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HomeMy WebLinkAboutBuilding Permit #1298-2016 - 544 JOHNSON STREET 6/10/2016 BUILDING PERMITo� NORTH hbtbN� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0 (� Date Received Permit No#: gSSHCH►1`+�� Date Issued: D ORTANT: Applicant must complete all items on this page LOCATION Soo STSre% Print PROP,F4RTY OWNER :c arlh,e Print 100 Year Structure yes no MAP I PARCEL. ZONING DISTRICT: Historic District ye no Machine Shop Village y 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 �✓�Svla He H ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District o Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: A',I`Se Ir'nu ,QTTiC irSvlakteti Tv -Kf ✓-ewhl190100 Identification- Please Type or Print Clearly OWNER: Name: M,Chael Donnelly Phone: sof TLL3,�-6 `/ Address: 4 709h! o % 'Ie Peter Leblanc Contractor Name: ' 2 Fact Pine Street Phone: Email: Dla,;ksk..li_, AT L7 03865 Address: Supervisor's Construction License: Ld Cgol? Exp. Date: Home Improvement License: IExp. Date: ; /k 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 SPO-00 FEE: $ Check No.: Receipt No.: 30�cj� NOTE: Persons contracting wO unregistered contractors do not have access to the guaranty fund 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 Reviewed on Signature COMMENTS A _ 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 'ARTMEN $SFIRE DEP _._ . t c `Temp ®�umgster�ontsite yesa__ o �Lo atecl{atlr1MainSteet _ = dCQepraf1t) s gnatu`r�e/date N �`COMMEN�TS, � � � is 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 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 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) 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 Location l� -! (� i 1 J r7 1, IJ 414 e No. Ci Date Gilt 1 l • TOWN OF NORTH ANDOVER !.. Certificate of Occupancy $ ' Building/Frame Permit Fee $ Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ Check#� 7 ✓ Building Iritpector �,- NO R T-H f Town 3� _ Andover to h ver, Mass, ilurile, 0006 COC NIC Nl WICK 1' V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System G �. 41 BUILDING INSPECTOR THIS CERTIFIES THAT ........................ .�.. ...............�......... .. ....^. ......�........... �......��� ...�O ........ Foundation has permission to erect .......................... buildings on ....�. ........... ....... ............... Rough to be occupied as ......hy�1�e .. ...... ..-.. . ....�.�.... R.1�►. . 1�. -.�u...Q......... Chimney.... ...... ..... provided that the person accepting this mi shall 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 Ins ctlon,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS 10 T Rough Service ..... ... .......... ..... Final B L INSPE OR 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. n[DO 05-04 EagilleerhIg McoRegon No 6186 VA00.1radn.Registration No 1t'A97 � A division ofibietseh&gineering RISE 8 R 11?ERCompany Address,City,MA 00000 401-123-1234 FA1401-123-1234 CONTRACT COfdTRACVT Page 1 PROGRAM CMA-90 WHOM PROM WE QJENTO WWIUY[ER Michael Donnelly (50&)M-3254 050016 433911 aannce sauumr SUM smear 544 Johnson Sheet 544 Johnson Street Inn P�QQ;= U V sauvrr�ertr smE.a mune cm.wr4zP North Andover,MA 01845 North Andover,MA oisolfil M Ay - 9 2111 JOB DESSCRII''1M BARRIER:A Blower Door Test will not be conducted at your home,dae to the presense of asbestos $0.00 BARRIER:The following contract is not valid unless acoompanied by the Pre-Weatherinnion Barrier Invent ive form.signed by you-Imense'ebxtrick►n.Work will not proceed vdh this work until we receive a copy of the form. $4.00 AIR SEALINQ Provide laborand materials to seal areas ofyour home against wasteful,excess air teakage This work tall be pcdonned in concert with the use of special tools and diagnostic tests to ason that your home tail W left with a heahhfid level of air excImage 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 hakagr to attics,basements,attached garages and other unheated areas(windows are not 9mcrariy addressed)This will require(8)twrking borax A reduction in cft feet per minute(cfm)of air infiltration tali cc=,but the actual numbs of cfm is not guaranteed I At the completion of the nmtherization work,and at no additional cost to the homeowtxy a fuml blower door andtor combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. 