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HomeMy WebLinkAboutBuilding Permit #1169-2016 - 77 CHADWICK STREET 5/10/2016 I . 10RTF Oy M w,L�, BUILDING PERMIT o tio TOWN OF NORTH ANDOVER 32 h '`- - ,• APPLICATION FOR PLAN EXAMINATION 7D 1 O Ob Permit No#: � ,v^v"\ Date Received SSgCHus���y Date Issued: (� I PORTANT: Applicant must complete all items on this page LOCATION ?7 ('l,Ad k/0,a S i Print PROPERTY OWNER Pere r- )1qiet�yl g 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: ❑ Demolition ❑ Other YI5,✓l41'�d 7 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ,02ZTS It' 'pl o r wg// TirSv/at oti D,a►Sr���i� �,✓; -FL, <<//y/aS-e Identification- Please Type or Print Clearly OWNER: Name: ��'Ttt— Phone: Address: Peter Leblanc Contractor Name: ast Phone: 0. Email: Plai03865 Address: , .t 'I • qw/ U7-7638 Supervisor's Construction License: 10 Gel Exp. Date: Home Improvement License: 4 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: $ 12 -o O FEE: $ � ?�bsd� Check No.: —I 1 Receipt No.: NOTE: Persons contracting with unr istered contractors do not have acce to the guaranty fund Oy ma4 BUILDING PERMITO NORTH TOWN OF NORTH ANDOVER c Ott` ;b q"o APPLICATION FOR PLAN EXAMINATION � Z " Permit No#: /Up Date Received Ii9 ADR4TED SSACHUS� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 77 C'lcd w►Cx. 15;— Print iPrint PROPERTY OWNER Pee-e,f F'reet rt g 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: ❑ Demolition ❑ Other -/a 7 ❑Septic' ❑Well ❑FCoodplain ❑'1N-tlan-,s: ❑ 'INate Shed District Water/Seiner DESCRIPTION OF WORK TO BE PERFORMED: ,'>h /1ASrrr�Fi� W%1 L, l'e//y/aS Identification- Please Type or Print Clearly OWNER: Name: r+ tt— Phone: Address: 77 C"kedr.✓irk 6 Peter Leblanc Contractor Name:7 East Ds_., a4. _, Phone: AL XMI& Email: . . Address: 9 . . 03865 Supervisor's Construction License: 10 Got Exp. Date: Home Improvement License: Exp. Date: - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ .2�et7w -0 D FEE: $ �--- Check No.: -11 W Receipt No.: NOTE: Persons contracting with unr istered contractors do not have acct to the guaranty fund Location - tt No. 1 ' C} — / G t, Date f • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ -- Foundation Permit Fee Other Permit Fee $ TOTAL Check# Building Inspector . _ --!4 L—---I'.I--,' .--:�---_--_.�-.-.., ----- .: o___,_._. -_s�, 1-. - ^----` �___ _ �- - •.r- :-.�tw-•.;..� . .. - - ... . .. -.. - -" ... - ::.. .; 3 - ._ ,. - - _ :� .-�- . - - _ - 11 I- .. .. _' - . i r W.„I ` _ } - Location ! C�� —t, i�-- . ;I } Q No. i "i.— �j� Date � � - . - Tp w 0 - WN OF NORTH ANDOVER _, ,. • Certificate of Occupancy . $ ; ,_;; . . , . rM Building/Frame Permit Fee $ gam-- _ Foundation Permit Fee $ - Other Permit Fee - $ ,,. :TOTAL , _:_�Z _ ;- . . Check#� /, I - Building Inspector - . ,�. . - :. r. , .. -..., . , .. .�5. s. 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 - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i' ;�, _t - 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: r Located 384 Osgood Street FIRE DEPARTMENT -`Temp ®umpster,onrsife no,__ Locatetl�af 124�Maiii�:St�e'et Fire D:eparfinentsignatureldate COMMENTS Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL : Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS s ening Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street } FIRE DEPA� TR1MENfT,r Temp Dempster onisite t Located at 1.24 M n°Streets ., Fri a Departmenf si,g a/_date ..._��=�M _ r BPI" - - - 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email l Date Time Contact Name I Doc.Building Pernut Revised 2014 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 .6 Floor Plan Or Proposed Interior Work .i. 