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HomeMy WebLinkAboutBuilding Permit #725-2017 - 90 BLUE RIDGE ROAD 1/18/2017I� 44 Permit No#:' p t ff� Date Issued: t BUILDING PERMIT o` t%ORTHtL6D 616 TOWN OF NORTH ANDOVER c APPLICATION FOR PLAN EXAMINATION Date Received ADRATED nPay,�S �gSSACHUS IMPORTANT: Applicant must complete all items on this Daae LOCATION 9 D C3 IU 2 PROPERTY OWNER MAP PARCEL: Print Print 100 Year Structure yes no ZONING DISTRICT: Historic District yes no Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building One family ❑ Pddition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑,Septic ❑ Well ❑ Floodplain ❑Wetlands 0 Watershed District ElWater/Sewer w .: OWNER: Name: Address: Gt 012W Contractor Name: DESCRIPTION OF,YORK TO BE PERFORMED: I ii n ^w% 1%...' -_o . X i ? h �N - Please Type or Print Clearly Address:,J744 CtV3•111• St03S- Phone: C( ITj 3 'S`1 �3 3 • (-Sc..no a.2B Supervisor's Construction License: Exp. Date: S 1 7-rI I �— Home Improvement License: I -1� Exp. Date: I b I V ti 1 � 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: $ 3613 1 • FEE: $ Check No.:Receipt No.: NOTE: Persons contracting witli unregistered contractors do not have access to the guaranty fund It) � r t Location It) L� t 1l i No. �f `7 -% 211v Date t 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r r ! Check # l/,fir 4 v Building Inspector 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 COMMENTS Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed o Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Nanning Board Decision: Comments Conservation Decision: Comments 'Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea 664 usgooa Street 'T n_ iy�es �t noL s :Locatediat�'�124� F�reD°e`partr COMMENTS 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 MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (tor clepartment use ❑ Notified for pickup Call Ema Date Time Contact Name Doc.Building Pennit Revised 2014 No 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 TOTE: 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 ,4. 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) ,4; Building Permit Application 4, Certified Proposed Plot Plan ,4. 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) 4. 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 < 00 -mm 0 c =r --IO o -o °1 = O O CD n .. 1 _ r XO C = 3 Z p?SMov>• --ICN LA. T -h r -4 -OO ,V. O O Q m +, �N cn CD Op N =•cD 2 . 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O CL cu C D FC O .O -f / co. o =0 .O IWD CD .a = (D � to < CD O 0 N - to o 0, � s •��, . f _W.alls �q O CD v, C' N n 3 <O 0Q— U) CD U) su CD Q� N W� O cn � y r .a i� a� N '• 0 CD c Cy oD0 d lD n N _► O �_+ - m fu o 0 o CL cn O X, (D 0Z ' �o N (D `Y O c 3 C o0 S - G_ cn m < o C 00 3 „ m C oa S T d n S 3 3 m z °c 0o S T °C C C. w p cn '0 f1 tn O C. \ n oH D m z Z H n O m r, m '° D r LA m C °' Z ni vZi n C wfD C ° H m 0 - 3 s ' W m ° O x x \s S 'c6S. rD � 1 momo op Z'l O ow 0 C CLEAResult 0 CONTRACT FOR PRODUCTS I SERVICE WORK This Agreement is made by and among Ik Yun • 90 Blue Ridge Rd North Andover, MA 01845-2117, Site ID: 500050237500 Project ID: P00050272490 Customer ID: C00050239150 Contract. ID: 201451215 ASM This service is brought to you through support from your local utility and CLEAResult Anti: HES 50 Washington Street, Suite 8000 Westborough, IWA 01581 ; Federal ED No. 222457170; -. -(Mail completed contract to address above) 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these "Premises in a professional manner and in accordance with the terms of this Contract, including the attached recommendationslwork order describing the work in detail (the -Work-) which