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HomeMy WebLinkAboutBuilding Permit # 8/31/2016 -- --- -1 ...... ............................... IA®RTH '9 I Town of _ ,,. a ®ver 0 �►a No. ;16 n° Ah �.K. h ver, Mass, coc..,cncM,rcR P ` BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .................... *401V :....�, . .. .. BUILDII►l6INSPECTOR .......... has permission to erect ................. buildings on ..I. ... l�!;!...... �V� ,,, Foundation ...... g ... ... .�.h1� :, .s�:1111 Rough t0 be OCCLlpled as ..... ...a/ Thapplication Chimney provided that the person accepting this permit shall in eve respect conform to the terms of� pFinal 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 PERMITMONTHSELECTRICAL INSPECTOR UNLESS 11: CTI Rough Service . ..... .... ......... .......... Final BUI G INS CTOR GAS INSPECTOR ccMancy Permit Required to Occupy Builclin 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 Approved by the Building Inspector. Burner Street No. Smoke Det. www.Revi%eEnargy.com Revise Energy Home Performance Contractor 5 South Summer Street,Bradford,MA 01835 CONTRACT 978-914-2214 FAX(401)784-3710 Page 1 PROGRAM CNA-HPC eGSTONER PHONE DATE CLUEMT0 WORK ORDER Kenneth Campisi (978)852-7942 07/28/2016 437943 21202 SEAM MAE" BILUNG STREET 134 Mablin Avenue 134 Mablin Avenue IME1 MY,PATE,DP a ciry'vrAir.Zip North Andover, MA 01845 North Andover,MA 01845 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use ofspecial tools and diagnostic tests t0 assure that your home will he left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(12)working hours.A reduction in cubic feet per minute(cfm)ofair infiltration will occur,but the actual number of efm is not guaranteed. At the completion of the Avealherization work,and at no additional cost to the homeowner,a final blower door andlor combustion safety analysis will be conducted by the sub-contrdetor to ensure the safety of the indoor air quality. 51,020.00 AIR SEALING ADDER: (7)working hours. $595.00 KNEEWALLS:Provide labor and materials to install 2" FSK faced septi-rigid fiberglass board insulation to(4 4)square feet of kneewalt area. S t,554.00 KNEEWALL.FLOOR:Provide labor and materials to install a 6.25"layer of R-19 unlaced fiberglass bans to(732)square feel of kneewall floorspace. S 1.083.36 VENTILATION:Provide labor and materials to install(2)insuluted exhaust hose to existing bathroom fan(s). 5100.00 VENTILATION:Provide labor and materials to install ventilation chutes in(57)rafter bays to maintain air flow. $114.00 ' ' x � R Planview Diagram Ustomer : e r r Advisor Name; jr Address - Advisor Phone, #: S G U Town f J Any limitations to acce�s�Y truck? site ICS NOTES Any work scoped outside of Best Practices? }} Approved by: ; (gi4c L. j , ao AS a � � 3 3� 1 I 8/29!2016 134 Mabiin Avenue North Andover MA 01845—Salesforce-Professional Edition fsorce- _ Close Window = Print This Pane • Expand All Collapse All 134 Mablin Avenue North Andover MA 01845 Account Name 134 Mablin Avenue North Andover MA 01845 Contact Name Ken Campisi Parent Account Rise Engineering Phone 978-852-7942 Account Owner Tara Carroll Phone Type Home Preferred Time to Call Email campisik@verizon.net Address Information Billing Address 134 Mablin Avenue Shipping Address North Andover„MA 1845 Building Information Living Space Sq Ft 1,600 Type of Home Ranch Number of Units 1 Year Built Condo Association No Years in Home 50 Owner 1 Landlord/Renter Owner Number of Occupants Utility Information Primary Heating Fuel Natural Gas Gas Account# Primary DHW Fuel Electric Account# Gas Utility Columbia Gas Last Name on Utility Bill Campisi Electric Utility National Grid First Name on Utility Bill Ken Fuel Assistance No EBR/EFR/EAC -Advisor Heating System Eligibility Customer EAG Rebate Form Customer Has EBR(EFR Cooling System Type Rebate Form Heating System Type Cooling System Year h#ps:i/na30.salesforce.com/0013600000SFA4t/p?retURL=/0013600000SFA4t 116 8/29/2016 134 Mablin Avenue North Andover MA 01845--Salesforce-Professional Edition Heating System Year EBR I EFR I EAC Notes - Heating System Manufacturer ESR/EFR I EAC Submitted to Clearesult Heating System Model Number Heating Serial Name Photos Submitted System Information Created By Dana Hills,7/11/2016 12:33 PM Last Modified By Sam Webb,8/29/2016 9:53 AM Custom Links Google Maps Google News Google Search Opportunities 134 Mablin Avenue North Andover MA 01845--Rise HEA Opportunity Record Type HEA Stage Closed Won Amount $759.38 Close Date 7/27/2016 Probability(%) 100 Lead Source OiPietro Referral Owner Full Name Tara Carroli Won s/ Fiscal Period Q3-2016 Next Step Type Last Modified Date 8/2912016 Description 134 Mablin Avenue North Andover MA 01845 -Weatherization Opportunity Record Type Weatherization Stage Opportunity Identified Amount Close Date 7127/2016 Probability(%) 5 Lead Source DiPietro Referral Owner Full Name Dana Hills https:itna3O.sal esforce.com/0013600000SFA4t/p?retU RL=/00136000003FA4t 2/6 8/29/2016 134 Mablin Avenue North Andover MA 01845—Salesforce-Professional Edition Won Fiscal Period 03-2016 Next Step Type Last Modified Date 8/2612016 Description Contacts Ken Campisi Landlord !Owner/Renter Owner Email campisik@verizon.net Phone 978-852-7942 Phone Type Home Fax Mobile Open Activities WX Install -Revise Energy Truck 1 Name Task Due Date 8/30/2016 8:00 AM Status Assigned To Dana Hills Location Related To 134 Mablin Avenue North Andover MA 01845--Rise HEA Comments Truck Maintenance WX Install -Revise Energy Truck 1 Name Ken Campisi Task Due Date 911/2016 8:00 AM Status Assigned To Revise Energy Truck Location Related To 134 Mablin Avenue North Andover MA 01845 Comments the homes for 911 and 912 are right next to each other and owned by same homeowner so if needed can work on both on both days if one is faster than the othe r Activity History Rise HEA-Do Not Move Name htLps:fina3O.sal esforce.com/0013600000SFA4Vp?retU RL=/0013600000SFA4t 316 8/29/2016 134 Mablin Avenue North Andover MA 01845—Salesforce-Professional Edition Task Due Date 7/27/2016 8:00 AM Location Assigned To Kyle Meredith Related To 134 Mablin Avenue North Andover MA 01845--Rise HEA Comments Columbia Gas Customer please call&email the day prior to confirm Email: Pre Visit Email 7127/2016 Sam Name Kyle Meredith Task ,/ Due Date 712612016 Location Assigned To Dana Hills Related To 134 Mablin Avenue North Andover MA 01845--Rise HEA To: kyle.meredith@reviseenergy.com CC: BCC: dana.hills@reviseenergy.com Attachment: --none-- Subject: Pre Visit Email 7127/2016 Sam Body: EM Status: Not Submitted SitelD: Name: Ken Campisi Landlord 1 Owner 1 Renter:Owner Email:campisik@verizon.net Phone: 978-852-7942 Address: 134 Mablin Avenue Comments North Andover,MA 1845 Primary Heating Fuel: Natural Gas Gas Utility: Columbia Gas Gas Account#: Electric Utility: National Grid Electric Account#: On Fuel Assistance: No Last Name on Utility Bills: Campisi First Name on Utility Bills: Ken Living Space Sq Ft: 1,600 Year Suitt: Number of Units: 1 Condo Association: No How did they hear about us?DiPietro Referral Notes to Home Energy Manager:Weatherization.Referral from Donnie Briggs,DHC Install Mgr.Home was rebuilt in 2002 Email: Revise Energy: Scheduled Appointment Name Ken Campisi https:/Ina3O.salesforce.com/0013600000SFA4ttp?retU R l.=10013600000SFA4t 416 8/29/2016 134 Mablin Avenue North Andover MA 01845—Salesforce-Professional Edition Task Due Date 7/18/2016 Location Assigned To Tara Carroll Related To 134 Mablin Avenue North Andover MA 01845--Rise HEA To:campisik@verizon.net CC: harry.black@reviseenergy.com BCC:tara.carroll@reviseenergy.com; dana.hills@reviseenergy.com Attachment:--none-- Subject: Revise Energy:Scheduled Appointment Body: Hi Ken, Thank you for scheduling a home energy assessment with Revise Energy.You are confirmed for the following date and time.Please do not hesitate to contact me with any questions. Date:Wednesday,July 27th 2016 Time: 8:00am Energy Manager: Harry Black Address: 134 Mablin Avenue North Andover MA 01845 North Andover,MA 1845 Comments Kind Regards, Tara Tara Carroll Sales Coordinator Revise Energy 5 South Summer Street Bradford,MA 01835 Office:978.241.7091 Direct:978.771.9547 Toll-Free: 800.885.SAVE(7283) Tara.Carroll@ReviseEnergy.com www.ReviseEnergy.com tara.carroli@reviseenergy.com Call -Outbound 1 Name Ken Campisi Task ,I' Due Date 7/18/2016 Location Assigned To Tara Carroll https:lina3O.salesforce.com/0013600000SFA4t/p?retURL=/0013600000SFA4t 5!6 .............. 8/29/2016 134 Mablin Avenue North Andover MA 01845—Salesforce-Professional Edition RelatedTo 134 Mablin Avenue North Andover MA 01845--Rise HEA Comments Columbia Gas Customer-Rescheduled for 712712016 Files 0080 001 Ken campisi mablin Program Disclosure Last Modified 8123/201611:40 AM Last Modified 8/9/2016 4:33 PM Created By Dana Hills Created By Dana Hills Ken campisi mablin Material Install Summary Ken campisi mablin CST Last Modified 8/912016 4:33 PM Last Modified 8/9/2016 4:33 PM Created By Dana Hills Created By Dana Hills Ken campisi mablin Last Modified 819120161:06 PM Created By Kyle Meredith Copyright O 2000-2016 salesforce.com,inc.All rights reserved. https:llna30.salesforce.com10013600000SFA4Vp?retURL=/0013600000SFA4t 616 REVISE ENERGY EMENINKEEMENEMNIMMEEM A DIPI ETRO COMPANY As an employee of Revise Energy (DiPietro Home Energy) holding an Unrestricted Construction Supervisor Llcense (CS-056846), I hereby grant permission for either Dan Carroll, Matt Hammer or George Desroches of Revise Energy to apply for and or pull a permit in my name and under my license for Weatherization work. Weatherization work may include, air sealing, blown cellulose insulation, installation of weather stripping, door sweeps, thermax, etc. I approve this permit to be filed under my name by either gentlemen listed above in the town of: Sincerely, John Cullen License # CS-056846 Cell: 781-526-5581 7/26/2016 1M G_0605.J PG �v t zr� 4 �: �'`• �t�i��f' �£� zS5 �Y�.�S� ��$ �fs,Siz;a,z�a�S-�{e�?t��; "5.�:,-��,?.��`is ��ti ) � �F� ���� � 4 F https://mail.google.com/maill#knbox/156288b66940610d?projector=l 111 Unrestricted -Buildings of any use group whichMassachusetts Jepaf-me.- c* 3 Iii I sy �gu,aT:G; s u a,.ua s contain less t 35,000 cubic feet(931m )of Gtr: o. enclosed space. cense CS-056W JOHN is CULLEN' 46 VALLEY ST Wakefleld MA M80 i Failure to possess a current edition of the Massachusetts State Building code is cause for revocation of this license. s- For DPS Licensing information visit: www,tvlass.Gpv/APS 04103120' s I ' u 0 i tl 9 py6 r t i e�ff/ j, Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 185083 Type: Corporation Expiration: 4125/2018 Tr# 288111 DIPIETRO HOME ENERGY .JOSEPH DIPIETRO 5 SOUTH SUMMER ST. — --- HAVERHILL, MA 01830 -- Update Address and return card.Marls reason for change. SCA 1 .:? 20M-05111 Address [:] Renewal Employment Lost Car Ljxn((urec(t� office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRALTO pe: s Registration: 185083 Gorposaiion ExpiratloP�ow z�ly�l A18 DlPIETRO HOME I?Ala .: SOLUTIONS,INC. j0SEPH DIPIETRO � y `-- SOUTH SUMMER--T- 5 Undersecretary HPVERHILL.MA 01B30 i i i 3 u i °o i. i I B Y'he Commonwealth ofAIassachusetts � rrlrtr corm � epartinent of Intlustrial Accidents f fice of Investigations i J I Congress Street, Suite 100 Boston, tl?'A 02114-2017 n wltviv.mass.govldia Workers' Compensation InsuranceAffidavit: Build ers/C✓o>rYtractcars/Electricians/Plumbers Applicitnt Information Please Print Ire ibl 7,-,07, . . Name (t3usiness/org;antcatioti/Itidivic[ual): �°� �?^ �� �J� � �` ,�� .�a 'x;11 / "tale/ZtP` 7 :._ w .. M .. Y I hone #� Are you an ernployerT, .heck th6 appropriate box: 'type of project(required): l.'l.'M I ant a employer with_/" 4. E] I am a.general contractor and.l have hired the sub-contractors 6, New construction employees(full and/or part-time).* 2.❑ f am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have 8, F-1 Demolition working for me in any capacity, employees and have workers' 9. ❑ Building addition. [Ni o workers' camp. insurance comp. insurance.( ❑ We are a required.] S. oration and its 10.0 Electrical repairs or additions corporation 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of"exemption per MGL 12.0 Roof repairs insurance required.] f e. 152, §1.(4), and we have no employees. [No workers' 13.0 Othe�,V 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 subrit this affidavit indicating they are doing all work and then hire outside contractors trust subnut a new affidavit indicating such. !Contractors that check this box nxust 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'corp,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..__ " �^ mm.._ - Policy#or Self-ins. Lie. , . w 2 01p �7 Job Site Address City/State/Glp r � � mv; Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 1.52 can lead to the imposition of criminal penalties of 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 tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ado hereby certif under the gins nd penalties o ' er'ur that the in ormation provided above is true and correct. St mature: I7atc: ,, ,, . -__ c ::: ::A Phone#: Official rise only. Do not write in this area, to be completed by city or town official. City of-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#: Information n Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s), address(cs)and phone number(s) along with their certificate(s)of insurance, Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial. Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-201 www.mass.govldia ACOOR" CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDDIYYYY) 1 8/30/2016 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 Emily Costello Costello Insurance Agency, Inc. PHONE (978)374 6352 �� No:(978)521-5127 2 S. Kimball St. E-MAIL ADDRESS:ecostello@costellainsurance.com PO BOX 5248 INSURER(S)AFFORDING COVERAGE NAIC# Bradford MA 01835 INStIRERA:C010n Insurance Company INSURED INSURERB:Commerce Insurance Co. 34754 Dipietro Home Energy Solutions, Inc. INSURERC:St:ar Insurance Com an DBA: Revise Energy INSURER D: 5 South Summer St INSURERS: Bradford MA 01835 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1642500527 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 DDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE [il OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ PACEP305047 4/25/2016 4/25/2017 MED EXP(Anyone person) $ 10,()00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000f000 X POLICY PRO- SECT 0 LOC PRODUCTS-COMPlOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMccidBINED SINGLE LIMITent $ 1,000,000 Ea a B ANY AUTO BODILY INJURY(Per person) $ AOSCHEDULED HS6325 4/18/2016 4/18/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED ED Per accident X HIRED AUTOS X AUTOS X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1 000 000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ OED X i RETENTION$ 10,000 EXC305048 4/25/2016 4/25/2017 $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER Y f N ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) WC 0856525 00 4/20/2016 4/20/2017 E,L,DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 (978)688--9542 dbelanger@northandoverma.g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE W[LL BE DELIVERED IN Inspector of Buildings Don Belanger ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Emily Costello/HOYECI ��`, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS(125onunii