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HomeMy WebLinkAboutBuilding Permit # 11/30/2015 BUILDING PERMIT ®f �Ap RY 6 +o TOWN OF NORTH ANDOVER " APPLICATION FOR PLAN EXAMINATION _ � y — Permit No#: �rr ��� � Date Received "„°" ATeo P $SRCFIUS Date Issued: PORTANT: Applicant must complete all items on this page . ! r r r r r . ) {' /s rrr �,. / 1. !... / r/ � 1. / r r / ///9 ,✓ r�.i.-. / r / i rr / ✓. � i r � l ✓r, l ,9/i,��,/,y Jar/,,,,,����r,//rilr///rlr�ri.✓cr,c-J/,r„/�„r �. r/ ,�r,�r��, .,a,�,,,, - a r-, ����; r,.�,,, .4„y4!,�.:� a„�,� „ .,,,, ,,, , 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: ❑ Demolition ❑ Other v I el t a �,'� %-�'� � G „ °'� ,�/ 'r .� r ooc!�`I `ins%r ❑Wetlands ,❑r�UVatershed D`istr ct„ ,,, ❑ Se ticr< ,/❑C,1Nell rr ❑�FI a r ,,, ,� � , , ,r,�,, , / r , r�-, n../u Tic���/rv.! / !/„r„/r/rG���, , ry , / r /.,.. / ///.. ,,, .,�, �„,. /„r�... �/. ���� /r. .,r �r iril�r r✓.r.ca,, +;❑,�Wate.rlSevve,r,,.,,,,r,/�,r,,,, <.,,,,-a,/,r,e r�,�.G.r._/G/, ��, �, /ri, �,,,, r. ,,, / cu, / DESCRIPTION OF WORK TO DE PERFORMED: l egr-f-fC- TPX5U Identification- Please Type or Print Clearly OWNER: Name: ---v d i rt, v J 5 o&I Phone: Address: rfe&L P b %r n, ,b /I//i/irrr��%/�rj r/.r /r / r ronPhone rr r, r r r r Oman”"�, -,,arr..lr,r„i ✓. ,./ i rr /i ,r h/r /lr< ci l rrr r / / /, / / ✓/ ///,1„,/ re //�Ernail ��/!�r����/�r%.��✓���ii %/��.�,./:�rirfr,r„ :,�/,; rri r 41/1 /... , � ; f r , / // r .G,r,/ r l „ r, ,r /.. it,, / � / r/i////, rrl r r� ,✓ r/i r r / oAd ress �/� �����1� i�, r,'l/r,�✓�irr�i,� /, �/ L'�r/,, ,' , `il�/V�����'r� r , / ,,/ �,Bah///�i��Ji'r/��I�l//%✓"N/L/'��l��l��� r , ��1 l rl r / / / / r r r / l /,/ ✓ .,,..l,,.r. r ../.. ...1/ /„d/; ,r L I//./� �// ✓�rl./ i..,,.r / r/lli r...,. ,,.,,. . .,.. ,..r.r / //�(r r, � � ,/ - r:,,..,. r��//,:fir,,,, c% a,, rra �l���r�/�1 /H/r! 4 u�;, /l/r / / / // r /r � „ , � f✓ l�� l P J / / ,_ r V//�� r/ r � /% r/ i, / // ,/ /ri r ,,_r r /o r ,i r✓„, r , / / �/r ,,, � rr, // l / i// ri �4Jf��//ilry r/��f�//�r/��ll�t.//���✓1/ „ .r�rl.. � r/ e r., r /i- r r r.,,.r/,/ ,cr.,. r,�✓ / �%/// 1. � ��r,/,/,/r r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINO PERMIT:$12.00 PER$9000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $. . FEE: $ 4L” Check No,: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Agent/Ovvrier Signature ofcantractor 1 �oRTH Town of "N ndover 6 4 1� ® JIL 6 16 Z-F.- t�oLANs ver ass, tl • COC NIC"EWICK �,95°RgrE o U BOARD OF HEALTH AW IR Food/Kitchen Septic System P E �R T L L D THIS CERTIFIES THAT ............... . . ............. d ..........................&.... .... ...... BUILDING INSPECTOR g Foundation has permission to erect .......................... buildings ..... .. ... .... ..�-. .... ... ...... .. .... .. ..... i� Rough to be occupied as ...... ... .. ... ...0114 . ............ ..... ....4^� .. ........................................... Chimney provided that the person accepting this permit sh... n 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHSELECTRICAL INSPECTOR qW LES S TS Rough Service ........... .... ....................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 I D# RISE Engineering RI Contractor Registration No MA Contractor Registration No RISE A division o(Thietsch Engineering CT Contractor Registration No ENGINEERING 60 Shawntut Road,Canton,MA 02021 CONTRACT (401)784-3700 PAX 339-502-6345 Page I PROGRAIVI THIS CONTRACT 19 SIOMED IWO BETWEEN RISE CMA-HES MJGWMMWG MWI419 OUStOMER FOR WORK AS I*SCRMWBELOW CUSTOMER PHONE DATE CUIRITO WORK ORDER Judith Judson (978)314-3776 10/01/2015 423380 00002 SERV"STREET sitr-wo STREET 933 Great Pond Road 933 Great Pond Road SERVICE CrTY.STAMMP SILUNG CM,STATE,ZIP North Andover,MA 01845 North Andover,NIA 01845 JOB DESCRIPTION .. BARRIER:ABlov6vr 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 ngainst wasteful,excess air leakage. This work will be performed in concert with die 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 scaling include nir leakage to attics,basements,attached garages and other unheeded areas(windows are not generally addressed.) This will require(4)working hours.A reduction in cubic feel per minute(cftn)of air infiltration will occur,but the actual number ofefin is not guaranteed. 