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HomeMy WebLinkAboutBuilding Permit #1020-2016 - 50 JOHNNY CAKE STREET 3/30/2016 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1 w !�"� Date Received Date Issued: hY IM ORTANT:Applicant must com Tete all items on this page LOCATION 570 - So rill Print. PROPERTY OWNER TU i Me_,eIfO Print 100 Year Old Structure yes no MAP NO: PARCEL: � - 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 Others: ❑ Demolition ❑ Other El Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: S*411,y74 ?—ATS?c irfvAW#m ;To r-NS lJt/tTflaT.'oti Identification Please Type or Print Clearly) OWNER: Name: 'Jul%r rn«Iro r Phone: Address: �� ;onr% ('g�C �gr t Peter Leblanc CONTRACTOR Name: East Pine Street Phone: 61 Address: Plaistow, N.H. 03865 Supervisor's Construction License: l✓foo I Exp. Date: to /� LHome Improvement License: Exp. Date: 71---hG J 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: $ yS­o o • n o FEE: $ , L Ol Check No.: � �-T Z-- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracto Plans Submitted L.3 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ .'Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ :TY-P—OPSEWERAGEDfSPOEAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ Tobacco.Sales 0 •Food Packaging/Sales ❑ Private{septic tank,etc._ ❑ Pennaneiit D Mpster on-site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY _ INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &DEVELOPMENT` ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS .= At Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planfning Board Decision: Comments Conservation Decision: Comments Dater& Sewer Connection/Signature& Date Driveway Permit DPW Tow;2 Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT- Temp Dumpster on site yes_ no L•ocated'at'124,Mair Street- Fire Departme►it.sighature/date''' 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, rest 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 NOTand DATA— (For department use ® Notified foricku - Date p P Doc.Building Permit Revised 2010 Building Department "rhe foh*wing is`=a-'list of<the required.forms to be-filled out for:the appropriate permit to be obtained. Roofipg, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit { ❑ Photo Copy Of H.I.C. And/0'r C:S:L: Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: 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/Crossection/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 NOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cas<s.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw•al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Locations i No. � U7U — �u+� Date ��a '�� • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $� _ TOTAL $ Check } ,Building Inspector r 1 NORTH - _ . . ver No. h ver, Mass, 2bilp y COC KIC MlWKK �- �a4p�RATED 7S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THATT1-CAC BUILDING INSPECTOR ...... .. .. . .. . ...,. Foundation has permission to erect .......................... buildings on ........ ........ ..... g �� ... ..L 5VI� Rough tobe occupied as ........ .... ............ . .. ................. .. ...... Chimn y ' eprovided that the person accepting this pe all in every respect conform to the terms 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 STA Rough Service ......................... ......... . ..... ............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. 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' t?et� The Contmompealtlt of Massachusetts Department ofIndustrial Accidents I Congress Street. Suite 100 Boston, IMA 02114-1017 ` 1V"1 it'.rrrlrss.got!/dia Nl orkers' Compensation Insurance Affidavit: Builders/('ontractors/llectricians/Plumbers. TO BE FILED NVITII THE PERMITTING AFTHORITY. Applicant Information Please Print Legibh• ��lT/° Name (F3usitie:s'(�t_aniration/lnPC)dtitdual): � 1ArBjt°4 F ��sb 0 tit Address: .P©. 