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) .� 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 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit .Addition Or Decks 4. Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. Copy Of Contract :4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses 4 Workers Comp Affidavit ;. Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) :rR 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 NORTH own of h ver, Mass, —A I IDS 2w(P COC NIC Nl WICM 1' x,95 RA rE o LI BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THATdw BUILDING INSPECTOR .... .. . ..... ............................�: ........... ...................... .. Foundation has permission to erect .......................... buildings on .... ..... V!t.l :.......... 7.1 � Rough to be occupied as ... ii.. ....... . .. . . ......�rr.�.1.1�, iw.r. Chimney .�� provided that the person accepting this-per r>�it 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TARTS Rough Service ... ..... . . .... . .t Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. S I->�RozS ' Federal 1D 9 08.0408629 RISE Engineering Rl Contractor Registration No 8186 MAContraetorRegistration No 120979 = A division of Thielsch Engineering �/� RISE ENGINEERING' 60 Shnwmut Unit 92,Canton,MA 02021 CONTRACT 339-502-6335 FA\339-502-6345 Page 1 PROGRAMIncomweltis_ ENIUSE CNIA-HE EMMEDU aEL0 CUSU. FWWORKAS oncricuStfilR P"M WE CLMKS WORK ettaEit Peter Farina (617)939-8729 04/26/2016 426743 00004 SERVICE SHEET BUM S1 UT 77 Chadwick Street 77 Chadwick Street any"cnv,svty.zr t UNG cm,ang,zs+ North Andover,MA 01345 North Andover,MA 01845 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal armor your home against %;mcfLd.excess air leakage. This pork mill be performed in concert pith the use ofsptciai tools and diagnostic tests to assure that your home Mill be left«ith a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include catdks,foams and other products. Primary areas for scaling include air leakage to attics,basements.at inched garages and other unheated areas(uindous are not generally addressed) Th is%vill require(3)%corking hours.A reduction in cubic feet per inintne(cfm)of air infiltralion will occur,but the actual ntrnber of cfm is not gu 3mraced, At the complet ion of the«eat her i7ation stork,and at no additional cost to the homcovsner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor io ensure the safety of the indoor air quality. 5255.00 WALLS:Furnish and install blotm in Class i Cul ltdose to(1192)square feet of vinyl-sided exterior%%alis.Homeotmcr has received a copy of the EPA's Renovate Right Lead-Fare information dude explaining the potential risk of the lead hazard exposure from the %%cathcrization v%ork to be performed.Your signal tire is your ackno%%c*ment of receipt and agreement io proceed. $2.205.20 RISE Engineering gill apply all applicable,eligible incentives to this contract. You still only be billed the Net amount. Currently, for eligible meas rm Columbia Gas offers 75%incentive,not to exceed 52.000 per calendar year,and an incentive of 100%for the Air Sealing mcastres tip to the first$680 and an additional$340 if savings are juustified by the auditor. For the safety and health of your homes indoor air quality.sue%%ill be condutctinga bloater door diagnostic of