are incorporated herein by reference: DrnIpftn• Quatrlity Lacdion Perform Air Sealing at Es*rtfad 62.5 CFM50 Per Harr 10 LivittA Space 5843.20 Aft Stair Cover T herrrtal Barter with cwper*y 1 uvkv Space: $26D.23 Door §!tm 3 WA S69.64 Ertbt W Door W68111W Swopping 3 WA $82.77 Sub Tobil: $7,255.74 Utay btcend" Sham $1,255.74 Caskww Conhibudon $0.00 CD For oftka use only Pri~.12!'1512016 Pape 1 of 1 11. PAYMENT Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows Payment #1: 3, 0.0c) as a Deposit payable to CLEAtesuit upon signing the Contract (not to ex /3tatal retail costs). Mail check & contract to CLEAResult, Attn:AES, 50 Washington St., 000 Ste. 3, Westbar engk MA 01581. FWW Payment S o e � as the final payment for the Work shall be payable to the Independent Installation Contractor (011C") uponsa Lebon or the Work. Customer understands that helshe WZ not be regdTed W pair the Ud ty Incentive Share of the Contract price in the amount of S to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. 111. DISPUTE RESOLUTION 'Me BC and Customer hereby mutually agree in advanm that in de everu.thatthe 110 has adispute coni uningMis Contract, the ne may aftWt such dispute to aprivate arbitration am -Am which has been approved by the Offieeof mother Affass and 1 t and Custonter'shall be required to adurO to such arhiirabon as pnnided in M.G.L c 142A. You may cancel this agreement if it has been signed by a party at a plate other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agree ent. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. toll) C m Ind'cate you set II� if applicable initial here if you want Dale n` (,� fire Program to ntrac a �Yt� i' a' I he Program Participating Contractor -- rgnatute Name of CLEAResult Rep ve (Printed) TErt M AND COMMONS APPIUM ON 1$B REVERSIL 2200-12-R1.16 CLEAResult� CONTRACT FOR PRODUCTS ! SERVICE WORK This service is brought to you through support from your local utility -This Agreerrlent is made by and among I(k Von and 90 Blik Ridge Rd CLFAResult ' North Andover, MA 01845-2117: I AftnHES Site ID: ;00050237500 50 Washington -street,- Suite 3000 Project ID. P00050272490 Westborough, XV 01581 Customer ID: C00050239150 Federal ID No. 22247170. _ ` Contract II): 20161215_WORK (Mase completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these "Premises" in a professional manner and in accordance with the terms of this Contract, including the attached r+eoommendationslwork order describing the work in detail (the "Work') which are incorporated herein by reference DsseTipdon awtt6ly Latwon Attic Floor Open Blew Cellulose W 1,336 t i," Steam $1.963.92 Damming 60 WA $131.40 Propavent 7 or 4' 84 Aldc $321.72 Vert ba% fait to root dapper 2 Atte $256A2 Sub Total:" $2,675A6 Uduty ft=n"W Shane $2,00D.00 Customer Conblit"aon $675.46 lem"M a _ _. For mics kmo* Printed:12115f2016 Page 2 012 11. PAYMENT s� a .) Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows: Payment #1: S as a Deposit payable to CLEAResult upon sigaing the Contract (not toex of rite retail costs). Mail check & contract to C1.PAResah, Attu HES, 50 Washington St., 000 Ste. 3, Wftdmrou^ STA 01681. Final Payment $ r as the final payment for the Work shall be payable to the Independent Installation Contractor ("HC") upon sa eom letion of the Work. Customer understands that he/she, not be required to pay the Utility Incentive Share of the Contract price in the amount of i ^Oq,'Changes to-ind"ividuat line item andror previous incentives nmy increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The IIC and Customer hereby mubmily agree is advance that in the event that tare IIC has a dispute car omft this Cor&=4 the HC may sulxa t we h dispute to