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HomeMy WebLinkAboutBuilding Permit # 11/30/2015 71.. — OORTH BUILDING PERMIT o�R���� f"'q4, TOWN OF NORTH ANDOVER. a APPLICATION FOR PLAN EXAMINATION Date Received Permit No#: A7EP �S�'�c eaus`��c Date Issued: b IMPORTANT:Applicant must complete all items on this page LOCATION I Co u/0 oflJ C" i P t PROPERTY OWNER Iq ot, M 4 Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye 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: ❑ Other �� / t 0 El Demolition u, �y,�,�;�tib, ::..Mill tl P DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: 01 6e. Phone: Address: woo Contractor Name: Pere 4` t e (et V,,,C- Phone Errmail: Address: rg�7 krrf e, 7- Supervisor's , oSupervisor's Construction License: o t,,o r> Exp.. Date: Home Improvement License:-1 0 Exp. ®ate: �® ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �`I�o-�o FEE: $ Check No.: Receipt No.: .F DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund � anaweoa/arrr�rai ' town of .._`_ 11 R Andover ® ffi Zver Mass, 3 01 COCKIC MI MACK y1. x,95 AT U BOARD OF HEALTH Mir In Food/Kitchen PER T T %9P Septic System 0 THIS CERTIFIES THAT ........... ,,,1.4.............. BUILDING INSPECTOR 94.1 ".. Dhas permission to erect ............. buildings on ... 'ab o-A,,, Foundation * Rough to be occupied as ... .. . . ........ ... . ... .... .. . ®......�...�................................. Chimney provided that the person accepting this permit 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 PERMITONTHS ELECTRICAL INSPECTOR UNLESSTI Rough Service ................ .... ........ .............................................. 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 Approvedby the Building Inspector. Burner Street No. Smoke Det. Federal W ii 664405629 RISE Engineering RI Contractor Reglatratlon No alas MA Contractor Registration No 120979 A division of Thle4ch Engineering I 60 Sbawmut Unit i{2.Canton.MA 02021 CONTRACT 339-502.6335 FAX 339-502-6345 Page 2 PROGRAM THISCONW-WISENTEREDINIoeaTINMRISS CKA-Hn OXWERVICANDTHacuaro GRFORWORKAs OMCRIam sELnw —daftaNw— PHONE DATE cttFNTo woRHon Adam Ragab (617)834-9181 10/08/2015 410038 00002 8emce STREW OWLLWO 110 Woodcrest Drive 110 Woodcrest Drive —da1K=--MY.WATB.DA 1393AQ C1rf8TAV,2W North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION ATTIC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic.This will allow the cover's integral weather-stripping to restrict air leakage. $737.65 VENTILATION:Provide labor and materiels to install(4)8"diameter roof vent(s)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,brown,gray or mill finish. $342.00 VENTILATION:Provide labor and materials to install ventilation chutes in(40)rafter bays to maintain air flow. $80.00 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 1000/6 for the Air Sealing measures up to$600. 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 ham both before the wort:is begun,and after the weatheritation work is complete.We will also conduct a full assessment of the combustion safety ofyour heating system and water heater.This has a value of$90 and is at no cost to you.Total allowable weatherization incentive is$2,690. $90.00 Total: $5,955.45 Program Incentive: $3,110.00 Customer Total: $2,845.45 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE MH ABOVE SPECIFICATION&FORnW SUM OP ***Two Thousand Eight Hundred Forty-Five&451100 Dollars $2,845.45 UPON FINALWSPECrIONAND APPROVAL BY RISE ENGINEERING.CUSTOM AGREES TOREWANOUNT OUEIN FULL.MERESTOF 1%WILL 88 CHARGM MONTHLY ON ANY UNPAID aALANCUtW 3G