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HomeMy WebLinkAboutBuilding Permit #1103-2016 - 55 MILK STREET 4/26/2016 Hly 4444 BUILDING PERMIT "°oT"�ro TOWN OF NORTH ANDOVER 3 - 0 APPLICATION FOR PLAN EXAMINATION * ,� 9 Permit No#: O Date Received o-cl w SSACHUS� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 57�7 /'h % I / 5 Print PROPERTY OWNER Icr-t 7t,P!'i'K e- eo v'y Print 100 Year Structure yesPARCEL:_ZONING DISTRICT: Historic District yes Cono Machine Shop Village ye 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 a Others: ❑ Demolition ❑ Other �-✓� S vJ 4 lid v� ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: S /0 A, S TJ, rri Identification- Please Type or Print Clearly OWNER: Name: Le-'�7Iw p►v e Cbi'Q Phone: -5 Address: S�5— M0 k S i /'I- 1i4, A dver- Contractor Name. Peter Leblanc Phone: �7�- `� o ff' 7(03 Email: 2 East Pine Street Address: �'� rtow, N.H. 03865 -- Supervisor's Construction License: /V (00 17 Exp. Date: j b 0/8 Home Improvement License: Ib (e Exp. Date: 2 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST LBASED ON$125.00 PER S.F. Total Project Cost: $ 7c�r►�- b b FEE: $ "f Check No.: Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund 96—_ - --- ___�------- ---- -- ---- — — - 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 Workers Comp Affidavit r~ Photo Copy Of H.I.C. And/Or C.S.L. Licenses i6 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 4. Building Permit Application 4. Certified Surveyed Plot Plan Workers Comp Affidavit 4. Photo Copy of H.I.C. And C.S.L. Licenses 4. 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 ,r< 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 getthis recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 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 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 , y 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 FIRE DEPARTMENT - Temp,Dumpster on siteyes Located at 12"4'Main Street Fire Department signature/date COMMENTS Location No. I - r Date I • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frclme Permit Fee $ -- - Foundation Permit Fee a$ 0 ' Other Permit Fee $ TOTAL Check# Building Inspector F NORT1•/ Town of 0MIA,Z h ver, Mass, 2tp o coc"Ic"I w�cN �1 q°'4�rEo • S V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .5 K'�� Foundation has permission to erect .......................... buildings on ....... ... 1. ..�.. Me.�i.�:................::. 1� . Rough to be occupied as .....kx%...1�.�..l.. .. .�►..,....�........ . ..�� • Chimney provided that the person accepting this permit 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 Inspection, 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 CONSTRUCTI?,N STARTS Rough i Service ............1.... .`:!.:::�;l. .�r.:......................................... 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. a I hca' n� rrosas-04ostlzs RISE Engineering Rl Contractor 86 MA Corttraclor aeglaa$noo iso 12WO A division of Thlelrch Ettetaeerlog 60 Shawtnut Unit a2,Cantoo,MA 02021 CONTRACT 339-S02-6335 FAX 339-502.635 Page 1 PROGRAM trtseortrwacrraotrINUMPtrottttrrtMrtroa CMA-HF.SAs nteexraresmtwateant ogscramaftw Catherine Cora (978)886.4355 12/172015 402433 00003 �c 3 ' Milk Street bCJ to ¢rJ 55 Milk Street ?forth Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PHASE ONE-Propose!for this calendar year. $0.00 J{EALTH&SAFETY: Have yaw tenting system tuned