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HomeMy WebLinkAboutBuilding Permit # 1/7/2016 BUILDING PERMIT VkORTH TOWN OF NORTH ANDOVER �� s::`` .. o� APPLICATION FOR PLAN EXAMINATION D Date Received A�ApiT- �Permit N®fieD pPpy��J " AC U5 ' Date Issued: d IIVVIiF�R-'I'A1i1'�': Applicant must complete all items on this page r i r .,, n r,r r , r , J,�i / ;/ / e 1r /i/a/! ,i.� c „/ l I /r,ir ✓r Ir %l n / ///, ✓r r �, r 0 //, r// d/r J i 1 „Jrrrr r 1 i l,r< 1 / /l / r/f/l,(", ,/ r // / r / ,/. ! / I/ ,, //,/, ,:-, wb ll, /I , // ref v lir l f / / � r � �/ r,,! ,i/ r/- i /!//i1(, ✓/ r / � ���,, / 1/ ,//,/ r '. r // f/ , /. 1/a ��/ r ,1�r. �n��/. 1 ✓ � ��ir��/I%rr,,,/,�`J.✓/ //�//��/J �� (l� J./l�n/r�r '� / /�l.l/,,,, ,�' r/ aI I rNI /r /" �rr r✓-, � .,/ Ir %r f,,�,:. ���� r.ac�/,,,�� a ,1��,/t��rr�r rr ./rY t' r� I� i �r�r/r / 1 � ; J��/!�� �, /,, � ,�,o. r� / H l��l����, 4 r%�r�'�/r�/I/// rnJ/11,/r/ .rl �/ ✓ � i ���f ��f% �'% .w; O S' ,RIT Jrr '/lr/Histone ®istnct„ r r, e's, ,a/na,/// A." rrr 1 r..l /�/I/�1r~ ✓r ,,,,,� r i ,��/�,./�..//r �//.��// �e.�// 1,/// <,.� / r...// ,/i .i,... /. /�//, �. r �. /� %/„/,r////✓�/,.,r,r, ,,,„r.. ,,,„,,r ,„,,,,,r ,,�r,.,,, r�..rv,�r .,Pr/ <,�,,,,";.. ...,.li ,.., _.. ,c lr��/��ir/��r�/�irs�/r,�r%r���ri✓ ,./�,�r,//,r�0 r/r .,,,.1�„[,.,��,G'G�-�/11,��rl,m 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 SO4-�- 04 ' ✓9 rrr / En d / r r ✓-,//r?r .a,fsn / / "r' r, r/ rJir,�Yr,T:. 2' ..�..5; 1,,. r,/,e ,�, ,,, � ,/„/ ❑ flood Iain., ,, ❑.Wetland ,,i „///„ , rrr❑ Se ticF 1,❑ir s r // ,, r, / r r � /� ., r, rrr✓ / r r 1 �r /�„ � ,, , r //i „_ ,, /� z - r,i///j l v; / / ���1 Yr if ����/%%//yr�/l/f�� ///ii// /, ,rr r r „/, ,,,r- � /'� / r ✓ ���� ,r r r ,/ ❑Water/Sewer �� s, �� „ � / � �iDiG /, � � ,� ,,/drr/ ,r,,r„ a-,,..r,.� �.�,_a ,.�..,.�a r� ,rrr, ”- r„/� i�//.or/�N/G,,Ar��/Hk.d, /a//,,ice, .r,..,� .r.f � ,r,�✓,a ,,. ,..rr,. r,�.�., ,,,,rG / ,�.r avfGU Ic, DESCRIPTION OF WORK TO DE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: ;epAA Y 4 h6 Y Phone: Address: Woo eA0 ''///R/� r� / / /. / 1 j / rConfra'ctor/rNarne„ Ph.o.ne rr rr r,..rrr , , , / r -rr ,, r r, /r r/ r r r r r/ >r r / rI // / // / r /..../r/.. ,. / /. r.r / r. .,. r , / / // r r ir/ // /, / /, //r.i, r,r / /r/ f /,. / / r / r r �/ / /���lu�/rl/�,1� �� / „ f / r/ r/ / r ✓ rr i r/r// .r r// / r 1, 1, r ,�/ / ✓r / r/ // r / /r/ r, 1 , / ,f 1r / / / / / / I/ 1, / r ✓r/ r 1 � r/ 1 / /. J, / ,.r... /,/J/r✓1 //.Ir ,/. //r! r.. i/.0 _r, / rir / / /,. - / t �1��, r /r'/ l ��/I/1r,r/////� .r/// ✓✓n//,/r ri,r ,i,/, ./ ,,r /r / r"/ //r /,./, //'i/' ,. r'/� rH, � r /l,r// r_, Home�lm ��,a,r, - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000,00 OF THE TOTAL.ESTIMATED COST BASED ON$925.00 PER S.F. «^ I Total Project C®st: $ *>0 O °® 0 FEE: $ Check No,: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Agent/Ovvrier Signature oof_contrcto I 'Town ofF NORY}i �q A" ndover O Jo : �.K. h ver, ass, l COCNIC49WICK 4ATE9) Uff BOARD OF HEALTH PERMIT T L LLO Food/Kitchen Septic System THIS CERTIFIES THAT ., ......