HomeMy WebLinkAboutBuilding Permit # 6/4/2015 F FORTH
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COCNIC Nl WICK V
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BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
THIS CERTIFIES THAT „ ......... A..`.®.� ` BUILDING INSPECTOR
............ ...0. .......... ................
. . . . .... ....
has permission to erect ................ buildings on 1A..14. Foundation
. .. . Rough
to be occupied as
.......... ..... ... �. ... .. .�. .... ................. Chimney
provided that the person accepting this permitAlI 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
MONTHS
PERMIT EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR
LESS ST CTISTS S Rough
Service
............ . .. ................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector! Burner
Street No.
Smoke Det.
Federal ID#
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thiclsch Engineering CT Contractor Registration No
60 Shawmut Unit 112,Canton,MA 02021 CONTRACT
339-502-6335 FAX 339-502-6345
"Rhw Page 1
PROGRAM
THIS CONTRACT IS ENTERED INTO BETWEEN RISE
ENGINEERING CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS
DESCRIBED BELOW
CUSTOMER PHONE -- -^� - -._---
GATE CLIENT# WORK ORDER
April Varricehio (203)671-4582 03/13/2015 410232 00002
SERVICE STREET BILLING STREET
12 Richardson Avenue 12 Richardson Avenue
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
BARRIER:A Blower Door Test will not be conducted at your home,due to the presense of asbestos.
$0.00
AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be
performed in concert with the use ofspecial tools and diagnostic tests to assure that your home will be left with a healthful level of
air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary
areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally
addressed.) (8)working hours.
At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality.
$680.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass baits to(66)square feet for damming
purposes.
$135.30
ATTIC FLAT:Provide labor and materials to install an 8"layer of R-28 Class I Cellulose added to(792)square feet of open attic
space.KEEP A 14X 12 SECTION OF FLOOR IN ATTIC FOR STORAGE/ACCESSS STAIRWELL SLOP AND KWALL BY TEMP
ACCESS THROUGH ATTIC FLOOR/1 HAD NO ACCESS TO OVER REAR AND SIDE BUMP OUT AT fICS ASSUMMED SAME
AS MAIN ATTIC.
$1,085.04
STORAGE BARRIER:Homeowner is responsible for the removal of the stored items blocking the installation of weatherization
work in the attic. Removal must occur prior to the scheduled work start.
$0.00
SLOPES:Provide labor and materials to install a 6.25'layer of R-19 fiberglass baits to 952)square feet of sloped ceiling area.
Wherever possible baffles will be installed to the entire length of each bay to maintain ventilation space.KEEP A 14X 12 SECTION
OF FLOOR IN ATTIC FOR STORAGE/ACCESSS STAIRWELL SLOP AND KWALL BY TEMP ACCESS TI-IROUGII ATTIC
FLOOR/1 HAD NO ACCESS TO OVER REAR AND SIDE BUMP OUT ATTICS ASSUMMED SAME AS MAIN ATTIC.
$105.04
KNEEWALLS:Provide labor and materials to install R-13 faced fiberglass to(92)square feet of kneewall. Then install 2"rigid
board insulation.Seal all seams with FSK tape.
$335.80
ATTIC ACCESS:Provide labor and materials to make(1) access opening from one attic area to another by cutting a passage
through sheathing. This access will be left open as it is between two common unheated non firewalled attic areas.
$31.31
ATTIC ACCESS:Provide labor and materials to make(1) temporary access to an attic area through the roof. The opening will be
closed with materials similar to those existing.Roofing will be scaled properly when insulation work is complete.
$92.42
ATTIC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. The
cover has integral weather-stripping to restrict air leakage.
$200.00
Federal ID#
RISE Engineering RlContractor Registration No
MA Contractor Registration No
A division of Thieisch Engineering CT Contractor Registration No
;. 60 Shawmut Unit#2,Canton,MA 02021COINITRACT
339-502-6335 FAX 339-502-6345
Page 2
PROGRAM
THIS CONTRACT IS ENTERED INTO BETWEEN RISE
CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS
ENGINEERING DESCRIBED SELOw
CUSTOMER PHONE GATE CLIENTtl WORK ORDER
April Varricchio (203)671-4582 03/13/2015 410232 00002
SERVICE STREET BILLING STREET m'
12 Richardson Avenue 12 Richardson Avenue
SERVICE CITY,STATE,ZIP 61LUNG CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
VENTILATION:Provide labor and materials to install(2)insulnted exhaust hose with soffit mounted flapper vent to exhaust
existing bathroom fan(s).
