HomeMy WebLinkAboutBuilding Permit # 12/21/2015 �kORTH
BUILDING PERMIT
MOWN OF NORTHANDOVER �� ��:;}r ,_.,,.46 ®�
APPLICATION FOR PLAN EXAMINATION
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Date Received AWP4¢
Permit N®�: �6 VSs sE��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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P OPER;T�Y OWNER f
t`'v,'.�r�,�fa'�7r~r,LkX: ,ir t2 3^'✓>:U s rxr,.:, ;� : c F�n^�n�t..
rat �� ,f� �, 100�Yrear Structure k, � � J.yes� � j nog
�t'y ,,?, fj ry.�.-.':✓ °�rrz31'�''="yY...'�r�I`,; �ir1�/ffrr`t,..l rr-��„�,jr:�,n >yl
� � ZONING
S- Ill DICT Wistonc Distract esu no
r � ��� �, � �: "Macfline�Shop Village yes no
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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 4t Others:
❑ Demolition ❑ Other
❑ Septic ❑YWell ` � �❑ Floodplamr ❑ Wetlands � ❑r Watersh`'ed District
❑'UVater/��ewer° j
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DESCRIPTION OF WORK TO DE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: � O Phone: qW AV o34,
Address: WV0LtA be
Contractor Name ���` L = �L►°i=e Phone: 7L �G
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Address"'��� S`,r f s��-«�.. ��`- ,.�/��5��.✓ f � ;f ��1W� F��,,,
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Supervisorts�Construcfion°License ����7 D
E tee
Hrome Im ro�ementYLicens`e �����y r ��
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ate
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED CO TB ED ON$125.00 PER S.F.
C st: m— ® o FEE: $
Total Project ® $ o
Check No.: Receipt No.:
DOTE: Persons contracting with unregistered contractors do not have access to the guar ant_y fund
gnafiure of Agent/Owner �gnature of_confracfor. .
F NORTH
own ofAndovur
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nO - CA`(E h ver, Mass, all
coc"Ic"t WICK �'�•
®s RATED
U BOARD OF HEALTH
Food/Kitchen
rrER T L
Septic System
THIS CERTIFIES THAT j
................. ...................... .......... .. .. ....... .. ........... ........ .......
BUILDING INSPECTOR
has permission to erect buildings onMA 16 ..,., Foundation
• �� Rough
to be occupied as ..... .. .... .. .. ...... ........ . .. . ... .. ................................ Chimney
provided that the person accepting this permit sh II 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CTRTS Rough
��_- Service
............. .................................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy PuildinRough
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.
13 f �J
Federal la x t1tF444 'd
Fz1S>F n utmwi g, cnCne►rliRogl. nNuaaraeG
11rWttr
RISE S2t19a 9
1k di+ision or77dd%ch Xttttirwisou
i:MGINEERING' 605hntstnal['nil V3,Can(ua,l[,k 117021
CONTRACT
Paage t
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u r+c,e+;au:krer�:Htnaeaurroarnresaar~e
d'SIr�"![F$ eur�rtxw.pr+uruo!occrrnalacoavaac+ty
fN3TyuCn N Ct1anL c„:r wrrn. WCaKdaDdla
Thomas Blass o 00 (0 9)2034,366 4,366 09123,0015 420796 iJUttt7�?
