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HomeMy WebLinkAboutBuilding Permit #1101-2016 - 70 HUCKLEBERRY LANE 4/25/2016 aoRTH A.V (�4t�t,D 1616 0 6 . p o PING pERM���ER gU1L ORTH pNp MINATION *M'9SSRAT AGNVS��� TpW pN FOR PIAN Ems` ae ptReceived e ms on th�S Dag complete all lte permit`.lo#: Applicant m no PORTANT• L� N yes Issued' 1 t�r no Date u C P�nt Structure yes o N H►st ric District Village yes n LOCATION �Gt G y t DISTRICT �_Machine Shop R G PROPERTY OWNS EL I ZoNIN on_Resident►al MPP oseu use M OP Industrial PR t►al o Commercial MENT Reslden it pE OF IMPROVE ❑one fommore family Other l T►o H rn TY TWo ------ 0 i No of units'. f'�hep►stri. ❑New Building ssesso►y Bldg _ -- O W aters . ❑AddW1on ❑A tion lacenent ❑Other - ❑Wet1ands -� 14TI0 ❑Repair,rep Q Floodpla►n E pERFORNIE6 r ❑ -- WORKTO B -� pemoUt►on _ _OF o IST ►OA W F-�Sept►c �eell BESCRIPT1O� ,, ❑waterls n Pian And e or Pant Cteart3' phone 1 l please Type Identification' P t � L e 11 e'. L a C f Bldg perrrnt OWNER Nam %JC h�f Phone; ,e o -7 R Addresseter T,ebla''nlC �1 Namep as 11 lie pate Contractor Exp' to Email 7 1638 o 7 pate. I�- Address 9,�gionicense' ` Exp. Constru p � Supervisors Phor'e t 1-►cense' rink�er Plan And Home I,,rovemen Reg NO T BASED ON$12.00 PER S.F. ade Sp GINEER cos ARCHITECTIEN 0.00 OF THE TOTAL ESTIMATED 10o FE �1 PeCCn Address.cNEDULE:BULDING PERMIT'$ 12• 00 PER$ E. it -� uarant`' Rece�ptNo��access to the g to ►sSUance of Bldg FEES have ►or A Peals tat pr°sect Cost. $ ^ • eyed contractors d° not 00 of P dmg TD l ist _ from the 'oar of yecor With unreg mP the decisone cov9 and pr Check No tracting -- - y of Deeds. persons con NOTE: _ ___--- ------ Plans Subrnitted❑ TE G 1 of Sgt� Plates W ❑ aived - public Sewex E DrSpOSAL Certified Plot Plan ❑ private(septic tom, 0PeTxihaue�ntD u�us �pagsteeBx oo�dAS'tarnr P ed Plan- etc. Tobacco rt SW*unIn V Site Ing Pools } FOOd Packag-j,,, THE Fol D NTERDFppR IV'���CTI®NS Fo,/ PLAAfAIING ®� IT,gL SIC;.► re°a'�a� Co V�C®PM��T R e0k e<'���t° ° `atieQ QeQa a a�Q< Q� Q� `ed° C®ftERVATI�ry y�°re��� . Qe °k ,�� `d�Qec1' I �ce� °tom '��� O� Ge � Corwu n �tirete�J �eraa `Ge�eeS o VSLO teO NS HeA1-Tly e00, �3�a'� `'�P� �daJ`p,�`d,O d 990 �r `��, �Q eco ��e��o � CONIM�N �00 �a�e�e C Q O�aGo�eA � o O\ Go'�0, '? e�`��ws ted ���'��` �0 e ei o� -� Zoning Board '� F���� sex s a�`°� (� ees Sed C °fgppeaiS. Varian, d`�'�� Oeo� P,pP�Q�o'�Q`a 000Q, 09, \\\Q \0 0�Ss�a� ,ening Board �O `"- d O 'P Decision: O� �'�`° Q e� �e�e `daJ P� G P��� e� ��P��e �.'��'�� Pdd eds�°� ��G• � �.�od�, eeNation Decl �� e G o �e �pe ;19�asion:er Se e ��e�Go�L c'�`°�1 �e � � wee•Connection Q`�`° O�Ges`'' G��a�`° G° o���`o vOO x��1� Tow ��g ee ;S. /S,gnature: nature&Da, CJ09 �1C'���GG2, e��a`�`��eOQ`a� EP 4 NIT _ .- `gee ,a �nset. �r�emDUmpster , e `r ed ct e "` s�9!natUrejaate .F�{°este, y� °` S�e ti�0�`5 ``Ga� Q`a,� `Ge�ee e�e� s d 1�0 „ e O� Go �Q e�o oee �d G J`� e�O``Gap�e� Gee edQ� \C).P `d Q�a�` P�'p �od� � ` °�� o�� \`a�,�c�re��c ped eDe� Ge opo e G �� a��o ee �C`( ce o��ec eke O�G,a\ Od'e A vo\ e�� ��be o S ��G G o�o, q'� sk( o -sro�o,�aea � CO fie( �'� �� o ec .