90 'y 95_ City/State/Zip: 9j,Jo✓<P, M..4, 04to Phone #: Are you an employer"Check the appropriate box: Type of project(required) 1 ®I am a ernploNet %%-fill rnipiowes(Full andfor part-lime)` 7. New COt15trUC11Qt1 '_r-1 1 am a sole proprietor w partnership and have no emplaces working [iir nic in S. Rernodelinu (� ane capacih' lNo uorkers'comp insurance required) 9 El Demolition 3 01 am a homeowner doing,all work myself lNu workers comp insurance required)' 0 d❑I am a homammcr and will be hiring contractors to conduct all scurk on mi prupert\ 1 Nidi ] E] Building addition ensure that all contractois either have Workers'compensation nisrnance or are Note I I.Q Electrical repairs or additions piopriciors with no employees 12 ❑Plumbing repairs or additions s❑I am a Leneral contractor and I ha-e hired the sub-contractors listed on the attached sheet 13 F�Roof repairs These sub-contractors hate employees and have workers'comp insurance it❑11'e are a corporaLur.and its ulllcrrs h;n'e exercised their right of esentp(tmt per Itllil.c 14 FjOther 15' 1(41.and we have no employee, lido workers'comp insurance required) 'Any applicant that chccts box-'1 must also till out the section below showing their workers conipensalion polici intimation I loincowners'-Mio submit this attidarn indica-ung they are doing all work and then hire outside contractors must submit a nc:v affidavit mdicanne such :Coniraciors that check this box must attached an additional sheet show in the name of the sub-conuactuts and:iatc wttethct tit not those entities have. employees If the sub-contracnns have emplo%ecs.the% must pro\ide their woikers'comp puhc% numbct /and on enyaloj,er that is protdc/in workers'compensation insurancefor nir employees. Below is the polio,and joh site rf forinatiotl. Insurance Company Name._�_���� Police = or Self-ins Lic n 0 W_ Expiration Date b��di��d1 Job Site Address S�O >rin`/ e4 Are 6 19n�,L City/State/'Zip: 49�hdy-11+_ Attach a coAy of the workers' compensation policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under IMU c 15?_ §25A is a criminal violation punishable by a fine up to$1,500 00 and/or one-year imprisonment_as well as civil penalties in the form of a STOP WORK ORDER and a file of up to S250.00 a dad•against the x iolator A cope of this statement mai he fnmvarded to the Office of 1mvesti!!allons ofthe DIA for insurance coverage verification. I do hereby certtf-nmle r p the alns and pe nalties of perjnll'that lite ittfor»aitiott pros itletl ahot'e is trite and correct. • - Date J Phone r: Official nse ottlr. Do not write in this area. to be completed bt•city or town nfflcirtl. Cite-or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health Z. Building Department 3. City/Town Cylert; 4. Electrical inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: 1/4/2016 Preview:Certificates of Insurance AC40 CERTIFICATE OF LIABILITY INSURANCE F �o TE�oaMzolrcs) 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: Automatic Data Processing Insurance Agency,Inc. PHONE arc No Ext): . I'M.Nc 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIL M INSURER A: NoTGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E; INSURER F; COVERAGES CERTIFICATE NUMBER: 429696 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 KI LTR TYPE OF INSURANCE INSD XD POUCYNUMBER MWDD MIDDI LIMITS COMMERCIAL GENERAL UABILrrY EACH OOCURRENCE $ CLAIMS-MADE FIOCCUR PREMISES(Eaoccunance) $ MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY❑JECTT [__1 LOC PRODUCTS-COMP/OP AGG S OTHER: S AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS HU HIRED AUTOS AUTOS Par accident $ UMBRELLALiAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER A OFFICERAEMBEREXCLUDED? IN ANY �� Ya NIA N POWC772258 01/0112016 01/01/2017 VE E.L.FACHACGDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 Ifyes.desvibe under DESCRIPTION OF OPERATIONS bAow E.L.DISEASE-POUCY UMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional RemMo Schedule,may be attached I more 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 CLEAResult,Eversourse,and National Grid ACCORDANCE WITH THE POLICY PROVISIONS. 