up and ratested to be sma that the undiluted flue gasses do rot exoeed 100 Part}per million(PPM)carbon monoxide.Weatheriaation work ciumot proceed until this is fixed. $0.00 �AR}t[EIt'The following contract is not valid unless accompanied by the Pte-Weatherizat'ion Barrier Incentive form,signed by Your licensed electrician.Work will not proceed with this work until we receive a copy of the form. $0.00 AIR• EALING:Provide labor and materials to treat areas of your home against wasteful,excess air leakage.This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful leve!of @Ir exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary was for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally gddtpssat.)This will require(8)working hours.A redaction in cubic fat per minute(efm)of air infiltration will occur,but the actual apmber of cfm is not guaranteed. At the completion of the wealherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 MR tEALING ADDER:(2)working hours. S170.0D C FLAT:Provide labor and materish to install a 12"layer of R-42 Class 1 Cellulose added to(123)square feet of open atic (;ONTRACTOR DISCRETION AS TO WHETHER OR NOT TO BLOW INSULATION UP THERE 5196.80 g�O)'ES:Provide labor and materials to install a 6"layer of R-21 Class 1 Cellulose added to(224)square fat of slope area. %Ybare ver possible baffles will be installed to the entire length ofeaeh bay to maintain ventilation spate CONTRACTOR DISCRETION AS TO WHETHER THIS CAN BE PROPERLY DENSE PACKED 5416.64 P WALL SLOPE:Provide labor and materials to install R-19 tmtaexi fberglaas to(497)square fat ofwall. Then install l" 49id board insulation.Seal all warm with FSK tape. PLEASE INSULATE GABLE END KNEEWALLS UNDER THIS MEASURE AS WELL(SQUARE FOOTAGE INCLUDED) 52,037.70 GE BARRIER:Homeowner is msponsibie for the removal of the stored items blocking the installation of weahe iu6on in the knerwail areas. Removal must occur prior to the scheduled work start $0.00 F.deral 1D R 45-0409828 RISE Engineering RI Corttraetor Roglstnadon No 8186 AAA Cotfiaetor Registration No 120979 A dlvhiou of Thielscb Engineering 60 Shawmut Unit 62,Caton,MA 02021 CONTRACT 339-502.6335 FAX 334302-6345 PBila 2 PROGRAM Traaeat TPACMnsmuma OBEnV XAM CMA-HES o°os EDMAAawnIaa�srOMFOaAS woa Now DAVE cum# WORKMIX j 4czine Cora (978)885-4355 12/17/2015 402433 00003 Pow WrAw 55 Milk Street 55 Milk Stxect Nt olh Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION CATION:Provide labor and materials to install(1)insulated exhaust hose to existing bathroom fen(s). $50.00 VOMLATION:Provide labor and materials to install ventilation chutes in(45)rafter bays to maintain sir flow. $90.00 'TqS#Engineering will apply all applicable,eligible incentives to this coubact. You will only be billed the Net amount Ctu v*. 0 cligible meastues,Columbia Chis offer$75%incentive,not to exceed$2,000 per calendar yew,and an incentive of 100°X,for the 41r Scaling measures up to the fust 5680 and an additional 5340 if savings are justified by the auditor. Fpr the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in $i ur home both before the work is begun,and after the weathahzlion work is complete.We will also conduct a full assessment of t?!e combustion safety of your heating system and water heater.This tars avalue of S90 end is at no cog to you.Total allowable ?p1heriration incentive is 53,110. $90.00 Total: $3,731.14 Program Incentive: $2,940.00 Customer Total: $791.14 AYE AO WKER 8T TO FURKM 5ERVICE6-CMPLM 1N ACCORDANCE WTM AGM aPECIFICAMM FOR TIM S=OF 'Seven Hundred Ninety-One 814/100 Dollars $791.14 FlNALUUMECTMAND APPROVAL aYRISC 10000020M Canturen AORens TO RMT AWUMcue NPus.WVUWOP 1%VM Be CHARGED MOMMY ON ANY DlMtANte DAYL EFa RGElASa PDRIYPORTAM WFORTrAnON ON MMRARfEM taMEOFRUMMMSOMMUMAMCONMWMRRfial MMK DO NOT SIGN THIS cONTRACr IF THERE ARE ANY BLANK sPACEs > d� 60,4 1(1. Nptt:TKSCONTRAcraAYSE RF amcumwma'h� 0020FACCEPTANca AeeEPrAtreaOPeeNrRAer'MMAaevaPRICQ aPaWFiWrINtaAIM CONOMONEANG 30 DAY: &ATIaPAerarr To as AND AIM H RMYACCEPTED.YouAREAURNOWEDTODOTHGWON As .PAYMEKrwALaENADEAsOURDOMAOM OWNER AUTHORIZATION FORM 1, -rh e✓jyt e, Cor-q, (Owner's Name) owner of the property located at Ik (Property Address) .,/ acre✓`, /17 c; . O 18'ti_s (Property Address) hereby authorize kC('� -� r —;-,h d (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building I permit and to perform work on my property. i Own Signature . i I Date i i i The Commonwealth of Massachusetts Department of Intlusttial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 WWit'.mass.govIdi t Workers' Compensation insurance Affidavit: Builders/('ontractors/Electricians/Plumbers. TO BFB. FILED WIT11"I'IIE:PERMITTING AI'THOR1T1. Applicant Information Please Print Legibly Naiiie (Business'()rgamzattonjfndt�•tdual): b (G/'lj,,4 r T.lnst//4,1 0 N (10. riMC Address: P©. tlr>0 X 9sj� C1ry/State/ZV ,&h Jou-e , yt�J/¢� oiflo Phone tic fou an emplmer:'Cheer;the appropriate hos: T)-pe of project (required) 1 ®I am a emplirvci wall rmplu}res(till!antbur part-rime!` 7. New construction '_❑1 ant a sole propnctur ur partnership end have no cmploNecs v.ort„ng, tier file rn S Remndeline any capactly [No%%orkers'comp insurance required 1 ❑ [?emol 3 Ej I ant a homeo,%im dam,all\+ark mcsclf [No%%orkers'comp insurance required 1 9 ition 4 ❑1 am a homcuwncr and will be kinin_contractors to conduct all«irk m on \ pnipert� I sell 10 E] Building addition ensure that all contractors either have workers'compensation insurance or are sole I 1 R Electrical repairs or additions pnrpnctors anh no emplovecs 12 f-1 Plumbing repairs lir additions t ant a°eneral contractor and I hwt i hired the sub-contractors listed on the attached sheet 13 F_jRoofrepairs These sub-contractors have employees and base workers'rump insurance b 0 We are a enrporatiun and ms olticers have exercised their ,ht til cxrmpttnn per fvtGl c 14 E]Other 152. h41.and we hair no cmploNecs INo workers comp insurance required 1 'Aviv applicant that checks box:;1 must also fill out the section bel(m showing,then workers-coin pcnsanon polwN utfirnnatton l luttteowners Wio submit this affidavm rndicaime the\-are dmna all .vork and then hire outside contractors must submit if nc\c atlida%it indicating such =Contractors that check this bin must attached an addrhnnal sheet showniz the name of the sub-conttaclou and Mate\thethct or not those enttucs have emplotces ll"thc sub-cunuactors have employees.thcN must proti tde then aurkers'comp putts) nunibet am an entplo)'er that is pr•oaidinb workers'compensatian insivance for me•emplt evees. Below is the police,and joh site informatiom insurance Company Name. n 06 q'if- Palits » or Self-ins Lic n_ p q 67 a a S Expiration Date cbI ai/�tt9) Joh Site Addressf7 Ctty/state/Zlp: Attach a copy of the n•orkers' compensation policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under MGL c 152. §25A is a criminal