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 ofthe indoor air quality. $340,00 AIR SEALING ADDER: (4)working hours. $340.00 AIR SEALING:Provide labor and materials to install Q-100 weatherstripping and a doorswecp to(4)door(s)to restrict air leakage. $300.00 ATTIC FLAT:Provide labor and materials to install a 9"toyer of R-32 Class I Cellulose added to(704)square feet of floored allic space. $1-174.24 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass butts to(&I)square feet for damming purposes, $131.20 ATTIC FLKT:provide labor and materials to install a 9"Inyer of R-32 Class I Cellulose added to(448)square feet ofopcn attic space. $(A0.64 STORAGE BARRIER:I-lomLowner is responsible for the removal of the stored items blocking the installation of cvicetherization work in the attic. Removal must occur prior to die scheduled work start. $0.00 ATTIC ACCESS:Provide labor and materials to insulate the back of the-,title door with 2"rigid Thermax board and seal the doors edge with weatherstripping to restrict air leakage, $7191 STAIRWELL:Provide labor and materials to install Class I Cellulose—insufalin to the shectrock or plaster ceiling and/or walls ofa stair%Ncli which are common to heated space,through a surface drill and plug method. 'The holes are plugged with styrofoam plugs, and spacklcd 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 thri(s). $100,00 Federal to# RISE Engineering RI Contractor Registration No MA Contractor Registration No RISE A division ol'Thiciscli Engineering CT Contractor Registration No ENGINEERING 60 Shawmut Road,Canton,ivL%02021 CONTRACT (401)784-3700 FAX339-502-6345 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEIRUNG AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENTO WORKOnDER Judith Judson (978)314-3776 10/01/2015 423380 00002 BILLING STREET SERVICE STREET 933 Great Pond Road 933 Great Pond Road SERVICE CITY,STATE.ZIP BILUNG CRY,STATE,ZIP North Andover,MA 01343 North Andover,MA 01345 11 ''Vi JOB DESCRIPTION VENTILATION:Provide labor and materials to install ventilation chutes in(44)railer bays to maintain air flow. $88.00 BASEMENT CEILING:Provide labor and materials to install(92)linear feet of R-19 unlaced Fiberglass insulation to the perimeter ofthe basement ceiling at the house sill. $161.00 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 otTers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for die Air Scaling measures up to die first$680 and an additional$340 irsavings are justified by the auditor. For the safety and health ofyour homc!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 tic weallicrizatioll work Is cc lett. Wevii1lalls conduct a ruH asscssmentof "e 'e the combustion safety or your heating system and water heater.This has a valu f 5 di no on. otalullowable wcatherization incentive is$3,110. 590.00 ]jjr Total: $3,713.99 Program Incentive: $3,062.99 Customer Total: $661.00 WE AGREE HEREBY TO FURNISH SERVICES.COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR TWE SUIA OF ***Six Hundred Sixty-One&00/100 Dollars $661.00 UPON FINAL UISPACTION Alto APPROVAL BY RISE WIGINEE[UNG,CUSTOMER AGREED TO nEMrT AMOUNT DUE IN FULL INTEREST OF i%VALL ME CHARGED MONTHLY ON ANY UNPAID DALANCE AFTER 30 DAYS,SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES A -A to ACCEPTAtCE AUTHOR OR flOrL'7111 COIITRACTMYBEVAMiDRAVI?113YUSIFIIOTEXECUTIEDViffilUt DATE OF ACCEPTANCE ACCEPTANCE Of CONTRACT-THE ABOVE PRICES,SPECH'ICATION3 AND CONDITIONS ARE 3D DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORMEOTO 001112!VIORIC AS SPECIFIED.PAYMENT WILL DE MADE AS OUTUNED ABOVE OWNER AUTHORIZATION JudithJudson I, (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. O)Nner's Signaturef Dat OP iD.SS DATE(MMIDDIYYY'/) CERTIFICATE OF LIABILITY INSURANCE03f9315 THIS CERTIFICATE iS ISSUED AS A MA'iTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER71FICATE 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((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 lieu of such endomement(s). CONTACT PRODUCER NAME: Durso&Jankowski Ins Agcy LLC PHONE FAX No 198 Massachusetts Avenue Arc No. North Andover,MA 01845 A L1 Durso&Jankowski Ins.Agcy. PRODUCER ID e:POtmAFt-1 INSURERS)AFFORDING COVERAGE NAtC& INSURED Polar Bear Insulation Co.Inc. INSURER A:Penn America 32859 P O Box 958 INSURER s:Safety Insurance Co. 33618 Andover,MA 01810 INSURER C INSURER D: INSURER E: INSURER - 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. !NSR ripe or INSURANCE PCUCYNUUBER PPOM&Ufi FF �POLICYEm UBSILS LTR GENERAL LWBILnY EACH OCCURRENCE S 1,000,00DAMAGE TOR0 A COMMERCIAL GENERAL LIABILITY PAC7052023 03/24/2015 03/2412016 PREMISES Eaoxurrence $ 50,00 CLAIMS-MADE ®OCCUR MED EXP(Any one Person) 5 5,00 PERSONAL BADVINJURY $ 1,00D,00 GENERAL AGGREGATE S 21000,00 GEN'LAGGREGATEUMITAPPUESPER: PRODUCTS-COMPIOPAGG S 11000,00 17 POLICY PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 11000,00 B ANY ALTO 2100926 01/04/9015 01/04/2016 (Ea accident) BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident) S X SCHEDULED AUTOS PROPERTY DAMAGE S X HIREDAUTOS (PERACCIDENT) X NON-OWNEDAUTOS S 5 UMBRELLALIAB X OCCUR EACH OCCURRENCE S 1,000,00 EXCESS LIAR CLAIMS-MADE PAC6906M 03/24/2015 03/24/2016 AGGREGATE S A DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION TOS STA1U-ITS E H- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERM(ECUTIVE Ya NSA E L EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E L DiSEASE-POLICY LIMIT S DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ifmom oPBcoInrequired) insulation Work-Mineral;Additional Insured foreneral liability,with S cts to work performed on their behalf by tho above insured is'Thielseh n IneerIng CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielscti Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. Columbia Gas 195 Francis Ave AUTHORIZED REPRESENTATIVE Cranston,8182990 AA911FL ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Alassachtisetts ._ Delvi-finent of Industrial Accidents Lt Office of Itnvestigatioits `' =ice► �? 600 TMashinaton Street Boston,JIM 02111 IV1t minass.,ov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electi-iciins/Plumbers Applicant Information Please Print Leaibl \ame (Business%Organization/Inditidual): po lgtr' A f'cl rf �i�y��7-- o in C 0 Address: y ' Cit)-/State/Zip: n J o M Phone 0: Q 7Y- d!; �l� Are you an employer?Check the appropriate box:1. Type of project(required): . am a generacontractor an.[am a employer with�_ I l d I❑ -- employees(full and/or part-time)." have hired the sub-contractors 6. ❑letc construction 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for mein any capacity. employees and have Nvorkers' q ❑Building addition [\o workers` comp.insurance comp.insurance.` 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 12.n Roof repairs insurance required.]' c-l52. §1(4),and we have no employees. [\o workers` 13.ROther- MAI-J&740 A comp.insurance required.] °An\-applicant dial checks box=l must also fill out the section helot shooing their corkers'compensation policy infornation. r I lomeonners who submit this affidavit indicating tile\-are doing all cork and then hire outside contractors must submit a new affidavit indicating such_ =Contractor that clink this box must attached an additional sheet showine tite name of the sub-contractors and stale whether or not those entities hate employees. If tate sub-contractors have employees_they