crmxt:v"mW CV draw.str=lr
170 ltr!Sa3rfikri4 a Read al 270 Mwhlerik}ge Road
w
.armee crar_srxtr..aF to sum crslr.smmar
Nutth Atttlover,XII 01911 .. Aordt.Andavor,kiA 0 1 W
IU$DESMPT[ON
:�1R,tih1t11�Ys:Rnt►ide inhrrundmulmlals to su-r1 aan:us or;tx,r,iwuac:tt:ahast:�ai+lcrui,4te4:sc airtratatra 'Ihi�ts�nrk t�hl1 hu
,.•t£urnacal:n+.rar ncrrt witNtfact�Y4t1'spvial uofi and diar�tr++:.ic te¢s to actatrclhat}e+ur haxa:uiA a:iu-il Killtutx-ultltl'ut t�wrl,:f
airimclimv notinlrorsKgnuli y.�f:anis to bc curl toxut war lica»ctrmn x+eiudr rnulk.,fo m .me.a!•irlm&=. Prim=y
arc=for srul ifig ultdudc vir iraknrc k�nrits..lt GnN.wc.:rla:.'Y:d rams and other unkcated at rj;j5m:-,W mo arc nni;.�+x+ally'
.u:da We.1 'rhixzvill:cgUiW(SI urri nr fivm..A%am,itm in ,,fai:insiltratinnµill occur,but Lk-actwl
nunal`r orcYna:r 01'r fimrantrai
:k 11w run:
I42d5rlansnafg'CinAicrteprcLin><gniatrcerirv: F►ec►lCam4tl
FUCont�r�Dfn dctcoots
RSn�ldi�mtntbtaofinmah10Dtus=W
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RISE
tttl!ltsawattn unit;canrnn.�Lt utt t
339•::02-L33a FILI' CONTRACT
Pdsre 2
PROGRAM
C�1t-ilEti arf.eNi:sT,u�Mrmm T*4r w`MPr r
VlXrnll;a/.gLtin
CO3TO-iii nNt}V¢ MYf Ctt:nTr hORrCORXR
1'homtcs llll � (978)1-05-0366 01).i .2U 15 420736 ut�007,
CMI=•U.OW NZARM NTNrt=1
370 M v bicritlie Rcy.i 370 MArblc.-14.9 Road
imus Ure s-1A'C:p ur_tac ofmo;tan;.tr
Norh A,.t&sur.MA 01345 adorn Antloves J1A 01 PA3
JOB DESCRIPTION
Citr�itl S'1'h['1;:Irnntdr t:lt:rc:md ntatcri:d>Tu ntWnit ;ti,)ctpsrc Yeah nt t-1It rigid`thrhnax IRv.:l�ion tatht crwt:psch:
peritrxt�rxatl cp to dte All:aid q7A:l t circ hand lui,.L
SitR.Sit
ftiSl:Cin�ant�Ylrr,�a 111 p11 alar,pinab a,all_rjmt I C ntwYt:n ttac caTua-r 1,11e mill cal}•tx billed the Net srtnurrL C urraw .
(or aligiblcmal-,rua.%Columbia(;acoMm:5=binro w.ao:toc:ccoais2.c,)upatz3ax1W.c;u.;rtJ;u►ru�l+u,co!Itrt;:ranhc
/1i► xdlnf me t3urc�I j1 intht tarn$:;S():r�an nAd(ia►sl s:.ifl if+a.itm�arcjaaifir2 fha audiux
Meetb3vefeh.t i health aryaur hi=,.s wow air4aalikc,xL ail be cmhd:mIrg a 111crva ducr 02 nUc of the acuilwx uis now ill
y;1ar howc bush benne ft utck 10,xtum.Itnd atlrf qui wtxk is Compl iv.We wall atsai cande:r a U awtawt or '..
Me carnbimirAmirclapr2varh=in;:Itiaicm:A%—,ata7tdsfal,zwl;t:orsooand i..im..-cuscW-pa. Tci;Mv%tuldc
xLrLhcrifJt:wr m.Yatae ro 53.!til.
SaIY.tY.t
Total: $4,123.60
Program incentive: $3,109-99
Customer Total: $1,013.61
h4[bCREEHEREBY:Y3WRtr3rr5'c. i".Ev-cbNvLCT:Cahrocnthanntcr.wmtnnadr^rtuac,inn._h,an
tr' Of
"•One Thousand Thirteen&S11100 Dollars S1,Ot3.Si
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IS�gVlwalsaaLGt at.uaMNs?rat.tk+INnFESGxfFOUA.tra1 xGNn-70"mTf lour—rif"ivnf=TartSXRU.D«CIwozaN04nr-feriaY
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CON 310N THiSCONmAiCT IF TNME ARE ANYP,a&ANKSPACFS
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stnarcl.gn wttu..ntvray,r+rwnfrr•a�tnnf6rAtir
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OWNER AUTHOR17-ATION FORM
{O�rmer's l�[ams�
oumer of the pry wW located al
(proparhrAddi-ass)
f
(Property AddMOS)
hemby;author¢e '
{S.ubt�rdractor}
an authorrml subcontractor for RISE Engineer�ag,to act on my behatf to ob sin a burift
permit and to perform Yiark on my proPAY•
5;1 Lw�-P-
64mees
Signature
rl<
Date
ye\ !°liL C011I17Ionwetallh ofillassfichilsetts
Dgnri*2z&rn of lea fladstri(d 4ccitictlts
Of ice of ffilfCStiKItl[t7i25
•`= Y�r -•
600 Niusilill aton Street
{ Boston, JI'L' 0711 i
Workers" Campensation inst-1raneeA it idai'it' i�i�llideY'5l�(3��;2e aF'�Iy4��t�'Lelzi�l5/1'�f?iIIl7�3�
t_b int Legibly.
ppiieaiit 111fOrmation
Pleare F r
Name (Business=Orromiizationllndi.idttal): 0 1P�s� F b`a�?J r%1 c iQ FC t Al� �'f'�� —
_ ddress: u =?
CI1IIState1zi _ �^L
P- .,� tt�J0V-f 71 ARO Phone':-
Are you an emplovet?Checi;:the appropriate bo;:: Type of project(required):
1_ rf 1 am a employer li'ith_ ' 4- ❑ 1 am a general contractor and I
entplovees(fitll andior part time).' have hired the sub-contractors
b_ [.11ett�caltstruction
3_❑ I am a sole proprietor or partner- listed on the attached sheer- 7. Q Remodeling
ship and have no employees Thesesub-contractors have S. ❑ Demolition
irorhin� forme in an;-ca crit)_ employ ees and ha'Ve\V orkers_
P 9_ ❑Building addition
[No workers: comp_insurance Comp.insurance.-_
. CI Vire are a corporation and its 10.❑ Electrical repairs or additions
required_] 5
1 I atn a homeol.Vner doing all-work officers hate exercised their 11.17 Plumbing repairs or additions
myself[\o workere comp. richt of exemption per_'rIGL i 2_E] Roof repairs
insurance required.]" c_ 153_L 1(�1)_and n-e have no e c
e:itpioi'ees.[�o workers-
13_M_Otlierc
-
comp_insurance required_]
`Alli-zpplicaar aw ehedks bo--<=I nnut also till out lite section hciowshotein=_t(rciruorkars Compensation pDRa hu-•ornatinn.
` i lorit�otvners who submit this aftida.it indiealine tlrc.-are doing all.corl,and then hire outside contractors must submit a n2tr atridayll indicating such.
-Contractors that ch<<l:this hos nwst n[tached an additional sheet showhlQ the name of the sub contractors and slate.rhedterornuc tiwse entities bare
entniovets. mite sub-contractors llave employee_;_titer must proride their corkers'comp_,olio number_
I torr an employer Mar is proi'itling ryorkers'compensatiatr i1rS1(ry11ce for riff enapinl:ees Beloit,is f11e policy and job site
nrfortlutr'ir11I.
9
Insurance Company Name:
Policy E or Self-ins-Lie.= , }�r��- L-xpiration Date:
Job Sitc Address: ,�>owc, Citmistate/Zip: -.n r/1.,,��
Attach a cope Of the trorkers'comflensation policy declaration page(shoe=ing the policy number and e-�piration date).
Failure to secure coverage as required under Section 25A of NMI_c_1-5-1 can lead to tate imposition of criminal penalties of a
fine up to SI_500.00 androroneFear imprisonment,as well as civil penahies in rite fonn of a STOP WORK ORDER and a fine
of up to S250.00 a dad aQaiost the violator- Be adxrised that a copy of this statement may be for
rarded to the Office of
Investi`ations of die DIA for insurance cOrera9C verification.
I tlo hereby eertif antler the(grins and penalties of perjray tlrnr the inforn ation proirided aboi:e is title atilt correct.
Sianature: Date
r
Phone
O fficial use wily- Do illit write in this[freta,10 be C0111111eletd Gr city ort INI of lcifff
City or Town- FermitdLicense g
Issuing Authority(circle one).
I_ Board of Healtil ? Building Departnivant 3-Cit%,ITot;a Clerle s. Electrical Inspector i.Plumbing Inspector
G. Other
Contact Person: Phone'-:
i
A<C0fM.Eli CER-FIFICA�� OF LIAG tL €�>( INSURANCE 121182014 I
THIS CERTIFICATE f5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THECERTIFICATE HOLDER.THIS f
CERTIFICATE DOES NOTAFFIRMATIVELY 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
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTAN-11 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 policy,certain Policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu ofsuch endorsement(s).
