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HomeMy WebLinkAboutBuilding Permit #718-14 - 80 BRIDGES LANE 12/11/2015la. -%7._ /5 - BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#. Date Issued: 4 ��� t J - IMPORTANT: Applicant must Date Received all items on this LOCATION l7 i3,�� coq C -S LrLnA Print PROPERTY OWNER f(-Lk1_„W%,,S Print 100 Year Structure yes MAP PARCEL: ` ZONING DISTRICT: Historic District yes 11 Machine Shop Village yes no no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building ClIbne, family ❑ Two or more family ❑ Industrial oAddition Alteration No. of units: ❑ Commercial epair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ Septic a-UVell❑ �Ffo_ odplan Wetlands' 0 1Natershed p®stnct� �J- Water DESCRIPTION OF WORK TO BE PERFORMED: Q -S 1 K CAi r S -C of 5,df"9V J in J� C �u 0, :`V' L,, Alk'mm,X31 1 \l trx�— ► `V &t-) Identification - Please Type or Print Clearly OWNER: Name: Pcx-, -ha\ L o�'x Phone: L3 - q SSS Address: (60 13,n c-� Lo,;-� Contractor Name: wy}- + -N Phone: CJ J'Po - 3 S-�p • 34 la 3 Email: Q o-O-YV\\Cl- ti(SQ4-h W) e)!�P,-At' jn^ Address: Po i3ox 34 4 t iN'0QI; HA b 1`138 Supervisor's Construction License: Exp. Date:I- Home Improvement License: t T3 -i I ° Exp. Date: i b I )I I 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: $ '3'�J 2� `� FEE: $ v Check No.:k Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location Na �/ Date / Check # rs 18 9 . TOWN OF NORTH ANDOVER r Certificate of Occupancy $ Building/Frame Permit Fee $4 YA Foundation Permit Fee r Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi,mning 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 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: Com Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREDEI?AR�TMENT�Temp Dumpster +..f-.'died a t',.°3�.5 • �,y 17 ..s i.4'S+o. {c i .-. �1'`ri+1.x n0 4.. atediat 124�■FiVIamStreet Y J�f[!_T^�2R .�Z I ire jD6partnient,signature/date Y },'+t?�( �r�j�_13.t'r3 '^Pa;. -.cl dd�''as �q.,,�.c ,,��°^,,,yy,,, :. �. :c..-�. ,+ il...+ AY�.€GC. -)•a i-tia4.,!!.s ,.s� r.R' ..t.,..t�w '+L,- ':..e�J?I.....d. ....L,— 1..� ra.��.,� i�t�'"�r �.��..Y t�cL'�`�rt•S. zitt�';'ii �S ��''; *'�£ a; �'�.f� �y5,i ;fib i�'CRR'Y ? ��„n.�� jE��..��� ��4-,. s. w �x�^r.�.a*Q•v�.,i•..+�. ! I # COM�� ,u 4'_f,.ae't `� ci �.r y ..� 'R 4,. 4 , .ht1a:YT� ,,r%i, L4t�1{+'t^ �a�i•T`�,'`�::�"f r•tc.V; �;.,y�{y. IVIENTS�, PraA ,#; p•r. j{, z "r f?�L� o- � � � .+Y�' � �u`{ r •I i! r,a , � y *i3�rF' 3 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 ®ANGER ZONE LITERATURE: yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$1o6o fine 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 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 TOTE: 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 < c= � c = _ r Q ��CL -a 'CDC) - m t/�' p Z C .��, .. Q. 2: =r -0 � . fl;• cD C o o CL 0 c m ,h � -h =4 _ a) CO) CD CD o Baa `D = D O 0c N n �' H � O _ CD 0 CD � z y c =. CD CL r rn EL V)- 0 cc �rt p 'Tj Cn CCD o 0ch vi O r' � D Er CD n O c0 < o °1 CO) CDS O �m CD CD 91 CD c=r� � r jw W 'D CD � Z CD r VU) l tti, � D ; C CD U) : C CD Z c CL O =CO a `C! Cl) 0 o CQ (D C/� v- = C v CDCD N O A' �► O� S-0 O CDnCD z CA o� Q a °.'r, < n CD p o � . CL O N m m (D rt NW — 0 T m n m zO T ;;aT o 3 O H O Ln Z7 � mm m A m 0 T 2L r - aq C m 0 T (� 70 3 T Q O C z G1 m A (n 0 n 3 T n S W O O D 2 0 s �` RCS PLANVIEW DIAGRAM Customer: Gi Ci_C._L_j-G7V l,5 Address: Cl0 t� fta... � S .................................._....__ ._ .._j....- Tcwn: kvffll Any limitations for access by lerge truck? No Yes Ir. yes, descibe Any specific directions or Iandmarks?- No ties _._._.,_._......... _ if ycs, describe: Home Phone: Work Phone: ( )- Cell Phone: ..._ s..5`...... -_- ........ ._._. Site ID: Z7—O {77 Energy Specialist: ....................... ......... .. .......-___. e e� G� t�U ..........'