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HomeMy WebLinkAboutBuilding Permit # 1/7/2016 BUILDING PERMIT `AORTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No : ` ;, Date Received �RA'RarroWP4¢��� �ss�caao5�� 1 Date Issued: ° IMPOP TANT: Applicant must complete all items on this page r / , JJ I / r r � , r✓ i lr � , l/�rr , f� /r� ./ .r/ �� y � /��,,,. // ,, ,r/. >�/✓// r,ir,/;::r//// ///,. � / / � r I �f 1, ,r I Y 'I I � € y I� .M,�y:Ywuw y ;�w' •�,r �.€v'Nrr€ru� �uu��m�lmer€ �' I w:lu✓m°inrw � �������1°��,;;f. /r/�i%//J�,///rr i�ZIr///+I J/O�',/Ir.r/�/:i//'.�:,N/r�'�r�d,„�It../NI��.li�n�Gr,,�/,.Il4%/.1Di�/1/G%u/�.U!,o,/Ir,g.aS,l,%r�/./r�,'L.�TI,//�l,/�9.�r,R+�"i/r/!'/lI/I C�//,/.//T�r,rr+/�/,..�. re//,//1/,�>:,�: �r��r rr�.�/.,(r.�,/,:,raHoe,M/Y/irHys�a,r/a/jt�c/✓/or:f)1 rh/,rP�n%�tni/�cn��i.YrD�nm!�S'uns&h"/% r rr.er Ila, Y1t�r.I,r�,/s.eJ?e/r f,.raY�Sls,�lr✓,.� „l>/ rn/,Onn r. 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 4 i•:° r / / / Flood lairif ❑ UVetlands, / / r, ,Watershed District, cr Well ,/, ,: ❑ P / / rr � , /' In" >/ �/ it,r❑(----elder DESCRIPTION OF WORK TO BE PERFORMED: tA Identification- Please'Type or Print Cleary OWNER: Name: 15 M Irk, Phone: '�`�- ���P��X Address: .::J// r//i Dl,/I/ r/,::.,✓(//n rn,,.N/ / /,! ,r,,,r,,,, ,r I z N ,r,,,l„ ;,, � ,. /�j r/�//�fj�/%O%/r/�� i r rr r / ✓i /,,�r //�, � !/ ,lir / / r / r r i/i /, / /r �� l / a.. /a�r%„ru„rl.//«�r(/r 11��// ��.�,�� ��/ �//.�� .,,,,.f/„ l/ r �7f f/9, .;✓/ // r.,..;-r %/�., � .� v/ , f / / r�/�.,,;..,,: r r r /rrr r r/ �� ��f/�l/ //r/,,, .,/„/i/ i r/ �r</f,r�, , ✓ /�1//,/ , ,,, /,r'/ �/.�.,r r.c �,r/l,/,,_„/%r ��/i,,����/�� �/� ��///J/��r /�,,,/r l r, / / 1 fir, ,✓ , /,, / L / ,,, / r ,t / / r �, ,,_ ., omeflm�".rovement�rLicense 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: $ FEE: $ Check No.• 7Receipt No. J NOTE: Persons contracting with unregistered contractors do not have access to the guaraW ff and ignature_of Agen /Owrier Signafiure of contrac i rin t%O RTH lown Of2 violdoverL O n' ' ® C% LAKI h ver, Mass, a • t (O C OC NIC NE wIC K. 1' A. RATEo S u BOARD OF HEALTH PERM- IT T D Food/Kitchen Septic System Li THIS CERTIFIES THAT ............ ...... BUILDING INSPECTOR ............ .. .. `. ............. .. ......1�... .......... .................. .... ... has permission to erect .......................... buildings on ............. ....... ....Y44.... Foundation Rough tobe occupied as ........... .....lA .... ... .... ..... ................. ►. ......................................... 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 PERMIT EXPIRESIN 6 M 11THS ELECTRICAL INSPECTOR UNLESS CTI® rA'A Rough Service ........................ .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. Federal 10 9 RISE Engineering RI Contractor Registration No MA Contractor Registration No A division orThicIsch Engineering CT Contractor Registration No 60 Shavvinut Unit 112,Canion.,NIA 02021 CONTRACT 339-502-6335 FAX 339-502-0345 R I S E PROGRAM .1 THIS CONTRACT 13 ENTERED INTO BETWEEN RISE ENGINEERING CNIA-IIES EJ21NDESCRIBEEERING BELOW AND'DIE CUSTOMER FOR WORK AS D CUSTOMER PHONE DATE CLIEUTO WORK ORDER Terika Smith (847)902-924,1 07/14/2015 408841 SERVICE STREET BILLING STREET 14 Edinands Road 14 Edinands Road SERVICE CITY,STATE,ZIP BILLING CITY,STATE.ZIP North Andover,MA 01845 North Andover,MA 0 184 .JOB DESCRIPTION BARRIER:A Blower Door*rest will not be conducted at your home,due to lite prescrise ofashestris. $0.00 Alit SEALING:Provide labor and materials to sent areas of your home against wastellul,excess air leakage, This work will be perforated in concert with the use ofspecial finds and diagnostic tests to assure that your home Will be tell with;I healthful level of air exchange and indoor air quality.Materials to be Used to seal your hong:can include caulks,fiounis and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other