PRODUCER LON1.LI
NM1E: I
Automatic Data Processing Insurance Agency,Inc. (AG.No.E u:
1 Adp Boulevard AO'RESS: )
Roseland,NJ 07068 INSURERIS)AFFORDING COVERAGE NAIC A
I,ISORE.A: ND UARD insurance company 31470
ENSURED POLAR B EAR INS ULATION CO INC ENSURER 6:
DBA:Polar Bear Insulation CO Inc LMSURER C:
PO BOX 958 INSURER D:
Andover,MA 01810
ENSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER
THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOY.,HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED_NOTWITHSTANDING ANY REQUIRE\;E NT.TERM,Oil CONDITION OF ANY CONTRACT OR OTHER DOCU\;ENT:'d ITH RESPECT TO`RHICH THIS y
CERTIFICATE\MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED aY THE POLICIES DESCRIBED HEREIN IS SUBJ ECTTO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHO\'i MAY HAVE BEEN REDUCED BY PAID C.AId;S_ j
l7R TYPE OF MS URANCE IVSD tY1rO POLICY NUMBER (III LOD:YYYY) EVIL O:YYYY, LI\11TS 1
l
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ I
CU-0.15-i.,ADE OCCUR PREtu5E51Ea cctarcrc<! —
MED E\P bLn'Eee penErn S
PERSONAL E ADY TNI URY
GEAY.\GGREGATE LIMIT AI'1'UES 1'Elt. GENERAL AGGREGATE
POLICY iTo- PRODUCTS-COt.1PAP nGG S
�JECT El LOC
S
OTEER
LUI BIN raI I.11I S
AUTOt.�eaF LIABILITY 'Ea aluCer.0 '.
.vas AUTO BODILY IN)URY(Pel t=Isco! S i
,LLLOW ED SO,EDULED BODILY IN,URF(Pte a jeerl S
Autos AUTOS P UPEIU Y •art.
HIBED ABTOS Nor-Orw D
mer ztudtr.9 i
AUi05
5
UA9RELL1LM Occult EACY.000URRENCE
ESCESS LIAB CLAIIISi.WDE ,1GGItEGr1TE
DED RETEt:710ta i x _
5
WORKERS COARI&S"MoN ST1ITUTE ERS
ANDElt1PLOYERS'LIARILr1Y Y IN ELEACHACCIDEnT i 1.000,000
MY PRo"lUETOR'PARTr.E((fXECutIF£
A OFFICERAIENSEREhCLUDED? Y❑N!A N P01VC661r'190 IOlA1R075 OlU1Q016 L000.000
(Uitlawry in Mi) EL.DISEASE-EA Er:u•LOYEe s i
I,000,000
IIYa.CexnUtlmUer 7 E1.01SEASE-110UCY IIIRT S
F OI'EItAT10NS Lthls
DESeit vna,4 OF OPERATIONS:LCGITIONS f VEHICLES(ACORD 101 MhGliunl Remulo Schedule.may Ee att+ched iI morespace is reeluueU,
Columbia Gas massachusetts
I
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Theiisch Engineering,Inc. ACCORDANCE Wrl'dTHE POLICY PROVISIONS_
195 Frances Ave
Cranston,RI 02910 AUi1HoftlMDREPRESENTATIVE
1✓
AG 1988 2014 ACORD—COUP-011—AT-10%.—All rights reserved.
ACORD 25(2014,01) The ACORD name and logo are registered marks of ACORD
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-TE(?,wMww.-4
CERTOFOCATE OF UABOL OTY ONSURANCE yonmols
THIS CERTIF(CATS IS ISSUED AS A MATTER OF INFORMAIROM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THiS
CERTIFICATE DOES NOT AFFIRMAWELY OR NEGATIVELV AMEND, MCTEND OR ALTER THE COVERAGE AFFORDED av TOE POLICIES
BELOW. THIS CERTIRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BM-WEEN--jr- ISSUNG INSURER(S),, AUTHDRITS-0
.
(REPRESEWA-t-WE OR PRODUCER,AND 11-1ECER RIFFICATE HOLDER.