_ _ ..... ....... _..,..._.. Reviewed by: Air Sealing: 10 hrs (936 x 1.25 =1170 sq. ft.); Attic Stair Cover Thermal Barrier with carpentry 3 Door Sweeps and 3 Weatherstrips 1. Vent bath fan to roof flapper: 2 2. Propavent 2' or 4' (if necessary): 93 3. Damming: 52 ft. 4. Attic Floor Open Blow Cellulose 6": 936 sq. ft. i I E P 2 RL 3 2X � Z 2X L 2L 1' I I i i For Office Use Only Bushes Ladder ....- _...._.._.. Neighber Proximity Packet Doors i Insert Radiators Fence Existing Conditions X = Access ❑ = Vents Note Inside Square R= Roof S =Soffit G=fable RV = Ridge Vent .—.. CS - Continuous Soffit CDE = Continuous Drip Edge T = Triangle ........ ..._.. ___ _ install O = New Access Note in Circle _... _.. C = Ceiling W = Wall S = Sheathing --- Temp Unless Noted Otherwise 0 = Vents Note in Triangle R = 3" Roof S = Soffit G = Gable M =12" Mushroom For Access Rev 1j)4 Description Quantity Location Perform Air Seating at Estimated 02.5 CFM50 Per Hour 10 Living Space $843.20 Attic Stair Cover Thermal Barrier with carpentry 1 Hallway _....,... $260.23..._ Door Sweep...... ... ...... 3 NIA... _....... $..69.54 Erdedor Door Weather Stripping _... - 3 NIA $62.77 Sub Total: $1,255.74 Utility Incentive Share $1,255.74 Customer Contribution $0.00 ®f"0 IF For office use only Printed: 9/9/2015 Nage 1 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows: Payment #1: $ 0,00 as a Deposit payable to CSG upon signing the Contract (not to exceed 1/3 of the total retail costs). Mail check & contract to CSG, Attu: RCS, 50 Washington St., Ste, 3000, Westborough, IVIA 01581. Final Payment: $ C). f?0 as the final payment for the Work shall be payable to the Independent Installation Contractor ("IIC") upon satisfactory completion of the Work. Customer understands that he/she will not be required to pay the Utility Incentive Shag of the Contract price in the amount of $-J.2,5.1174 . Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree to advance that in the event that the IIC has a dispute concerning this Contract, the IIC may suhnvt such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L. c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day folio ing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. *C t er Signa ,-Dat�1—L� Indicate your selected IIC here, if applicable (OR) Initial her you want -the Program to assign a CSP i r �"� D to Name of CSG Representative (Printed) Participating Contractor TERMS AND €ONIDITIONS "PEAR ON THE REVERSE. 3/14 UU %0W1V1ffjM%W9 run PRODUCTS 1 SERVICE WORK Conner anon Location Services Group Vent bath fan to roof Flapper __ ....... ..- _ _ ... .._.._ ....._ 2 . This service is brought to you through support from your local utility This Agreements made by and among Propavent 2 .or.4'. .. _................ ........... .......... ....... _.__. ..................... 93 ..... anis $356.19 Conservation Services Group (CSG) Patrick Louts Attu ftCS ;` 80 Badges Ln North Andovei, iVIA 01845 2225 60 Waslxuigton Street, Suite 3000 _ .. _ _. .. _, 936 .. tVestboxough, MA :O1581 Site i1D SODOOZ288807;`. Reg Na 173484 ` Project 1D P00000295052 Sub Total: CustomerID 000000298917 Federal ID No 222457170 Contract 16,2 ,Q:150909_:WORK: (Mail completed contract to ackhess above), . I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be perforated the following work on these "Premises" in a professional manner and in accordance with the tens of this Contract, including the attached recommendationstwork order describing the work in detail (the " VVork") which are incorporated herein by reference: Description Quantity Location Vent bath fan to roof Flapper __ ....... ..- _ _ ... .._.._ ....._ 2 . .... Attic. $258.42.. Propavent 2 .or.4'. .. _................ ........... .......... ....... _.__. ..................... 