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HomeMy WebLinkAboutBuilding Permit #774-2016 - 693 JOHNSON STREET 1/4/2016Permit — Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI N I, Date Received IMPORTANT: Annlicant must complete all items on this nage Identification Please Type or Print Clearly) OWNER: Name: Phone'c1Ilb Z�3 • Z�piZ- 9 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: $ Zgci . Ol FEE: $ _ Check No.: Receipt No.: 7 NOTE: Persons cont cti g with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑i _ 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 m U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature, CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature 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 ;Jt54 Usgooa Street FIRE DEPAR+TtMEN�t�f,Temp Dumpster onsite,,yes .,%n ka.,.4. 7a- +.c �r..F.-`'a ' "Fs fir: �' �°1%►S.Ri, 4,.n : { ,�" `} �p i "tl. tl .''.7t%i"i4t ...�......-.i —� ' i�.. LrocatecJat 124Main#Street 411 r r T fats tti. fy.S y 1 P Cir � 1 j.i ,. • � 4,..i sfS � �7YT fr.�=;, rt y. �,"�"`r` • "1. h S y 41r�-1 w. � a Glx. Mi ~ i i� �l • . +i . f'� I ��� � i � ',1 .� 11.. 3 COMMENTS: Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 1 J 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 4� 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) 4. 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 4. 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 o-5 No. 1 -1 k4 Q%1 Check # i �7 59' Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $3(a -::- Foundation Permit Fee $ Y Other Permit Fee $ TOTAL $ Building Inspector O Ln --q 0 = " —h0 cr -n CD a°4 C.) = _<. C0D _0 cn ct -- CDCL CD c 0 CD 0 m 0 rL C.) O =--o U) fu �.% iD 0 -n z Ln m CD M r, m CD CD CD m cn Cl) 0 Orn — > cn x to ;a m Cl) E; =r 0 — Z O fD z 0 CD -0 0 < CC 0 h rr CD N 0 co 0 N CL S' CD 0 2. CL CD 00-0 0 — Ln --q 0 = " —h0 cr -n CD a°4 C.) = _<. C0D _0 cn ct -- CDCL CD c 0 CD 0 m 0 rL C.) O =--o U) fu �.% iD 0 -n 0 0 CL h :* A) Ln m CD M 0 1— CD CD CD CL > 2 CL 0 IMP - to o E; =r 0 CCDr- Co) K fD CD 'o 0 CD -0 0 < CC 0 0 Ln 0 0 CD - POP cr r x - -n CD a°4 C.) 40.& -n 0 0 ;o Z, < CD CD U) 0 fu �.% CD < NPX �4 CL CD . Wo �- - F xv L CD U) @ 0 o 0 SPOON Er" :116 0 Erp CD CD C=n _0 ID 00 CD SOP 0 • > CD 0) or . ���:A : sw= o 0 su 0 Ln Ln co -n ;o -n Ln ;o -n :;a -n n :0 -n Ln -n 3 1— c 0_ M 0 5 o 5' =r 0 0 fD 0 0 m c RL c cu C _0 0 X, (D m UQ z CL rD 1 rD :3 =r CL 0 M w Ln M 0 < m M r- r- w rD rD m c 3 z C) 0 m > 2 > rmz E z > G) > LA 0 V z rm M fl rn m 0 m rn m > Z r) r) 0 0 0 O h '4"o ,W, RISE Engineering Faderall00 g g R1 Contractor lt4stmtion No A division or'1'hlelceI, Cugiu, cring MA t.ontiaeter Ro9ietration No CT Contractor Repietretlon No This work will be N..r... -` rivnuc ,sour ane muteftals to Seel areas Of your home Mgauust wasteful, eXecSs air leakagt pertbroad in concert with the use of special tools and diagnostic tests to ussuft that your hump will be lett aitb a healthful Icvej of air axu:hange and indoor air quality, Materials w be used to seal your home can include caulks, fauns and, the( ptoducts. Pfimaay areas for staling Include air leuk4ge to attics, busartortoot generallyU, attached ga cs; and other unheated areas (windows arc addressed.) (8) working hours. At the completion of the wt:Mtherixation work, and at no udditional cost to he homeowner, a ftnul blower d, or and/or combustion safety analysis wM be conducted by the sub-cunttactor to owure the suthy of the indoor air quality. ——";&N�. rtvvtue taoor an0 Materials to ins m u 12" teyeer of purpoaas. ATTIC FLAT: Provide tabor and materiels to install a space. 