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HomeMy WebLinkAboutBLD-23-000794 Office t#Use Only o ••Y'iR dO. Permi 0 \ Ct Amount 3 , 4 CO J CO' 'Permit expires 180 days from {}issue date ,$c1)-23-c0)39q EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -- ---� 1146 Route 28 AUG 12 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 — — (� C U.(� (L'� BUILDING DEPARTMENT CONSTRUCTION ADDRESS: LI -I Cm 4 +- �- Ar ........ . � T (� W ASSESSOR'S INFORMATION: Map: Parcel: OWNER: YCtnS WGrren S CtA412.. as Job NAME PRESENT ADDRESS TEL. # CONTRACTOR: I41 66.4 (tS Cr r'W Ili (Arlons4 3t.r;-k.LL5 Nero gecro4. 1 )4-2t o— (a(0-13 NAME MAILING ADDRESS TEL.# Residential 0 Commercial /O�^ Est.Cost of Construction$ 15 W Q Home Improvement Contractor Lic.# /91`6 t9 Construction Supervisor Lie.# C< — /1/3Q U S Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor III have Worker's Compensation Insurance Insurance Company Name: /II hi t4L4 14a1 ,CncliZt17CL CCD Worker's Comp.Policy# VWCI0O(0023ro7S202LTI WORK TO BE PERFORMED 2 Ins,«0 Tent II Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation 1 1 Old Kings Highway/Historic Dist. (J)Replarit±g like for like Pool fencing I 1 *The debris will be disposed of at: IC LI5 s h a wryiu ave, New A CA Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial r revocation of my my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ,e 6�.,G�t..6.. Date: g/'S /Z 02 2— Owners Signature(or attachment) Avity\ 1 p1rtZ . C 110k Date: PP B Approved : r Date: 6 - /�Y Building Offic' ' ee) EMAIL ADDRES . Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes 0 No _ The Commonwealth of Massachusetts IMMAP _a _ I, Department of Industrial Accidents ,1 = 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): CQS Eherr5y Li C Address: (2$ Linibn - 51,6 LL5d kk w ReA- -Z\ City/State/Zip: MA C62:1 y 0 Phone#: `1-1 L -2(90- (D Ce 7 3 Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with `6 employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.®Other bltrfVle(t 2cif Gri 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then 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 sub-contractors have employees,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: 4114 ui-uci Tylstwar)"e (o*vt .4Ay Policy#or Self-ins.Lic.#: VW C 100(962-S(p72 2b22 A Expiration Date: 03/0 q/zta3 Job Site Address: lig(D Main B+l YGrrrlt,t.141r) R3r# City/State/Zip: MA O2615 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 day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: !jL �L Date: V5/Z022 Phone#: 1 7 t f 2(a o— (R (P 73 Official use only. Do not write in this area,to be completed by city or town official 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#: DocuSign Envelope ID:001C5591-2CDF-452D-8096-CDA98DEDF617 Federal ID#05-0405629 RISE Engineering RI Contractor Registration No 8186 g g MA Contractor Registration No 120979 CT Contractor Registration No 620120 R I SE 765 Attucks Lane,Hyannis,MA 02601 ENGINEERING CONTRACT - WZ 508-568-1926 FAX 508-568-1933 Page 1 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERMIG AND THE CUSTOMER FOR WORK AS CLC-HES DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT# WORK ORDER James Warren (774)330-3992 04/22/2022 344741 90702 SERVICE STREET BILLING STREET PROPOSED BY: 496 Main Street 496 Main Street Jeremiah Lupinski SERVICE CITY,STATE,ZIP BILLING CITY,SI ALE,ZIP Yarmouthport, MA 02675 Yarmouthport, MA 02675 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE 75% For eligible weatherization measures,the Cape Light Compact is offering an insulation incentive of 75%,with no limit,and an incentive of 100%for the air sealing measures.You are eligible to apply for the 0%Heat Loan to finance your co-pay,applications must be submitted before the weatherization work begins. CRAWLSPACE HEIGHT NO VAPOR BARRIER Because the crawlspace cannot be safely accessed and the earthen Co (initials) areas covered with a vapor barrier,all planned weatherization measures in the other areas of the home will need to be put on hold until the proper control of the crawlspace humidity is addressed.via inuo s 50 pint dehumidifer KNOB&TUBE WIRING We have identified the potential existence of Knob&Tube wiring in Cyj, (initials) your home.The following contract is not valid unless accompanied by the Weatherization Barrier Incentive form,signed by your licensed electrician.Work will not proceed until we receive a copy of this form. HOME AIR SEALING 3 $240.00 $240.00 Provide labor and materials to seal areas of your home against wasteful,excess air leakage.