93 ..... Attic $356.19 earring ......... .. ...._. _. _._ 52..... N(A....... $113.88 Attic Floor 0 en. Blow Cellulose 6" _ .. _ _. .. _, 936 .. Living Space . $1,375,92 Sub Total: $2,104.41 Utility Incentive Share $1,576.31 Customer Contribution $526.10 CIf`C] For office use onty Printed: 9/9/2015 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work, the Customer Share of the Conti -act Price as follows: Payment 81: $ 5. 3 as a Deposit payable to CSG upon signing the Contract (not to exceed1(,3 of the total retail costs). Mail cheek & contract to CSG, Attu: RCS, 50 Washington St., Ste. 3000, Westborough, MA 01581. Final Payment: $ 3 S�, 14 as the final payment for the Work shall be payable to the Independent Installation Contractor ("IIC") upon satisfactory com Ietiou of the Work. Customer understands that helshe will not be required to pay the Utility Incentive Share of the Contract price in the amount of $_...(. s.�Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Ill. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in arhance that in the event that the IIC has a dispute concerning this Contract, the IIC may submitsuch dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided. in M.G.1, c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. t mer Si a e Date Indicate our selecte C herer if applicable (OR) Ini ' ere if you want Cf y (� .f !!C �/ _the Program to assign a CS at D to I Name of CSG Representative (Printed) Pazticipating Contractor TEIMS AND CONDMONS APPEAR ON THE REVERSE. 3/14 mass save PAW"CING PATRICK LOUIS owner of the property located at: dOvvne,'s Name, printed) 80 Bridges Ln NORTH ANDOVER (Property Street Address) hereby authorize the Mass Save Horne Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. 1-i o;ier U5i is ure Date Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date F1 Rev.12132011 The Commonwealth of Massachusetiv Department of IndustrialAccidents ORIce of Investigations I Congress Street, Suite 100 Hoston,,VA 02114-2017 kv�—Wj wwwx;assgov1dia Workers" Compensation Insurance Affidavit: Builder siContractors/Electricians/Plumber,,s Appikant Information Please Print L -e Ably Name Jry&SAJj*n JY�--k— Address: 60 SOX 344 citv,tstate/zin: 4 c fh t1k 00 3B Phone #: Are you an emplo-mi? Check the appropriate box: I M I am a — over with e%, 4, C) I am a general contractor and I ernployet., (full andfor Part-time),* 2. [3 1 am a solc proprietor or partner- ship and have no employees working for me, in any cqwity. [No workers' rzomp. insurance , requirodtl 3, r3 I am a honwowner doing all work rnyself. [No workers' comp. insurance "uired.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have, crnploy=. and have workers' comp. insurance.t 5. We are a corporation and its of have exercised their tight of exemption per MGL e- 152, § 1(4), and we have, no ernpleyee-s- No workers' come. insurance re wred.1 'I'ype of project (required), 6. UNcw constrwfion 7. Rvmodcling 8. Dernolition 9. [3Building addition 10.0 Electrical repairs or additions 11.[3PIumbing repairs or additions 11[3 hoof repairs 110 other *Any apt licam itm ctiocks box 41 niust a1w fill oat the wi�w showing rheic workra- comM, snimVltcy ir fonrx-4ein, t HoMCOMM who AlbMil this affi&---ft indicati.jg they are doing all wwk and *cn hire We contraoms mum submit a nm affivdavit indicat h�g such, 'GMVa0W5 that cboikltlis box mug attached an addiiionashmzsho%wai the wrm of she sob-comawors and state whether or no: �= caatiucs have anploym. ff the sub-coruvam h =V$ayvcs, they 111ILS, pzov idc rhm'u- woflkm' CMT, prA ic Y rtaadbe,t. I an an mployer that is providing wwrkers' oomprmwdonimuramerfear my emplo ers Below is the policy andiet site orf art. Company Name--k-ta i . ..... Imair Policy # or Self -ins. L:ic, t,"Ke]p ® Expim tion Date�-A 0 Job Site Address: 94-o— ay, i. &aA-i UtA city,,.statezip:k)(I(vv\r-ve\"vtrRA 0164S' Attach a copy of the workers' compensation polity dechim,tion Wage (showing the policy number and eViration date). Failure to secure coverage as required under Section 25A 4MOL c, 152 ean lead to the imposition