12" foyer of R-42 Chess t &NMWALLS! Provide labor and ntatenals to install 2- FSK fuM s knoewatl M&ON FAMILY ROt)M GABLE VAULT TO GARAGE! ......aw,, rruviac moor ane materials to insulate porimoter. vuty I ILA I IVN: Provide labor and materials to existiog bathroom fan(s). to of the bl►Semertt ceiling at the home sill. ane materials to i butts to (20) squat c feat fin damming added t� q,uurc jWt of tptttt attic board insulation u (66) square stmt of hatcb with 2- rigid (Itcfn= b-,afd. wcathersttrip the ase with Streit mounted fl appa• vent to exhaust 4) rWkr buys to maintain air fl. ,w. of R•19 anfkcd fiberglass ins latiun to the Deriate4 ��- ,—lug lawn tate materials to install 84 R-28 densely packed Class 1 CeJlwose insulation to (32) square Med exterior uverheng located below a heated floor area, by drilling holes in the overhung from below. !lutes drilled win be plugged. Plugs will be Sealednwill wilt exterior lgradelmrs spackle and Jcti in a rclddvely smooth condition, Finish sanding and n ugh -up priming/paintingcoill bo the eustarua s n spottsibility, r-upu%ermg wtu apply all applicable, cllgible incandvos to this MMrdct. Yuu will only be billed the Na amount, Currently, for eligible ntawuros, Columbia Gas ofDrs 75 % inena6ve, not to cxcacd 82,000 pp adendar year, and an incottMo of 10Uur for the Air Sealing measures up to efts first $680 and an uddlGunal $34t), 340 Jf savings are justified n the uuditnd For the safety and health of your home's indoor air quality, we will be conducting a blower door diugaostic oft w available air flow in your borne both bcfm the worts is begun. and after the waaMeritation work is comptet. We will also conduct .� full asSe5sment of tete combustion satbty of your heating system and water hcater.'1'llPltis has a value o ' and is at no cost to You. Total allowable $680.00 $41.00 $1,344,00 $231.00 $60.00 $118.75 $48.00 $255.50 Y125,76 E0/10 39bd SI S83NidVd 66069ZLLT9 9560 STOZ/6T/0T 60 Sbawmut (Jolt 42, Caatun, MA 0.021. ��---332.6345 CONTRACT R I S E �nn Page t PRWRALI 6NGINEER3NC o i311U CMA -HES � Womb Me X,, MwitiaEo ".Low Ste hen Mouzakis P y Wil( NONE --•• (978)273.2482 Q0. _._.-. ....__ ..._. eIIENT. 04/10/2015 W 404887 0003 6931ohnson Street o � 693 John soa Street aeavieE 6T4. -04t -B_- \ tuWNG CITY,&TpTa gp ___ _.. _—.. •_ .�_ North Andover, MA 01845 T -- ----• ._.._ .._... t . _��...%1 ..._. North Andover, MA )) 845--- JOB DESCRIPTION This work will be N..r... -` rivnuc ,sour ane muteftals to Seel areas Of your home Mgauust wasteful, eXecSs air leakagt pertbroad in concert with the use of special tools and diagnostic tests to ussuft that your hump will be lett aitb a healthful Icvej of air axu:hange and indoor air quality, Materials w be used to seal your home can include caulks, fauns and, the( ptoducts. Pfimaay areas for staling Include air leuk4ge to attics, busartortoot generallyU, attached ga cs; and other unheated areas (windows arc addressed.) (8) working hours. At the completion of the wt:Mtherixation work, and at no udditional cost to he homeowner, a ftnul blower d, or and/or combustion safety analysis wM be conducted by the sub-cunttactor to owure the suthy of the indoor air quality. ——";&N�. rtvvtue taoor an0 Materials to ins m u 12" teyeer of purpoaas. ATTIC FLAT: Provide tabor and materiels to install a space. 12" foyer of R-42 Chess t &NMWALLS! Provide labor and ntatenals to install 2- FSK fuM s knoewatl M&ON FAMILY ROt)M GABLE VAULT TO GARAGE! ......aw,, rruviac moor ane materials to insulate porimoter. vuty I ILA I IVN: Provide labor and materials to existiog bathroom fan(s). to of the bl►Semertt ceiling at the home sill. ane materials to i butts to (20) squat c feat fin damming added t� q,uurc jWt of tptttt attic board insulation u (66) square stmt of hatcb with 2- rigid (Itcfn= b-,afd. wcathersttrip the ase with Streit mounted fl appa• vent to exhaust 4) rWkr buys to maintain air fl. ,w. of R•19 anfkcd fiberglass ins latiun to the Deriate4 ��- ,—lug lawn tate materials to install 84 R-28 densely packed Class 1 CeJlwose insulation to (32) square Med exterior uverheng located below a heated floor area, by drilling holes in the overhung from below. !lutes drilled win be plugged. Plugs will be Sealednwill wilt exterior lgradelmrs spackle and Jcti in a rclddvely smooth condition, Finish sanding and n ugh -up priming/paintingcoill bo the eustarua s n spottsibility, r-upu%ermg wtu apply all applicable, cllgible incandvos to this MMrdct. Yuu will only be billed the Na amount, Currently, for eligible ntawuros, Columbia Gas ofDrs 75 % inena6ve, not to cxcacd 82,000 pp adendar year, and an incottMo of 10Uur for the Air Sealing measures up to efts first $680 and an uddlGunal $34t), 340 Jf savings are justified n the uuditnd For the safety and health of your home's indoor air quality, we will be conducting a blower door diugaostic oft w available air flow in your borne both bcfm the worts is begun. and after the waaMeritation work is comptet. We will also conduct .� full asSe5sment of tete combustion satbty of your heating system and water hcater.'1'llPltis has a value o ' and is at no cost to You. Total allowable $680.00 $41.00 $1,344,00 $231.00 $60.00 $118.75 $48.00 $255.50 Y125,76 E0/10 39bd SI S83NidVd 66069ZLLT9 9560 STOZ/6T/0T S".00 Total: $2.994.01 Program Incentive: $2.438.01 Customer Total: $656.00 MMOF —Fin Hundred Fifty -ft a oolloo Dollars $586.00 ML oreabonoma�oAPnaovAtiar mwra,seaAGUMjVRQWAM*Wff&,M *JftLLwf&=T MMAq!wdft4M-cw a OpI%%L6CqMwM% 2VMPN`LM-�Ad-0ETLWV ON GUARAMU& Mmm MONIftraft"I 00 NOT WON 2-0 F M. --M= ^—S_CKW U MG. A 10 CONTRACTOR I t IF ANY abliq 30 &9="AXCB OP CONTRACT TT a #AM= pUM opogUnyan woo ARB "MEW= PAVAMWM4 ftIvMMQAQM EG/Z8 39Vd SI SaNlWd 66069Z4LT9 GG:SG GTOZAT/sT RISE ZO&eering W0 PJ c"UMW ftafflumon No 72 A divides OfThirbel, Eugunrigg MA ftnftmr Rept"OnCOCONTRACTHe CT Co iogftr Ragatgd= No R? 60 SbAwMut UOIC 62, Conlon, MA OM FAX 3394024M IL I SPage E a PROGRAM CMA -HES Stephen Mounkis (979)273-242 04/10a013 404887 00003 693 Johnson Sum MWAG vrCW — — 693 Johnson Sum North Andover. MA o1845 NOM Andover. MA 01845 JOB DESCRIMON S".00 Total: $2.994.01 Program Incentive: $2.438.01 Customer Total: $656.00 MMOF —Fin Hundred Fifty -ft a oolloo Dollars $586.00 ML oreabonoma�oAPnaovAtiar mwra,seaAGUMjVRQWAM*Wff&,M *JftLLwf&=T MMAq!wdft4M-cw a OpI%%L6CqMwM% 2VMPN`LM-�Ad-0ETLWV ON GUARAMU& Mmm MONIftraft"I 00 NOT WON 2-0 F M. --M= ^—S_CKW U MG. A 10 CONTRACTOR I t IF ANY abliq 30 &9="AXCB OP CONTRACT TT a #AM= pUM opogUnyan woo ARB "MEW= PAVAMWM4 ftIvMMQAQM EG/Z8 39Vd SI SaNlWd 66069Z4LT9 GG:SG GTOZAT/sT io OWNER AUTHORIZATION FORM I. cr. owner of the pmperty bcaWd at ki-S hereby authorize (subcontractor) an authorized subao mar for RISE Engineering, to sot on my t*hatf to obtain a building permit and to perform work on my property. E0/E0 39Vd SI SaNINVd 66069ZLL19 98:60 B10Z/61/0T The Commonwealth of Maasrachucettc De artnrient of Industr&lAccidenfs fOffice of Investigations I Congress Streelr Suite 100 Boston, AKA 0 II4 201 ww s�govldia Wor eW Compensation Insurance Affidavits uildea Cont ctorsXl tt ions/Plumbers Ag Wlcant Igortlr tion Please Print Lfteibly Name (B ims. tii; €ion,lndiviJusi-, tJ q Are you an a mploi ert'" C itee3e the appropriate hat;. t arts a employer with S =t. 0 1 am a general cantmclor and I employees (full att&br part-time).* 211 1 am a sate proprietor or partner- ship and have no c tployees working for me in any capacity. No workers* comp. insurance nxluired..]! 3. ® l am a homeowner daring all work rnyself: (leo workers' comp. insurance required.1 t itrtve hired the subcontractors listed on the attached shit. These sub—contractors have employees and have workers' comp, insurance 5. We are a corporation and its officers have exercised their right of exrmptionper MGL c. 152, § ](4), avid the have no emplayms. [No workers' corop. insurance required.] �" wrarly 'rype of pro*t (required): G. r3Nein cert miction ?. M Remodeling i's. 13 Demlition 9. r32tuilding, addition 10.r3Electrical repairs or additions I Lr3 Phttubiag repairs or additions 12.[3Roof repairs 13.0 Ober *AJWAPPqMtIhUChCCkftVX of atk%alp fill out alae ion Wow g r as t policy infamatrr _ t Honvownem, who submit avis affidavit r alieatrata they ars doing all we atter him otmQc a minctrus must satiarnie a ncx saffadas^at indicatow such. ',CMtWmM that check avis txec ta.ttse attKbet€ as a4&,ionzh,,hft4 stmwing she amine cache sub-omuavom azar state whedmr or nnet;t+uc cnancs have emptoym- to the 5*-csar _ lm spk)yr , they mimt pun-tde their wwkefs'cmip, polis _v number. J int tan emptayer xhat is pravidiat is rrrtterx' cn9airp ttti era urr »ce ar arty emptn Below is the poficy and lob site informafian. lnsuranm Company Policy #car Self -ins. Lie. #-._rKft tp .l? Expiration date ) Job Site Address: (act 3 �vn,% ° h �� �YV • �'rn�vt,r f l city;*stat��z1 Attach a copy of the workers' compensation polity declaration page (showing; the policy number and expiration, date). Failure to secure coverage as tequircd tinder Soction 25A cif Mtii, c_ 152 can lei to the imposition oferimmal penalties of fine tap to $1,M.00 andior one -fir irnpr sottrra t, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day agar the violator. Re advised that a copy of this statement any be forwarded to the. Officc of InVestiptions of the DI<A far iMSUfaneC coVer3ge vetiEfiali0n. I do hereby ecxt# under Ore pains and pees of penury that the information provided above is true and correct, bate Phone, ks 3sLo 34 3 Official use only. Do nor write in this area, to be completed by City or town oflxcia City or Town: Permitll icer . Issuing Authority (drde one), i. Board of Health 2. Buittling Department H, Cit;4ITown Clerk C Electrical Inspector 5, :Plumbing Inspector c other Contact person; Phone pz CERTIFICATE OF LIABILITY INSURANCE , THIS CEATIRCATE tS ISSM-0 ASA OATMA 4F DOMMA'"ON -' (,AND CONFERS NO PJC.HrS UPON T"EiMrICATE 4OL CR, TmJS CERTIFICATE DOES NOT APrtRMA'Tf$ LY Ok NM3GATIV£1,.Y A)AM, eXTZNQI OR. ALTER TKE COVERAGE AMRDEV BY THE, PCOCIES SEIOW TKIS CERTIFICATE OF 117S NCE OMS NOT CG2fa C A CONTRACT BETWEEN 'ME ISSWNG JUSURERtS , AS-NoRLZED REPRESMATWE 9R PRODUCER, A" THE CERTIFICATE HOLO IMPORTANT- If the -* hooter #s ;7IMMONAL G!