DAY1.818:MERBe FOR Dd MANTWORMATION DR OUARANTEM I8GHr80P RUMS SCHMUUNG.AND CONTRACTOR REGISM71014 00 NOT SIGN TH NTRACT IF THERE AREA BLANK SPACES 444400�000� Signature: Adam Ragab(Oc 3.2015) NOTHIS CONMOTMAYBEWITHDRAWN BY US IF NOTMCUTOWMM. mall: bevetlygaSQhotmail.COm TE ACCEPTANCEOPCONTRACT-7HeAEOYEPRK:E8,8PECttTCATi4ci8ANDOOtD7RlQfffi ARE 30 DAra. ffiATTSFACTOMTOUSAND ATta 8=A ACCWW113 OuaREAUiHORIZEDTOOOTHEVAM assPEaFT®.PAYM WBLDatdAOEIt80UTUNffDAE0116 OWNER AUTHORIZATION FORM Adam Ragab 1, (Owner's Name) owner of the property located at 110 Woodcrest Drive, North Andover, MA 01845 (Property Address) 110 Woodcrest Drive, 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. Owner's Signature qt / 1�, l,� t Date Z 00-. Feaeratmaasoaoasm RISE En�iaeetrieg al c« or kegletratlon Ito etas ,�caomtrarz� tw,t A division otThletacb E+�Saaxlag 60StatamrutUaka2,Cautoo,MA0 21 CONTRACT 3"404M FAX 3N-602.6345 Page 1 PROGRAM ttmeonrttucrreatroowc serneerrtaas t,--�—� CMA_CNA-HMwsanta�¢aewas nnni Adam Rapb 9 0 (617)8349181 10/08/2015 410038 00002 UWAM WIN 110 Woodcrost Drive 110 Woodcrest Drive North Andover,MA 0 nnn o North Andover,MA 01845 r---) JOB DESCRIPTION AIR SEALING:Provide WN406 Matr=to SM eras your home against wag"access aIr tealmge This work wlil be perflumedinconcertuftthauscofqwWwband diagmatic teststo risme drat your home will be!eft wish a beeMf lavelof afr exchmW and htdoor air quality.Materials to be teed to seal your home can include caulks,foams,w ftstrlpping amd other products. Primacy areas for sealing include air teekege to attics,basements.Mc ed garages and other unheated arses(windows are not gasaally .(17)working btu L At the oempledon of the weatheraatlon wont,and at no addltMonai cost to the homeowner,a famh blower door and/or combustion safety wtaiysls will W conducted by the subvm*ww to arson:the safety of the Indoor air qud*AUDtPOR'S NOTES THE HOUSE IS A GIANT 19WS RANCH.V SHAPED.THE BASEMENT IS 314 FINISHED WITH FHW HEAT SUPPI IED BY A DIRECT VENT 95%BOILER.THS SECOND FLOOR HAS A HYDRO-AIR SYSTEM SUSPENDED FROM RAFTERS.THERE IS ONLY 3 TO 6 MCH OF INSULATION BETWEEN THE ATTIC AND LIVING SPACE.1 PERP06E THAT THE HYDRO-AM SYSTEM HAVE A IOXIO ROOM FRAMED AROUND IT.THROUGH THE PROGRAM WE THAN INSULATE ME IOXIO ROOM AND USE Y RIDGED BOARD ON THE OUTSIDE FACE OF STUDED WALL,THIS WILL BRING THE HYDRO-AIR SYSTEM INSIDE THE THERMAL BOUNDRY.NEXT WE AIR SEAL BETWEEN THE ATTIC AND LIVING SPACE,THEN ADD 8 INCH BLOWN INSULATION ON ATTIC FLOOR.ALSO NEED 6 ROOF VENTS ON BACK SLOPE OF ROOF,SO THEY ARE NOT VISABLE FROM FRONT ANY WORK IS CONTINGENT ON THE HOME OWNER HAVING THB 10X10 ROOM FRAIMED IN AROUND THE HYDRO- AIR SYSTEM,THEN I MUST RE4 NSPECT TO ADJFST FOR INSULATION.. 51,275.00 $0.00 DAMMING:Provide labor and materiels to butall a IY layer of R-38 uaticaed 8bergIess balls to(120)sqi mo felt for damming pmpom $246.00 ATTIC FLAT:PmWde labor and matedsls to latah an 80 hyer of R-28 C lass 1 Cdhdose added to(2016)square fat ofopat attic wow AUDITOR'S NOTES THE HOUSE IS A GIANT 19WS RANCH.V SHAPED.THE BASEMENT IS 314 FINISHED WITH FM HEAT SUPPWED BY A DIRECT VENT 9S%BOILER.THE SBOOND FLOOR HAS A HYDRO-AIR SYSTEM SUSPENDED FROM RAFTERS.THERE IS ONLY 3 TO 6INCH OF INSULATION BETWEEN THE ATTIC AND LIVING SPACE.I PERPOSE THAT THE HYDRO%MR SYSMN HAVE A 10X10 ROOM FRAMED AROUND IT.THROUGH THE PROGRAM WE THAN INSULATE THE 10X10 ROOM AND USE r RIDGED BOARD ON THE OUTSIDE FACE OF STUDED WALL.THIS WILL BRING THE HYDRO,AIR SYSTEM INSIDE THE THERMAL BOUNDRY.NEXT WE AIR SEAL BETWEEN THE ATTIC AND LMNO SPACE„THEN ADD 8INCH BLOWN INSULATION ON ATTIC FLOOR.ALSO