50 Washington Street Westborough,MA 01581 AUTHORIZED REPRESENTATNE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD '4CC)RV CERTIFICATE OF LIABILITY INSURANCE DATE(MWD/YYY) 3/2 3/ 16 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 endorsemen s. PRODUCER CONTACT NAME Linda Bogdanowicz Insurance Solutions Corporation PHONE (603)382-4600 FAX (603)382-2034 AIC No 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC N Plaistow NH 03865 INSURERA:Western World INSURED INSURER B:Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO Bos 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 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 TYPE OF INSURANCE ADDL S BR POLICY EFF POLICY EXP LT POLICY NUMBER MWDD/YYY M YY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE 51 OCCUR DAMAGEED PREMISES Ea S(E.oau..nce $ 100,000 re HPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 B POLICY❑JECT [:]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: f $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea axident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED tP INJURY(BODILY INJUer accident)AUTOS AUTOS ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per., $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEF—] NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addltlonal Remarks Schedule,maybe attached It more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE /�A Reith Maglia/SJA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I149025 r9num) POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE P ATE(MMIDDIYYYY) 1/6/2016 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 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 978 6 — 11 Saunders Street A/c N�9)- .- .)_..88 7000 !FAX,No:() 978)688-7001 North Andover,MA 01845 E MAIL — ADDRESS: i INSURER(S)AFFORDING COVERAGE NAIC S -.-- -- - --'—. -- _-_ --- INSURER A:NaUtilUs Insurance CO. _ 117370 INSURED INSURERS:Safety Insurance Company— 33618 Polar Bear Insulation Co.Inc. INSURER C Peter Leblanc&Steven Leblanc D: I P 0 Box 958 INSURER- 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - --- iNSRi -- - —_ '—'AD'OLSUBR;- 1 POLICY EFF j POUCYEXP LTR i TYPE OF INSURANCE E iNSO 1 tNVD! POLICY NUMBER MMUD MM/DD LIMITS A ;COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s DAMAGE TO-REN fE0 --' CLAIMS MADE OCCUR i PREMISE5AEa occurrence) S MED EXP(Arty one person} s PERSONAL&ADV INJURY IS GEN'L AGGREGATE LIMIT APPLIES PER: f GENERAL AGGREGATE !S ft` PRO X__POLICY JECT LOC PRODUCTS-COMPIOPAGG S � OTHER: -- � � -- -- --'- -- S --- !AUTOMOBILE LIABILITY j I COMBINED SINGLE LIMIT i S 1,000,000 - ! !(Ea accident.— ---- S ANY AUTO 2100926 01/04/2016 01/04/2017'BODILY INJURY(Per person)ALL s AUTOS OWNED )t_1 SCHED AUTOSU�O i I BODILY INJURY(Per accident)!S _ xNON-OWNED i PROPERTY DAMAGE _S 'HIRED AUTOS —AUTOS i weraccidentl UMBRELLA LIAR OCCUR EACH OCCURRENCE 'S ) E A EXCSS UAB - --_!CLAIMS�uIADE { r; AGGREGATE __ S DED RETENTIONS s S WORKERS COMPENSATION !PER :0 ' :AND EMPLOYERS'LIABILITY i.STATUTE ± ER YIN, E.L EACH ACCIDENT S ANY PROPRIETOR/PARTNERlEXECUTIVE _ _ OFFICERR,6 MBERinNH)EXCLUDED? �!N!A ! E.L.DISEASE-EA EMPLOYEE!5 (Mantlatoryin NH) :lives,describe under i DESCRIPTION OF OPERATIONS below, I } E.L.DISEASE-POLICY LIMIT i S i i DESCRIPTION OF OPERATIONS/LOCATIONS f VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached it 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 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE elsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN Thi ThiFrancis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,R102910 AUTHORIZED REPRESENTATIVE (1 4000 nn-IA A t%e%mr%9%r1C0f10A'r1r1o1 All�:..L.s.-�r.w.....w.J , Aff . S 2—nd Bis�a2iflIl c Office of 10 _�te 5170 - 10 P 02116 B fl�fl'M � pie aYeme R� D s T* 2MM ppLAR BEAR IUSO �talA nt LeBlanc r -- t!tn 80X958�RbOVM MA AddrMwd cemrn� � � D iastCad 1 Address VVMALVBLWC Opg.CAi ss� '� WK 03995 _ �,�.,�.,��:- - • ' sins