Loading...
HomeMy WebLinkAboutBuilding Permit #1022-2016 - 70 HUCKLEBERRY LANE 3/30/2016 ,A -q 11 , TOWN OF NORTH ANDOVER `1 � APPLICATION FOR PLAN EXAMINATION Permit NO: -aol� Date Received Date Issued: 313614, IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER L9 C y be h d r +r Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no it 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other ❑:Septic 0 Well ❑Floodplain ❑ Wetlands ❑ 'Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: A�E"Srg/i✓�,9 P7� 1-FC /P15U1' '/'o W Ta Q - 1/5, (Identification Please Type or Print Clearly) OWNER: Name: LqC Y r h d ry- Phone: Address: 7y' 11vCt1r b?0rrY G, n e CONTRACTOR Name: Peter Leblanc Phone: ast Pine Street Address: Plaistow,-N, 039-6.5 978-407-7638 Ila /i� Supervisor's Construction License: 1,0 t"017 Exp. Date: Home Improvement License: /'O'xw- Exp. Date: ARCHITECT/ENGINEER Phone: 14 Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Coat: $ 3g0o. e O FEE: $ 4-7— Check No.: 1-1 q2- Receipt No.: ?)b le(7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatu.reroflAgent/Qwne Sianafure of.contractor 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 o Workers Comp Affidavit o 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 Perrr 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 Li 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) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 .Permi- 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: Doc.Building Permit Revised 2008mi L 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 J 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on_ Signature COMMENTS Zoning Board of Appeals: Variance, Petition No:4A? irk if Zoning`Deci`sion/receipt submitted yes y Planning Board Decision: Comments f Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location No. L r Date ��" t�° • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �"1 Foundation Permit Fee $-- Other ti;Other Permit Fee $ TOTAL $ ;_ a Check# 110 Building Inspector NORTH own o ndover o No. b)J _ 6 * - �` h ver, Mass 3DI,261(o o cocH1c"awlcw �,ps RATED LU) BOARD OF HEALTH Food/Kitchen PER IT T D Septic System THIS CERTIFIES THAT ................... BUILDING INSPECTOR ....................... .n. ..... ....�1� ..!!�s.................................. . alum � r JA Foundation � has permission to erect.......................... buildings on .. ...... .......a.. ................. Rough to be occupied as . . .....................,... :.t... .... ...� � S►�4t,►. �.,..... ��..�..... Chimney provided that the person accepting this pe hit shall in every respect conform to the terms he application p 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 RTS Rough Service .................... ..... ,�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. t �. Z741 RI 10 0 0"0156W RISE Engineering RI comrM r Regboutirm No 8186 RlSeNA COntrueWr Regisballon No'IMM +: A division of Thiersch Engineering ENGINEER'NG eoShanttrnit#2�CaN ^atoa, A02a2! CONTRACT 334-502i335."'�~-1FAX 9-502 6345 --" ---- I Page I PROGRAM �--� ,kaca+rrtAetaaurMaDrrtueUYINaase e� CMA-HES EMODO UNG AMT HECUsmrcxseRYMMAS r— OESCRREDDO.OW _..__..._.._.. _ . . ..; . ._ Q --- _ - -._. __ _ __.. G1tlTOltF.n CN.J PHONE DAVE CUENTa tHOrtrt ORDER Lacy Bender :n (610)304-8085 03/032016 431461 00002 SERVICE aTRM P t.• I 94LAi0 STREET 79 Huckleberry Lane f h 79 Huckleberry Lane taRYrCE CnY,STAT1:,,.t8f==-- 'JOB '� trLLR�6 Crm.SrAm LP North Andover,MA 01 North Andover,MA 01845 DESCRIPTION HAZARD HARRIER:We have identified that there are recessed lights present in your home.unless the recessed lights are certified as IC-rated(Insulation Contact Rated)we will create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. 