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HomeMy WebLinkAboutBuilding Permit #1021-2016 - 59 NORTH CROSS ROAD 3/30/2016 k1_4Y TOWN OF NORTH ANDOVER r7, APPLICATION FOR PLAN EXAMINATION Permit NO: "� Date Received Date Issued: $ IMPORTANT: Applicant must complete all items on this page ,Jc)eZ1-f,_ LOCATION S5 Co S S Ad Print PROPERTY OWNER S?r &n r :h41-0A1 Unit# Print MAP NO: 3(� PARCEL:%ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure 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 0 Septic 0 Well 0 Floodplain I] Wetlands ❑ 'Watershed District L Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: A%('5t9f:hq of- P-7-*4c rSula>i0y io A - Y90 , V"n),)A4 ,/\v � (Identification Please Type or Print Clearly) OWNER: Name: 57'r Pin P,L., /A rr, -7 a 7o n Phone: Address: CONTRACTOR Name: Peter Leblanc Phone: 763 a 2 East Pine Sweet Address: N.11, 03865 Supervisor's Construction License: /C?&o i 7 Exp. Date: v/ Home Improvement License: Exp. Date: 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: $ L-/000. © 0 FEE: $ 4:� —_-- Check No.: I I q-2, Receipt No.: 16 11 NOTE: Persons contracting with unregistered contractors do not have acc s to the guaranty fund Signature 6f Agent/Owner Signature of contractor . Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 DATE REJECTED DATE APPROVED I PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS V . Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Drivewav Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located384Osgood Street Located at 124 Main Street Fire Department signature/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, 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 - Date Doc:.Building Permit Revised 2011 June/mi c 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 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 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: Doe.Building Permit Revised 2008mi Location �, ` � �� � No. t b2 Date U � i • - TOWN OF NORTH ANDOVER • iii, Certificate of Occupancy ` $ Building/Frame Permit Fee $ Foundation Permit Fee $_^ Other Permit Fee $ A TOTAL $ wr Check# LtZ. `� Building Inspector NORTH Town of 2Andover Jul— aol W : LAKE h ver, Mass C0CMIC"9WICK 1_ �qs RATEO JkVP �y - V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. .. .... ..5.�. ��r� � �"'� BUILDING INSPECTOR ........ .......... ...... .... ...... . ........ ........... ................. Q� Foundation has permission to erect.................... ..... buildings aCl�4....!....................... .........`J..s..�'�!......... to be occupied as .. � �� .. ... ..�� Chimney .......... .... i&V ............................ Rough provided that the person accepting this per hall 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 CONSTRUCTION S Rough ................ Service .................. ...... . . ....... Final UILDING 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. puma RMM*nmft fncotaractorRa r�ontaoatae etACootraeEorRoBNtra9at 1talaoere RIS . Aww=Qfnwl,&EWftft ENGINEIt!NG d0EAewwmUattds,c"i*%4m4a= FAX X6138 63d5 CONTRACT pup 2 PROGRAM tssesr�asotatm�aeoomr�tess CMMAF,S etoasa�atat�attmertobum owtaaa _ vaoie am CLOW$ niotstarmet Stephen Herrioen (978)682-8917 03/10/2016 43I832 00003 aeertm stamT a:uats stmt 59 Nortb Chose Rcad 59 North Cross Road arxv+m an stmr<aa mm cr".G mw Notch Andover,MA 01845 North Andover,MA 01845 JOB DFACREMON NE.NtIIAIMPlow