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) ATTIC DAMMING-R-38 FIBERGLASS 50 $123.00 $92.25 $30.75 Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass batts for damming purposes. ATTIC FLAT-7"OPEN R-26 CELLULOSE 368 $507.84 $380.88 $126.96 Provide labor and materials to install a 7"layer of R-26 Class I Cellulose to open attic space. ATTIC HATCH:SEAL&INSULATE 1 $60.00 $45.00 $15.00 Provide labor and materials to insulate the back of an attic hatch with 2"rigid insulation board.Weatherstrip the perimeter. WALLS WOOD SIDED 3,120 $6,271.20 $4,703.40 $1,567.80 Furnish and install blown in Class I Cellulose to shingle and/or clapboard exterior walls.The butt of the upper course of your wood siding is cut to drill holes into the wall sheathing behind.The holes are then plugged and the wood siding is reinstalled using exterior grade nails. Touch-up painting,if needed,will be the customer's DocuSign Envelope ID:001C5591-2CDF-452D-8096-CDA98DEDF617 Federal ID#05-0405629 RISE En ineerin RI Contractor Registration No 8186 9 9 MA Contractor Registration No 120979 I. CT Contractor Registration No 620120 RIS` 765 Attucks Lane,Hyannis,MA 02601 ENGINEERING CONTRACT - WZ 508-568-1926 FAX 508-568-1933 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS CLC-HES DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT# WORK ORDER James Warren (774)330-3992 04/22/2022 344741 90702 SERVICE STREET BILLING STREET PROPOSED BY: 496 Main Street 496 Main Street Jeremiah Lupinski SERVICE CITY,S IA1E,ZIP BILLING CITY,Si ATE,ZIP Yarmouthport, MA 02675 Yarmouthport, MA 02675 DESCRIPTION QTY COST INCENTIVE TOTAL responsibility.Homeowner has received a copy of the EPA's Renovate Right Lead-Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed. Your signature is your acknowledgement of receipt and agreement to proceed. COMMON WALLS RIGID BOARD 16 $63.36 $47.52 $15.84 Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to a common wall area. VENTILATION CHUTES 52 $181.48 $136.11 $45.37 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow. CRAWLSPACE HEIGHT Your home's crawlspace height is lower than our standard for work to proceed. The sub-contractor assigned to install these weatherization measures reserves the right of refusal,upon visual inspection of your crawlspace. Total: $7,446.88 Program Incentive: $5,645.16 Customer Total: $1,801.72 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***One Thousand Eight Hundred One 8172/100 Dollars $1,801.72 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMR AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDUUNG,AND CONTRACTOR REGISTRATION. DocuSig ned by: by: r7/� DocuSignedcs U�al�mc.uL ���SEEE 4/24/2022 I 4:12 PM EDT NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE SIGN DATE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE DocuSign Envelope ID:001C5591-2CDF-452D-8096-CDA98DEDF617 RISE ENGINEERING OWNER AUTHORIZATION FORM I James Warren (Owner's Name) owner of the property located at: 496 Main Street (Property Address) Yarmouthport, MA 02675 (Property Address) hereby authorize C2S Energy LLC Subcontractor(to be filled in by once) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. DocuSigned by: t- �aYYt,ln. 77F5270FD39E4F4... Owner's Signature Date RISE Engineering,a Division of Thielsch Engineering,Inc. 765 Attucks Lane I Hyannis, MA 02601 1508-568-1926 www.RlSEengineering.com Commonwealth of Massachusetts Division of Occupational Licensure Board of Building�RR�m�ulations and Standards Const�9 �p" r 'visor CS-113085 Empires:06/03/2024 KYLE J 'p i 14 COTTON1� t DARTMOUTOIA it .