the available air flow in your home both before the murk is begun,and after the weatherization swrk is complete.We vtiill also conduct a full assessment of the combustion safety of your heating system and aster heater.This has a value of 590 and is at no cost to you Total allottable %%catherization incentive is 53,110. $90.00 RISE Engineering%%ill apply a credit of s100 towards this contract,in acknovviedgemcnt of the deposit you made to Next Step Livingto%wrdsyour original urithcrization contract.THESE ARE IST.FL.WALLS LESS FIDE BUMP. Living 50.00 D Federal ID tS OS-0405629 RISE Engineering RI Contractor Registration No 8186 MAContractor Re91str2tion No 120979 RISE' `+ A di�9sion ofThiclsch Engineering 60 Shawrout Unit#2,Canton,NIA 02021 CONTRACT 339-502-6335 fA\339-502-6345 Page 2 PROGRAM 103 CONIRACTIS ENERED*M SEMEN RUE CILIA-IIIS EN N�EEOEo�A�1+E CUSTSlR FOR WORK AS DESCUS13yoR P"M DALE CLIENT/ WORKORDER Peter Farina (617)939-8729 04/2612016 426743 00004 SERVICE SKEET RKLNIO 31RFET 77 Chadwick Street 77 Chadwick Street SERVICE cny.SWE.aP BIWNG COY,SATE,21P North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,550.20 Program Incentive: $1,998.90 Customer Total: $551,30 WE AGREE HEREBYTO FURNISH SERVICES-COMPLErE IN ACCOROANCE W rTH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Five Hundred Fifty-One&301100 Dollars $551.30 UPON FOUL INSPECTOR AND APPROVAL BY RISE ENGWiEERUID.CUSTOMER AGREES'DREIRTANIOUNTOW tN FULL WERESTOF t%Wa1BE CHARGED AIONHLY ON ANY UNPAID BALANCE AFER 30 DAYS_SEE REVERSE POR DPOILWMNFCFJA WON GUABANEES.ROM OF RECUKH,SCHEDOUNq AND CWIRACCR RE@SRAIM. DO NOT SIGN THIS CONTRACT IF THERE AREANSPAC S AU111101110rD=CTFA%Y E. eeror a CUBTONER ACCEPTANCE / NOL':103 WIHDRAWN BY US IF NOTEXECUED WrM DAT.OFACCEPANCE ACCEP9INCE OF CORMCT-tai ABOVE PANES,SPECF"V=AND CCKDnX NS ARE 30 DAYS. SAISFACMY A U1 AND ARE HEREBY ACCCPED.YOU ARE AUIIORMD 10 D01M WORK AS SPECUIED.PAYNEHTY/aLBE MADE AS OMINED ABOVE t \ V -. APR 2 9 2016 - USE60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING` www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: (Properf�Address) A�p y-?-1✓i v�a . (Property Address) hereby authorize 0 0. J—jk(a (' ✓amu fcO- 0 N (Subcontractor) j aV � an authorized subcontractor for RISE Engineering, to act on my behalf tat permit and to perform work on my property.This form is only valid with a d contract.y Cu16 Owner's Signature Date The Commonwealth ofMassachusetts Department of ludustrial Accidents Office of Investigadong 600 Washington Sheet Boston,M4 02111 www.ma_ssgov/dia Workers' Compensation Insurance Affidavit:B>alders/Contracfors/Electricians/Piumbers Applicant Information �'7ease Pru�.t Le�bly Name(Business/organization/Individual): Address: PO BOK 958 •City/State/Zip: Phone#: (7 [re n employer?Check the appropriate box: _ a em to er with4. Type ofproject(required): P y ❑I am a general contractor and Iloyees(full and/or part time).* have hired the sub-contragtors6• ❑New construction a sole proprietor or partner- listed on the attached sh%et.t 7. ❑Remodeling and have no employees These sub-contractors have8. [�Demolition ing ,for me in any capacity. workers'comp.insurance.orkers com .insurance 5. 9. ❑Building addition ' p ❑ We aze a corpoxation and ifsred.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.p Plumbingrepairs or additions lf.[No workers'comp. c.152,§1(4),andwehave no12.[�Roofrepairs nce required.]f employees.