violation punishable by a fine up to$1,500 00 andJor erne-year imprisonment_as well as Civil penalties in the firm of a STOP X-VORK ORDER and a fine of up to$250 00 a day against the x iolator A copy of this statement mai_ he forwarded to the Office u1-Investigations ufthe DIA for insurance coverase verification. i do herehl• certif'under trite pains and penalties of perjury that the hiririation prorided abore Is trite and correct. Si_natttre. t� "L" Date GI �Wh Phone r: Official use otdt•. Do not write in this arett. to be completed be'city or town gfficiaL Cit` or Town: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City1Town Clerk •I. Electrical inspector 5. Plumbing Inspector E. Other Contact Person: Phone Y: Yr ATE AC40 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(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 endomemen s. PRODUCER CONTACT NAME: BogdanowicZ Insurance Solutions CorporationPHONE (603)382-4600 No):(603)302-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A Western World INSURED INSURERB:Nautilus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO Bos 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBERCL1632326134 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 ADOL S BR POLICY EFF POLICY EXP LT POLICY NUMBER M YY M Y LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAA CLAIMS-MADE ❑R OCCUR PREMISES TIRErr 100,000 PREMISES Ea occurrence $ � MPPS274967 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 % jE- FILOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY F-1 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea a cklent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR CLAIMS MADE AGGREGATE $ 1,000,000 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A 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,Additional Remarks Schedule,may he attached if more space 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 !� Reith Maglia/SJA `- (�jG--- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/901401i POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODlyYY10 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 ME: Durso&Jankowski Insurance Agency _MME: FAX 11 Saunders Street ac N�J:(978)688 700D _ j(Aic .L(978).688-70.0.1_ North Andover,MA 01845 EMAIL ADDRESS: - i INSURER(S)AFFORDING COVERAGE i NAIC. INSURER A:Nautilus Insurance Co. _ �17370 INSURED INSURER B:SafetY Insurance Company_ 33618 Polar Bear Insulation CO.Inc. INSURER C Peter Leblanc&Steven Leblanc INSURERD: P 0 Box 958 I— -- — i- - — 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 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 OFINSURANCE — —ADDLfSt16R; POLICY EFF POLICY EXP —~ LIMITS LTR !INSD 1 VIVO! POLICY NUMBER MM/D MM1DD A COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE S CLAIMS-MADE OCCUR ! - i PREM SEDAMAGETO NTED cel S - i I MED EXP(Any ane person) S PERSONAL&ADV INJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE !S — - X_POLICY! PECOT- -..