NEED 6 ROOF VENTS ON BACK SIAPE OF ROOF,SO THEY ARE NOT VISABLE FROM FRONT. ANY WORK IS CONTINGENT ON THE HOME OWNER HAVING THE 10X10 ROOM FRAIMED IN AROUND THE HYDRO- AIR SYSTEM.THEN 1 MUST RB-INSPECT TO ADJEST FOR INSULATION.. $2,620.80 FIX EXISTING INSULATION:Slash the vapor barrio;tlfpt or reg (2016)square feet of bmtbdn in the aulc area. 5504.00 KNEEWALLS:PwWde labor and metetials to bsstall 20 FSK And semkigid fiberglass bard hauiation to(160)squ=feet of ImaweA nna.THLS IS FOR THE ROOM WHICH WILL HOUSE THE HYDRO AIR SYSTEM IN THE ATTIC. $moo CERWICATE OF LIAGILITY INSURANCE DA,E(A,A,pp:YYYn 1zn62o14 ' 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 NOTCONSTLTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I REPRESENTATIVE OR PRODUCER,ANDTHE CERTIFICATE HOLDER. ; IMPORTANT:Ifthe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If5UBROGATION 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 LL AL NM1E: Automatic Data Processing Insurance Agency,Inc. �nHc°No Ext)- Automatic (A NY,Y 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 NSURER6)AFFORDING COVERAGE MAIC-: LVSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B: DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NA\IED ABOVE fOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIRE\LENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i CERTIFICATE MAY BE 1S5LIED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT TO ALL THE TERAIS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRTYPE OF INS URANCE +IVSD LYVD POUCYNUhiBER R'IALD+YYYY) 0AMDO.YYYY) LUII75 COAWIERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAUdS ftAUE OCCUR PREUwJRIISES IEamm.to S IdED EXP IArtyune retscrt 5 PEBSONALEAD injultY S CENL ACGREGATE LIMIT APPLIES PER. CENEfUlLACCREONTE 5 POLICY PRO- ECT ❑LOC PRODUCTS-COAIP.OP A.GG s OTHER AUTONIOMELIA8ILr1Y LUPSINE U N 1.1 5 MY AUTO BODILY INJ URY(Pe+Wison) S ALLOWNEO SCHEDULED BODILY INJURY(Pu-,tided 5 AUTOS ALIT 05 NDN.01YNEL) I U• I Y . 1.L 5 HIRED AUTOS +WTOS IPer atudenP i S UA9 RELLALM Occult EACH OCCURRENCE S EXCESS IAR CLAIMS-(:bADE ACGREGATE 5 DED RETENTIONS S - IVORKEnS COSIPENSATION X STATUTE ER ANOEMPLOYERS'LIABILITY Y MLY PROI'It1ET01td++ART1ERfXECUTl�1c IN EL.EACHACCIDENT 5 1,0001000 A OFFICERA'tEMBEIt EhCLUDED7 Y NIA N POIVC660990 0101(1015 0101(1016 ` (Mandatory in All) EL_DISEASE-EAEAIPLOYEE S 1+000.000 1 II yes.destnlK Oder21000,000 l)ESCRIPnONOF01'EIUATIDNSLtiIus Ei.DISE+LE-POUCYUkIIi 5 DESCRIPTION OF OPERATIONS fLQr,%*no S!VEHICLES(ACORD 101 Ad&duwJ Remarls Schedule.may Ix attached ilmom sWce is required) '.. Columbia Gas massachusetts CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DES CRIB ED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TheilschEngineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave i Cranston,R1(12910 AV(HORREDREPRESENTATNE , f. A©1988 2014 ACORD CORPORATION.All rights reserved. ACORD 2S(2014,01) The ACORD name and logo are registered marks of ACORD 4 ®P 113:SS DATE(MNromm�Y) CERTIFICATE03113=15 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 poltcy(tes)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 Durso&Jankowski Ins Agcy LLC pN ONE 198 Massachusetts Avenue Arc o RJC Nc' North Andover,MA 01845 DDRAte: Durso&Jankowski Ins.Agcy. PRODUCER cusTO ER ID e.POLAR-1 INSURER(S)AFFORDING COVERAGE NAIC S INSURED Polar Bear insulation Co.Inc. INSURER A:Penn America 32859 P 0 Box 958 INSURER s:Safety Insurance Co. 33618 Andover,MA 01810 INSURERC: INSURER D: INSURER E: 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 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. ILIMITS