5680.00 DAMMINQ Provide labor aml materials to install air layer of R-38 unlaced fiberglass baits to(112)sgwe fed for damming pwpwM SM.60 ATTIC FLAT:Provide labor and materials to install a 14'layer of R-49 Class 1 Cellulose added to(474)square fat of open attic Spam S801.06 SLOPES Provide labor and materials to install a 6'layer of R 21 Class 1 Celhdose added to(294)square feet of slope area Wherever possible baffles will he installed to the entire length of each bay to maintain ventilation spasm $54684 ATTIC ACCESS Provide labor and materials to insulate the back of(])attic batch with 2'rigid Thermax board Weatherstrip the perimeter. 560.00 VENTILATION:Provide labor and materials to install(4)8'diameter roof vent(s)to increase ventilation in attic areas. The vent can be sq►pticd in(circle color)black,brown,gray or mill finish. $34200 VENTILATION:Provide labor and materials to install ventilation chutes in(43)rafter lays to maintain air now $86.00 COMMON WALLS Provide labor and mateiats to install R-13 urfireed f b ndassto 48 square feet of common will. Then install I"rigid board insulation that mats the sections R 316.5.4 and 316.6 mWjkcmcnts of bmlding Code. Seel all seams with FSK tape. $17520 BASEMENT CEILING Provide labor and materials to install(118)linear feet of R 19 unlaced ftbergknm insulation to the perimeter of the basement celing at the hose sill. Federal to205440M RISE Engineering Rl Conh War Registration No stse A division of7bietseb Engineering OOn Or Registration No 1 879 RSECompany Address,City,MA 00009 p 401_i23-1234 FAX401-123-1234 CONTRACT Page 2 PROGRAM a09 awxsaAM a>aWIEo aro BEmEma RISE CMA41M MOV@eUSTaMRRwa— CUSIDAER Palate Rug Caamrm aroPoCOrmeB Michael Donnelly (508)932-3254 05/05/2016 433911 00002 std STIM7 an=11MMI 544 Johnson Street 544 Johnson Sheet 89RU a em.svmzp gin air gytgap North Andover,MA 01845 Notch Andover,MA 01845 JOB DESCRIPTION $206.50 BASBMFNT DOOR Provide labor and materials to insulate the back 01`1119 basement door beading to the bulkhead with 2"rigid board that meets the sections R-316.5.4 and 316.6 requirements of btuldaag eod. Seal all edges and seams with FSC tape. 572.22 RISE Engineering wall apply all applicable,dil ible incentives to this contract. you will only be billed the Net amount. Currently. for eligible measmes,Columbia Gas offers 75%incentive,not to exceed 52,000 per calendar year,and an incentive of 100%for the Air Sealing mcavvaes up to the first$680 and an additional$340 if savings are justifced by the auditor. For the safety and health of your homes indoor air quality,v►e wail be conducting;blower door diagnostic of the available air now in your home both before the vwrk is begma,and after the aeatheriailon pork is complete.We will also conduct a fall assessment of the comb wUon safety of your heatingsystem and water heater.This has a vahs of 590 and is at no cost to you Total altowdile vveathmizWon incentive is S3,110. 590.00 D , 9 2p16 Mai Total: $3,289.42 Program Incentive: $2,249.43 Customer Total: $1,039.98 WEA3 MMUNYTOPrI UMa S-COWLQEINACCOR MCt3WRNatrdtiESPECOMT OMFOtTIMSUNOF ***Otte Thousand Thirly-Nine&981100 Dollars .$1,039.98 LW=f=LUMMCMANDOffRWMLiNMEEMMMMMCWMRMAGMM REKlrANOWn WFUU.DIMMTOP/%waL6a CHARMUCKI CHAtr aJPAIDBAtANCE SEE rarOSVWXY01301amneN 0UARANEBI.RCMDOPRSCWa4SCKWX W*= AE06FA4aV. O HOT SIGN THIS CONTRACT IF THERE ARE ANY ANI PAC 1 0411111 aronAama-lase J5. 5. 141 MCS:YCS COi@{ACiY1Y BEwititHA9rNar iR iFSOTE]iBCttE.DYA4ta ung CPACCEPPRICS ACCEPTOMOPOOMILW-115WP SPEaflCAIIa1SAEIDOaamWWAiG 3D UNTS. A88P��ItELLp fpF77ryrA1.BEdp08 AS Wi�IIEDrAEW AOftORlagDlDtlOtiEwaae a RISE60 ShawnM Road,Unit 21 Canton,PAA 020211339-5024336 ENGINEERING www.RiSEengk*Wng.com OWNER AUTHORIZATION FORM t, fYliG1? 