of criminal penalties of time up to $1,500.00 andlor one-year imprisorinvot, as welt as civil penalties in the form of STOP WORK, ORDER and a fine ofupto$250.00aday apiwtree violator" Be advisW that a, copy of this statement may he forwarded to the Officc of Inv estigations of the DIA for insurance coverage verification. I do hereby errUft sauler the pain and penaMes of perjury that the infwmafton provided above is true and correct, Phone Official use onO.iso not write in this area, to be completed by city or town official. City or Town. Pennit/License 9. Issuing Authority (cirde one) . 1. Board of Health 2. Building Department J. Cilytrown Clerk 4. Electrical Inspector 5. Plumbing Impectur 6. Other Contact Person: Phone AC"RjO CERTIFICATE OF LIABIUTY INSURANCE T"IS CER iFiC� i iS ISSUED AS 1, ATr £$F Af TION tf4MY AND CONFERS NO €C€ RS3 u ON THE CesMfICATE HOLOM Trois MTl €; :ATE AFF -1 WArMLv M NVAMELY AM D, exTEND, OR ALTER THE COVERAGE Ap.-tPLP = OY THE POLICMS row TMS CMTMCATE OF INSURANCE DOtS NOT CONSTMT-i A CONTRACT BETWEEN THE iSSUI fusURER(s'o, Avr4opano RmEi 3'ATU-v € R PROOKER, ANO THE M11"CATE HMOER IM,RTAMT 3B 0 K- c�ac�+ce - E* ;n Z 5 zrT1Wm= 7; 7 is 1 ', if to10NN I k W m5 acid iaanid"bom of tae pa6cy, ca ta* pauc may on Wvdcv" A s'. ani "Ws ce#t#kv* Oats mot corder rights to the bf V) of eftdors rws). €laytm Marbn J ass Agency tnc eitrkt AS" 1"9 mon St PO sox n9 : �� t''� � t n t�[5 i3S-611ENoty*" MA 01"I PON moor Irlaufation k4 Po BOX Ud IPSWW MA 01M R i . t 4 tk A ReiREWRENeJ, TESW OR opt+,'pmuN OF AW c6mrikiOR t�3 R ,i E z# 6d R ^r F(3 ilii i CE '€MMATE MAY SE WZLWOR MAY PStAN, IKE WUMANCE AAF BY Ii W KXICESUMM1990 mmgm m gf f mr-f tri u , tie �a�ee s„na wnn^ x<a+w.�s w+ve.a u r €X.Mb ear ." V-1 o MIDaxaa VAY HAVE BEEN REDucm By PAM CSS. IZA IND Mr, i�",41f1GkbY.'i#fk. saw' ,�'4i��:�i •:••••••• 0;t CIO zffxr,k, k 3.'NWWARY A S AW 0.M J OAM4 eAaUA sPbK � t UM tit.. f EXCE UAD C #£cit�as� �. � rsx c ��7 �`",?�}i€J 1t%4Fi €i.E,k�Ct✓2+ .. �., SR t~'��+'i'�k �4�ET60.7Fb @sdt+rt Et Ca"�A s"CA+xi $ Ct D 0 ,..... C4ea"Sult co"blact" Svcs 50 w I"1f' n street iA "t "ousk MA 01501 Th--- E04RATON DATE `HEIREOF= 4*a"&L SEMS,a, m ACM 2S (201(V S BRAC 1138.. A � V CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDmYY) 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 endorsements . PRODUCER Martin J Clayton Insurance Agency, Inc. 1649 Northampton Street P. O. BOX 989 Holyoke MA 01041-0989 CONTACT NancyUsher NAME: PHONE Ext: (413) 536-0804 aC �: (413)534-7874 BUBR _ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:Nationwide Mutual -Harleysville NATIO INSURED Gauthier Insulation 44 ESSEX ROAD IPSWICH MA 01938 INSURERB:Allied World Natl Assurance Co INSURER C: ` INSURER D: INSURER E_: INSURER F: COVERAGES CFRTIFICATE NUMRER-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. INSRTYPE LTR OF INSURANCE ADDL BUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE X❑ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 X GL43487F 7/6/2015 7/6/2016 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 POLICY 0 PRO ❑LOC JECT $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ --- ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE (Per accident) $ . LIAB OCCUR EACH OCCURRENCE $ 1000,000 AGGREGATE $ 1, 000'_L00 JBUMBRELLA EXCESS LIAB CLAIMS -MADE �BE020792125-194985 DED RETENTION $ 10/18/2014 10/18/2015 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / 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 IIa:L9J11111113:1 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 IPSP'di`b§tbd with pdfFactory trial version www.pdffactory.com a c c OD O Q T a so aFn �. 9 m o �. icJT Q C o z m pkv: r G 0 M cn I�g � f + � , � t i i N 3 AA gggg 13�i�pg� 5�.P4p t F. F OD O t�9 C d � r r I�g � f + � , � t i i 4� �r�9�✓ 3 i 3 MIM f }2 A CT Li of day R a Oc a R tC m� a 4 i na i y - cr i jjjl it N to A o. AA gggg 13�i�pg� 5�.P4p t F. F