Loading...
HomeMy WebLinkAboutBuilding Permit #664-2016 - 933 GREAT POND ROAD 11/30/2015O'&RAW c 3 'ism BUILDINGPERMIT Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 0 Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg Others: ❑ Demolition ❑ Other a> f a 0 ®Septic . ©Well- Cyte .�; 4..3v,L'a ®Floodplain ®WetlaMs�-®.. Wateyyrshed ®istnct - fi } ©Water ewer,' DESCRIPTION OF WORK TO BE PERFORMED: A `r5tQ�i►ne ygTTlG =txiul4r► abok_ _ 7d Y4" Identification - Please Type or Print Clearly OWNER: Name: -T-v d t rk �t v d 5 a h Phone: f >F 3' Address: 133 terra i Pard >rd Contractor Name:r?zrf �4 Plum,77 be Ad rens C�'t , na . �k Supervisor s ConsI. truction License. mor✓ ot7 Exp. -Lome Improvement Lice se £ i7� F' 4 Exp 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. %00_00 FEE: $ Check No.: n 61 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty f and -r r . -- - SiariaturE 5 �• I 4 Plans Submitted ❑ flans Waived_❑ Certified Plot flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Ari ❑ Swimming Pools 0, well ❑ Tobacco Sales ❑ Food Packaging/Sales ' ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 10 Planning Board Decision: t Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: ILiI11F'i1S (9)W11 Number of Stories: . Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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.$100-$1000 fine Doc.Building Permit Revised 2014 �IEI�CiIfIC• D�'i•��i tlit"Ilt The following is a list of the required forms to be filled out for the appropriate permit to be obtained. ❑ 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 ❑ 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 DTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products :)TE: 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 n all rA Z LU LL a mc O LL °1 T O. (n 0 u CL 9A z z m aa 0 y 7 LL 7 d' i cu U C 11 0 0z w Vf z z o w Lbo 000 LL O a N z Q v w w t :3 W u to C LL oC p V a z t .3 oC C LL z w oc w LU U. i no O z ej v (% ,j N Y O {n O W :a z z m V N 0 G W)z Lu CL Cl) X. U) W LLJ -j LL Z -9 E •F+ Z y N .E L CL O V a V C4 O 0 cc c� N w : O O V Z �a o 0 CL L y • 0 o L rn L = c a 0 L (� N "3 d � CL 0 J ' w >+ L O = d o N -0 0 0 _ V QI � E0m oz 0-W n.2 0 Mn _ �..3 = 0 o CL w cc o 'N CD o c = _ y0 w � 4, .2m LU c '0— 0 0 M �a E C) Q O -a a co .Q w CLA0 O W :a z z m V N 0 G W)z Lu CL Cl) X. U) W LLJ -j LL Z -9 E •F+ Z y N .E L CL O V a V C4 O 0 cc c� N w 00 0/� Federal to 4 RISE Engineering RI Contractor Regldrallon No ContractororRe gi�Oon No A division of Thirtseb Eagineering CT ContractorgLstraOon No R i S CT ENGINEERING bo ShatvmutRoad, Canton, AIA 02021 CONTRACT (401) 784-3700 FAX 339-502.6345 Page 1 PROGRAM CMA -HES TMOONTRACTrmMmtns rtEeraaemeanw uraroma FW= oATE cueffs WORK0110M Judith Judson (978)314-3776 10/01/2015 423380 00002 asavrcs srRM. anLm artrmmr -- 933 Great Pond Road 933 Great Pond Road'" - 8GMQECnY,arAMZP eta.urta—.WAMMP ..'., - +f •'i North Andover, MA 01845 Noah Andover, MA 01845`31: :OCT 13 i i rr JOS DESCRIPTION BARRIER A Blower Door Test will not be conducted at your home, due to the pnsense of asbestos. _ $0.00 AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This %ori: will be performed in concert with the use ofspeciat tools and diagnostic tests to assure that your home will be left wish a healthful level of air exchange and indoor air quality. Materials to be used to seat your home can include caulks, foams and otter products. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (windmvs are not generally addressed.) This will require (4) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cf n is not guaranteed. At the completion of the weather talion work, and at no additional cast to the homeowner, a final blower door andlor combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. $340.00 AIR SEALING ADDER: (4) working houm $340.00 AIR SEALING: Provide labor and materials to install Q49a %weatherstripping and a doomweep to (4) door(s) to restrict air leafage. $300.00 ATTIC FLAT: Provide labor and materials to install a 9" layer of R-32 Class 1 Cellulose added to (704) square feet of floored attic space. $1,274.24 DAMMING: Provide labor and materials to instal a 12" layer of R-38 unlaced fiberglass batts to (64) square feet for damming purposes. $131.20 ATTIC FLAT: Provide labor and materials to install a 9" layer of R-32 Class 1 Cellulose added to (448) square feet of open attic space. $610.64 STORAGE BARRIER: Homeowner is responsible for the removal of the stated items blocking the installation of weatherization work in the attic. Removal must occur prior to the scheduled work start. $0.00 ATTIC ACCESS: Provide labor and materials to insulate the bad: of the attic door with r rigid Thermax board and seal the door's edge with weatherstripping to restrict air leakage. 573.91 STAIRWELL: Provide labor and materials to install Class 1 Cellulose insulation to the sheetrock or plaster ceiling and/or walls of a stairwell which are common to heated space, through a surface drill and plug method. The holes are plugged with styrofoam plugs, and spacl led to a rough finish. Any sanding and painting required are the customer's responsibility. $175.00 VENTILATION: Provide labor and materials to install (2) insulated exhaust hose to existing bathroom fan(s). $100.00 Federal ID 9 RISE Engineering RI Contractor Registration No Registration No A division of'fbielsch Engineering CT Contractor ReglstraUon No R I S E CT CContractor ctRegistration ENGINEERING7 60 Shawmut Road, Canton, 1IMA 02021 CONTRACT (401)rAX339-502-6335 Page 2 PROGRAM CNA -HES ENENOINEGUNG�MCUSTOMMEERFO�RNCAS OFSCRISEDBELOW CUSTOMER PHONE DATE CuENTe WORK OROSr Judith Judson (978)314-3776 10/01/2015 423380- , -. 00002 tt SERVICE STREETT., BILUNO STREET 1 � (� '' }= ,' 4J ±.- • 1' � 1 933 Great Pond Road 933 Great Pond Road SERVICE CrM STATE. ZIP BILLIRO CITY, STATE LP North Andover, MA 01845 North Andover, MA 01845 � G t _ JOB DESCRIPTION VENTILATION: Provide labor and materials to install ventilation chutes in (44) rafter bays to maintain air flow. . , 588.00 13ASEMENT CEILING: Provide labor and materials to install (92) linear feet of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. 5161.00 RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures, Columbia Gas offers 75% incentive, not to exceed 52,000 per calendar year, and an incentive of 1005ra for the Air Sealing measures up to the first $680 and an additional $340 ifsavings are justified by the auditor. For the safety and health ofyour home's indoor air quality, we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun, and after the wcalherizalion work is co tete. a kYill also conduct a full assessment of the combustion safety of your heating system and water heater. Ibis has a valu f d i no cost to you. otal allowable \ mveatherization incentive is 53,110. $90.00 Total: $3,713.99 Program Incentive: $3,062.99 Customer Total: $661.00 WE AGREE HEREBY M FURNISH SERVICFS - COMPLETE IN ACCORDANCE VIITH ABOVE SPECIFICATIONS. FOR THE SUM of "**Six Hundred Sixty-One 8':, 001100 Dollars 661.00 " UPON FRULL WPECTtON ATID APPROVAL BY RISE ENGLNEERWG. CUSTOMER AGREES TO REMITAMOU14T DUE Or FULL MTEREST OP m WILL BE GHARDED MONTra.Y ON ANY UNPAID BALANCE AFTER 30 DAYS SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES, RIGHTS OF REEBION, SCHEDULING, AND CONTRACTOR REOISTRATWIL DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES _t AUTHOR ION E-RISE lsOIMeUnu CU ACCEPTANCE NOTE TH CONTRACT MAYBE VAYHDRAWN BY US IF NOT ExECUTEO WRHW DATE OF ACCEPTANCE V ACCEPTANCE OF CONTRACT-THE ABOVE PRICES, SPECIFICATIONS AMD COMOmONS ARE ✓✓✓ DAT.S. SATISFACTORYTO US ANDARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK - AS SPECIFIED. PAYGTENT Wal BE MADE AS OUTLINED ABOVE P Judith Judson 1, (Owner's Name) owner of the property located at 933 Great Pond Road, North Andover, MA 01845 (Property Address) 933 Great Pond Road, North Andover, MA 01845 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. ¢' ner's Signature( iol I