50.00 AIR SEALING:Provide tabor and materials to seal areas ofyour home against wasteful,excess air leakage.Ibis work will be performed in concert with the use ofspecial tools and diagnostic lists to assure that your home will be left with a healthful level of arc exchange and indoor air quality.Materiels to be used to seal your home can include caulks,foams and other products. Primary meas for sealing include air leakage to attics,basements,attached gamma and other unheated areas(windows are not generally addressed.)This will require(8)working hours.A reduction in cubic feet per minute(efm)ofair infiltration will occur,but the actual number of cftn is not guaranteed. At the completion of Ore weatheri:ation work,and at no additionai out to the homeowner.a final blower door andfor combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. S680.00 DAMMING:Provide labor and materials to install a 12"laycrof R-38 unfazed fiberglass baits to(196)square fat for damming purposes. $401.80 ATTIC FLAT:Provide labor and materials to install a 7"layer of R-25 Class I Cellulose added to(1148)square fat ofopen attic space, $1,492.40 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(40)square feet of knmvall area $140.00 ATTIC ACCESS:Provide labor and materials to make(1)access opening from ane attic area to another by cutting a passage through sheathing. This access will be left open as it is between two common unheated non frtewailed attic areas. $31.31 ATTIC ACCESS:Provide labor and materials to install(1)easily moved,insulating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic. This will allow the cove's integral weather-stripping to restrict air leakage. $237.65 ATTIC ACCESS:Provide labor and materials to make(t)temporary access to an attic area The opening will be closed with materials similar to those existing. Finish sanding and painting is rart included. 585.00 VENTILATION:Provide labor end irum als to install 15)8"diameter tool'vcm(s)to increase ventilation in uric areas. The vert carr be supplied in(circle color)black brown,gray or mill finish. 5427.50 VENTILATION:Provide labor and materiats to install(2)insulatod exhaust hose with gable wwl mounted Rapper vent tocxhaust existing bathroom frn(s). 5X37.50 • t�adermtno RISE ED&eerjng RlCaioaeoorRegtatrattonNosits A drkon of Tdsh Egac8RfSE ' l�IlcottonseearAe�testian No,f48r9 ENGINEERING 60 Shmataat UWI a2.Awa.MA 0=1 CONTRACT 339-SU4 X33 FAX 339-SUANS Rage 2 MOGPAM CMA-M &An ctmlwmm+ro m awa®aear cos a m Rlolm "Ta cum& woatonaN Lacy saw" (610P0441085 03/03/2016 431461 00002 smvice stntsn ... muga sraetr 79 HudtMmy Lane 79 HuckUmTy Lane sttmee emrarats:m eaaaa am$seta t3P North Andover,MA 01845 Nonb Andover;MA 01845 JOB DESCRIPTION VI?J'11tATIAN:Rovide labor and materials to it=M vaWWmt chola In(64)aft bays m meinWa airflow. S128M ffor el will ot=bmf��S%�moenu bmdvas w ex000d 0 pa will only be billed the Na aaaamt cwnndy. d � and an atoauive of 10096 for d,c Alr Seating nttststaa up to ata flat 5680 and an WMdotm15360 if savings toe juttted by the auditor. Far the satixyr and tm b of your Irornds iadaor air quality.we will be cw&w keg a blowadoor dieWMie of the avaiM6 alr flow in your bomo both before ttx work Is begm=daft the wadmizadon work is oomolm We wdl also a,,h o fall amessmatt of the oombteaon s ft of yoor beating syaum sad wars bma.Ibis hat a vatoa of 590 and is m ao cast a you. Total dbwa* WembabolOo broeotive is$3.1 to. 590.00 TOM: $301.16 Program Inceadve: $Z770A0 CustonwTotaG $1,1$1.16 vesAuMMtnTowtMMat3mees.00ttReruaeAtrooVuroeW MasovaanetsstcAV MawRTMaOMot= *"One Thousand One Hundred E%ft-ORe&IGMO0 Oonm $1,1811.16 trona FOM aavem=mmAtatovu,rtrueo>a CrAlarataAMMto[rearAtaa,trovaaALLarr�tarrt►vmiasowabmmnroasur �oma4nuwke�rreeaeMraa�aalA roaaaeur r----- arawarRtsa.aoMraas 0�taaq�wmaotnaeemaR�nartmN. 00 NOT SttN171aB CONTRACT ff THOtE ARE ANY RIAtttt 9P Mare<tasa�r�eraeraartsnmaewuarusv■oteeatwr�rrua, ataareoae.auKa ..... ..���/G�/�_....... __..__. soevrareaavao,nase►.nmaaovens,em�avte�m�twie4raoamauas�ua °11n � vau�aemimasaa,naQa rarrnosssoT000trmwaa RlSt'�� 60 Shawmut Road,Unit 21 Canton,MIA 020211339-502-6336 ENGINEERING wwwAISEengineering.corn OWNER AUTHORIZATION FORM I, Let �eo-i, a/. ✓ (Owner's Name) owner of the property located at: P.r ti' (Property Address) JV. a^ W12 (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for 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. ees d o� 6 Date The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gotJ�d7a NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunibers- TO BE FILED WITH THE PERMITTING AITHORITY. Applicant Information Please Print Legibly Narne (Business'Oreaniz-ation/Individual): j�b la rh r4 r NSV/kr/' N /4t). T�tC Address: ;P 4. A0 X 95c City/State/Zip: f}/xd oyrtf, yV?