� � �1� °k GG� da �e s ��ea�re ttr�s� G OC Ce p ep$e N eeA��e�``�� ,��o5 Jstitir 2! �r CO 0��• ���t�°a,S tibe� ases,� b e� tir Sti 4 BUILDING PERMIT o� NORTy q 1 Stereo ti A9 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7D 1 e Permit No#: — 7-0 Date Received �9°°qAr reap�5 �SSACH�1S Date Issued: A�y I PORTANT: Applicant must complete all items on this page LOCATION f uCk�t'hieerY Lgl/I{ Print PROPERTY OWNER Lacy r ptd e Print 100 Year Structure yes no MAP�PARCEL:(�ZONING DISTRICT: Historic District yes no Machine Shop Village 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: 0 Demolition ❑ Other 4 ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: g �('S1Glir, �7'ric �7�SvlaTiOvl Tb /�- Y�l, f/ynT!/4T10vt Identification- Please Type or Print Clearly OWNER: Name: L OtC y a -r to d v r Phone: 6 /V - 3 O V-?VF5— Address: 7 9 ,/vck-lr b-errr topie Contractor Name'Peter Leblanc Phone: Email: I EastPine Street Address: Plaistow. N.H. 03865 978-407-7638 Supervisor's Construction License: /y(y O/7 Exp. Date: Home Improvement License: I ox Exp. Date: 7 41 Aro ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ o a FEE: $ 0- m Check No.: - 7 5z Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantrf' — 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 4Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit .Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 I 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 lies No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ,nning Board Decision: Comments OTE: Allervation Decision: Comments r er& Sewer Connection/sIgnature& Date Driveway Permit In all cases that the aper Town Engineer: Signature: must be subn Located 384 Osgood Street - g ARTtMENT , ,u Doe: Doe:Buildinifiii�24IMain*Street:, l �ar;�finensi�gnafure/dafet_ Location [(� t ° f No. A •� UJ Date i r • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $4--l— , Foundation 7— Foundation Permit Fee $_ Other Permit Fee $_ TOTAL R $_ Check#��� ' . r Building Inspector NORTH own of ndover No. Z h ver, Mass Z� OL COCNIC.j.". y1. J,9s RATED U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT .. .. ....&Jae . BUILDING INSPECTOR has permission to erect g ` � . Foundation .......................... buildin s n .... ... ..... ... .. ............... ��� Rough to be occupied as .� � .�...... ..... ..�......1�,,.� ..�.. j.-. Chimney provided that the person accepting this mit 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 CONSTRUCTION STARTS Rough Service ............... ..... �......................... 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. If 5Y, RISE Engineering RI Contract"Registration,N08186 MAContractor Roglabralloont4o'IMM RlSe* A division of"nielseh Engineering ENGNEERINCY 60 Sba ut Unit 074 Canton.MA02021 CONTRACT 339- -P335 ^1 FAX 9-502-6345 Page I Rol PROGRAM 0000WMAff 13 ENTUM WTOWMI"RW to CMA-HES E0029MMIG AM THE CUSTOMM FORYMirK AS 0C5cR=8EL*W 4—=> C"i POONE DATE CLWW 4 "01MORDER Lacy Bender r,n (610)304-8085 031032016 431461 00002 UWADE aTRM BaLm STRW 79 Huckleberry Lane ct:� 79 Huckleberry Lane SMILE CrrY.STATE.ZW aliAV6 CRY.aTAtQ LV North Andover,MAO 1 North Andover,MA 01845 OB DESCRIPTION HAZARD BARRIER:We have identified that there are recessed lights present in your home.unless the recessed lights we certified as[C-rated(Insulation