+t vRM tt& pwic'g(m%) numt be endorrWll cseS aUXTaON i`S WAiVED. Subjea M Oe ts"Ms and - of the vow, COMA P03095 May Feq.u" smttff*' T f47Sms cerL3kat do" f+ot Ciwer rwAs to the O&Wgate hakfer in Geta of WCh e McMO! . Clsytm Motto J Ins Agency lnc n€€� Ass grrrct aaai � 1649 morolampton st PCS Box is$ kac, e�(DW) 634-4589 (666)215-8118 Holyoke MA 01041 - :.Ya�x�z ccs ase, PO Sex U4: IpwvAc t, MA 01935 VWRM V. lame f F; vA+*GIMA'UfW A+CR3wlu^AC M11MOCK KC.Y1:N mm31 utg: THIS IS S ME PWC.IES OF USIM MOWti BtMN MIFM£2 TCF 7 THS 94MCATM, :Nry7WM0STAMM MY REOUPSMENT, TE;W OR CONtNTION OF ANY CONTRACTOR I. TWR flgC;30SEN T V tH RESPECT To WKC" 7 CERTIPMATIElAky SLS MSkJEe} CAMAY MAY Eh iii" IOM WS~M5 AFFORDED BY ThE isCAf = Et€ER HERE* ES SL7 70 A1.t ThE 7�_RitS, EIeC.�A.t5ti�5 ANgC:CIt�SrKktS iiFSiiL`�4?'R;dCu LS�ITS S+^i43�"kE33 tt',l:Y 9b4E BE$?,F4tECY3CEGFBY P CSl41ieR.rt.. ''A'.`.. C!P:dS - i �if,1r :""kWtiYS tom& smus-uAsury ERCr+9:9s�s E E .. 0 0„�rX„rE�sarva' "Ov-C's -f.[14`IYAi I= "M c4Si�liLAW *p t"Pak: _ iKFtEC!r _ . 4ti' S siIdT01/liwltf tiiditSY - Afy "..... AF 'y' 4 m i]E AEU AQ- A�CAE.xftoarsastr d8i.82YtN EaiS:�E E7tOM OA"—"—JA. __ s ft-r_w "s �satftiaw �Et Ell Ak.Y gfytXM�w'S'h�TnE'PS`'S,»tYi'4u'&, f'E`y ecsKrA00AMAEAf. r� t&4AARP2XV7 eA tS si 3 tiS6 p _ fi 2'�+.kS AtfAS Cw`Y2 I i�.3 Pi „3*M,.ai,"M' GIMP:: :.S- t'iE5t6"'1'Yg9Ra1sdFN'IPkS Worn _._.._.. - t�tllen 'v�`AC•� i+iRne AA xk!xi'�l46; % O &E Aa1YOr'?°tE .c?i`E iii.5#3Ef'r Pa7`_S B; c/�hamu t TWE EXP AT t i'IA'C'1.4E OF. M019M'WLI BE Sd R ft ie�or $v4s, A=DRDANM 'saFIN THE: PCM)CY "IONS, sMl Yi1�hM Sfirael .b. Wes*0roUgh, MAMA 61501 ACMD 2S(20I S) BRAC 3139 ACORO0 COO CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYYY) 7/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Martin J Clayton Insurance Agency, Inc. CONTACT Nancy Usher _PH No Ext _ (413)536-0804 FAX ,No): (413)534-7874 1649 Northampton Street E-MAIL ADDRESS:_ INSURER(§) AFFORDING COVERAGE NAIC # P. 0. BOX 989 INSURERA:Nationwide Mutual -Harleysville Holyoke MA 01041-0989 NATIO INSURED INSURER B.Allied World Natl_ Assurance CO ENTED DAMAGE TO RENTED-PREMISES PREMISES (Ea occurrence) INSURERC: _ Gauthier Insulation INSURER D: 44 ESSEX ROAD INSURER E : 7/6/2015 7/6/2016 INSURER F: IPSWICH MA 01938 COVERAGES CERTIFICATE NUMBER:CL157701379 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER D LIMITS X COMMERCIAL GENERAL LIABILITY _MMIDDNYYYIM EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE [i]OCCUR ENTED DAMAGE TO RENTED-PREMISES PREMISES (Ea occurrence) $ 50,000 MED ECP (Any one person) X GL43487F 7/6/2015 7/6/2016 $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_ $ 2,000,000 X POLICY E PRO LOC JECT PRODUCTS COMP/OP AGG 1 $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY C(Ea accOMBINEDident)SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident __ $ NON -OWNED HIRED AUTOS AUTOS $ g UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE B EXCESS LIAB CLAIMS -MADE �BE020792125-194985 $ 11000,000 DED RETENTION _ $ 10/18/2014 10/18/2015 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED) N/A -""— E.L. DISEASE - E_A_ EMPLOYE (Mandatory In NH) $ If yes, describe under DESCRIPTION OF OPERATIONS below - -- --" E.L. DISEASE - POLICY LIMIT -- $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSUREDS) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION (;tK 1 Irl(:A I t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MF?rdrd9tbd with pdfFactory trial version www.pdffactory.com c cam. x AM Q T a a O 0 aR k � V;§ c x Q A Ono G A a My E Myi. I oil ` q V ElW a ^J I f 1 nj t7t