LTR TYPE OF INSURANCE POLMM ICYNUMBER M Y� MMm poucr� GENERALUABILI Y EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY PAC7052023 03/24&015 03/2412016 PREMISES Ea occunencs S 50,00 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5100 PERSONAL BADVINJURY $ 1,000,000 GENERALAGGREGATE S 2,000,00 GEN'LAGGREGATELIMMAPPLIESPER: PRODUCTS-COMPIOPAGG $ 1,000100 POLICY JECT PRO- LOC S AUTOIAOSILELU%BILI Y COMBINED SINGLE LIMIT S 1,00(),00 B ANY AUTO 2100926 01/04/2015 01/04/2016 (Ea accident) BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Peraccident) $ X SCHEDULED AUTOS PROPERTY DAMAGE }( HIREDAUTOS (PER ACCIDENT) S X NON-OWNEDAUTOS $ $ UMBREILLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS UAB CLAIMS4VJADE A PAC6906385 03/24/2015 03/24/2016 AGGREGATE S DEDUCTIBLE S RETENTION S S WORKERS COMPENSATIONTO Y T MTS 1- E H- ANDEMPLOYERV LIABILITY ANY PROPRIETORlPARTNERIEXECUTLVE Ya N/A E L EACH ACCIDENTOFFS (Mandatory aR1MEnNEXCLUDED9 E.LDISEASE-EAEMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS belcra E.LDISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AddillcndRemarks Schedule,ifmom epocoiorequired) Insulation Work-Mineral;Additional Insured foreneral liability,with pec�ts,o work performed on their behalf by tho above insured is Thlelsch rnjCERTIFICATE HOLDER CANCELLATION 'iH1ELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRADATE THEREOF, NOTICE Thlelsch Engineering ACCORDANCE(OWITH THE POLICY PROVISIONS. WILL BE DELIVERED IN Columbia Gas 195 Francis Ave AUTHORIpEDREPRESENTATIVE Cranston,R102940 461P ©1908-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD {i DATE(A1NJ)UNVVY) i CER-11FICATE OF LIAGILrY INSURANCE 12n.812014 } THIS CERTIFICATE IS ISSUED ASA 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 I REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. + IMPORTANT.If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.IfSUBROGATION 6 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 WMNIF'SS; Automatic Data Precessing Insurance Agency,Inc. tA�.ND,1 Adp Boulevard Roseland,NJ 07068 RERR)AFFORDING COVERAGE MAICRD Insurance Company 31470 INSURED POLAR BEAR INSULATIONCOINC DBA:Polar Bear Insulation CO Inc 4VSURER C: PO BOX 958 LVSURER D: Andover,MA 01810 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE B=EN ISS UEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY it EQUIRENIENT.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 SUSJ ECT TO ALL THE TERMS, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSi) t AWL TYPE OF INSURANCE POLICYNUAIBER 111%tohYYYY) Q.IM)7D:YYYY) LLtlnS LTR IVSD IVVD COINIMERCIAL GENERAL UABIL17Y EACH OCCURRENCE S S CLVLLS-Id AUE OCCUR PRERIISES tEa ccmrerm! ', LIED EXP UAnyvne persar.) i PERSONAL E ADV I:)URY S CENt AGGREGATE LIMIT A'I'UES PER. GENEWIL ACCRECATE S POLICY❑J ECT E-1 LOC PRODUCTS-COEIP,OP ACG S OTHER AU101,1011LLEUARIL0Y IEa I(,2,:n11!'INCEEt7ffr I S ANY AUTO BODILY INJURY tPet lxucn) S ALLOWNED SCHEDULED I AUTOS AUTOS BODILY INJURY(Pv auidnrl S NUTO'YNEU P ' UYV'"' , LG S HtREU AUTOS AUTOS tPer acuden0 S ULHRELLALMH OCCUR EACH OCCURRENCE S I EXCESS LIAS CLAI.ISd:DADE AGGREGATE DEO RETENTIONS S f WOMEtcs COMPENSATION X STiVUTE ER + AND ENPLOVERS'LIABILITY ANY PR0PRIETOIt.PARTNER.EXECuIal ItlN 1111P 1.000,ODO ACUDEt:T S A OFFICERKZ&ISER EXCLUDED, Y N to N POIVC660990 O1J01/1075 Olpl(L016 (Muidtary in NN) EL DISEASE-EA ENI'LOYEE S 1+000,000 II Yrs.desu+W-der EL.OISEASE-I'OUCY ULIIT S 11000,000 UESCRIPT ONOF OPERATIONS Ltlu.Y DESCRIPTIONOF OPERATIONS!LOCATIONS IVERICLES(ACORD IOL AtUIl.wJ 11m 1,sSch�lute.may beattached ifrn—psce is reQfimd) Columbia Gas massachusetts 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 AUMORUED REPRESENTATIVE r ALv 19B8 2014 ACORN CORPORATION.All rights reserved. ACORD 2S(2014,OD The ACORD name and logo are registered marcs Of ACORD i i The C'oniniotivealth of Massachusetts Departiirent of Inthistrial Accidents .