Contact Piled)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 thetop and closed cavities which contain recessed lights will not be insulated. $0.00 AIR SEALING:Provide tabor and materials to seal areas of your home against wasteful,excess air leakage. Ibis 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 Wd of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foam and other products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(8)working hours.A reduction in cubic feet per minute(clm)ofair infiltration will occur.but the actual number of chn is not guaranteed. At the completion of the wcathetization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will he conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass bans to(1 96)square red for damming pwpos4m $401.80 ATTIC FLAT:Provide labor and materials to install a 7'layer or R-25 Class I Cellulose added to(1148)square feet of'open attic space. $1,492.40 KNEEWALLS:Provide labor and materials to install 2' FSK(heed semi-rigid fiberglass board insulation to(40)square(w of knocivall area. $140.00 ATTIC ACCESS:Psuvidc tabor and tnaterials to make 11)access opening from one attic area to another by cutting a passage through sheathing. This access will be left open as it is between two common unheated non firewalled 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 cover's integral weather-stripping to restrict air leakage. 5237.65 ATTIC ACCESS:Provide tabor and materials to make(1)temporary access to an awe area The opening will be closed with materials similar to those existing. Finish sanding and painting is not included. 585.00 VENTILATION:Provide tabor and materials to install(5)9*diameter roDfv=Ws)to increase ventilation in attic areas. The vent can be supplied in(circle color)black.brown VW or mill finish. $427.50 VENTILATION:Provide labor and materials to install(2)insulatod exhaust hose with gable wall mounted flapper vent to exhaust existing bathroom fm(s). S237.50 ..r • FaderatwaQbOfQ�9 RISE Engineering IN f,-ha-ha RaglSbIG a NDS186 RISE-'�- td4cotlnasborRe mNoimm A diNslon ofTbletteb Eagtaeniag ENGINEEIIIN6 40 SbMWW U,,s 02,Cariiro,NA 02021 CONTRACT 3343026735 FAX339-SUAMS Page 2 PROGRAM THOCCE"UmCMA-HES r vwcmom Ono Adim aata,aw aasaLmt tw" m ane warts woaraaosR Lacy Bender (610)3044085 03103/2016 431461 00002 asavee ertttstr swLLaa smear 79 Hucklebeny Lane 79 HuckWw"Lase t♦Awl@ enrarawa.aF awtaso arr.s►Awa,>DP North Andover,M.A.01845 North Andover,MA 01845 JOB DESCRIPTION VEN 11ATiON:PwvWe tabor and nmxtials to hmll vamleam chutes in(64)rafter bays to mermein air Row. slum RISE Engbmiog will op*ell applita W eligible brae d m to this conowL You wW only be biped the Het amo mt.Cwmraly. for eligible memo es,Colmbis Gas offal 75%inventive,am to cwwd 52,000 per adwWw ycm,and an amattive of 10095 for the Air Scaling ntea 1 ap to dx Rist 5680 and an additionel 5340 if savbv aro justified by the aa&w. For the safety sailbeabb of your home's iadvor air gimiip,wY will be wnductim a blowadvor dWpo nic of the availabta air Row in your hoax both before dx work 0 begmr,sad atter the wtadmitstdon watt is wmplft We will also c oodm a fidl easessmaet of dx combwdm sd*ofyour beafmg aysum sad water boa.Tbts