[No workers' comp,insurance required] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Yam an employer iliat it providing workers'compensation MyUrance for my employees. Below is the policy and job site infoPmation. Insurance Company Name:_���d Policy#or Self-ins.Lic.#:_?V LJ`C `7> Expiration Date:_ .p l0 z Job Site Address: 7 7 e 'h 4 V A C,le —�- ST City/State/Zip-__A_ /Q11 Oft 1� Attach a copy of the'workers'compensation policy declaration page(showing the poncynumber and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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. De advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby ce y nder the pains and penalties ofperjury that the information pf ovided above is Prue and correct: Si ature• G Date, 7 / /(, 'none Offccial use only. Do not write in this area,to be completed by city or town offrcial City or Town: Permit/License# Issuing use (circle one): I.Board of Health 2.Building Department 3.C141T9wn Clerk 4.EIectrical Inspector 5.PIumbing Inspector 6.Other Contact Person• Phone M ACO QR ® CERTIFICATE OF LIABILITY INSURANCE FDATE(MWDD/YYYY) 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(ies) must be endorsed. If SUBROGATION IS WANED,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 PFIONEEt). (603)382-4600 FfAX A/C No (603)382-2034 60 Westville Rd E-MAIL lindab@isc-insurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A Western World INSURED INSURERB:Naut:Llus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO BOX 958 INSURER D.- INSURER :INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER_CL1632326134 REVISION NUMBER: THIS 15 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. IN SR I TYPE OF INSURANCE AD DL S BR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDrYYY MM/DD/YYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A CLAIMS-MADE r OCCUR DAMAGE TORENTED100 000 REMISES Eaocwrrrtertce S , NPP8274967 3/24/2016 3/24/2017 MED EXP Any one person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 1:1PET El LOC PRODUCTS-COMP/OP AGG S 2,000,000 riOTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea aaident ANY AUTO BODILY INJURY(Per perscn) S ALL OWNED SCHEDULED BODILY INJURY $ AUTOS AUTOS (Per accident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident S S R UMBRELLA LIAR OCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 DED RETENTIONS AH026107 3/24/2016 3/24/2017 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NFA E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 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 @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025rvm4ml 1/4/2016 Preview:Certificates of Insurance DATE lixxo YYYY)C11ERTI sCATE 01GLIABILITY tNSU AIslCES ovoarzole THIS CERTIFICATE 1S 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER COrITACr NA••AE: PHO iE Ax Automatic Data Processing Insurance Agency,Inc_ tAiC.Ha Eat IAC Noi. S Adp Boulevard ADDRESS: Roseland,NJ 07068 UISURER)S)AFFORDit)G COVERAtF j NAIC7 INSURER,;: NorGUARD Insurance Company 31470 INSURED INSURER B POLAR BEAR INSULATION CO INC e1suRER C. PO BOX 958 Andover,MA 0181 D 1gSURER D: wSURER E: { INSURER F. COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS:S TO CERTIFY THAT THE POL:C-rS OF HISu RAUCE USTED B ELO:J HAVE BEEP.';SSUEO TO THE 1PSUREO Nn4tLD ABO•:E FOR THE POLICY-ERIOD IIID:GATED NO r::ITHSTANDIi-IG::PI•i REOU:REI ErdT-i ERF_OP.COND:T,Or-I OF+NY CONTRACT OR OTHER DOCUtaEI-IT L7;TH RESPECT TO:'HIGH THIS CER T iFtCATE M..;Y BE ISSUED OR.'