+ r;;' Office of Investigations 600 Tl�ashln- n Street :x- ; -.=�_ Boston, 1111A 02111 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicarit Information Please Print Lt:aibl�' �alrie (Business%Qreanizatiot�l[ndiyidual): PO LqT- P9�i ��r 171\6 � 't�vq �' p Address: ® C1ty1State/Zip: r,jQ MA olFla Phone A: Are you an employco Check the appropriate box: Type of project(required): I.[ i am a employer with 7 4- ❑ I am a general contractor and 1 employees(ftril and/or part-time)." have hired the sub-contractors 6- ❑�e1t'construction 2_❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees Thesesub-contractors have S. ❑Demolition working for me in any capacity_ employees and Kaye workers' [\o workers' comp,insurance comp.insurance.: 9. ❑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 1 I.❑Plumbing repairs or additions myself[\o workers'comp. right of exemption per MGL 12-17Roof repair's insurance required.]` c--l52 S 1(4).and we have no employ=ees. [\o workers' 11MOther 4 M6� comp.insurance required.] `:1tn applicant Uta[ctteCt box=[must also till out the section heronry shoring their workers compensation policN'inrornatinn. t lomeoyners who submit this affidavit indicatina the.-are doing all.york and then hire outside contractors must submit a nets affidavit indicating such =Contractor that chm-k this box must attached an additional sheet shovine the name of the sub-contractors and state whether or not those entities lune employees_ If the subcontractors have eniplovees_they mast provide their corkers'comp,policg number. 1 ttnr an emplai,er that is propidilig workers'compensation insurance for nil'etitplgl!ees Beta it,is the policr ant/job site hiforirration Insurance Company Name: ' I "iC-4 U Q rA Aq 17 Policy'=or Self-ins.Lic. ,�® we,�5 &ev� � Expiration Date: P ! ,& Job Site Address: 1 CO Wood eh! Sl- at'Vep CitylStatelZi tfth Attach a cope of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 2SA of MGL c_ 152 can lead to the imposition of criminal penalties of a fine up to Sl.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 5250.00 a day against the violator_ Be advised that a copy of this statement may be fortyarded to the Office of Investigations of die DIA for insurance coverage verification. I tlo hereby certifi•wider the pains and penalties of perjitrj-that the information provided above is true and correct. Signature: � � Date: /f/3 8A Phone 0 - Official use only. Do iutt write in this area,to be completer)bt•vitt,or tonin offeial. Cin'or Town: Permit/License R Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Citi•/To«n ClerI: -l. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone 4: �1 s anduseless Regulat�.on Office of Goes er Aff`W 10 Park Plaza 4 Suite 5170 st®n,lviassa�hwetts 02116 n �3o ctox R.egistra�o Rome huprovement Contxu - Registration_ 102726 Type: DBA -. Tr4 252249 Expiration: 712/2016 POLAR BEAR INSULATION CO. _ Vincent LeBlanc Update Address and return Employment - P.O. BOX 958 _ rd,Mark on for change. ANDOVER, MA 018`10 Lost Card ` � (] i Address Renewal J DPS-CA1 �r StlM04t04'*�012te E� ss�1 of Bus Cflm Y'e Wats or's s 19cC : o.c sae s C,)Ij,truction Scull rNiwOF gay aiaa�gw se:C,BL•10#3017 � PETER A LEBLANC 2 EAST PME STREET plaistow PIN. 03865 VC 171 0412812018 ug'Y miss4onV