apm%ue arbitration smite which has been approved by the Office of Corsrm rAtfam and Busies Regulation and Customersball be required to submit to surly arbitration as provided in bLG.L. q 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. C Date indigate your were, ''( applicable ioR) Initial here want i !S / b Iy6ih InG(the Program to assign a C rgnature Name of CLEAAesult Repr�ative (Printed) Participating Contractor . TRIU15 ANL.CW1W 0XS AVPZM ON TAM XZVMtM 2200.12,R1.1f. mast raver :s>ane�.sin�►. Permit Authorization Form Site ID: 50237500 Customer. Ik Yuri 1, Ik Yun , owner of the property located at: (owner's Name, printed) 90 Blue Ridge Rd North Andover (ftop i street Address) (aty) hereby authorize the Mass Save Nome Energy Services Program assigned Participating Contractor fisted belowto act on -my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: •�O���i���i�����������i�����������������f�������������i���fa�����«time• FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date In CLEAResuit a 50 Washington Street, Ulte 3000 • Westborough, MA 01M • IM"W7472 0 _ For owwe Use only Rev. 102015 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 `may'' www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Legibly Name (Business/Organization/Individual): ��� t� `ASUl 6—Nin t \V` ., Address: °C - 0 Box -3+4 N Ci /State/Zip: \ 01Wl" Lt\ N 1i 0 J0J 3 f6 Phone #: • 3LU , 14,e 3 Are you an employer. Check the appropriate box: Type of project (required): 1.�I am a employer with 4. ® I am a general contractor and I 6. ® New construction employees (full and/or part-time). ,� 2.[3 I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ®Remodeling ship and have no employees These sub -contractors have g, ®Demolition working for me in any capacity. employees and have workers' insurance.# 9. ® Building addition [No workers' comp. insurance comp. 5. We are a corporation and its ® 10.® Electrical repairs or additions aired. required.) 3. ®I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions ® g p myself. [No workers' comp. right of exemption per MGL 12.®Roof repairs insurance required.) t c. 152, § 1(4), and we have no 13.® Other employees. [No workers' come. insurance required.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: red 1 a- I mQ anu, U0 - Policy # or Self -ins. Lic. #: oft KV_ 3 QO Q Expiration Date: o Job Site Address: q 0 Q 1 u t (U!�Y44 City/State/Zip: N O(A ft& WK (tl 11N bl GK ,� Attach a copy of the workers' compensation policy declaration page (showing the policy number 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pedury that the information provided above is true and correct. - I , Date: I. I lel Il Phn„P ii. a� G - I s m- -3,16 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permlt/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #' Aco O CERTIFICATE OF LIABILITY INSURANCE �e/ Y) DATE(10/1188//22016016 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 MARTIN J. CLAYTON INSURANCE AGENCY INC 1649 NORTHAMPTON ST., RTE 5 HOLYOKE MA 01041 NT NAMEACT Meg Munroe AX a°NN E , (413)536-0804 FAC Ne: E-MAIL ton.com mmunroe m cla ADDRESS: @ j Y INSURER(Sl AFFORDING COVERAGE NAIC # INSURER A: ACADIA INS CO 31325 INSURED GAUTHIER INSULATION INC PO BOX 344 IPSWICH MA 01938 INSURER 8: INSURER C: INSURER D: INSURER E: INSURER F: n0071CVIATC LHIRAIMCQ• Odr71 REVISION NUMBER: VVVCFIAUCJ vGn�n we+.� nvmv.�. .. ..-vim. 