`r t.iv,INa' Commissioner ;'. :;,.,;,;�, construction Supervisor Unrestricted-Biuidngs of any use group which contain less than 35,000 cubic feet(IM1 cubic meters)of enclosed Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license For information about this license Can(61T) 4200 or visit www.rrlass- dlA bOSton j Home I mprov+ ,),‘,.,,) E. - C2S ENERGY LLC 128 UNION STREET UNIT LL5 NEW BEDFORD, MA 02740 4 1 3, 1. n SCA 1 0 20M-05/17 .f+ R .fm 5. . ..,,z, r ,C . s,- s ,.-rr .;.__. ... .«rr«,«r -.ar ^r -{r ,, . . . . .f R u on marsBusnggr i r.:,... ..:._ . . . ,,„„„:.„".„,,,:,,,,:,,,,,,,,,,,,,,,,„: „,„,,,„,,,,„.,,,,.,,,,...„.„,,,,,,,,„,„,,, `O ice of Consumer � �munintel ENT NTRHOME IMPROVE r :, . : ilititt..,.., 8 . , . . . Expira c a2/27/2 y ,: ... fir C2S ENERG . . . 41 } '''.;1• ' a ,.- :.---:':..:::::- 1,401 :, 1 KY GABRA _ - �f 128 UNION STR� :, �.*0'1,h •• '. . ' 1014‘410.0( ,/7:: :.: . ' ! 10 NEW BEDFORD, 11 Undersecretary . 3 DATE(MM/DD/YYYY) A cRiLi CERTIFICATE OF LIABILITY INSURANCE `„ter 06/28/22 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 have ADDITIONAL INSURED provisions or 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: FAX Donald J.Medeiros Insurance Agency (A/C.No.Ext): 508-678-1271O No): 774-365-6552 154 Rhode Island Ave E-MAIL DRESS: Fall River,MA 02724 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: GuideOne INSURED INSURER B: Pilgrim Insurance Company C2S Energy LLC INSURER C: GuideOne C2S Construction LLC INSURER D: 128 Union St Unit LL5 New Bedford,MA 02740 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. INSR ADDL61.1BR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A ENV562010017-00 05/14/22 05/14/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n EC n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B AWNED X AUTOS ONLY AUTOS SCHEDULED Y CSC00001008276 05/14/22 05/14/23 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C X EXCESS LIAB CLAIMS-MADE ENV562010018-00 05/14/22 05/14/23 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE7 N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Per Occurrence 1,000,000 Pollution A Y ENV562010017-00 05/14/22 05/14/23 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) As per written contract,RISE Engineering is an additional insured on primary non contributory basis with respect to the General Liability and Excess Liability policies and additional on the Pollution Liability and Commercial Auto Liability Policies CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Thielsch Enginnering Inc 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE f I. ft I 4` • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD '``, D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYI 03/17/CERTIFICATE R. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER RIGHTSHE 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 DONALD J MEDEIROS INSURANCE AGENCY NAME Alison Pilotte PHONE I FAX (A/C.No.Ext): (508)678-1271 (A/C,No): E WAIL ADDRESS: apilotte@donmedeirosinsurance.com 154 Rhode Island Avenue INSURER(S)AFFORDING COVERAGE NAIC# FALL RIVER MA 02724 INSURERA: AIM MUTUAL INS CO INSURED 33758 C2S ENERGY LLC INSURER C: INSURER : INSURER D: 128 UNION STREET UNIT LLL5 INSURER E: NEW BEDFORD MA 02740 INSURER F COVERAGES CERTIFICATE NUMBER: 754524 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDY/YYYY) (MM/DD/TYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ — ANY AUTO BODILY INJURY(Per ALL OWNED SCHEDULED N/A person) $ AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) $ — UMBRELLA LIAB — OCCUR EXCESSLUIB EACH OCCURRENCE $ CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ WORKERS COMPENSATION X $ AND EMPLOYERS'LIABILITY Y/N I STATUTE I I ERH A ANY ROR/MEM EREXCLUDED?ECUTIVE N/A N/A N/A W (Mandatory in NH) VC10060236782022A 03/09/2022 03/09/2023 E.L.EACH ACCIDENT $ 1,000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Inc ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave AUTHORIZED REPRESENTATIVE Cranston RI 02910 ak I Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA ( ) The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. All rights reserved ACORD 25 2014/01