bas a valor of 990 and is eft no oast to you. Total WWwa* weadtaa btoanive iS S3,110. "GAO 1 Total: $3,881.16 Program Incentive: $2,770.00 Customer Total: $1,181.16 VMA8at MOtlOrlOtUMMSERVIM-cawLerewAcoonDA%CewnnA9ovHSPOCWICAMMwanmSMaF "'One Thousand One Hundred Eighty-One 8r 16M00 Dollars $1,181.16 warsa,ALaAtPeealOrAlloAFPROFAtaremoaMmm o.aafOrf7a,�alt0amaaarArtlatroeaaasLaaaRe6r0F1%W"eaC M Mt D1LraMAM WVW*0ALAk=AFtl0lf/aV1L= wl�QRgaY�ORfAMf9neRw110rar.GmAgwraLRO opaco lLat_Ira1Q,#M*0WrRK=9X00 TW8L....... �.....__._.. __-._... - - 00NOTSIONTHIS CONRACTWTHERE ARE ANY eIANK9P Maori rsreartoscarrRnerwveawmmRALwroruso*roreawr�arrra, ataorAoeasawee ..... ..��(L��C!"/�.».... . „...._-_- AoetFTA,aeeaaFasAarRAer.flmAaaCa gaeQ.O�iaaiplsa04rtDO01mnr0,lAARa 30 y wmsAeranrousAlxARarAaavr®moAaeAuaxameow000newsooL Ae evtoowu vAwa<xr wAnL.ao was Ae aurmra Aeam 1 • li RISEVol r' 60 Shawmut Road,Unit 21 Canton,AAA 02021 J 339.5024335 ENGINEERING www.RI$EengMewMg.corn i OWNER AUTHORIZATION FORM I, L-ac 1-geiseiQ,✓ (Owner's Name) owner of the property located at: (Property Address) V . f9 n,aa-64 Prodrll�e_�zZLi l hereby authorize_ PO (G ( ( -e cr (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 i atu d 0�6 Date Vie Commonwealth of Massachusetts Department of Indrtsttial Accidents 1 Cont cess Street, Suite 100 Boston, Il•9A 02119-2017 d' ✓ iii-wii'.ntass.s o vltll a NVorkers' C'onipensation insurance Affidavit: Builders/(-ontracti)rs/Electricians/Plumbers. TO BE FILED ti'ITH TTIE:PERN9I"TINC AUTHOR)T . Applicant Information p Please Print Legibiv Name (Business(�r_anizalion/indi%tdual): PO 14 f'b t°Ci r til ('t�. I�y►C Address: P p. Ao X 95"5 City/State/Zip: f}h d o✓-eil`, ytrl/¢, only Phone #: :fire you an employer'Check the appropriate box: Type of project(required) 1 ®I am a ernplo-,ci anti (full andfor part-time)IT ❑ IVC\-construction '_ 1 am a sole proprietor or partnership and have no employces V;Ork-1112 for memS. Remodel Ing any capacity (10 workers comp insurance required] 3 of am a homemnier dump_all ivurh m.seti lNo\tinrl:ers'com9 El Delnolitiotlp insurance required)' 10 E] Building addition -I�1 am a homeowner and Will be hiring contractors to conduct all\�iirk on m% nropert\ I Will ensure thud all contractors either have v:orkers'compensation insurance or arc sole I I E] Electrical repairs or additions proprietors Willi no employees 12 ❑Plumbing repairs or additions I am a general contractor and i have hired the sub-contractors listed on the attached sheet '1 13 Roof repairs These sub-coniractors hate employees and have nurkers�comp insurance G❑We are a corporation and it ollicers have exercised their nlrt ufexempumt per hiGl,r 14 E]Other 152. 1(4).and we have no cinploN ccs [No workers'comp insurance required] 'Anx applicant that chccl.s box-'1 must also 1-111 out the section beton showing their tiyorkers'compensation police uitorroation I lonicowners-olio submit this ailidivit mdicatute they are doing all pork and then hire outside contractors must submit a new atlidavn mdicat:n_such -'Contractors that check this box must attached in additional sheet shomne the name of the sub-contiactoi,and Siatc nhcthcr or not those entities have employees If the sub-contractors have employees.the, must provide their %wikers'camp pulicN number 1 ant an enipilt)yer that i.s providing workers'eampensatton insurancefor nil'emplot•ees. Below is the polier and job site it formation. insurance Company Name. 0 G cAA Policy 4 or Self-ins Lic # �itl� Joh Site Address 7 Wy rle/r � t!