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. LTR INSRrCOMMERC[AL F INSURANCE ADDL SUBR NUMBER MM/DDY EFF POLICPOLICY M POLICY LIMBS GENERAL LIABILITY OCCUR EACH OCCURRENCE $ DAMAGE TO RENTEDADE PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY El JECPROT - LOC OTHER: AUTOMOBILE LIABILITY (EaacclctlenSINGLE LIMIT $ t BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE N/A AGGREGATE $ X STATUTE 'ER"' DED RETENTION $ WORKERS COMPENSATION E.L. EACH ACCIDENT $ 500,000 A AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/M EMBER EXCLUDED? WA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below WA WA MAARP300327 10/30/2016 10/30/2017 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE MULUEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE �) CLS NORTH ANDOVER MA 01845 Daniel M. Cr y, CPCU, Vice President— Residual Market— WCRIBMA .:. Anne. AAA A Annnn 1%n00A0ATln1d All AnhYc rncarvwrl ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD —DATEDATEM( IUDDJYYYY) eco v® CERTIFICATE OF LIABILITY INSURANCE 7/142016 AND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF Y XTEND OR ALTER THE COVERAGE AFFORDEDABY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND BELOW. THIS CERTIFICATE OF INSURANCE RT�{F NOT CATS HOLDER.CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CE 11 !SU subject to IMPORTANT: If the certificate holder is an ADDITIONALay Srequre+an endorsement. the polli� 11 kI89) m A statement on this his certffRlcaGe does r►ot Pconfe •+fghts t the the terms and conditions of the policy, certain policies certificate holder In lieu of such endorsement Q. A T Nancy Usher NAME: (413)434-7874 PRODUCER PHONE (413) 536-0804 No): Martin i Clayton Insurance Agency, Inc• E E-MAIL 1649 Northampton Street ADDRESS: NAIC;1 INSURER S AFFORDING COVERAGE P. 0. Bos 989 NATIO INsuRertA:Nationwide Mutual -Harleysville Holyoke MA 01041-0989 INSURER B Allied World Natl Assurance Co INSURED INSURER C Gauthier Insulation INSURER D: jP.O. BOX 344 C. — MA 01938 INSULA n r : IPSWICH REVISION NUMBER: COVERAGES CERTIFICATE NUMBER:CL1663001850PERIODED ABOVE FOR 1HE POLICY PERIOD CH THIS THIS ISTD CERTIFY THAT THE POLICIES OU REMECT NTNTERM OR CONDIZE6 LISTED TION OFANYCONTRALTEEN ISSUEDO OR OT R BED HEREER CERTIFICATE S SUBJECTTH ALL IS TECT TO CH THIS HE ICY TERNT V\n MS, INDICATED. NOTWITHSTANDING ANY REQ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DES EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED OLICY EFF PAID CLAIMS. PO IC EXPLIMITS n, - rMM/DD +an7R TYPE OF INSURANct i E . r $ COMMERCIAL GENERAL LIABILITY I A CLAIMS -MADE a OCCUR g t}L43487F 7/6/2016 7/6/2017 GEN'L AGGREGATE LIMIT APPLIES PER: X I POLICY ❑ R- X [] LOC OTHER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS X UMBRELLA LIAB OCCUR B EXCESS LIAB CLAIMS -MADE 10/18/2015 10/18/2016 Bg020T92125-194985 DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNERIEXECUTIVE nIN/A OCCURRENCE $_ 1,000,000 t T E TED $ 50,000 USES(Ea__ocau+serwa — 5, 000 EXP (Any one person) $ TONAL & ADV INJURY $ 1,000,000 E_RAL AGGREGATE $ 2,000,000 _ . n .orno ar^_r Y 2,000,000 Is ED S*5=70 II Ea accident BODILY INJURY (Per perBODILY INJURY (Per accPROPERTY DAMAGEPer accident) E.L. EACH AUUIUM' E.L. DISEASE - EA $ DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additlonel Remarks Schedula may be attached if more space is required) CLEARESULT, WgIRSOURCE AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSUREDS ON A PRIMARY NON-CONTRIBUTORY BASIS 'ERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CLEARESULT HE EXPIRATION WITH THE POLICY PROVISIONS.WILL BE DELIVERED IN ACC ATTN. CONTRACTOR SERVICES DEPT 50 WASHINGTON STREET ESENTATIVE WESTBOROUGH, MA 01581 - ivan/MEG ©18-2014 ACORD CORPORATION. Afl rights reserved• ACORD 25 (2014101) The ACORD name and logo are regisared martcs of ACORD Haft -d with pdfFactory trial version www.pdffact©Iy.cc�m N M `'-' 0 0 x 40 r w oGW0°' w_Wo =):6 00 t-Hv� 0) CO v- - a w r Ila rn v� I ow - It, ga, 'cl PK I ow - It, ga, 'cl