ombormsatnsteri stobttmiip)ttaaratodabaosttmsawitbtooftmoos<oodBa�atreatm+ad�ame cdsftbs*oo:oftmts). xis6as vFNtU.ATfOid:Peo�tdslebosa�dt�stoi�livsr�tes�opr�m@erbgysmam�saBaw SZZsco CGtd M WAIT&Rra+tdo tabor mdmmai*to boor FSK f w s mi4p botod tamdattwt MOM squms ftof oaanW VW sten.TM DXU=THE Sint UGIT SHAFT. sarAw RISE FagimeaEagar8l8p*8i WUmblk todiseoomt.YaswMcdybebMcddwNd=mL Ctotady, AitSesUugtn ap 5680 tmd ea addidone15340 itaarirtgs SZ,= dLY =btteaairsof 1009616rtbe FmtbesdetyeadheMofywbomesbtdoat**mMy,mewMbeoo abtamtrdootdwaww afdxsysameshf win �botms bath t+etbsstbs wmk bt�.tmd stDatbe anon mods is ootaptetR Ws wilt 8tso ooadmx s f68 of tMc=bwdmsaftWdywbwftsyMmwdmmclsmter.ThisttassvabmolS4oendisatmoaosttoyoo 'Maloliomabie Eonbsoaaivsis53,1rQ $MOD Toaaf: S49T1.72 Program Interum 53,110A0 Customer ToRak MOEF WHAOREE!MMW70RaWJMOt $-COMPLUMINAODONDAf[CEtIMASOVtEt19�11fOfta.FWtIMMt=CP *"Mae Hundred SbdySwm&72HOO Doffs ✓ S887.72 WWFOW oovtet10NA1�APt YAstmeeftaset�7fsastome�aa�suptnOatamutftoaQmwu.mte�erwwtmae5awosot�an4Ta�aQ m� aaaiasm tam�aQ+antattoeaeanosoY maneoar�aoiapeaosrtwmtsR �tos. DDWrSW7i0S©CNlRACTlF7AREMIY SPACES a� tea�aaaooaew►erraaawneroswotsrasm30 tatmmas�taom� mr:nsaao�rm �fD//(� ovemrewer-umseast�ueaesto�comaamAo�mam caro. w RVFAWWALL KAaass OUnACOAMW autxoo�mos titmu Federal ID/06.0405= RISE Engineering N ConUact ReglabratonNoaces RISENINAC*uttrsctorRagiatraOonNot20978 A division oflbldseb Waeeriag ENGlNEERlNG 60 sanR7maa Uall.#2,Cautfin.MA 0=: CONTRACT 339 602-6335 _FAXM9507.6315 r % Page PROGRAM ' OW c^�- ---r-, nesomrmAesesex�mnaoBEIWEaame CMA-HES astraeutaroreusoausounrAa 1:J vtq� cera urgers ve*rtxotmat Stephen Harrington 7) (978)682-8917 03/10/2016 431832 00003 saw=errrear L' oororo arnEar 59 North Cross Road 4 59 Notch Cross Road atamee CM,WAW-UP i autaro WY.WAIF.MP North Andover,MA 01845 _ North Andover,MA 01845 JOB DESCRIPTION PHASE ONE-Proposal for this calendar year 50.00 HAZARD BARRIER:We have identified that there tae rcoessed tights present in your hom antes the t M A N fights ate certified as 1C-rated(Insulation Contact Rated)we will create a 3"clean moa spate=and the fixture by using fiberglass blanket insulation as a damming material,to insulation will be installed across the top and closed cavities which contain ttxxsxd lights will not be insulated. 50.00 ADR SEALING:Provide labor and materials to seal areas ofyoar home againstwasteful,excess air leakage This work will be performed in concert with the use oftpecial tools and diagnostic tests to aurae that your home will be left with a healthfW level of air exchange and indoor air quality.Materiels to be used to seat your home can include caulks,foams and olherptoducts. Primary areas for sealing include air leakage to antis,basements,attached geragm and other unheatcd areas(windows are not scaetafiy addressed.)This will require(12)woddng Fours.A reduction in cubic feet per minute(afro)*fair infritnstion will octxv,but the actual number of efrn is not guaranteed. At the completion of the wealheraffiimt work,and at no additional coat to the homeowner,a final blower door mWor combustion safety analysis will be conducted by the sub-oommutor to ensure the safety of the indoor air quality. $1,020.00 AIR SEALING:Provide labor and materials to seal arras ofyour hoax against wasteful,—air leakage This work will be performed in concert with the use ofspecial tools and