('r% City/State/Zip:_ 8 tme Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure co\-erage as required under MGL c 1-5-1- �25A is a criminal violation punishable by a tine up to$1,500 00 and!or one-year inlprisontnent,as well as ci\'il penalties in the torus of STOP WORK ORDER and a fine of up to S'_50.00 a day against the violator A cop} otthis statement may he lorwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebl•certify tinder the pains and penalties of perjutj-thitt the iiilbrinutiou provided above it true and correct. Signature. t�, - I' i Date' /��y�ly Of fic•ial use on1r. Do not write in this area. to be coinpleted br city or town off ciaL City or Town: Permit/License# Issuing.Authority (circle one): 1. Board of Health 2. Building Department ?. City/Town Clerk 4. Electricni inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Y: AC40REO CERTIFICATE OF LIABILITY INSURANCE Dli.� r TE(MWO016n 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(iss)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: Linda Bogidanowicz Insurance Solutions CorporationPHONE (603)382-4600 M. No):(603)392-2034 60 Westville Rd E-MAIL ADDRESS:liadab@isc-iasurance.com INSURERS AFFORDING COVERAGE NAIC d Plaistow NH 03865 INSURER A Western World INSURED INSURERB:Nautilus Insurance (iron Polar Bear Insulation Company Inc INSURER C: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 INSURER 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. NOTWTHSTANDING 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 ADD SBR POLICY NUMBER MM(DD/YYYF POLICY EXP Y LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑8 OCCUR DAMAGE TO RENTED 100,000 PREMISES z.=..) a oaunence $ MPPS274967 3/24/2016 3/24/2017 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECTT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ R I UMBRELLA LI ABHCLAIMS-MADE OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAR AGGREGATE $ 1,000,000 DED RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION STATUTE EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORfPARTNER/EXECUTNE ❑N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It 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 -r I^ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 t9nta m 1/412016 Preview:Certificates of insurance ACICO OI 'CERTIFICATE OF LIABILITY INSURANCE- DATE Ii^!1DDYYY7) lk.� 011041ZO16 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 15 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 CONTACr NAME: Automatic Data Processing insurance Agency,Inc. lac-tn.E:u: (arc.No). I Adp Boulevard ADDRE55: Roseland,NJ 07088 RISURERISI AFFORORNG COVERAGE NAIC d !!!SURER:,: NorGUARD Insurance Company 31470 INSURED INSURER 5: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: IIISURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE PIDUC:ES OF INSURANCE LISTED BELO7:HAVE BEEN ISSVEO TO THE INSURED PIAL:ED P.BOVE FOR THE