must protide their workers'comp.policy number. I ant an etnplol'er that is provlding}porkers'conipensation insurtmce for ntr enipiglwes. Beloit,is the police and job site information. Insurance Company Name: 1- Policy r or Self-ins.Lie. :��`® 5-6c j Expiration Date: P �� Job Site Address: �l�� 6 Cr t r &\d J 1 d CitylStatelZip: /1► Attach a copy of the workers'compensation policy declaration page(showing the policy number and expitation date). Failure to secure coverage as required tinder Section 25A 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do herehr eertif under the pains and penalties of perjttrl•that the information provided rtbove is trite and correct- Signa ure: orrect.Si4nature: P% �^ Date 1 r l3 a/�s® 9 Phone Official use onll% Do not write in this area,to be completed bt•cit,or town offcitrl. City or Town: Permit/License# Issuing Authority (circle one): I. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector i. Plumbing Inspector 6. Other Contact Pelson: P h o n c#- l i CERWICATE OF LIAGILI&Y INSURANCE UNI l12/182014 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 NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED ) f REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.1151 11RO11ATI0N 15 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). f PRODUCER ALI NM1E: Automatic Data Processing Insurance Agency,Inc. nc Na Eau (nom wx 1 Adp Boulevard ADDRESS Roseland,NJ 07068 LVSURER(S)AFFORDING COVERAGE MAIC s ,,,,RE,,, NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B: DBA:Polar Bear insulation CO Inc ENSURER C: PO BOX 958 ENSURER Dc Andover,MA 01810 INSURER E: ENSURER F: COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMSM THIS IS TO CERTIFY THAT-THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED-NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECTTO ALL THE TERM-S, 1 EXCLUSIONS AND CONDrTrONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OR TYPE OF INSURANCE IVSD IVVD POUCYNUMBER (hINIDD+YYYY) QdhfILY 9D:YYYY) LIMITS CO,Y1hiERCIAL GENERAL LIABRIIY EACH OCCURRENCE S CL IMS-MADE DOCCUR PREF ilS ES'Ea act—rte) _T DIED EXP IMyure rKuunl S _ PERSONAL E ApY IN)URY 5 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGCRECATE 5 ❑ POLICY 1'ROEl- JECr LOC PRODUCTS-COMP,OP AGG S OTHER S AUMI-10BR.E L1A81LITY IL hIbIN US !ErauilltmD ) ANY AUTO BODILY INJURY tPe,txlsan) S ALL ONNED SCHEOULEU AUTOS .Ui 05 BODILY INJURY(Pt,utide,'I 5 NON-0i'iNEU P ' U Y , HIREDAI AUTOS Ino,MT j S UhB W REILIAB Occult EACH OCCURRENCE S l EXCESS LIAR cLAIhi5-r.lADE AGGREGATE S DED RETENTION i S IVORMEas Co.UPENSAIRON X STiITUTE ER'- AND EBIPLOYERS'LIABILITY 1,000,000 ANY PROPItIETOR.i4UtTNE1tEXECUTR£ y'N Ei-EACH ACCIDENT S A OFFICERA:EhISElt EXCLUDED ❑NIA N POWC660390 01101/2015 01,012016 1000,000 i (hia,dalory in Nin El-DISEASE-EAEh11'LOYEE 5 R ya.destnw TIONOde, El -POLICY LIMIT S 1,000,000 t)ESCRIPTIONOF OPERATIONSL•elur: DESCRIPTION OF OPERATIONS'LOC,%nO%1 VENCLES(ACORD IDL Ad&f;ond Remaly Schedule,may be atUched i(mamspace is require!I Columbia Gas massachusetts CERTIFICATE HOLDER CANCELLATION SHOULDANYOFTHE 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,R102910 AUTHORIZEDREPRESENTATNE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 2S(201401) The ACORD name and logo are registered marks of ACORD I -60/m� Regulaflo er Affairs and usiness Office of COnsuln 10 Park Plaza- Suite 5170 Bostan,Massachtts 02116 use ctor Registration 11,O'171.e Improvement Contra _ R. -suawn: 102728 Type: DBA Tr# 252.249 EXpiMtion: 71212018 pO AR BEAR INSULATION CO- Vincent LeBlanc p,O. BOX 95$ _ Mark reason for change. ANDOVER, MA 0181 Update Address and return Employment n Lost Card Address Renewal J DPS-DA1 €$ 5UM44M-G101216 1 'Aassac:ju�s„t'ts =Cre �r su�4 G 3,o rd of 3c:',�'i1'u e :abas u��� Standards _tce:use:CSSL-106017 PETER A LEBLANC 2 EAST PM STREET” _ Plaistow NK 03865 0412812018 Ca�arra¢ss��rs�r