indicated areas(windows are not generally addressed.) This will require(8)working,hours.A reduction in cubic feet per urinate fella)of air infiltration will occur,but the actual number ofcfiu is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner.,I final blower door and/or combustion safety analysis will be conducted by[lie sub-contractor to ensure the safety ofthe indoor air quality.'I'l IERE ARE WYVI'C.R PIPES IN KWALL ALSO KWALL SLOPES I[AVE IM INS.IFPOISABLE DI)"6 FINISHED SLOPE/IF POSSAIIH AIR SEAL UNFIISI IED KWAL SLOPE WHERE 1113 EXISTS, $680.00 Alit SEALING ADDER: (4)working hours, $3,10.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass trials to(80)square fleet for damning purposes. $164.00 ATFIC FLAT:Provide labor and materials to install It 10"layer of R-35 Class I Cellulose added to(447)square feet of open attic space. $657.09 SLOPES:Provide labor and materials to install it 6"layer or It-21 Class I Cellulose added to(580)square lect ol'slope area. Wherever possible battles will be installed to the entire length ofeach bay to maintain ventilation space.!"HERE ARE WATIlt PIPES IN KWALL ALSO KWALL SLOPES I IAVE R11 INS.It-'POSALILE D11"6 FINISI IED SLOPE)If-*POSSABLF AIR SEAL IJNFIISHED KWAL SLOPE W1113111'RB EXISTS, S1,078.80 ATTIC ACCESS:Provide labor and materials to institute the back of(1)attic hatch with 2"rigirl'I'lienriax board.Weatherstrip the peritacler. $60.00 VENTILATION:Provide labor and materials to install(I )8"diameter roof vents)to increase ventilation in attic areas. 111c vent can be supplied in(circle color)black,brown,gray or unit finish. $85.50 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roohnounted flapper vent to exhaust existing hathroon)fan(s), $118.75 VEN't-ILATION:Provide labor and materials to install ventilation Chides in(38)railer bays to maintain air llow. $76.00 Federal fD# RISE Engineering RI Contractor Registration No MA Contractor Registration No A division or,ridetsci,Engineering CT Contractor Registration No 60 Shawinut Unit#2,Cauton.,NIA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 R I S E PROCiRANI Page 2 THIS CONTRACT IS ENTERED INTO DMIEEN RISE ENGINEERING CMA-t1 ES ENGINEERING ADD THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT 0 ORKORDER '," 'o Terika Sunith (847)902-9244 07/14/2015 4084+"`- 0002 SERVICE STREET DILLPIG STREET ........ 14 Edinands Road 14 Edtnands Road SERVICE CffYSTA7E,2JP BILUUG CITY,STATE,ZJP North Andover, NIA 01845 North Andover,MA JOB DESCRIPTION VENTILATION:Provide labor and materials to install 8),1"X 16"rectangular alurninurn soffit vents to inerea "kroii in attic areas.Specify color:While or Gray. $200.00 BASEMENT CEILING:Provide labor and materials to install(142)linear feet oI'R-I 9 unlaced fiberglass insulation to the perimeter of,the basement ceiling at the house sill $2,18.50 FIASEMENTDOOR:Provide labor and materials to insulate the back orthe basement door leading to the bulkhead with 2"rigid board that meets(lie sections R-316.5.4 and 316.6 requirements oftmilding code. Seat all edges and scams with FSK tape, $72.22 CRAWLSPACE:Provide labor and materials to itistall(160)square feet ol`6 Hit polyethylene over open ground in designated crawlspace/carthen basement areas. $123.20 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, lbr eligible measures,Columbia Gas offers 7594,incentive,not to exceed$2,600 per calendar year,and an incentive or 100%,for the Air Scaling measures ill)to the first$680 and all additional$340 ifsavings are justified by the auditor. For the safety and health oryour home's indoor air quality,we will be conducting it blower door diagnostic of the available air flow in your home both before the work is begun,and after the wcalhcri7Adion work is complete.We will also conduct it full assessment or lite combustion safety ol'your heating system and water header.This has it value of$90 