POLICY PERIOD INDICATED NOTI:!THSTAPlDIidG ANY REOIJ;REL{ENT.iEERL:OR COPID:T'.OPt OF AN'.COPITRACT OR OTHER DOCUMENT V:ITH RESPECT TO:YHICH THIS CERT!F:CATS t.,.AY BE ISSUED OR L IAV FERTF.ifd.THE:NSUP.ANCE AFFORDED GY THE POL`CiES OESCMBED HEREIN:S SUBJECT TO ALL THE TFRI.;S, EXCLUSIONS:.PID CONDIT;O:.S OF SUCH POLICES LIVNTS SHOIYN VAY HAVE PEEN REDUCED BY PAID CLAl:'S INSR I. LICT I. POLICY P I LTR TYPE OF INSURANCE ItISD YNO POLICY NUMBER ILtR:OD:YYY73 iMM•DDQYYYYi LI—ITS COWASRC1AL GENERAL LIABILITY EACF-::CLLI:ht(.Ct , LIEU tJ.r°J.c:;:,_•.:•s,r' GtIrL nGUFiEC::.lEL1LIlI:A'I°LIt51'EIi. ! 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ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRFSEnTATIVE I A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLASEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DAT CERTIFICATE F1/6/2016 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(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 NAME: Durso&Jankowski Insurance Agency PHONE 978 688-7000 -' - !FAX 11 Saunders Street A/C N_o_E�_� .-. )._ _._ (A/c No):(978)688-7001 North Andover,MA 01845 _LAIC — ADDRESS: INSURER(S)AFFORDING COVERAGE ; NAIC 9 INSURER A:NaUt1IUS Insurance CO. _ 117370 INSURED INSURER B:Safety Insurance Company- 133618 Polar Bear Insulation CO.Inc. INSURER C: _I� Peter Leblanc&Steven Leblanc — ---- -- - — ----— P O Box 958 INSURER D_ - Andover,MA 01810 INSURER E: INSURER E - — 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 VVITH 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. fNSRi -- ADDLSUBR; POLICYlF j POLICY EXP — LTR i TYPE OF INSURANCE INSD WVD POLICY NUMBER MMD MMJDD LIMITS A COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S -_ CLAIMS-MADE I OCCUR - OHMAGE TO�2ENYEo .-- .. 1 _ 1 PREMISE5jEa occunence) •S _ MED EXP(Any one Person) S PERSONAL&ADV INJURY 1S GEN•L AGGREGATE LIMIT APPLIES PER: f i GENERAL AGGREGATE j S ' r t PRO- POLICY _JECT LOCPRODUCTS-COMPlOPAGG S OTHER: -_.5 -- I AUTOMOBILE LIABILITY j I COMBINED SINGLE LIMIT i S 1,000,000 B 1(Ea accident-- ---- ANY AUTO 2100926 01/04/2016 0110412017 BODILY INJURY(Per person) ;S ALL OWNED i 1C ;SCHEDULED f 1 BODILY INJURY(Per accident)!S 'AUTOS AUTOS ___ NON-OWNED { j I i PROPERTY DAMAGE S - i x HIRED AUTOS x `AUTOS (Per acaden) - _.— _ .- S UMBRELLA LtA6 OCCUR EACH OCCURRENCE S J Qt ;_i IXCESSLtAB - —1 CLAIMS-MADE: AGGREGATE S OED RETENTIONS i ! ;S -WORKERS COMPENSATION !PER 0TH- ' AND EMPLOYERS'LIABILITYY/N _;.STATUTE l ._ ER ANY PROPRIETORIPARTNERIEXECUTIVE r---1I EL EACH ACCIDENT ;S OFFICERIME1,19ER EXCLUDED? I N/A! - - i(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under I ( I ---- -' '-'- •-- --- ---- DESCRIPTION OF OPERATIONS bel DIV 1 4 E.L.DISEASE-POLICY LIMIT i S i i I i i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached it 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 145 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE 6h AGOG nGAA Armon rr c nr%nA•rinwr All er Af Wm and - - office 01 :.Co to Si�Q 1€l p l'I o,2116 OIIIe pVemCnt f ORIO0a #02726 - -_ DBN 6 Tr# ? 9 TP112�'i - BEAR It�t5�1�'`TtC)l�t Co- Vm,po� LeBlanc p_Q_BOX 958siorct�nae- can Co ANDOVEP,MA 04 ___ t i Aaa Rag US Can CFALI 2_=E-- prMA MOM ZZAS'FPM S ptai M 63M =