WPORTAN#. ties)must(3e endorsed.
the terms and conditions ofthG policy,caftin policies nay fe4ulra an endorsement. A Memeni on this c--M-acdwdGe5 neconfer rights to the
certiftate holder in lieu of such endorsement(s).--- CO CT
PRODUCER MA
Durso&,denflowslif Ins Agcy LLC FRY.
f Ito
198 Massachusetts Avenue aIa jo.EZI:
Worth Andover,MA 01ML
ADDRS99t
Durso ir,lankowslil Ins.Aguy. PRODUCER
CUS, 1-4921130"POLAR-1
INSURER(%ArIFORDING 10011ERACE MAIC 9
INSURER A:FeflT8 ArI er'Ga 32359
P 0 Box 968INSURER B-.Safety Insurance Co. BIB
Andover,MA 01810
I'muRen C-
INSURERDIiPSllAER F:*
L
COVERAGE$ cr--FITIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED BOVE FOR THE POUCY PERIOD
INDICATED. NOTVMSTANDING 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.
4 R ii—our.,FEFF PourvERP ums
INSR 00L nwrn (Mummy"
TF' r1priormu NOE T-4qB PoLlavNULMER
GENERALLIABILM' EACH OCCURRENCE 1,000,000
0,000
A N COMMERCIALGENFRALLIABILITy PAC7052023 OMM2615 0=412016 PREMIS'ST6,
rA -:1-c�Eff-0
ICLAIMS-MADE MR OCCUR MED EXP(Any one Pers S 5'1300
PERSONAL aADVINJURY S
GENERALAGGREGATE IS
pRODUCTS_CoMpIOPAGG S 9,000,01313
GENL AGGREGATE LIMIT APPLIES PER: S
Poucy F�PRO- 0 Lac
I EU
COMBINED SINGLE LIMIT S 9,0p13,0130
AUrOMOBILE LIABILITV 21013926 01/0' 1315 01/04120116 (Ea acadent)
ANYAUTO BODILY injuRY(ParPe's0l))
ALL OWNED AUTOS BODILY INJURY(p.,acdclant) $
,m SCHEDULEDAUTOS PROPERTY DA1,1AGE
HIRED AUTOS (PER ACCIDENT)
Il NON-OVVNEDAUTOS S
UFAB1,151.1 'UR EACH OCCURRENCE S 1,0130,0011
B(CESS IAGGRE pTE S —
A
DEDUCTIBLE
RETENTION S
U-V--rAT OtT H-
1,VORkMTRS COMPENSATIONWC
ANI>W.-IFLOYERS'L14BILr.-V TORY
j r
"MI
ER
ANY PROPRIEFORPARTNEPJEXEcLffwE YIN EL EACH ACCIDENT S
OFRCERIMa;BER EXCLUDED?
(MendatoryfnNH) M /A
E.L.DISEASE-EA EMPLOYEE 5
If yes,desaft)under E.L 1),SEASE_pDUCY LIMIT S
DESCRIPTION OF OPERATIONS b0go,
DESCRIPM0I,30FOPERA-tiONSILOCATlDl4SIVEHICLES(AttachACOR0101,Additionel Reimrito SchEuiula,if more opcoiamquirad)
:Insulation Work-Mineral;Additional insured for general Ilabifitij vilth
respects to wort-,Performed an their behalf by the above insur'SuMfeFsall
Engineering
CERTIFICATE HOLDER CANCELLA-110M
'RIIELS2
SHOULD ANY OFTHE AHOVE DESCRIBED pOIJCIES BE CANCEMM BEFORE
--ME r
g _j(plFaTIOM DATE -fliEREOF, NOTICE
ALL BE DEUVERED IN
-R1IeISCn r=r1@InL--rIng ACCORDANCE Vffffl-I HE POLICY PROVISION$.
Caiunk bia Gee,
-195 Frawls Aue AuTrioRIZED REPIFIESENTATME
Cranston,R1 0291()
TION --ar"d
@)l 88-2009ACOROCORPORA - AU 719'"a rez -
ACORD 25(2009109) Tj-jeAGORD name and logo are registered m2fks 01 ACORD
e of C �� ' sand usiness Relation
t'lfficonsumer 5170
10 park plaza- Suite
ulgBogt0u*massar"
etts 02116
ctox Registration
13.ome hnprovement Conga
Re9isMhan_ 102726
-rype_ DBA -rr* 252249
Expim Uorr 71212Q16
Pt7t-AR BEAR INSULATION Co-
Vincent LeBlanc ------
P.U. gQX 958181 _ Ya.Mark reason for change.
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