4e , �o � �ll� , (Owner's Name) owner of the property located at: a fi sc� (Property Address) (Property A dress) a� ' hereby authorize I j r -t-C'r �^i' (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to ob in a building permit and to perform work on my property.This form is only valid with a signed contract. d4nees Signatu Date The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations' 600 Washi4ton S&eet .Easton,MA 02_111 www.ma_sv gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A Iicant Information .'lease Print Le l Name(Business/Organiwtion/Individual): Address: PO BOX 958 J 1:11 0A M40 -City/State/Zip: Phone#: A-to you an employer?Check the appropriate bog: _ I. I am a employer with �_ 4. ❑I am a general contractor and I Type of project(required): employees(full and(or part time).* have hired the sub-contractors 6 El Now construction 2•❑I am a sole proprietor or partner- listed on the attached sh%et.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [�I emblition working forme in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9. El Building addition required.] .officers have exercised their 10-El EIectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption perM(3L 11.[1 Plumbing repairs or additions myself[No workers'comp, c.152, §1(4),and we have no insurance re aired. �•[]Roof repairs Q ] ' employees.[No workers comp,fim rancerequired.j 13.0 Other Any applicant that checks box#1 mustalso 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 anew 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. Iain an emptoyeY that isproviding workers'compensation insurancefor information. my employees. Below is tlzepolicy and job site Insurance Company Name: (' Policy#or Self-ins.Lic.#: )�b Ld`C 7� o /D7- Expiration Date: / J'ob Site Address.--<-9,1 City/State/Zip: n_ Ot�. 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 ofMGL c.152 can lead to the imposition of criminal penalties of 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 fine of up to$250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby ce der the airs and enaltles o i P P fperjury t7iat the information provided above is true and correct. Signa e: e Date- --c ate: Fl�ssu=lng only. Do not write in this area,to he cornpTeted by city or Town offciaL Town: Permit/License# ority(circle one): I.Board of Health 2.Building Department 3.City/T9"CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9. A�RV CERTIFICATE OF LIABILITY INSURANCE FD3/23/2016Y) 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(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 Linda Bogdanowicz NAME: Insurance Solutions Corporation PHONE (603)382-4600 Noll::(603)382-2034 60 Westville Rd E-MAIL ADDRESS: corn INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A.-Western World INSURED INSURER B:Nautilus Insurance Chou Polar Bear Insulation Company Inc INSURER C: PO Box 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER�L1632326134 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 MATH 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. ILTR TYPE OF INSURANCE 11 DL BR POLICY POLICY NUMBER MM/DD/YYYF POLICY MDIYYYP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CIAIMS MADE 1 OCCUR DAMAGE TO RENTED 100 000 PREMISES Ea occurrence $ R NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JEGT ElLOC PRODUCTS-COMP/OP AGG 1$ 2,000,000 OTHER: Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BOOILYINJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOSAUTOS Per accident $ L $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 000,000 B EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOY $ if yes,describe under DESCRIPTION OF OPERATIONS below E.L.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 �_hsch Enginee-_ N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NS025 r9n tan 1 i POLABEA-01 JONEILL '�I ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD,yYYY, 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(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 A PHONE — FAX Agency y 11 Saunders Street ac•Na (978)688-7000 Ate— (� 978)688-7001 North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE ; NAIC S INSURER A:NautllUS Insurance CO_ — k17370 INSURED INSURER 8:Safety Insurance Company_ 133618 _ Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc --- P 0 Box 958 INSURER D Andover,MA 01810 INSURER E: INSURER F: COVERAGES - 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_ ---- DOLISt1BR: - {{ POUC4EFF POLICY(9(P LTR; TYPE OF INSURANCE IAD i WUD: POLICY