IPP.AT:VELY CR ti.EGATIVELY AMEN:) <Y—END OR LLTER THE CCVERAGE AF-CPDED BY TIE PO..ICIES BELOW THIS CERTIFICk"L Of WSURAVCE DOES NOT CONSTJTUTE A COM17RAC;SETY.EE'+'-E IS5Vlr:,I':SL'RER(S).AUT'NORI<T.Ep I REPRESENTATTVE OR PRODUCER,Ari?THE CERTIFICA"E HOLCEP I !WGRTANT:t`the cer.,"te holder is an AOOITTCNAi I.SU.ED,tklo Pa"> es'must he ent mea if SVDFOr.ATION 15 WAIVED,subject to:he teffns and ccncl bons of the po:+rk,certa:r,pc.kies mar rcRv4^r.a+r e*+Gnorser-Ert.A staters-._,3 cn M,5 cert tkyte does no;confer rights to the Certrr,cate ho:oer r lieu of&xn eM1G'Se�e'tU Si• Clayton Martin J Ina Agency Inc ,� Berkley Ass,,ned Risk Services 1849 Northampton St PO Box 989 u h�kr, tai fat r5@8 w�w, t@5til 2t5 @ 11° Holyoke MA 01041 �,�-;s a�x.Ser"tm, t+etsieyrakc°n C.S:4"F P.S AFCO�:N+.:iO4'ER.iE N:-A F •cs.AHk, A:.sta fns..�rrs t:r. 31.3?" Gauthier Insulation Inc ` ` & PO Box 344 Ks>QE-7 t losvAch,MA 01938 ery sst I ►.s:�=e I i<S�oS COVERA ES CERTIFICATE NUMBERS REVISION NUMBER: H S IS TO CERTIFY THAT THE POL;CtES OF I.SLPAW:E<<.STED SELDA HAV-=EEEN;SSUED'C T-E: St AED%At.cC ABCs_FOP i Ic F O iC'r'P=1 CC INNCA"E1 N3 r•.1T8STA,%VD'4G 41NY R£.^,t:+REll'eN i "ERM 0;; ;O%fjniO%Of k%Y CON-RACT OR OT-ER DOC-.Y.ENT Mh RESPECT TO,k'-tL'-7mZ CERTIFICATE MAY BE!SSUSDO OR MAI;N-A;.4,TH_ ,.,sLRAN-tE AFFORDED eY 14 KXIVES DESCRIBED.,ERE N IS SUSJECY TO ALL :4E TEAMS. EXC-USIONS AND CONOIT+ONS OF SLC,PC,-S-ES-_'VFITS OtY.MA,HAVE 8==N RED:.'CED sY P.A.D CLAIMS x.. '..a h'i•s i:- Ttti.h::k i� sh7 _ rat C,l.JtQ[R GE++Etbtt Wp111'Y EAC'•-t4 tom.R+kE,•c't 3 1 I CG�r+faCrei..;r_htP•A:✓.Gt"'Y LarM�:.SES F. �❑CiAKS X•JJf v:Y.0.Ht V.FC-X?Ao y'ERSCM:6 Ao4`,"p, S I &&%'PP4 A-50W-r -F 3 jGE at KSS*.:A-k int*APo«sacP. 'ari�cC"'!-c:w-y u., 3 .cv .ov 7 S C "'OMOQILE Lwain U L • ..•". ""'" S a a-euv: AL.At i IKrA I y-�C �SC-fes iC:••-A..'t5 3 y"-p?=.0+U.'[.. u 1i.'Y.`i ATtt= c:.^+'k r•T'r 1AlU3E S ry,�p,Wyr. 1 is (.:hCCRL1U.A& LJ OCCUR L_s EACH r,;�._1RIN'f S E<1E35 LAID --VAZ)t :1: ;tF—#rK^s S WORK !compEw6Arfv, r w .� s •y�pr Aro FVJk4Y"%"kbkM w�`° aY'*Jk tiwK'hEkLX2 yt.�+E Cf<Kt'►+rYCkPExtl__Fia _ ,,. L AtAfARo.!'t7??; 'J';C'?Ol; ta'',)f.°:DSB `-LEAC,asc-Dtr.• S 5^4'Yix3 twwa.a..r w wr rtes:zsrioe.raw _-S?ACE{a EXKlr�it S �ti'7SY.� OEiir,P-KY.PF 9�of r,Or<y e.o. c r^r5f.l'.F.a�;.cr.rA- S BCC�J r ❑ El R x5x a ..L..e q+.a•s.a..ttAr✓.._ ._r...ik=.r�r.+ __-•_- ..� r.i,-�.�a.saaa r+�ita�s+wzn. tiLO.T CA"— E4.ctc•37A•a k— CERTIFICATE?+OLDER CANCELLATION i ShOU%.;Avr VF'IC:tOVE DEZKr3ED PL-Y_t::E5E CANCEL r:et:rra.0 Ciearesult THE EXP RATK)N:a'E'HEREC-* VJ' :tit.BE:,EL%TR;E '4 Contractor Svcs ( ACCGRCA'_E W.T+.Vim4E-O CY me S D445 50 Washington Street _. Westborough.MA 01581 gflalure: ACORD 25{20141051 BPAC 3139 ACORO® DATE(MMIDD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 7/7/2015 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 Nancy Usher Martin J Clayton Insurance Agency, Inc. aIc°No Ext: (413)536-0804 FAX moo) (413)534-7874 1649 Northampton Street ADDRESS: P. 0. BOX 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance CO Gauthier Insulation INSURER C: 44 ESSEX ROAD INSURERD: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 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. INSR ADOL SUER, POLICY EFF -POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER D TIMMIDDIYYYYI LIMITS X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,990,00-0 ' DAMAGE TO RENTED A _ CLAIMS-MADE U OCCUR PREMISES(Ea occurrence $ 50,000 X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ _ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 2,000,000 X POLICY❑JET LOC PRODUCTS_-_CO_MP/OP AGG $ 2,0 00,000 OTHER: $ 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 Per accident X UMBRELLA UAB OCCUREACH OCCURRENCE_ $ 1 000 000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $_ __ 11000L000 DED RETENTION BE020792125-194985 10/18/2014 10/18/2015 $ 'WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN :STATUTE ER . ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED(S) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 19.5 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Mrt'? tbd with pdfl=actory trial version www.pdffactory.com