.':.Y P[RT:.SFI.THE:NSUTRANCE AFFORDED BY THE POLtCiES DESCRIBED HERE:td:a'SUBJECT TO ALL THE TERL 75. EXCLUS:ONS A11D COtdD:TIOdS OF SUCH POL:C:ES L'UITS SHOt:'td VAYHAVE SEEN REDUCED GY PA;0 CLA..I:'S LYSR TYPE OF IUSURANCE c PUDGY L:CT I LMITS LTR IVSD YNp POLICY UU.•.tB_R {IIAtk'CD.YYYY} I:AC'OO:YYYYgi COSRAERCIALGENERAL LIABILITY ::Li,ILt_LL:Lrc �:�CCLI: li •..• •.rc �:_,c "' I'EIiS::[.:L c•%C-1 I:Jllit I GELL aGGIiEL:iq E U:.Ill AFFUh�iPEI, i_E::EF:iL RGGhEGatt {= .•Lttl-L�JE:t l IL ( Ir;L+_ _ _�Lv�;:1-•:C�=I� - AUTONMBILE IJABILrY 1 i•ta6-L•aua.lt ULhl _ U1. f i SIP_"'U:JUiT:F='a.r.Nana 5 LL - L• t'1''�I1I_LhcLLLEU I I t:�L'IL':itJL7i-r{=:- _._C:J: • ��rltiEU i.l l:__ 1•:Lit.: I � � I � :l� _-:.ill: 1 UL3P,ELLAL4T6 EJ:CESS UAB 1 CL�ILI L:zL•h �i_c- II: IL'•tU I 1-7�I�G Ih;i.> I I WO RK E115 CO.PEUS AnOR I :-1 HOE.PLOVERS LIABUTY LIE I H:r I Y:ti a::"Id=CPr11_ir]ICI::: rJ�iiExt;.uu•,e • E:•cam:.IXIc;=i_i tAD6.000 M L. rv7 iA) �: P0:".rC7:2258 X01101:2016 01101201.7 -- I' =H:�i:�l.::t.16tl:E::�L L'�ii' {•andarorymUP.) �—� EL Cas-:;: 1.000,000 ) 1 I t�t:.6LtPUJ""cE : [zSfKII,inJ zGFCP=r:.IIci_ r I , ItL.D>_=.-s_ rcu�•uiin 1.ODO,DOD i � I DESCRIPTION OF OPERATIONS-LOGATIOrIS r VEMCLES(ACORO Tot.ACditionJ Schedule.—i be atnei:d it mo:C 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 AUTHDRL'ED REPRESENTATIVE A^1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD,yYYY) 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 PHONE g8 88 7000 I No ( S88 7001 11 Saunders Street A/c NoEE�_t7.. )6 ._ _ _.t__._-I 978_�. North Andover,MA 01845 E-MAIL — ADDRESS- INSURER(S)AFFORDWGCOVERAGE ; NAIC9 INSURER A:Nautilus Insurance Co. — 117370 _ INSURED INSURER B:S2f_@t1/Insurance company— 13.3618 Polar Bear Insulation Co.inc. i INSURER C; Peter Leblanc&Steven Leblanc INSURER D - T P O Box 958 — --- -- — -- Andover,MA 01810 INSURER E_--- ----------_- — — 1 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 CONTRACTOR OTHER DOCUMENT VVITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR — - -- �ADDLSLIBR- " POLICY EFF j POLICYEXP ---- LTR i TYPE OFINSURANCE 11NSD I WVD: POLICY NUMBER MM/D MMlD LIMIT A ;COMMERCIAL GENERAL LIABILITY 1 i EACH _— OCCURRENCE S AM 4GE TO—RENTED CLAIMS-MADE _'OCCUR PREMISE�Ea ocwrrencet S -- _ -------- -- ;MED EXP(Any one person) S PERSONAL&ADV INJURY 1S GEN'L AGGREGATE LIMIT APPLIES PER_ GENERAL AGGREGATE S _ _ n_POLICY f JECT _LOC I PRODUCTS_COMPIOPAGG!S OTHER: -- --- - -- S --- AUTOT+tOBILE LIABILITY Ea eDSiNGLE uMir Si1 1_,000,000 B ANY AUTO 2100926 01!04/2016'01/04/2017 BODILY INJURY(Per person) S ALL OVWED j( SCHEDULED E — AUTOS AUTOS j BODILY INJURY(Per accident) S i �� - u NON-OWNED j € PROPERTYDAMAGE - - HIRED AUTOS S AUTOS -(Peraodderul — S — UMBRELLA LIAR OCCUR '-EACH OCCURRENCE :S ) A _EXCESS LIARCLAIMS-MADEAGGREGATE _ S - DED RETENTIONS— 'S WORKERS COMPENSAnOti :PER 0TH- :AND EMPLOYERS'LIABILITY STATUTE ! wER. Y/N i ANY PROPRIETORIPARTNERIEXECUTIVE `EL EACH ACCIDENT ;S ,OFFICERIMEMBEREXCLUD_D? ��INJA: 1 — — —"" (Mandatory in NH) EL DISEASE-EA EMPLOYEE-S Ii ves,describe under — DESCI2IPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT;S t 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 I 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,R102910 AUTHORIZED REPRESENTATIVE rA-Inoo nt%AA Annon All­11­t-..,.w,.....,.,a Office of Comer ASS a�..d� - 02116 - ©IIS V ti OIltr� 1 R n jIM726 --_ _ TVPM- DBA T* 252M - -_ 7WO1 POLAR BEAR INStOA1 Co- tlincent LeBlanc - P_O.BOX 95$ 4$io ANDOVER. MA Up = t Address Letva3 DPS DAt ct S*wG*mCI=r. - - ti V&TE $ALBBC _ glabtoR P&03M _ �' - s N"