$237.50
VENTILATION:Provide labor and materials to install ventilation chutes in(62)Taller bays to maintain air flow.
$124.00
VENTILATION:Provide labor and materials to install(8) 8" X 16"rectangular aluminum soffit vents to increase ventilation in
attic areas. Specify color.White or Gray.
$200.00
WALLS:Furnish and install blown in Class I Cellulose to(45)square feet of shingle and/or clapboard exterior Walls.The butt of the
upper course of your wood siding is cut to drill holes into the wall sheathing behind.The holes are then plugged and the wood siding is
reinstalled using stainless steel finish nails.Touch-up painting,if needed,will be the customer's responsibility. invoicing will occur
upon completion of installation. Subsequent to your payment,as an added service,RISE Engineering will retum when weather
permits to check for any voids with an infrared scanner. Any major voids that may be found will be filled at no additional cost.
$83.25
STORAGE BARRIER:Homeowner is responsible for the removal of the stored items blocking the installation of weatherization
work in the basement. Removal must occur prior to the scheduled work start.
$0.00
BASEMENT CEILING:Provide labor and materials to install(110)linear feet of R-19 unfaced fiberglass insulation to the perimeter
of the basement ceiling at the house sill.
$192.50
BARRIER:Homeowner is responsible for the removal of any ceiling tiles blocking access to the sills.
$0.00
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$2,000 per calendar year,and an incentive of 100%for the
Air Scaling measures up to the first$680 and an additional$340 if savings are justified by the auditor.
For the safety and health of your 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 weatherization work is complete.We will also conduct a fill assessment of
the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Toinl allowable
weatherizntion incentive is$3,110.
$90.00
Federal ID#
I RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of"I'hicisch Engineering CT Contractor Registration No
60 Shmmut Unit 112,Canton,MA 02021 CONTRACT
339-502-6335 TAX 339-502-6345
Page 3
PROGRAM
--- THIS CONTRACT IS ENTERED INTO BETWEEN RISE
ENGINEERING CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS
DESCRIBED BELOW
CUST041ER _--_-- PHONE - -- DATE yV�CLIENT# WORKORDER
April Varricchio (203)671-4582 03/13/2015 410232 00002
SERVICE STREET BILLING STREET
12 Richardson Avenue 12 Richardson Avenue
SERVICE CITY,STATE,LP BILLING CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
Total: $3,592.16
Program Incentive: $2,770.00
Customer Total: $822.16
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Eight Hundred Twenty-Two& 16/100 Dollars $822.16
UPON FINAL INSPECTION AND APPROVAL BY RISE ENVEERIT(.CUSTOMERAGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF tYo WILL BE CHARGED MONTHLY ON ANY
UNPAID BALANCE AFTER]D DAYS.SEE REVERSE FONTINFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION.
NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
AU7N ED SIGNATURE•RIS ngl e' g CUS70 ACCEPTANC_
NOTE THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE
30 DAYS SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK
AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE
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APR 2 7 2015
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OWNER AUTHORIZATION
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(Owner's Name) r '
owner of the property located at
(Property Address)
(Property Address)
hereby authorize ,
i (Subcontractor)
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an authorized subcontractor for RISE Engineering,to act on my behaff to obtain.a building
} permit and to perform worts on my property.
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Owner's Slgn re
Date
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The Conrenonwealth of Hassachusetts
Department of Industrial Accidents
a
31 ,q
Office of Investigations
~;` 600 T 'ashington Street
.� Boston, MA 02111
wtvtu.nrass.;ov/ilia
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicarit Information Please Print Legibh
Name (Business!Organizationllndividual):
Address: & A 0 X f
C1ty1State/Zip: Jkp Phone#:
Are you an employer?Check the appropriate box:06 Type of project(required):
4 I am a gel contractor and I
L [am a employer with _ ❑ general 6. ❑\ew construction
employees(hill andlor part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- 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'
[\o workers' comp.insurance comp. insurance q ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3-❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [\o workers' comp. right of exemption per MGL
insurance required.]'' c- 152_ C1(4),and we have no 1-2
❑ Roof repairs
employ=ees. ['�o workers' 13.MAtherlidA►p9
comp.insurance required.]
*Any applicant that checks box=1 must also till out the section below shoxyins their urorkerr compensation polio information.
I lomeoxyners who submit this affidavit indicating they are doing all%vurk and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional slice[showing the name of the sub-contractors and state"iietheror not those entities have
employees. If the sub-contractors have employees.they must provide their workers'comp.policy number.
I ant an entploJer that is providing workers'compensation irtsarrnice for nth entplolves. Below is the polio'ttnd job site
information.