and is at no com to you. Total allowable weatherization incentive is$3,110. $90.00 Total: $3,994.06 Program Incentive: $3,106.99 Customer Total: $887.07 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ""Eight Hundred Eighty-Seven&07/100 Dollars $887.07 UPON FINAL INSPECTION AND APPROVAL BY RISC ENGINEERING.CUSTOMER AGREES 70 REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED?AOulHLYOn ANY SEE BEVER FOR UNPAID 13ALAYICE AFTER 30 DAYS. IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF DECISION,SCHEDULPI AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE AR BLANK SPACES RATH ADD R DSIGNATU -RISE En serine COS MER ACCEPTANCE NOTE:11113 CONTRACT MAY UE WITHDRAWN BY US IF HOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO T1111 WORK DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTUNFO ABOVE s (Owner's Name) owner of the property located at tvtq vt 4 5 /26, - (Property Address) (Property Address) '' r hereby authorize (Subcontractor) A an authorized subcontractor for RISE Engineering,to act on my behalf to 4�ih'arti lidip," permit and to perform work on my property. Own is gna u Date The Commonwealth of Massachusetts Department of IndustrialAccidents h I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/P)umbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _} 1 Please Print Legibly Name(Business/OrganizatioafhAividual):_ Address: I`,_ r, 8,o Y_ City/State/Zip: v-� F Mit IT/ Phone#: Are you an employer?Check the appropriate box: Type of project(required): Lal am a employer with (full and/or part-time).* ?_ D New construction 21—]I am a sole p victor or partnarsbip and have no employecs working for me in 8. E]Remodeling any capacity.[No workers'comp.insurantx required_] 3.01 am a homeowner doing all work myself(No workers'comp.insurance required.]t 9. D BuilthDemolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property- 1 will 1 D Building addition ensure that all contractors either have workers'compensation insurance or are sole l LE)Electrical repairs or additions proprietors with no employar 12_❑Plumbing repairs or additions 5�1 am a general oontractor and I have bired the subcontractors listed on the attached shod These sub-couuactors have employees and have workers comp.insraancat I3.�RoOf repairs 6.❑We aro a corporation and its officers have exercised their right ofoccmptioa per MGL C. 14.E]Other 152,§1(4)�and we have no amploycm[No workers comp.ias»rancc rcqu4t&] 'Any applicant that chocks box#1 must also 611 out the section below showing their workersCompensation policy information_ t Homeowners who submit this affidavit indicating they arc doing all work and thea hire outside contractors must submit a new affidavit indicating such_ [Contractors that check this box must attached an additional sheet showing the name of the sub-contractors-and state whether or not those entities have employees. if the rub-contractors have employes,they must provide their workers'comp.policy numbs. I am an employer that Is providing workers'eorapensat7on insurance for my employem Below is the policy and job site information. y Insurance Company Name: p Policy#or Self-ins.Lie.#: ��i7(iJG ���k-� ?, Expiration Date: 62// lob Site Address: t-l! rdOh dA City/State/Zip: V?,An JJ//`Pr Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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$250.00 a lay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. t do hereby certify under the pains and penaltnes of perjury that the information provided above is true and correct z'� �Z i'p ® � - --- --- Date- >o�� t afore: e 'hone 2 _/&, i 06ieial use only. Do not write in this area,to be completed by city or town offteiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5 Plumbing Inspector 6-Other Contact Person: Phone#: POLABEA-01 JONEI LL DATD/YYYY)CERTIFICATE O RTIFI T F LIABILITY INSURANCE 1/6/2016 