•............. BUILDING INSPECTOR .................... ......ti..._WW4 ... ..................................... Foundation has permission to erect.......................... buildings on .:...... . .QI .!!��,:.................. Rough to be occupied as ........ .. . . ......� ®....... .....�.!'11f#..!' f!.!�!...�!�r. . .L Chimney ....... .... ................ provided that the person accepting this permit hall 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 CONSTRUCTION START Rough OOOPService ............................................ ................................. 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. Federal 10#054405628 RISE Engineering RI Contractors Rel istr loo No 8186 FM Regtatration No 120878 RISE A division of Thietsch Engineering CT Contractor Regtatratlon No 820120 ENGINEERING 60SbawmatUoit#2,Canton,HA02021 339-5 39.502-6345 CONTRACT Page 1 8nn PROGRAM L� nascoxraAcrwa+reu�amoea�w�wse CMA-MScascraw am" aarrora3ewavroweAs ou"MER N PaOKE DATE CLUEffs WORKOpDM Senay Abbay t= to (415)430-8054 10/07/2015 424645 00004 nap smv=erFtm erunco aneEE. 31 Wood Avenue U 31 Wood Avenue SIUMMS CRY,STATE,9P WAM CRY,STATE,Za' North Andover,MA 01845 North Andover,MA 01845 OB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas ofyour home against waste 4 excess air leakage.This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a heahhful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and otherproducts. Primary areas for sealing include air lealtage to aides,basements,attached garagas and other unheated areas(windows are not generally addressed.) Ibis will require(8)working hours.A reduction in tabic fact per minute(cftn)of air inf ination will occur,but the actual number of cfm is not guaranteed. ALL AIR SEALING IS FOR EXT KNEEWALL TRANSICIONS AND ATTIC 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 AIR SEALING ADDER:(3)working houta $255.00 AIR SEALING:Provide labor and materials to install Q•lon weatherstripping and a doomweep to(1)doors)to restrict air leakage. FRONT DOOR $75.00 AIR SEALING:Provide labor and materials to install Q-Ion weathastripping and a doomweep to(1)door(s)to restrict air leakage. SIDE DOOR $75.00 KNEEWALL SLOPE:Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(282)square feet ofkneowall rafter area. $987.00 STORAGE BARRIER:Homeowner is responsible for the removal of the stored items blocking the installation of weatherizWon work in the knoewall areas. Removal must occur prior to the scheduled work start $0.00 ATTIC ACCESS:Provide labor and materials to make(1)temporary access to an attic area The opening will be closed with materials similar to those existing. Finish sending and painting is not mchuh4 GABLE VENT IS W ME THERMAL ENVELOPE,TEMP ACCESS WTO AT11C AND BLOCK GABLE VENC WITH 2"FOAM BOARD $85.00 COMMON WARS:Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(4)square feet of common wall area $14.00 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 Sealing measures up to the fust$680 and an additional$340 if savinp8 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 ofthe available air flow m your home both before the work is begun,and aft the weatherizadon work is complete.We will also conduct a full 