NUMBER I MIND MMIDD LIMnS j A COMMERCIAL GENERAL LIABILITY `: --- i .EACH OCCURRENCE S DAMAGE TO-RENTED. . CLAIMS-MADE S OCCUR - PREMIS 51Eaoccurrence) MEDEXP(Any one Person) S PERSONAL&ACV INJURY iS GEN"L AGGREGATE LUVIIT APPLIES PER: iGENERAL AGGREGATE i S �r POLICY JECTPRO _,OC I PRODUCTS-COMP/OP AGG S OTHER: j - S -- !AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT S 1,000,000 I3 ANY AUTO _ 2100926 01/04/2016 0110412017:BODILY INJURY(Perperson) S ALL OWNED 'SCHEDULED - ' - -- :AUTOS )� :AUTOS i BODILY INJURY(Per accident)_S i 1 DAMAGE S r Per accident A 'HIRED AUTOS A ;AUTOSVJNED - .P(- --ROPERTY 1 - - --- -- 1 S — UMBRELLA LIAB OCCUR EACH OCCURRENCE e ) — A ;EXCESS UABCLAIMS-MADE; r AGGREGATE __ S OED RETENTIONS S WORKERS COMPENSATION !PER OTH- ' AIJD EMPLOYERS'LIABILr1Y i ,_-$TAME _ :ER YIN' iANY PROPRIETORIPAP.TNERIEXECUTIVEt { 'EL EACH ACCIDENT S OFRCERRAEIABEREXCLUDED? �1N/A! (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE-S If yes,describe under i t - —- —' _- - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT;S I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 161,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 Thielsch Engineering CER T IFICA T E HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OF-SCRIBED POLICIES BE CANCELLED BEFORE hietsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN T hiACCORDANCE WITH THE POLICY PROVISIONS- 195 Francis Ave Cranston,RI 02910 AUTMORRED REPRESENTATIVE n-rano All 3/23/2016 Print certificates:Certificates of Insurance (MMIDDJYYYY) ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE 01104/2016 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(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 CONTAC NAME: PHONE Automatic Data Processing Insurance Agency,Inc. A/c.No.ExtI! Arc.No 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NA1C p INSURER A: NmGUARD Insurance Company 31470 INSURED INSURER 6: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 956 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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- NSR LTR TYPE OF INSURANCE INSD V6VD POLICYNUMBER MWDDNYYY MIDWYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR PREWSES(Ea occurrence) 5 MED EXP(Any ane permn) S PERSONAL 8 ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY ElJEP LOC PRODUCTS-COMNOP AGG S OTHER: 5 AUTOMOBILE LIABILITY LIUMBIJdenll � S ANY AUTO BODILY INJURY(P.permn) 5 ALL AUTOS AUTOOSULED BODILY INJURY(P�accident) S HIREDAUTOS AUTOS S IPa ftHl ylj 5 UMBRELLALWB OCCUR EACH OCCURRENCE 5 EXCESS UAB CLAR:IS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILrTY ANY FROPRIETORJPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT S 1,000,000 A OFFICERA.IEMBEREXCLUDED? Y❑NIA N POWC772258 01/01/2016 01/0112017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 5 1,1100,000 If yzs.d�cnbe tulda DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,088 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schcdulc,may bo attached R mora 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 Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE I - l A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD https://adpia.adp.com/icertcf/#/run/printcerts/421984 111 Office of Consumer Affairs and Business Regulation r' 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 } 17, Type: DBA " f Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc !s $�_Pl�� 'Pf P.O. BOX 958 — 5 ANDOVER, MA 01810 7! / Update Address and return card.Mark reason for change. Address E] Renewal F-] Employment E] Lost Card SCA t t'a 20M-05/11 CJ1re CCanrnraxruelrll�o���i�ssac�uielt _ Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102726 Type: Office of Consumer Affairs and Business Regulation Expiration: 76201:8 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 - POLAR BEAR INSULATION_CO Vincent LeBlanc y -A-1 k ' - 51 SO.CANAL ST.#5A,-- LAWRENCE,MA 01841 ` Undersecretary Not valid without signature .s. Massachusetts -'Department of Public Safety Board of Building Regulations and Standards Construction Supcn icor Specialty License: C;SL-106017 T;T PETER A LEBLANC '' r 2 EAST PINE STREET Plaistow NH 0386-5 l 1 Expiration Commissioner 04/28/2018