__LOC 1 PRODUCTS- -COMPIOPAGG S OTHER: I I i S 1 AUTOMOBILE LIABILITY i I COMBINED SINGLE LIMIT i S 1,000>000 B ANY AUTO _ 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) i S ALL OWNEDSCHEDULED i - — !AUTOS X AUTOS i !BODILY INJURY(Per accident)!S X :: Y NON-OWNED ' j ! :PROPERTY DAMAGE :5 HIRED AUTOS AUTOS i ( Peracdd_nt i $ UMBRELLA LIAB OCCUR `EACH OCCURRENCE S ) A _EXCESS LIABCLA_IMS-MADE J AGGREGATE _ :S DED RETENTIONS I i WORKERS COMPENSATION !PER OTH- STA7UTE ! ER AND EMPLOYERS'LIABILITY Y/N ; ANY PROPRIETOR/PARTNERIEJCECUTIVE EL EACH ACCIDENT 'S O(Mandatory MBERin NK)EXCLUDED? �!N/A! ( E.L DISEASE-FJt EMPLOYEEI S t(Mandatory in NH) LL�� IF yes,describe under - DESCRIPTION OF OPERATIONS below ' ;E.L.DISEASE-POLICY LIMIT;S I , DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,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 CERTIFICA T E 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 145 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n 1600 nn�n nnnon nnoonOn TInAI All IW2016 --_--___--- PrerierY:Certifiexes of Insurance THIS CERTIFICATE IS ISSUED qs A M�ER O�A p E C� , CERTIFICATE LIAS L ITY IIN E DOES NOT AFFIRpitATIV �vrlH"� 8ELOW THIS CE ELYO RMATip111 ONLY AND L,r_ eaTE1«+t�D, RTIFICATE OF INSURANCE pO EGATIVELY CONFERS N YYYY) REPRESENTATIVE O ARIEND,EXTEND OR O RIGHTS UPON R PRODU ES NO 07/oa/2016 IMPORTgNT_ CER,ANO THE CERTIFICATE CONSTITUTE ALTER THE COV THE CERTIFICATE HO We ter !f the certificate HOLDEN A CONTRACT aETW ERAGE AFFORDED HOLDER THIS ms and co holder is an gDDITIONAL INSURED EEN THE ISSUININSURER(S). BY THE Pp Certificate hold ndltions of the G INSURERS• LtC1ES der in lieu pOII�'•certain ( ) AUTHORIZED PRODUCER or such endorsement(g Policies may require'the Poflcy(ies)must be ) an endorsement endorsed.!f SUBRpgAT10N IS W A statement an this certificate WAIVED Automatic Data Proc cate does not confer 'Subject t0 7 Adp Bo-le essing insurance A CORrACr ghts to the card gency,int :+ raE Roseland,NJ 07068 PxME lA:C.170.E:!C aVORFSs: INSURED WrC.not POLAR !nSUR:R15lAFFOP,pInG COl•ER;,Gc BEAR INSULATIONP751 ER:,: NOrGUARD Ins u PO BOX g2 CO INC1NRISURER a: ranee Company HAICa Andover,10A 07810 (UI 31470 SURER C: �--. ' COVERAGES I:+suRER E: I THIS TpTHAT CERTIFICATE NU +r+SURERF, I Ir10:C TEO �THc– .TtiE pL'L:CeES OF Ills;r MBER: 429703 USR E lU-fir O?l�A,'•!D C7FlD.'Ts EDr�i yt,+ R F L+1.IEt h�C�RJ rOR COtlp;r!pt~G�r'c_P:;SSUED Tn THE,y:SU REVISION NUMBER; 1 EX` c. t ISS r ^LO., LTR( TYPECCN PpL:C!ES L!t,'; CVRtittCE I'z .FFORp^ idi CONTRACT pR RED rIRtdED QFI:ISURat7CE S..HDI:?•!LS; cD GY THE Po r, OTHER DOCt t'- A$O''E FOR THE FOL: I CO«t',1ERCIry GEUERAL UA$ILIrY R1SD YrrD POLICY n 'YnirL F`L-t!R– t t-D p)� Dt LM'IBED HERE:t•7 TS gJ8 LC°ECT TO'.i4i7C RIIOD cDUC' r i16c•1,•r•1^UE 1..,.y U«!BER MUMMY,(r Ctr r 1. 7O ALL THE TERL7S. L r �-'• LI: YYl 1«1G:•00YYYY'-_'�—�— tJL—_lt l t MuTS LL VEI t`::Lt� t!1- 1 1 L... CfEC'�:•Jr _ I 1 OL70a10E IWeIL17y U'C7IL I e l.c!- I U:ZSRELLA LUIS � talL'r t1.JL-li!ri'c•;- I ES:(:ESSUag r _CF I•t:crtt -'`=cup o ( ,:EL.I ItiE7 `10 E •'::`-Iii_( RIGrY •�GGt{Er_q t� `t-tLtiSLti• 'l fil E`Clr f«%anduor, 1tSE1: .g U. s:•r.._u- tiA Tr Af)tirC [•aaiii•tn,;.,_F 772252 IX t'= r,:,.lp s I i 01/01:2016I:IL/E I >f-" 13 01/01QQj7 EL 6-.cI..r-..IL Lt ( E1,La E.r I' 7.000.000 I 7,000,000 Ot! oEscRrrl rOF OPERATtORs: f 1.000,OOU IOCaT/OrrS:vEWCCFs(a CORD to 1.Aatlition+ 1 `t�m�$S Sch�purc-m•L'O¢dtbctctl irmWcsP��c Lsr Muircd) CERTIFICATE HOLDER CANCELLATION Tf!ei+sch Engineering,Inc. 195 F SHOULD ANY OF THE ABOVE DESCRIBED ranee,A„e THE EXPIRATION Crans"On•RI 02910 ACCORDANCE WITH THE POTHEREOF POLICIES BE CAA'CELL BEFII LICYP:10F. NOTICE WILL BE DELIVERED N ONS. AUTHORVp ZPR,,ItTATILrE ACORD 25(2014/01) (! A_ it__ The ACORD name and!o A!^7988-2014 ACO go are registered marks Of ACORD RO CORPORATION. All rights reserved. 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