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.Total allowable. weithaizatien incentive is$3,110. $90.00 C Federal ID#054405829 RISE RISE Engineering Rl ContractorContractor Registration No 8186 MA Contractor Reghltrallo»No 120978 A dividoo orThielach Engineering CT Contractor Registration No 820120 ENGINEERING' 60ShewrautUnit#2,Canton,NA02021 339-502.6335 FAX339.507r6345 CONTRACT Page 2 PROGRAM T WB COMRALT toBfIH1ID MIO Bt11YlFtN ROB CMA-HES EKGO133=A1m TtECUSTOAtF7R FNRVIMAS OESORMOSM CUSTOMER P"OIN DATE cuefro ;;WORDE Senay Abbay (415)430-8054 10/07x1015 424645 00004 Sexwce Sum eum aTR�T 31 Wood Avenue 31 Wood Avenue owca CRY,STATE,IIP WLUNO CTY,STATCIDP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,261.00 Program Incentive: $1,970.75 Customer Total: $290.25 WE AGREE HERESY TO FUMISH SERVICES•COIPLM IN ACCORDANCE WrTH ASOYE SPEMOATIONS.RM ME SUM OF ***Two Hundred Ninety S 25/100 Dollars $290.25 UPON FNAL WPECTION A"APmwAL SY RUE 8teOR MOM CUSTOM ACIMS TO Rem AVOW OUR N PULL.WMW OF I%V&L WCWRGEDMORMYON ANY MWAR)BM.AML'ARM30 DAY&SEERS ENGFOROOORTAMNFOMATMON OUARUffMM=MCFREC=KBaiEDUL4to.Alm CONTRACTOR ROGISTRATM DO Nor SIGN THIS CONTRACT IF 7HEM ARE ANY�K"10A@ IZa�ra.��ZGU7 � — afUrxotRaEoeteNATUaE•IasEFryn.aUns C USTOMeI ANce ROTE TIDa count/CT MAY SHvnnmRAM SY US WNW EMOSTED VMM VDATEOFACC®TANCE '., ACCEMANCEOPCOMPACT-TFmABOVEPtOC�.RP1O:&7CATmNSAlmCOIXTONaAKE 3O DAYS. MTMFACTORYTOWACAREHEMAOC6 MVWAMAUMVRWTODDVMMM AS aPBCII PAYMEMYRILGOMADRASounb DAEOK - O OWNER AUTHORIZATION FORM (Owner's Flame) owner of the property located at (Properly Addrew) (Ropeft ) hereby authors (Sulmontractar) an authorized mAkCantrac tur for RISE Engfieering,to act on my behalf m obtain a buflding permit and to perform work on my property. igrtature Date D The Commonwealth of Massachusetts Department of IndustrialAccMents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mas&gov/dia 1NYorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _) / Please Print Legibh+ Name (Business/Organization/Individual): b 1,A i'� I ft Il! k- s1/"r /`/'C 14 -'r:- T I�� Address: [,- c V�) i- C15- CitY/State/Zip j- City/State/Zip: , L,--C {f r/Yl i lj/t Phone#: Arc you an emptoyer?Check the appropriate bos: Type of project(required): d l.al am a employerwith (full and/or part-time).• 7. 0 New construction 20 I am a sole pnprictor or partnership and have no employees working for me in 8- E]Remodeling 3 D any capacity.[No workers'comp.instutusce -quired_] I am a homeowner doing all work myself[No workers'comp.instuance required.]t 9. ❑BuiDemolition th g a 10 Q Building addition 4.[:]]am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no cmpbyccs. 12.❑Plumbing repairs or additions S o I am a general contractor and I have hived the sub-contractors listed on the attached shccL l 3.❑Roof repairs These sub-contractors have employees and have workers'cotes{,.insi moce.t 6.❑We are a corporation and its officers have exercised their right ofccanption per MGL C. 14.[]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below slowing their workers'compensation polity information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afndavit indicating such tCootractors that check this box must attached an additional sheer showing the name of the sub-conuactors_and state whether or not those entities have cmplayoes. If the sub-contractors have mrployoes,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: we a J 4 u-t_ City/State/Zip: n' 1� B✓ f Attach a Copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as squired 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 5250.00 a Jay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. do hereby certify under the pains and penaldies of perjury that the information provided above is true and correct. _ J zignature: jt. I c�_ - _ - -- Date- r 4 'hone#: Gi k 02 —%G3 Oflk- 141 use only. Do not write in this area,to be completed by city or town ofjtcial 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#: 1/4/2016 Preview:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCE DATE(tdh9iDDYYYY) 01/0412016 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 AX Automatic Data Processing Insurance Agency,Inc. ac.No.Eat: (A c.No. 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE MAIC d 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. LTR TYPE OF INSURANCE INST) YWD POLICY NUMBER POLIC LIC P I LIMITS (G4,VODIYYYY) (RUNDDrYriY) COMMERCIAL GENERAL LIABILITY Ei,CFIOCCOHHENCE S w CL+UI.IBI.IADE OCCU H P(%.Ef.11SES IEa o:curren�e; S MED EXP pin:one p-,-1 PERSONAL 6 AUV INJURY S '. GENL AGGREGATE LIMIT APPLIES PER. GENFKAL AGGRECATE S ' POLICY PRO ECI LOC PRO W C f S-CCLIP�CP i,GG 5 J OTHER: S AUTOMOBILE LIABILITY CU.1 NED ' SI CL IIJI IFI:�crJcnU ANY AU fO BODILY INJURY if',V3run) 5 ALL CIkNEDMCUI,jS�LIAUE BODILY INJURY)Per aa)denq S AUTOS HIREDAUTOSUMBRELLALIAS 6\CH OCCUI-NENCE EXCESSLIAB AGGREGATE 5 OEO HETEN TIONS 5 WORKERS COMPENSATION X ' t J H AND EMPLOYERS'LIABILITY STAlL'IE Eft Ntt'HiCIINEI CKTARTLERFXECUnL+E YrN EL EACHACCIDEW S 1,000,000 '.. A CFFICERLIEMBEHEXCLUDED? Y❑NIA N POWC772258 01101/2016 01/01/2017 (Mandatory in NH) EL DISEASE-EA B:IPLOI'E- ° 1,000,000 If':es.dcs:nbe cn^_ti OESCRO'HfNOFCPERAHONSbca, .uT 5 1,000,000 '.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Rcrn:uks Schedutc.may be att ched it more space 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 A©19882014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD �/ POLABEA-01 JONEILL CERTIFICATEE F LIABILITY i ' U N DATE(MMIDD/YYYY) 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 PHONE (978) 688-7001 70 ).(978)688- 0 �ac,No: 978 11 Saunders Street A/c No Ext):, _-- -- -- — �( E-MAIL North Andover,MA 01845 ADDRESS:- INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Nautilus Insurance Co. 17370 INSURED INSURER B:Safety Insurance Company33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc INSURER D P 0 Box 958 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR — TYPE OF INSURANCE �INSD WVD POLICY NUMBER MM/DD/Y MM/DD A ' X COMMERCIAL GENERAL LIABILITY LEACH OCCURRENCE $ 1,UUp,000 DAMAGE TO RENTED i i 1 CLAIMS-MADE OCCUR NN538691 1 03/24/2015 103/24/2016 pREMISEs(Ea occurrence 8 - 50,000 MED EXP(Any one person) __Is 5,000 PERSONAL&ADV INJURY $ 1,000,000 J GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ 21000,000 POLICYl PRO LOC PRODUCTS-COMPIOPAGG $ 11000,000 JECT 1 -- — OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I-(-Eaacciden� $ 1,000,000 B ANY AUTO I 2100926 01/04/2016 01/04/2017 I BODILYINJURY(Pe rperson) $_ ALL OWNED y SCHEDULED ~BODILY INJURY(Per accident) $ AUTOS XII NON-OWNED AUTOS PROPERTY DAMAGE $ X X (Per accident-__- HIREDAUTOS AUTOS $ � I 1 JUMBRELLA LU\B' X ' OCCUR I EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB I cLalMs MADE' IAN019284 03/24/2015 03/24/2016 AGGREGATE $ _ �_ DERETENTION$ _ $ I WORKERS COMPENSATION I I PER 0TH- AND EMPLOYERS'LIABILITY — STATUTE ER Y/N E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N/A ❑' E.L.DISEASE-EA EMPLOYEE $ 1(Mandatory In NH) - -------- ------ If yes,describe under ` I E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS below 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 L1, n-Inoo qn4 A A rnnn rnnnnoA'rrnkr A n....a,r. ...........+ 1!4/2016 Preview:Certificates of Insurance ACdR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MhUDDIYYYY) -C 01/0412016 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 pol)cy(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 CON AC NAME: PHONE AX Automatic Data Processing Insurance Agency,Inc. MP. E. : (A/c.No. 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC it INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC I PO BOX 958INSURER c: 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 TYPE OF INSURANCE P LIC POLICY I LTR INSD WVD POLICY NUM (Idh4'DD/YYYY) IMMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 UREU CLAIMS-NADE ❑OCCUR [EVEI.11SES S LIED EXP(An.one P_rm S PERSONAL h AUV INJURY S GENLAGGREGATE LII-IIT APPLIES PER. GENERAL AGGREGAI E 5 POLICY❑PIJECTiG ❑LUL' PRODUCTS-COLIP�CP AGG S OTHER: S AUTOMOBILE LIABILITY GO.1 IN U SIN CL If:ll (Ea a-crJtnll ANY AUIO BODILY INJURY(Pte T„rmn S ALL O.;NED SCHEDULEO BODILY INJURY IP,t—dent) 5 AUTOS AUTOS NOa N OVED P tU'E Y DAf.1G S HIREDAUIOS AUTOS IPa:rdr Il S UMBRELLALIAB OCCUR bNCH OCCURRENCE EXCESS DAB CLldLIS f.IADE AGGREGATE S DED I I RETENTIONS WORKERS COMPENSATION Xt J H AND EMPLOYERS'LIABILITY YIN s)AIV1E ER FYPRCPk1er-f,EXGLUDEDXECUTI.E EL E,OHAcaue;r s 1.000,000 A cFFlCERlJEI.IeEr.Exr,LUDED.> Y❑NIA N POWC772258 01/0112016 01101/2017 (Mandatory in NH) E.L.DISEASE-B,EMPLOYE- S 1,000,000 11;es.dcs_nbe,;nuc+ DESCRIPTION OF CPERAHONS b&oa EL.DISUSE POUCYLIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached if more space 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 i A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Regdafioll ,Af Ws all Office of consumerus 1 .plaza- Suite 5170 Ston, wsacbuselts{�Z 1 MV 'tJIl ®me �OVem62Lt�OIl `. _ R � ,tsan- 102726 _ -= Typw-- DBA 16 T# 252249 pir�tion- w2l20 T,ON CO !POLAR BEAR lNSIJUk Vincent LeBlanc P.O. BOX 958 �larkr,easantare6ange. a. ANDOVER, MA 0100 - 'up�Aadr��d,remra� lo��,t ❑LasCsra Address 0 Renewal UP5-GAY s:SQ@1ta1�ga12t6 gfi� s� i?1S = _ :_ s �EC:S3.F:::f;3'9a^«nrd,�:::. Cn,,,t-SSI'dri2"3 Siii;uI"i9*zz-Sp7:chill., }PETER x,OT-pMSTRFEt p,*dstow NK 03865 _ 042812048 vo�':�s�st�nai