Insurance Company Name: V_ a U Q If t� _
Policy'_or Self-ins.Lic.r: ?® hIC.- ,rj ` _ Expiration Date:
Job Site Address: Cit•/State/Zip:
Attach a copy of the workers'compensation policy declaration page(shoming the polio 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
Investigations of the DIA for insurance coverage verification.
1 do herevr cert)-tattler the pains and penalties ofperjnrl'that the inforinatioit providerl above is trite and correct
Signature: Date:
Phone C,3
Official itse oall: Do irat write in tltis ttrea,to be colupleted br city or totvtt official.
Citi•or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk -t. Electrical inspector $. Plumping Inspector
6. Other
Contact Person- Phone 9;
A ® DATE(MWDDIYYYY)
CERTIFICATELIABILITY INSURANCE
01/06/2015
THIS FCERTIFICATE A MATTER of INFORMATION N ONLY AND CONFER No R GHT ,�p,+ --I
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. { S
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pol)cy((es)must be endorsed.If SUBROGATION IS WAIVED,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 Ileu of such endomement(s).
PRODUCER NAME:
AUtOmat[G Data Processing insurance Agency,Inc. - S
11A =AA/ No
1 Adp Boulevard ADD :
Roseland,NJ 07060 INSURERS)AFFORDING COVERAGE NAIC 0
WSURERA; NorGUARD Insurance Company 31470
INSURED POLAR BEAR INSULATION CO INCINSURER6:
51 S CANAL ST INSURER C:
PO BOX 958 INSURERD:
Lawrence,MA 01$43 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 296670 REVISION DUMBER:
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 POLICY NUMBER MWD MWD LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMSAIME OCCUR PREMISES Ea orcunertce S
MED EXP(Any one person) S
PERSONAL 8 ADV INJURY S
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
POLICY D JEC M LOC PRODUCTS-COMPIOPAGG $
OTHER: S
AUTOMOBILE LIABILITY Eaaartlent G S
ANYAUTO BODILY INJURY(par persm) S
ALL OWNED SCHEDULED 130DILY INJURY(Peraoddenl) S
AUTOS AUTOS PROPERTY DAMAGE S
HIRED AUTOS AUTO Peracddent
$
UMBRELLA Lute OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED I I RETENTIONS S
WORKERS COMPENSATION � E
AND EMPLOYERS'LIABILITY STAT 11rE ER
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
N E.L.EACH ACCIDENT $ 1,000,000
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(Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 1,000,001)
ityes de=-bounder 1,000.000
DESEAIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,AdMonal Remarks Schedule,may be alt elied IT mors space Is requlrw4
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CPLUMBIA GAS ACCORDANCE WITH THE POLICY PROVISIONS.
195 FRANCIS STREET
Cranston,RI 02910 AUTHORIZED REPRESENTATIVE
01988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
---013114 OP IN SS
Plrazws
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THUS CERTIFICATE 18 ISSUED AS A MATTEROF INFORMATION ONLY AND CONFERS No RIGHTS UPON T#IE'COMROATE HOLDEN.THIS
CEIMCAJrE DOES NOT AFRRUATIVELY OR NEGATIVELY AMD, 0MD OR ALTER THE COVERAGE AFFORDED RY THE POLICIES
BELOW. THIS CERMRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BIND INSU (SA AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER.
IMPORTANT: tr the car6ftcate holder is an ADDITIONAL INSUQW)must be mdomed. 9 FUBROGATION 18 WAMEA sulTjeat to
the tenas and oonditions of Ute policy,certain Polities rimy require an endamement. A stebment an this cerffffcaM does not confer rights to the
cerliflom holder in lieu of such endoream2gs
PRODUCER CONTA
D� nue&Jan Ins ssachuseftAVeAge LLC PNM® GAR
North Andover, 01845 Emjamm
Durso S,JankaWskl Ins Agcy. PROD 1
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INSURER F
COV GES CERTI RATE NUMBER: REVISIONNIJ
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDMON 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.UMTTS SHOWN MAY HAVE BEER)REDUCED BY PAID CLAIPAS.
rm TMEOFRIMANCE Paucymmaaft
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rAT COMMERCUILGENERALUABIUTY PAC7052023 03AAMS 03FAUMS Pres $ 50,00
CLAIMS-MADE®OCCUR MED EXP(An one etsam S 5,
PERSOpI &ADVINJURY S 1,000,0
GENERALAGGREGATE S Z000.0
GENLAGGREGATEUMITAPPUESPEtir PRODUCTS-coUPIOPAGG S 1,00D,00
POUCY JECT
PRO- LOC $
AUTOMOMALTAMFTY COMBINEDONGLr:uwr $ 12000100
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01 6 SODR.Y INJURY(W PMO) S
ALLOWNEDAUTOS BODtLY1NJURY(PeraCddettt) S
X SCHEDULEDAUMS PROPERTYDAMAGE S
X NREDAUTOS (PERACCIDM
X NON-0WNEDAUTOS SS
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CERTIFICATE HOLDER CAN TION
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SHOULD ANY OFTHE ASOVE DESCRIB®POLICtORRCANC€LLED BEFORE
rhi h EItgI 1HE EIMMAMON DATE THERSyOF, NOTICE WILL BE DMNMED IN
ThIeColutv Gas 9 ACCORDANCE WrH THE POLICY PROVISIONS
195 Frmnols Ave
�nsiorl,Ri p p AunTOR�o RTPRt�[dTATNE
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0 1988-2009 ACORD CORP® %Olk All rights feawe&
ACORD 25( 9) The ACORD Raine and[ago are reglatered nmft of ACORD
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CERTIFICATE1 �a9f9 s
THIS CERTIFICATE IS ISSUED AS A MA OF INFORMATION ONLY AND CON NO UPON C TE HOLDTHE EIL THIS
CERTIFICATE DOES
O Nor
AFFIRMATIVELY
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AMEND,
DOR AL E GE AFFORDED BY POLICIES
BELOW. THIS CEFITIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BINO wsuRnm AumoRmw
REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDEFL
IMPORTANT: If the certiticalb holder is an ADDM70NAL INSURED,fife poffgy(i )muse to endorswL If SUER 'f10N IS WAWA eubbM to
the terms and conditions of the policy,coWn policies may require an endo A statement on this certIffegle does not confer rlgt t to the
cerocate holder in Lieu of such endowelnig US
PRODUCER
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Durso&Jankowald fns Agcy LLC P1faREPAX
198IMessadwsellsAventie u0
North Andover,MA 01845 A
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COVERAGES CERTlFlCATE NUMBER: ION NUMB :
POU
'nits IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED HAM ABOVE FOR TO WHICH THIS
CY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITt l RESPECT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.UMrrS SHOW01 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
P FAP
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G�g:ALAG{;RWATE $ 2,000,40
GENLAGGREQATELIMRAPPUE&PEA PRODUCTS-cow/OPAGG S 1XI1.00
POLICY PMF1
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NY 1,QOD,00
AAUTO OD926 5 Ot 6 BODJLY WJURY IP¢ P&M) S
ALLOYMEDAMS BODILYINJURY(Persw""M S
X SCHEDULEDAUTOS PROPERTYDAMAGE S
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A EXCESS UAB CLMMS44ADE PAC6906M ORF24=5 OSPA4=6 AGGREp WE 5
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RETENTION S S
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tns�u ation�or Mineral, � u fore raD)�1
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CERTIFICATE HOLDER CANCELLATION
Tir!!E
fi#{OUM ANYOFTHe ABOVE DEWSUBW POLICIES Or.CAAICI:LLED BEFORE
'illi h Eng! ring A=RDANCEEWffHT11EP0LICYR RREOFOVIBMONS. WILL BE DEUVEREp 1N
Columbia Gas
195 Francis Ave AutiroRlzEa BePRr teNrATnrE
CraMon,8182910
0 1989-2009 ACRD CORP6FIAj(0N. Alt riglds resemed.
ACORD 25( 9) The ACORD name and logo ars reglaftoxi marks of ACORD
elation
rs and usiness Reg
office of consumer -plaza Suite 5170
} 10 Park-plaza
Boston,Massachusetts 02116
elm improv Contractor Registration
�Om J? - Registration: 102726
7vpe: DBA2522x9
Expiration: 7/2/2016
POLAR BEAR INSULATION CO.
r
Vincent LeBlanc
P.O. BOX 958
ANDOVER, MA 01810 'Update Address and return card.M tukm ant° arLost card
i Address ❑ Renewal � Emp Y ❑
DPS-CAI ca 50M.04104•G10I216
9 Masson'11Setts
w Dlapau,tu"Il ult,of i�anirofi� �fet$(
Board of BuMing Regkj@a.flons sn d Si.aamb iau is
('onstauctim, SuPerNi"rSpecaaRN
C._i::en se: CSSL406017 '
PETER A LEBLANC 'rl
2 EAST PINE STREET
Plaistow NH 03865
E,,,(p raati0ro
04/2812018
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