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 policy(les)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 of such endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE978 ac"0:(978)688-7001 _ 11 Saunders Street arc No E>n);( )688-7000 North Andover,MA 01845 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Nautilus Insurance Co. 17370 -- - --- ---- ----- ---- INSURED INSURER B:Safety Insurance Company 33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc -- P O Box 958 INSURER D Andover,MA 01810 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. NOTVVITHSTANDING 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. LIMITS INSR� TYPE OF INSURANCE DL�SUBR� POLICY EFF POLICY EXPP LTR �ADINSD!WVD POLICY NUMBER MWDD MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED —I CLAIMS-MADE OCCUR NN538691 1 0312412015103124/2016 PREMISES(Ea occurrence) $ 50,000 -- MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO ECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 J I OTHER: I AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT $ 1,000,000 _(Eaaccident -__. B ANY AUTO 2100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNED ! XSCHEDULED BODILY INJURY(Per accident) $ AUTOS �I AUTOS NON-OWNED PROPERTY DAMAGE $ I_(Peracciden�_—_— X HIRED AUTOS X AUTOS II UMBRELLA LIAB X ' OCCUR ( EACH OCCURRENCE $ 1,000,000 EXCESS LIAB IAN019284 03/24/2015 03/24/2016 AGGREGATE $ A CLAIMS-MADE DED j (RETENTION$ i _ WORKERS COMPENSATION I PER JOTH- STATUTE ER AND EMPLOYERS'LIABILITY Y/N E EACH H ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE --_ OFFICER/MEMBER EXCLUDED? N/A E L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) —. - If yes,describe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 - AUTHORIZED REPRESENTATIVE rl. is\laoo nn-iA A1+f%Mn A1.rad++----A 1/4/2016 Preview:Certificates of Insurance ACO® CERTIFICATE OF LIABILITY INSURANCE DAT1104/2016 Y) II 0110 412 0 1 6 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 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 of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX Automatic Data Processing Insurance Agency,Inc. A c No Ext): (A/C,No): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC N INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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. INSR LTR TYPE OF INSURANCE )NSD yyyp POLICY NUMBER MINDDNYYY (MWDDiYYYY) LIMITS �ULKPOLICY EFF POLICY EXP COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE OCCUR PREMISES(Ea occurrence) S MED EXP(Anyone person) S PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PRO- OTHER: LOC PRODUCTS-COMROP AGG S OTHER: S AUTOMOBILE LIABILITY ODaddeU $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per acid..!) $ AUTOS AUTOS HIRED AUTOS N'ON-OWNED aO E $ AUTOS (Per cidenl S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S DED RETENTIONS WORKERS COMPENSATION x AND EMPLOYERS'LIABILITY STATUTE ER _ A O Y EZRT�M1a Flt EXCLUDEDa EC�I� YY❑N/A N POWC772258 01/01/2016 01!01/2017 ELF CH ACCiUENT S 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EHPLOYEE $ 1,000,000 Ifr.,dibe under DESCRIPTION OF OPERATIONS b@.ow E.L.DISEASE-POUCY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be allached if morospace is required) 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 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Is Regdafio" flf�ice of Consumer p rs 10 Pa&- -S jute ��0 16 Boston,M 'Sc`iCbeS RegIS $jon OI Iome jmpxovemne!t Cent _ Rpt ation� 102726 Tvp . DBA Tr# 252249 e0imatian- 71212©16 uTtCJtV CO_ t'Ot-AR LeBlancS 'Vincent p.O. BOX.958 =_ �htarkre�s°nfor et�ange. ANDONIER, MA 01$1.0 _- 'Ups Address a�►d remora II+Pt��°1 t p Lost card Address Renewal - - Via---- Opg.GA1 u 5aM•aatau.Gtaiazs i tea'els�cFFllCt.+t]?3 'dg'�J�Y"i151}F.�.r�L'L'3i3�.�'+ 6 _.[;sasa:CSSL-906047 p]&TM Al LBBL"C xEAS'ItP STR��g PIWAOv+M M65 0412812018 vo;-�:i z:sstana: