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Building Permit # 5/11/2016
1 BUILDING PERMIT �oRTe� q� 0��.�LED TOWN OF NORTH ANDOVER 0� APPLICATION FOR PLAN EXAMINATION _ Date Received �RA°Rc~c Permit No#: � � SSAC �1`S ' � H � Date Issued: It )'L�q- IMPORTANT: Applicant must complete all items on this page r r r`I f .�" ! ""�i... a" r. CC�f ,;c::;flr 0 r-. r r ,fire ./ r ;✓"` ,',. 7r. � ✓>" � �. s rr r �r!. r �v✓f'r' I fry.✓ f r , rf / r.,:✓r„ d.n /." a /rT"..r r l'. �,/ff,`f ,,-+rr f"rrr 7r r �J x �: )'- ✓s ,s,dt ,✓.J r'r ✓. f r• r r s/ u. -?'..,r .T.r ,,d ,s" ',U -s?f E-::. r ✓ d / r 1 / r .�i/ o;'r / :&✓ /. v r. r .....f.s../,., :,;,,� J :�., -r.!. / "-., ., i' r: r r,"i; ,UPJ v,:'r .r� ,.a/I sF,.. J✓,r r,.:.rf,r.'!l%. ,, "r ..%. r',?'x9 r..„„ r + .<_ t:” <sd,rlrJ r :..t rrZ'f'.":.v;-t �;;.si"'s lrr ."„G..,.. r''.U.r� r r r'v ,.,,:r / f. I. r ,r.✓' n-,.' yr r y- r. ,r/✓... .... r n. 1,.n r rf..,.F.. r��1,r' l.. h .r. ,, �! �: e;„ .�^ �>” ^�":✓xa� :1 r ale+*.�. r, f�"r_7 .?. v' z r #'(`',�`''✓1 Ull U �t nG r'Y G s� 1; ��" r � d fr" lr'' r r.,: ,. 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"� �fi-G'.'r-- ,�.�'�x c=. t J .✓r 3,';!if;1 �..�. .�. r I ,,n..'r; u Gfl .. 0. .�Ip<..,., -. ..r,�U55' Jf1r. 9 sr :� / ;�:rr� .d�r�l� d1_ ,x � �. ✓u, ,r7.f �.., .r�r e/.-:f lr ".1'. r+w f ��'S'. ,lf� ,3' ✓;,�."�r rYr�N:,�����, '�c„Y ry ,r- sr ...r, t3 1 .3. 'f���::. .f ,rr .r�r �, rr,"_mss. kr !orf,/ �.,,. xr -:{uti:1. ;�+,{ ,sa- �r F i,l,, rl f;::r�rrrY/✓, ,>Y fr,r..k.�, ,<.,.��'f'4Ur. r�rl`r r�r.,i r...,..,^ r,i. �, �r���-�` J � �; r ONII�G DIS RIOT �rr .historicrD str�ctl� f���✓��� M � U i t t r r !Fx�as +! f �W / aF / ✓" r'J' G s,,, s 'x dr� "¢ s - m n ,i>F r.>Ln.JG -sr�"✓`r r,.:; ,.rr rj'f rhfr::r f /�r,2 r v�� ,,.. , „,� � ,, .,,rmr/ ,,r �'r�'r;J GiU�r t r r s, r re`/{Urrsr✓,rY r�.r.w r9%"�,..'�r,u'�"/.i�r fair;"/,frr l".°�, � / r?....rr r :.,✓ r sf ,Y. �" rs .. „ �,,/✓,,, " ,,, ,F,,:".`?"sY-'r a'aa m,9csl.,,.$,i. ,,r,r.,;.?, „r.:,E/,r.., ,.,,z,b. .,,... TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Atlt&ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 411” / ❑ Flood Isere ;(r `d UUetlands / ❑ UUafershedfDistrict ❑ Se tic ❑Well , , p r✓vl rr/'F. , r. "✓r s �" ?, zf. r r .1.. L ✓ ;Y / xa urr ./ ',r r r ."�" SO, N r-y. Y ,IU J,,,r rv(F'/,f,,tsri t ..r:' tr � r 1 r�' .,P r r.r_.r �r t,H:..r� ✓ (/ r f 'f,'... ✓rr x, �. / ✓ ,ft'<i,lr,.. irfrw fir t rf .n �� r✓✓�.,..: �r y,arr/ r:.:ri .,;r t r.^rr.: / .r .'.F r .,,k`":'U� .y. /a v' Y:: r /.r�3 .;/,1 f 1 f✓x a �✓,r-./I a U r ✓s.r�cx C%z„fJ.�,;�" I Ulu' .r'/ti'/ ::<, „�„f,�„'„,.,h,r,.�>,r„'r �,.�.,..rt�'✓r.�✓,_'„,:�a„�._,<,� r < "arms, ., E R N ORKT BE RFORMED: Ide tion Please TinpeiLior Print Clearly OWNER: Name: Phone: Address: s s ✓ r r ✓r/"=/f %n 'j ! r r'.rN//riZ}r a i/ r a r r ✓.-B f.:f,;h(r r'y ! .^ r / ;r„` M �a d t ( / I": t rJf1 r!r � // :/ r /f .it i UU' r{/ Y r r rJx l” nfi /...: /r Jr'Y r„tr 1 rr,rrr r'l ✓r Ur ;� ✓f✓ fir'. 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J L ..!a,,./,✓ �,rtfi0r0..r',„ .l,d,:,^�ui rr��f..a 3 ,,;`J ”>.,m u Uf 5,"<...���rr.,/,�.,.,,�rUtf r r ,rr.,i.;,,.;;},,.. f ':rr /.+. rr,�, � , ,.or< 5C„/ .�r'r. f",x sxr to 9.;a /...F 7',:;3/xry,g,,.... / �lrr^+"..f ”.-wu. r �- ,,n✓tlrl - .0.r'rr. rmt ",: �.A f��:. , ri''n`fT ri ,-:xr ,.. ,.y:� ',n' 1 st „.✓.r`_ r � .ry..,B'1 1 t uw,r:c✓c J. Y`t2':r..,-. t" � t�'.. � "!o�r cw.s� ,m ,r%r<rt,..�,✓%�, r�ri rl� ��t>� y� t�' /✓ z nv <3 �� ern r r fv`nF x r nr ' r��fr r .!�' .� ,� � „ nra rtn�i✓F� crt' ./. F e �f+ ,.rl %' r"'J,'f. :.f, fA r1' J�.. { .m' N f (ff9 / � ,... -. ,:� / .f..ir'_ ✓, Y� ?��� 'F r r,�1�r`rla�a,.nl/" ..,.ly�� -xr/rrf rc4�' r r>"".,�.3 r .�. ,:.:rr, ;U � ,��..,,, �^', '` r � I r' ,� J '�.�t?'a�r'"�s�� ����-�, ,��1 u � r „r rr' ,r ✓� r. ,r l r x 7r /f ;x' 0 - rr fi���x�`�r��r v✓`_ U )"'.,, r � �� Fr/rr✓/7 r„"�x dU Daterl�U,PN'�f a`'✓idn?t ',lyr;� 7 fF�r����>;;✓sm`.r r:`I�< i'" �Hr��.m;�e��a�,P„r����yeq����n�L��cens�e���,J,,.,t,, , �, r ,., � .�r,1�: r ,Y✓M .,, �a��.l? r ,f��,,.r�, _ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ �'- Check No.: 1 !rl Recei NOTE: Persons contractin witli unreg sat eer d contractors do n ha a cP s t he guaranty fiend -77 CA 7 Si nature of A ent/Owner Si nature of',c ritracfor _— g - IA® 'TH Town ofoAndover 0 0 mok &000V ® 041 �i C, 1@5LAKE ver aS3' �A C0C"1CNlw'C.`1_'t' U BOARD OF HEALTH Food/Kitchen PEMIT I L D Septic System THIS CERTIFIES THAT .......................... BUILDING INSPECTOR .......... ..... ...... ... .. . . ........... ......................... has permission to erect ............. buildings on .. ®® Foundation ®......... ........ .... 4r.. . ......................... Rough to be occupied as ........... ..... . .... �1 ... ........ ... . ..!. ...... .. . . ........................... chimney provided that the person accep ng this permits 1 in every respect conformthe 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOK�17STARTS Rough ...... Service �" """ " /��............... ............. ...... . .... ..... .. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises — o of Remove Final No Lathingor Be® Wall o one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. MA Reg#146588 ULWONG -69V2)63 Coonnteral ID ract##20-2825129 CT Reg 00095210 RI Reg 028483 —�L�CHIWD� 26 Home Improvement Solutions co poste Cedar 34 Woburn,MA(P)800342-2211(F)781-933.8025(W)www.newpin.com THIS CONTRACT MADE THE day of �t _20_/9 betweeniU-,,4I 4_-4D- 93. 7 (Home Owners) (Homo Phone)1) (BuslCe7l Phone) �r ', . ,a t✓1�t�7�I?U T rS— 1V A17GUI11P n r4- 0/ F-�J (Addraaa) (Crty) (State) (ZIP) the"Owner"and NEW PRO Operating,LLC,'NEWPR0% (E-1110)for proprietary use only NEWPRO hereby agrees that it will,for the considerallon hereinafter mentioned,furnish all tabor end material necessary to install the goods purchased by Owner in accordance with the terms described on the front and the reverse of Eris agreement and on the ac;ompanying specification oheet(s)(collectively,this"Agreement)At the premtses located at: (� The job address Is a condominium. (Job Address) Spa6inoatlons -ApPROVBD MATEWALs vrit,"E ruRr SHED AND INSTALLED TO THESESPMIFICATIONS.PLEASE REAS CAREFULLY:ONLY ITEMS CNICKEO"Es"ARE INCLUnFLINYOURORUER, YE9 YES NO BEAAISIC 1 0 SOLID VINYL SIDING cover Onlynahvall areae designated for siding, .15 ElOLUMNS wrap with approved VINYL CLAD ALUMINUM. excepptt'h�o��a,rye�• daty�}��ted low, 4/Il _(No circular or round columns)Calor Pattern — Packme Custom Comer poste color 10 ❑ WY GUTTERS/DOWNSPOUTS remove existing and replace with new custom aephless gutters and daymspouls ❑ While ❑ growl Other 2 SIDING will be applied to the following areas only: y/` 01P 4 Dataits: 17 El f3� SHUTTERS provide&Install +� pair approved pety4tyieno nEre❑ Datoile: �- n _h_ dtJrS1... shutters. -Styles 'Color 3 ❑ INSULATION rxx er ftaMall areas dal nates for siding with 18 ❑ ❑ MASTER MOUNTS mvida&Install exterior iuht Mutes only. 0 Fined Inch 0 3.'8 Inch g 18A.)Lights f!� 16B.)Water?Elect Ougat 0 ❑Other IBC.)DryerVant#, --?— ._.Color-6-1-4- 4 olor6f44 UBiding to be appRod over EXISTING FOUNDATION. 18 ❑ 0 GABLE VENTS provide and Instal . vents. /'�� Color rS/r4'�LF+ No circular or triangle vents. 6 �❑ Usa apprOYed FINISH TRIM whore contractor deems necessary.In same color es aiding.(Not available vnth Nehito) 20 . 1 CLEAN UP property.at Completion of wok 0 qlel�WINOOW OPENINGS 21 LN`❑ INSURANCE ALL Workman's Compensation and UeblBiy to he maintained. U Custom wrap with approved vinyl tied aluminum �.•' 0 /I _ c w JJ A,.4 Lam' _ 22 U11 WARRANTY Mail(*customer after oompletion&full payment Is received. 0 Channol exlsdng window only lag.Anderson typo or pravlowly wrappad)8 _ . Coter 23. Tj�.ZPAYMFNTSonNON-FINANCED ordora-Installer isauthorized tocogect Other Oetaits progressive payments 7 DIT CAULK all sills with rubbedred color coordinated caulking 24 Q-13' Customer asked to remove breakables from walls 8 ❑ ORS custom weep with approved VINYL CLAD ALUMINUM, 25 ADDITIONAL WORK(not specified above) #Doors War M i••+ SurroundEk 0 J5 bs L S ^bra-Ic, 8 ❑ RAGE DOOR FRAME$custom wrap with approved VINYL CIAO A 11 .y� ALUMINUM 26 E30 Work Exclusions A'ONCL- T 11+M44125 O Single O Double with Mul O Double N0 Mull v 1L t aS 'a 1D 11P.-Cr FASCIA custom wrap with approved VINYL CLAD ALUMINUM Color &.j h ! 27 ❑ O Repair or Replace the following woods LAt:Y'C sem.r ""�•� 1 t 11 tr -SOFFIT(eave0ovarhargs)cover with approved SOLID VINYL SOFFIT 1�{, F-•-�S d��_, � ^',S.Y.SSTTE•'M Excepted noted h*25.113 Vented Color g:!!!?At f 12 LYU ROTTEN WOOD Will only be repaired or replaoed where sped0.ed on R` line Ilam 426.Any addi6onel areae needUg repair will be eaPmsted kno ••' i � �'}: '.. upon their liecovary and priced axardingly. Cash k_,; ap o (Doss not Include wood duds,or exiedor sheatMng.) er ;�'+i?7' y i;( f v 13 REMO STING M, TERIAtextedar of house 0Wood Siding Ffnanco y. Inyl l Aluminum 0 Wood Shingle ❑ Other amt m"p'vs°"h''a' s' a- aynMninysL _•.�)c. ,. L l.,J V ' 14 Q '4"10RC H CEILINGS cover with approved SOLID VINYL CEILING MATERIAL ! In the following weep: "r., � l 9 �. Est Start Aafa; !( Est Comp.Data;. Customerunderstands this is on"estimated date" v ' 6a� Owner has read and agrees to the terms and conditions on the front and the reverse of this Agreement.Owner specifically agrees to the(1)Total Cash Price;(2)work being performed;and(3)Work not being performed.Owner understands that this Agreement and any All aChments contain all of the promtses made by NEWPRO.Owner has boon orally advised of his right to cancel this prior to midnight of The third business day after the date of this transaction and Owner was provided with two(2)copies of a cancellation form explaining this tight, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only): Notice to buyer:(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of than available Information are left blank.(2)You are entitled to it copy of this.ot the time you sign It,(3)You may at any time payoff the full unpaid balance due under this Agreement,and In so doing you maybe entitled to receive a partial rebote of the finance and insurance charges.(4)The caller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(8)You may cancel this Agreement if It has not been signed at the main office or branch office of the seller,provided you notify the seller at his or her main office or branch office shown In UnJ Agreement by'reglstered or certlfiod mail;which'shall be posted not later than midnight of#4 third calendar day attar the day on which the buyerelgna the Agreement,excluding Sunday and any holiday an which regular mail deliveries are not made.See the aabitipahylnp dollce of cancellation form for an explanation of buyer's rights. (Rhode Island Soles Only); Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education materials. (k'�,\ Ownersin1ltltats By; (/�x.•,r ^� EINd Sign1 L:�.L J 1D.0./v\J�hK. ��LJ��tl✓"a y P,04. awe) / w r By 8�n NEWP OOper ng,L C( tore) a womv WHITE:Branch Copy YELLOW.Cwetnmees Copy PINK:File Copy *OLD:FnOnM Copy The Commonw. ,h of assachusetts Deparftent oflndusliialAccidents I Congress Street,.Suite 100 oslons Am 02114-200 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors)ElectriciansITiumbers. TO BE FILED WITH THE PERJW TMG AUTHORITY. lican ormstio - lease t Ldbjr Name(Business/Orgsnzetion%]ndividue]); _ Address: City/State/Zip: Saone#; Are you player?CbFtic. a appropriate bo: T e of project( llired)t t I. I am a en ploy"ar wit$ empkry 0(full ind/orpart time).« 7. 0 NOW C tuchon 2.01 am a sole proprietape rt�erahip and Ove no employyes wo jug forme m 8: Q em4de1111g any 04"IY•lNo Wide tern'co4 mice required] 1� 3. I am a homeowner doing all work myself.[No workers'comp insurance required]t 9: Q Demolition 10 0 Building'addition. 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensue that all contractors eitherhave workers'compensation uusmance or are sole 11.0 Electrical repairs or additions proprietprs.withaao�ployees. . 12.Oplumbmgt+epaietirtiddttinns 5. Ism a Benno wfibad&and I have heed Elie sub46tisetwi listed on the"attached sheet 07hyae.sukcontractmhveemployees and bavew6*='co. oe &M..n = OUR' : repairs. _ MGI c. 14. coporadadis6.0weaea anffieshavexenised tha fex oPQ ISZ,§1(4),and we lisveno employees:[No Woken,- •Any apptitynt that checks box gi:must also 1iU oatthe tetobm bebw showing t warlcers' policy infatuon, t Homeowners who submit this sffi�aviYiitdiia>tmg they are atl wofli and ihr�LinE ouiaide 6dZ' tors nwst"¢"1 fiA a new affidavit iadidii4g such. 4contractols that check this box must ettacbed eatidditioiW sheet showing the nantc,of the sub-cbatrectois and state_w r of not thox to have employees.7ftheyb egppaLsge employee;they mustpauridptheii-rvarYps;•comp.poliLyeuoba I am oat e►op,&yer thotisproviding wor4erseampensaNgn insurgoeefor m+empl ees ellary is tliRpaliiy site information. �---� Insurance Company Name: Policy#or Self-ins.Lie:#: Expiration Date: ` Job Site Address: Attach a copy of the workers'compensation policy declaration page(showiagtlie poBcy tonmber and expiration ate). Failure to se=e coverage as required under MG.1;c.152,§25A is a cammpal violation puntsheble by a fine up to#1,500.00 and/or one-year imprisonment,as well as ery l penalties;m the form of a STOP WORK ORDER anti a Pure of up-to$250.00 a day against the violator.A copy ofthis stattririeat may be f4rvv tbd to the"Office of Investigations'of the DIA for ins&ance coverage verification. " Ido hereby certify under enalti of a information provided above' true and correct. Sign Date: Phone#: t Official use only. Do not write in this area,to be Mop.Wed by city or town OOkw City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(MMroolvvvv)4J2s/2o1s 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 Melissa Pflug g Mackintire Insurance Agency Inc AICNN EAJ: (508)366-6161 Fnlc,No; (508)366-5202 11 West Main Street E-MAILss:melissap@mackintire.com ADDRE INSURER(S)AFFORDING COVERAGE NAIC# Westborough MA 01581-1931 INSURERANetherlands 24171 INSURED INSURERB:Libert Mutual Peerless 24198 Newpro Operating LLC -INSURER C Acadia Insurance Co. 26 Cedar St. INSURERD: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER-Master 15-16 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 7ypE OF INSURANCE ADDL UBR P POLICY EFF POLICY EX LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 TED A CLAIMS-MADE OCCUR PREMISES(Ea occurrence)l $ 100,000 CBP8589577 12/31/2015 12/31/2016 MED E)CP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GatL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY ECT LOC PRODUCTS-CGMPJOPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL O.MIED SCHEDULED AUTOS X AUTOS BA 8584174 12/31/2015 12/31/2016 BODILY INJURY(Per accident) h10N-OVANED PROPERTY DAMAGE X HIREDAUTOS X AUTOS (Per accident Uninsured motorist 51 split limit $ 250,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 51000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 CU 8582578 12/31/2015 12/31/2016 $ WORKERS COMPENSATIONx PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOMPARTNER1EXECUTIVEE.L EACH ACCIDENT $ 500,000 C OFFICERIMEMBER EXCLUDED? FY-1N/A (Mandatory In NH) UC-20-20-003506-02 5/1/2016 5/1/2017 E.L.DISEASE-EA EMPLOYEE,$ 500,000 If Yes,descnbe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIN41T 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Excluded Officer: Nicholas Cogliani CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TO Whom it May Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T Moynagh/DORRIE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD v f 71 Com-029090 HUMS PAUL 0' 0 N 230 INALMU'l-S T PR D IMG IvLA 018167 9120.17 U SS GTDI 0 of C l IN P" s 7. 02L vs @a chusett l Reg TTn-- TO 16689 Ul supplementclrd Type: .Al ING, A' 1\1 a-- 1. TIHOMAS TOXON OPDAR ST- A cl LaBt r cRra.Mark reason for Card 0-R e, 0 0 SCAT USe oap, _BnGs or r�gis€ration vatid fog is 'Regulafull bvfOurethetxOrstion date' lifOUnjliSinn eUSRagUl%lion Anita Consumer 112-suite 511 v ON-121, .0 WE 1M r- X10 i7?IMAM Qi qd.,Ithout slgllatula