diagnostic tests to assure that your home will be left with a btahhbffrd level of air exchange and indoor air quality.Materials to be used to seal your Mame can include caulks,foams and other products. Primary areas for scaling include air leakege to attics,basements,attached garages and other unheated anal(windows arc not generally addressed.)This will require(4)working hours.A reduction in cubic feet per minute(cf n)of air infiltration will occur,but the actual number of cfm is not guarantoW. At the completion of the weathaizetion 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. $340.00 AiR SEALING ADDER:(1)working hams. $85.00 ATTIC PLAT:Provide labor and materials to install a 6"layer of R-21 Class 1 Cellulose added to(756)square fed of open attic space.THIS IS THE SECTION OVER MASTER BEDROOM. $95256 STORAGE BARRIER:Homoamm is respam'ble for the removal of the,stored items blocking the installation of wmlfumvetion work in the attic. Removal must occur prior to the scheduled work start $000 ATTIC ACCESS:Provide labor and materials to insulate(2)back of the imcewail hatch with 2"rigid lbennmk boast and seal the edge of the hatch with wedbastripping. $120.00 ATTIC ACCESS:Provide labor and materials to insulate the back of the attic door with 2"rigid Thamax board and seal the doots edgy with wealhentzipping to restrictair kakaga $7391 t% RISE {4~ 80 Shawmut Road,Unit 21 Cannon,MA 020221 339.502 WS ENGINEERINT wwwJ6SEen9innrhVx*m OWNER AUTHORIZATION FORM Eh&14 LtCUXi hc�4 f- (ownees Name) (� owner of the property located at: /-J •Gia -I, A� ' (Property Address) 1 A 17o ttP- /s._.P_`� .-0- (Property Add ss) hereby authorize (Subcontractor) an authorized subcontractor fbf RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. s Sign Date \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 1VW1V.nlaSS.a oV1tha NVorkers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED 1YIT11 THE PERMITTING AUT1101111'1'. Applicant Information Please Print Legibly Nal11e (Business!nrE!anization/individual): /po (A r h>'A r >j-t^sV��Tr�1 N �'d. .�ri►G Address: p 4 goX 95- City/State/Zip: f h d ou-cr, )'till¢, Otho Phone ..#: Are you an employer?Check the appropriate boa: Type of project(required): I ®I am a employer with _employees(full and/or pan-time)° 7. ❑Nen<+'construction '_0 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capaci1v tNo workers'comp insurance required J 9 ❑Demolition 3 1 am a homeowner doing all work myself [No workcrs'comp insurance required J' ' 10E] Building addition d❑1 am a homeowner and will be hiring contractors to conduct 311 work on m� property I will ensure that all contractors either have workers'compensation insurance or are sole 1 I Electrical repairs or additions proprietors with no employees L Plumbing repairs or additions 5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet❑ 13 Roof repairs These sub-contractors have employees and have workers corny msurance I4 [ Other 6❑We area corporation and its officers have exercised their right of exemption per MGL c 152,00).and we have no employees [No workers comp msurance required] 'Am applicant that checks box 91 must also till out the section below showing their workers'compensation pohc) information °I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such 'C'ontractors that check this box must attached an additional sheet show inu,the name of the suh-contractors and state whether or not those entities have employees If the sub-contractors have employees,they must provide then workers'comp polic} number 1 ant an emploi!er that i.s pro+riding workers'compensation insurance for ni}'enipdovees. Below is the policy and job site information. insurance Company Name._f�_p Policy 9 or Self-ins Lic #_ p W fo -7 Expiration Date 0.)//d��it0J7 Job Site Address. 5-c? ✓1-o r 1 L, C'fo55 Q A City/State/Zip: j�_ Igh�O✓� r Attach a copy of the -workers' compensation policy declaration page(shosying the policy number and expiration date). Failure to secure coverage as required under MGL c 152. `25A is a criminal violation punishable by a fine up to$1, 00 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 A copy of this statement may be forwarded to the Office of Investigations of the DiA for insurance coverage verification. /do herehi•certifj-under the pains and penalties of perjury that the hiformation pro rided above is true and correct. Signature: f "L"� Date 4 Phone 9: CI I> Official use onli•. Do not write in this area. to be completed bl'citi'or town official. Citi'or Tos-,'n: Permit/License# Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone ty: dap BI INSURANCE POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURt�NCE DATE(MNUDD/YYY17 �-� 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 Agency HONE /978 688-700D j _ (978 688-7001 11 Saunders Street ac N`LF�_\ .._�.. _ _ _ (_.e No)_ ). North Andover,MA 01845 E-MAILADDRESS: ' — INSURER(S)AFFORDING COVERAGE ; NAIC 9 _ — _ INSURER A:Nautilus Insurance Co. _ 117370 INSURED INSURER B:Safety Insurance COmpany Polar Bear Insulation CO.Inc. INSURER C: Peter Leblanc&Steven Leblanc P O 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 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 ; 'ADDL SUER;-- POLICY EFF^ POLICY EXP [ LTR TYPE OF INSURANCE INSD Mo: POLICY NUMBER 1 MM/D MWDD LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S --_ CLAIMS MAGE OCCUR f i DAMAGE To E IE0 i PRFMISES�Ea ocarrrencef S i MED EXP(Any one person) S PERSONAL&ADV INJURY i S-_. GEN'L AGGREGATE LIMIT APPLIES PER: i i GENERAL AGGREGATE j S i- X POLICY' PECOT LOC ! s PRODUCTS-COMP/OPAGG S { -- -- i - -' ---- --- OTHER: I i S !AUTOMOBILE LIABILITY i S 1 COMBINED SINGLE LIMIT i 1,0Q0,000 __ B ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) j S ALL OWNED SCHEDULED X i !BODILY INJURY(Per accident)!S _I AUTOS i AUTOS 1 i PROPERTY DAMAGE X X 'NON-OWNED i !s ' HIRED AUTOS =AUTOS ! t(Peracciden) `S ; UMBRELLA LIAB OCCUR EACH OCCURRENCE 'S A ' _ IEXCESS LIAE1 __I CLAIMS-MADE J 'AGGREGATE _ :s l DED RETENTIONS i — S WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY _I STATUTE t 'ER- Y/N ZANY PROPRIETORtPARTNERIEXECUTIVE E.L.EACH ACCIDENT ;5 OFFICER/hM1E1ABER EXCLUDED? I!N/A I -- - —- - - i(MandatoryinNH) i--Ii E_LDISEASE-EAEMPLOYEE 5 If yes describe under —' _-'- - DESCRIPTION OF OPERATIONS below 'E.L.DISEASE-POLICY LIMIT;S i r I 1 i i 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 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,RI 02910 AUTHORIZED REPRESENTATIVE -r 000 nn,1 A Annon nnnono A'rrn&r Air 114/2016 Preview.Certificates of Insurance -CERTIFICATE OF LIABILITY INSURANCE DATE(idltDDY)(YY) 01/0411016 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 CONfACT NAME: PHONE Ar Automatic Data Processing Insurance Agency,Inc NA:C.Ho.E:u: fA+C,fmi I Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(5)AFFORDING COVERAGE MAIC 3 INSURER A: NorGUARD Insurance Company 31470 INSURED ENSURER B POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL)C:ES OF INSURANCE LISTED BELOV.HAVE BEEN ISSUED TO THE INSURED NALILD ABOVE FOR THE POLICY PERIOD INDICATED.NOT'AlITHSTANDING ANY REOUiREtAENT.TERM,OR CONDITION Or=ANY CONTRACT OR OTHER DOCUf:'ENT 4'EITH RESPECT TO.yHICH THIS CEP.T!F:CATE f.IAY BE ISSUED OR f.1A PERTAi1d.THE iNSURANCE AFFORDED BY THE POL!CiES DESCRIBED HEREIN:a'SUBJECT TO ALL THE TERMS- EXCLUSIONS AND CONDIT:OFJS OF SUCH POLICES UL;iTS SHO4:iJ I-.*AY HAVE BEEN REDUCED BY PAID CLA;;JS 'NSR TYPE OF INSURANCE P LI-Y 1- LICY P i LTR INSD YNp POLICY(NUMBER ttt6SDDNYYY) (f x1)D:YYYYi: LVAITS CO:IMERCIAL GENERAL LIABILITY t%,Lr L'=:JL HHH.Ct [L',if.I�f.1.:Ut =�::Clt: I't:tL1IJt=Icra�_.e:••.n: 1-tI:SSI-�.L AL MJLk Gtr(L AGO Z'EUAI t LITAII APPL1t5 G PEE FiPE4L AGGI,EUA l: PCLIC"11 IJEI_t LGL Ir=,.vJL'?'i:iS-CrLll�:;l'.:G'- o:I-EF.: AUTON-10811E LIABILITY -Ll-t.aU 9ta1 Le.11l lt=:' d: 8CUIL'[:JL"I::i ,;LL=:2LcU d.l-!=VLLEV 111 CS BtiU1L'r UCJC1i-rP;-a.a_crJi 1-1F:tU;.I.I;�L t:�1,r�Ct::l 1'I:�.1`t1:1"UnL1,1tt UMBRELLALIAB EXCESS UAB I CLAILIS:.I:,LUb A U-GKbG,1 E GEL'• IiL.EI:I IC I.j WORKERS COLtPENSATION X 'tit 1 h ANDEMPLOYERS'LIAall. S]:ri1')t Ili Y?N i.4o d IBU:El,:u,tl4c:itcU)t:E L t:,Ci-:•t:L1C•bT.l 15 1.000.000 A .H.U..-LEI.IBpe tUCc.i7 1N;A N POWC772258 Q]IQ1;2Q]6 01101120]7 -- (Stantlatory in NH) 1.000,000 CE5'.HII'Wx,Of-G9$k:.11Cl;c yco.: IL-L.U1a'EA86 PC:DL LI.111 - 1,000,000 I DESCRIPTION OF OPERATIONS i LOCATIONS f VEHICLES(ACORD 101.Adt itional Remarks S.hW.W...y be aM.I-xd if mo:c Spou m requirM) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCJES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Theitsth Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,R102910 AUTHORIZED REPRESENTATIVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ACORD® DATE(MMfDD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 3/23/2016 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 Linda Bogdanowicz NAME: Insurance Solutions Corporation PHONE , (603)382-4600 FAX No.(603)382-2034 60 Westville Rd E-MAIL ADDRESS liadab@isc-iasurance.com INSURER AFFORDING COVERAGE NAIC d Plaistow NH 03865 INSURER A:Western World INSURED INSURER B 37aatilus insurance Chou Polar Bear Insulation Company Inc INSURER C: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 USURER 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. I TR TYPE OF INSURANCE DDL SUBR POLICY NUMBER POLICY DD//YYYF PWDD/YYYP LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occunence $ MPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 % POLICY❑PECT r—]LOCPRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Poracco $ $ R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION 1AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE OR ANY PROPRIETOR/PARTNER/EXECUTNE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NM 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,AddRional Remarks Schedule,maybe attached U 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 - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 onufm p� 0Mce ofCans=er s an 517q} 1�}�atP 19 1 � 021 BMW% tar m o;neM� ,a ica172s roVe 79 ypes71226 ' �BEAR INs's���o�C poc 1. > - Vincent LeBlanc P_O-BOX,958 =_ _ =_- _ g afoccl �. 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