g) I �- - Dat OCT 2 0 2015 , OP ID: SS .44040) E �- CERTIFICATE OF LIABILITY INSURANCE IM -M o mwn-M 03/1312015 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: 0 the certificate holder is an ADDITIONAL INSURED, the poitcy(les) must be endorsed. If SUIBROGAMON IS WANED, subject to the terns 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 endoraement(s . PRODUCER Durso A Jankowski Ins Agcy LLC 198 Massachusetts Avenue NorthAndover, MA 01845 Durso A Jankowski ins. Agcy. COICIAOr pNpyE F H.1- o -North AD°�` PRODUCER I SMOLA 131 INSURER(S)AFFORDING COVERAGE MAIC S INSURED Polar Sear Insulation Co. Inc. P 0 Box 958 Andover, MA 01810 IASURERA:Penn America 32859 S�tY INSURERS: insurance Co. 33618 INSURER c : INSURER D INSURER E: INSURER F: rAVI;R®GPS f`8:CMRr &TF NIINIBFN- 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. LTR TYPE OF INSURANCE TILE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Columbia Gas POLICY NUAMMPOU EFF FOLIC EXP I IBdtTS Cranston, FII 02910 GENERALLIABILITY EACH OCCURRENCE S 1,000,0 DAMAGETORENIEU PREMISES Ea Xc urenca S 50,000 A X COMMERCIAL GENERAL UAsiuTY CLAIMS -MADE ® OCCUR AC705= 03J24Pd015 03/24P2016 MED EXP (Any am PUScrf) S 5,00 PERSONAL &AOV INJURY S 1,000,000 GENERALAGGREGATE S Z000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 5 11000100 S PRO- IAC POLICY F-1 JECT B AUTOMOBILE LIABILITY ANY AUTO 2100M 01/04=5 01104=6 COMBINED SINGLE LIMIT S 1,(100,00 (E8acditM BODILY INJURY (Per Person) S ALLOWNED AUTOS X SCHEOULEDAUTOS X HIREDAUTOS BODILY INJURY (Perat:ddent) S PROPERTY DAMAGE S (PERACCIDENT) S ii NON-OWNEDAVTOS 5 ri UMBRELLA WB I X OCCUR EACH OCCURRENCE S 1,000,00 AGGREGATE s A EXCESS UAB CLAIMS -MADE PAC69DE385 03!24/2015 03/24/2016 DEDUCTIBLE 5 S RETENTION S WORICERS COMPENSATION YYC ST ITU - AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNERID=VmjE YIN OFFICERIMEMBEREXCLUDED? (Mandatary in NH) If yes, describe under DESCRIPTION OF OPERATIONS bei= NIA EL EACH ACCIDENT S E.L. DISEASE -EA EMPLOYES S EJ_ DISEASE -POLICY LIMIT S DFSCRIPTIONOFOPERATIONS ILOCAMONS/VEHICLES(AtmehACORD 1M,AdddionolRemmkeSchedule, ifmmeepaeefit muked) 'n Work - Mineral; Additional Insured for eneral liability with to Work performed on their behalf by thilabove insured Is 191sch rring Oil CERTIFICATE HOLDER fl-ANCELL ATIAN THIEL S2 - SHOULD ANY OF THE ABOVE OESCRBED POLICIES BE CANCELLED BEFORE Thieisch Engineering TILE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave AUnWMMD REPR64EWTATNE Cranston, FII 02910 ©1886.2009 ACORD CORPORATION. Ali rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Conitnoniuealtli of iWassachusetts Departnient of Industrial Acci(lents Office of Investigations 600 11"fishington Street Boston, IVA 02111 W1Viv.mass.-OVI(11(1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Nalne (Business!Orsanization/Individual): f® ltv— Hca r T--", 't Address: V, Phone #: Q Are You an employer? Check the appropriate box: 1. 1 am a employer with —_ 4. ❑ I am a general contractor and I employees (full andior part-time).* have hired the sub -contractors 2. ElI am a sole proprietor or partner- listed on the attached. sheet. ship and have no employees These sub -contractors have working for me in any capacity-. employees and have workers` [\o workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.]` c. 153. S 1(4), and we have no employees. [No workers- comp. insurance reouired.l — �5—/,ef S— Type of project (required): 6. ❑ Neta construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.17 Plumbing repairs or additions 12.[:] Roof repairs 13.&Other r -i j4 11a &I tan%, applicant that checks box:! i must also fill out the section below showing their workers' compensation policy information. r I lomeowners who submit this affidavit indicating the.- are doing all work and then hire outside contractors must submit a new affidavit indicating strep_ Contractors that check this box must attached an additional sheet showing the name of the sub -contractor and state'Mielheror not those entities have eniplovees. if the sub -contractors have employees_ they must provide their workers- comp. policy number. 1 an: an enrp/oI•er 1/7al iS provllTing JPOrkers' Compensation insurance for nil. enlplgpees Beloit, is t/re policy anti job site information. Insurance Company Name: Policy r or Self -ins. Lic. Expiration Date: !��/j� Job Site Address: 9-s-< it A-7- OOA Cite/State/Zip:1). !9 n®Q Vir r' 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi-ations of die DIA for insurance coverage verification. I do herebr ceD rt6l'littler /the pains and penalties of perjttn• that the information prof ides/ above is true and correct. Slonature* .1 /l 1 ClIrP�C� _ / - ♦ _,:— Official use 011/1: Do not itrite in this are(1, to be complete(/ br city or tort,ll official. City or Town: Issuing Authority (circle one): Permit/License # I. Board of Health 2. Building Department 3. City/Tom.-ii Clerk 4. Electrical inspector j. Plumbing inspector 6. Other Contact Person: Phone #: CER-1-IFECAI1 OF LUAGIL{TY INSURANCE DAM(N1NM:YYYY) 12/18(2014 THIS CERTIFICATE LS 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, ANDTHE 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 por)cy, 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). PRODUCERAL NAntE: Automatic Data Processing insurance Agency, Inc. 1 Adp Boulevard NJ 0706$ IA G Na Eat-. (nL Nbk ADDRESS:Roseland, INSURER(S) AFFOROMG COVERAGE COMMERCIAL GENERAL LIABILITY CL,11t.)S�dAOE OCCUR INSURER A: NorGUARD Insurance Company - 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B. DBA: Polar Bear Insulation CO Inc INSURER C: PO BOX 956 Andover, MA 01810 INSURER D: N)SURER E- INSURERF- GEKL ACCRED ATE LILIIT APPLIES PER. POLICY ❑ iECT M LOC OT) -$It. LVVrKFiI,CD C:ER IIFICATE NUMBER: 2911529 RFV cinfu Iw.tnaoro- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NANMO ABOVE FOR THE POLICY PERIOD INDICATED. NOTLY ITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR N;AY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN LAY HAVE BEEN REDUCED BY PAID CLAIMS. MIL I. LTR TYPE OF INSURANCE MSD LYVO POLICY NUMBER @R+tOD:YYYY) OdNDD:YYYY) Lltittl5 COMMERCIAL GENERAL LIABILITY CL,11t.)S�dAOE OCCUR i EACH OCCURRENCE S t PREfa15 ES tEauttmmm,e) S DIED EXP IArqure perxnt S PERSONAL BAU•j INI DRY S GEKL ACCRED ATE LILIIT APPLIES PER. POLICY ❑ iECT M LOC OT) -$It. GENERAL ACCRECATE S PRODUCTS-COIIP,OP ACG S S AUIO698dE LIABILnY ANY AUTO ALLO"MED SCHEDULED AUTOS AUT 05 HIH EDAUTOS NON -OWNED AUTOS LUMSM tEa auidenP BODILY INJURY tiler prim) 5 BODILY INJURY (Per utidemY S 1' tr 1 ..o t. S IPCt •tttideAU S ]EDEDFRETENTION Occult CLAIMS-4UtDE EACHOCCURRENCE S icGREGATE S i S A WORKERS COMPENSATION ANDElt1PLOYERS'LLSBtLnY V ANY PItOPI(IETOR.1',VRTNERExECIITILE tN OFFICER AlEMBEREXCLUGED? �NlA 061mrdauuy in NH) It V.. d! stnUe ander OESCIUPTIONOFOPEINITIONSLvlusE1.OISE+IE-POUCYUWIT N PO1YC660990 01012015 01012016 X I STATUTE ER~ E1.EACHACUt>=taT S 1,000,000 Ei. DISEASE -EA EAII'LOYEE S 1.0K00D S 11000,000 DESCRIPTION OF OPERATIONS !LOCATIONS 1VENCLES (ACORD 101 A& t6wl Renato Schedule, mw be atuched if m spam is required) Columbia Gas massachusetts C-11111FK.nl[ HOLDER r'ANr-FII ATION) HV 1780-YU14 ALUKU t.UKPORATION. AU ngntS reserVe(1, The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Theilsch Engineering, Inc. 195 Frances Ave ACCORDANCE WnHTHE POLICY PROVISIONS. CranstDn, RI (2910 AUnIORQEDREPRESENTATIVE i HV 1780-YU14 ALUKU t.UKPORATION. AU ngntS reserVe(1, The ACORD name and logo are registered marks of ACORD tion s Regula Office of Consumer Affairs and air to -Park ?,=a - Suite 5170 achusetts 02116 Boston, Mass Conti . *4or RegistmfiOn Some Improvemen 102726 iswacin Reg� Type: DBA Tr# 25n49 6 on: 7MM EXPIM0 DPS -CAI a SWAWJ04-001216 massachusetts -Department Of Public Safety Board of , Building Regulations and Standards Construction Super"NOr Specialty License: CMLA060117 PETER A LEBLANC :TI 2 EMT PM STREET -C:,, Plaistow NEI 03865 V;cm.� Expiration of 002812018 commissioner �. � i 1 � 4 .� � 1 +/_ r. •� �, .