/¢, oifly Phone#: Are you an employer'Check the appropriate box: Type Of project(required): I ®I am a employer with_employees(full and/or part-time)* T New construction '❑1 am a sole proprietor or partnership and haNc no employees working for me in 8 Remodeling any capacity [No workers comp insurance required J 4 ❑Demolition 3 01 am a homeo-wrier doma all work ni self [No"orkers'comp insurance required J' 4 t am a homeowner and will be hiring contractors to conduct all work on my property 1 will 10 E1 Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.®Electrical repairs or additions proprietors with no employees 12.0 Plumbing repairs or additions j❑I 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 ha%e workers'comp insurance 6 O We are it corporation and its officers h:rs e exercised their right ol•exemphon per MGL.c 14 E]Other 152.§IN).and we have no employees [No workers'comp insurance required J 'Ani applicant that checks box 91 must also fill out the section below showing their workers-compensation policy mfimnation I omeowners who submit this affidavit indicatme they are doing all work and then hire outside contractors must submit a new aflidav it indicating such =Contractors that check this box roust attached an additional sheet showing the nante of the sub-contractors and state whether or not those entities have employees If the sub-contractors have emplocces,they must provide their workers comp policy number I ane air ernplo3�er tient is providing workers'c•onipensation insurance for nr}7 entpilgrees. Below is the policy and job site information. Insurance Company Name. 110 Gr_v r Police#or Self-Ins Lac # ��W 67 a;l. S Expiration Date 0,; 17 !ob Site Address 7 �/�G �jPT�y �t h L City/State/Zip: f�OcOti'C.r� Attach a copy of the *,corkers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c i 5_1 ti25A is a criminal violation punishable by a fine up to$1,500 00 and!or one-year imprisonment_as Weil 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 cope of this statement may be forwarded to the Office of Investigations of the DIA for insurance coVerage verification. I do hereh)•eertif}•under the pains and penalties of perjur}'that the information provided above is tree and correct. Signature: �, -v�-�--° — Date 3 h� ///v Phone-4: Official use onlr. Do not write in this area. to be completed by citt•or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector G. Other Contact Person: Phone#: AC4 RL> CERTIFICATE OF LIABILITY INSURANCE FDTE(MWDo16n 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 Linda Bogdanowicz NAME: Insurance Solutions CorporationPHONE (603)382-4600 No):(603)392-2034 60 Westville Rd E-MAIL lindab@isc-insurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC A Plaistow NB 03865 INSURER A Western World INSURED INSURER B:Naut:Llus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO BOR 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 I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MWDnfYYYY) (MM/DQ/YYYY1 LIMITS $ COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE � PREMISES $ OCCUR ETORENTED 100,000 PREMIEa occurrence NPPS274967 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 X POLICY❑JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED tid P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident $ R UMBRELLA LIABOCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB HCLAIMS& ADE AGGREGATE $ 1,000,000 DED I I RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATIONOTH- ANDEMPLOYERS'LIABILITY Y/N STAPER TUTE ER ANY PROPRIETOR/PARTNERIEXECUTNE OFFICERIMEMBEREXCLUDED? F-1 NIA E.L.EACH ACCIDENT $ (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 be 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 ©19W2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NS025 ooi4n11 POLASEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE F�1/6/20 ( JYYYYy 16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlC 0 TE 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 poticy(ies)must be endorsed- If SUBROGATION 1S WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 978 688 700D °FAx 11 Saunders Street Arc N,��c_( ._ )_-._ . - . __ —. !(A1C,NoL(978}688-7001 North Andover,MA 01845 E-MAIL -� — ADDRESS: — I INSURER(S)AFFORDING COVERAGE ; NAIC 3 INSURER A:NautlluS Insurance_Co. _ 117370 _ INSURED INSURER B:Safety Insurance Company— 133618 Polar Bear Insulation CO.Inc_ INSURER C:__ _I Peter Leblanc&Steven Leblanc INSURER D_ G P 0 Box 958 — -- - — -- - 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 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_ IEFF j POLIE(P LT -- --- R; 'ADOLI TYPE OF INSURANCE SUBR; POLICY- CY LTR i _ E INSD I WVD E POLICY NU ER I MMO MMJDD LtMITS A COMMERCIAL GENERAL LIABILITY ;EACH OCCURRENCE 5 I - DAMAGE TO RENTED -` CLAIMS-MADE =OCCUR i Pl SE�Fa occurrence) EMI $ _ MED EXP(Any one person) S PERSONAL 8 AD_V INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERRL i AGGREGATE 16 ' t r f PRO- E :POLICY;_ -JECT __LOC PRODUCTS-COMPIOP AGG S OTHER: ! t - — -'- -:_S -- AUTOMOBILE LIABILITY j !COMBINED SINGLE LIMIT is 1,D00,000 - �Ea accident-— _ B ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) S ALL OWNED ix SCHEDULED — _I AUTOS :AUTOS ;BODILY INJURY(Peraccident) 5 'HIRED AUTOS X NON-OWNED j I t PROPERTY DAMAGE - AUTOS 1.(Per a—den) — S — - UMBRELLA LIAR OCCUR EACH OCCURRENCE S ) {a ; IXCESS LIAR CLAIMS MADE; I I AGGREGATE _ S —DED RETENTIONS— is WORKERS COMPENSATION i PER 0TH- ' :AND EPAPLOYERS'LIABILITY _i STATUTE f ;ER _ Y/N, ' E.L.EACH ACCIDENT 'S ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIM(Mandatory MBPRin NH)EXCLUDED? �j N/A 1 ( E.L.DISEASE-EA EMPLOYEE S I(Mandatory in and If yes,descriW_under 1 i `----—— —' - '-' - --- -- DESCRIPTION OF OPERATIONS below I E.L DISEASE-POLICY LIMIT;S 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 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 195 Francis Ave ACCORDANCE WrrH THE POLICY PROVISIONS_ Cranston,RI 02910 AUTHORIZED REPRESENTATIVE Z-1 ra moo nnyn nnnnr•% All 114/2016 Preview:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCE OATERaiti12)016 ) ��- o1Jo41 zo1e 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: PHONE A Automatic Data Processing Insurance Agency,Inc_ (A-'C-No.Eat1: lac.No). I Adp Boulevard ADoDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC7 INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,rdA 01810 INSURER O: INSIfRER E- INSURER F. _ COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO.%HAVE BEEN ISSUED TO THE INSURED IIIAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT1.1j1THSTANDING ANY REOU1REM.ENT.TERl f OR CONDf TION OF AN:CONTRACT OR OTHER DOCU1'.IENT.'11TH RESPECT TO NHICH THIS CERTr.FICATE fdAY BE ISSUED OR J.IAY PERTAU-1.THE RJSURANCE AFFORDED BY THE POL!CiES DESCRIBED HERE-:N:S SUBJECT TO ALL THE TERLIS. EXCLUSIONS AND CONDITiOaJS OF SUCH POLICIES LRAITS SHOWN N L'AY HA`JE BE£-IJ REDUCED BY PAID CLAiLSS INSR UUaUb P UICY PF OLILY P LTR TYPE OF INSURANCE POLICY tU!tBER t PILiYYYYYit LVAITS COsIMERCIAL GENERAL LIABILITY EACF: r�'L4ikEi.Ct CLAVUS-L1•;Ut ❑G�CL Ii 1'IiE1.Ii's t`IE.:J_cl^cr._•; >_ LIEU PEIi5L'L:•L}.AU:I:JLI: Gtt.L AGCKEC IL LIt.IN i FFLItS FEE. UENEHAL ir(;t;htl•.It JECJg; l L:;C 1'IiCa'tL:iS �Cf.11?;:P•:L•G '"t-EK. i AUTOfiOBILE LIABILITY r':LI I.: :If:L1 LII.11 rt:1 _rl; :•1.�:JJ I L' BCL-IL ff:JUi+:P;r i,-o:om S %.!•IC_ :.L'!CS b:;U1L'i II:JI_1i 11'i•s.a�cldl FIKEVALI CIS 5 Uf:BRELLALIAB !-!'l:lt Eric!•::UUWKENCE EXCESS UAB El'L'11 11 LIVE AGGIiEC'•It UEU IiEltIc IIOLS -WORKERS COMPENSATION x AND EMPLOYERS'UABILITYrN SI••ILIt H; : 1,000,000 I`hYCEF-1.10.18U_EULL-LEV? Ll I1sE Y !IIA N POWC772258 01/011201610110112017 EL t%.cl :.I_catf.f s A F:Ef1di:f.18EJ�:E��.;tLC•EL'1 (.Mandatory in NH) t L-East;•st t„tr:u�Lc�'EE: 1.000,000 Ct5!-Illl•IICC CF CPEIv.:ICGS 9::�.: E.L.VISLiASE PGUC•UI.ilf 1,000,000 DESCRIPTION OF OPERATIONS;LOCATIONS!VEHICLES(ACORD 101.Additionai Remarks Schedute.ma/be attached it mwe 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 A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD on W&1*1 O consumer Affm aad Office 10 parkplam-SLn W5170 02116 BoODDMsm OIIie COIltGd ^+ Reg #02726 - = Types DIM �� 'ice 2 49 Expirffiiow- 7120 ////n���� BEAR II�iSt3�-fJON Co_ - Vmcent LeBlanc = p_Q.80'IC958 �roaiuccisaaae. ARfjovm MA 01810 __'__ :- __ ����,:Aaa����� Q LodC&d orscat u��6 - P;sistoR 1�Q38G5 - J�'