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HomeMy WebLinkAboutBuilding Permit #915-13 - 10 WALKER ROAD 6/26/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: h4 IMPORTANT:Applicant must complete all items on this page L®CATI©N,e:� k �u�� . t'?�'. y 4,n.1' � +� f! � a x :xdi x�x.Y <- +, R moo• '�.. a� •K. ��. � $ ,1 r f µFant!�,� ;� a�� TY/OWNER L•, s '� r f , }.. Y it� k 6;,iai • ,, � 5 8 t J #..n F .�y. Mi S"� r?.y�: r'� �a K h ya . 3 �Ax.... ..,, -� x ;PrnntASfi 10 ¢ 0YearOld#Structure yes o7 , '�i !r•Ni i r '�+.x, + w' s a ..1 t�. ,...s:.,Kv i MAP NO d ' PARCELZ �y ® ING DISTRICT HistoncgDistnctw ��" 1 no Machine Shop;Uillage eyes ono. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑+Septic 0 Well •. wt d 4❑,Floodplain ' .❑.Wetlarids... p Watershed,Districf; ❑Water/Sewer . , � _ DESCRIPTION OF WORK TO BE PERFORMED: ` �Identifli tion�lease Types or Pri�}t Clearly) OWNER: Name: Phone: Address: CONTRACTOR �Name . C{ Phorie > , Address +x4 � t exa- �. � � a�t� a ,y. �, a, •.t s .�� Supervisor-si` ctlon ice' a h nn aR v� b •U• Home;lmprovemeht License Exp: Date. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1 ;, y©y FEE: $ 2oq n' Check No.: I I �° Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,i Signature of Agent/Ovvner ;.g iature of contractoALM--.. I 1 ` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print. PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 11 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 0 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Slgnatufe Of Agent/Owner _ S€g lature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF.SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art E] Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS 1 a IIS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes � I Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature Date Driveway Permit i I DPW 7[owo ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mair, Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A=F and G min.$100-$1000 fine I NOTES and DATA— (For department use i i ® Notified for pickup - Date t Doc.Building Permit Revised 2010 Building Department The folawing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan. ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app%-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+.ted with the building application lication ,I Doc: Doc.Bui?ding Permit Revised 2012 I l l Z.Id �o No. -(� "�� I (3�'�! I�j - 1 Date X12? `� ��- �3 , iii Sr-�� qz ► —� • ' TOWN OF NORTH ANDOVER f Certificate of Occupancy $ Building/Frame Permit Fee $1�'3 Foundation Permit Fee $ w Other Permit Fee $ gyp` TOTAL i $ � Check# 26566 j Building Inspect i 11 i r 1 NORTH _ . vv: : ic , vTO No. * -t _ D� � Z C' , ver, Mass, cocN1C 2W.c« �1 RATED U BOARD OF HEALTH Food/KitchenPERMIT T LD . Septic System THIS CERTIFIES THAT A1VI10.e..Q .. ��,.... ,,,,,,,,,,,,,, BUILDING INSPECTOR ..... .. ..... . r has permission to erect........ ................. buildings on Foundation .... ..... .. .. P........ . �.............. Rough tobe occupied as .......... ... .... ... uft ...................................................................... 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR a� UNLESS CONSTRUCTIO S 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 Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 24 13 02:23p MGS Construction LLC 6034323282 p.1 PROPOSALIC11ONTIRACT Meadowview Condominiums 5 Walker Road � N. Andover, NLA, Roof Installation FROM: MGS Construction LLC 2 Lake Avenue PAGE NO. 1 OF 2 PAGES Derry,New Hampshire 03038 DATE: June 13.2013 Office: (603)216-2633 Cell:(617)293-7287 Fax: (603)432-3282 PROPOSAL SUBMITTED TO: Shawmut Management ADDRESS: Meadow View Condominiums 27 Charles Street 5 Walker Road North Andover,MA 01845 .,6:8, 10; 11, 12,and 13Building Contract) ATTN:Matthew Dykeman CITY/STATE: North Andover,MA JOB NAM---- Roof Replacement Project We hereby submit specifications and this proposal/contract for the:follol,'ting: BREAKDOWN: MGS Construction will remove 2 existing layers of roofing and flashing materials from roof field including the chimney lead MGS Construction will supple and install 6'of ice and water shield at roof eaves and valleys, 18"to either side of hip, 3'at all pipe boots/roof penetrations MGS Construction will overlap the ice and water shield 1"over fascia/rake boards to help protect against from ice dam damage MGS Construction will supply and install 301b felt paper to(he remaining.roof field MGS Construction will install all new drip edge and flashings MGS Construction will re-lead I chimney per building MGS Construction Will supply and install manufactured leading edge to complete the roof perimeter as the manufacturers suggest MGS Construction will supply and install limited lifetime architectural shingles. Color to match new roof(completed by others)on building 1 MGS Construction will hurricane nail 6 nails per shingle to protect against blow offs Meado,A•view Condominiums 1 2013 Roofing project Jun 24 13 02:23p MGS Construction LLC 6034323282 p.2 In the event,that unforeseen rot is found A plywood replacement charge in the amount of$45.00 per sheet(labor and matQrial)will be billed additionally to the contract amount. Any items not stated above are to be considered as an extra charge and will be invoiced separately from this billing..All other agreements to be made in writing between the customer and MGS Construction. SINGLE BUILDING PRICING: Each building will be re-roofed according to the above specii:ications Labor and material:$17,000.00 per building TERIVINNOTICES:RESIDENTIAL MGS Construction is not responsible for any sbrub,landscaping,la,;m or loose personal property damage while work is in progress.It is the home owner's responsibility to ensure that prior to the start of the project all arats of concern are prepared forstart ofproject.Any shrubs,plantings,should be pulled away from the house to ensure bat no damage will be endured by work in progress.All planters,grills, patio furnishings,and other precious objects should also be moved prior to the start of any roofing-or vinyl siding project All vehicles should be parked at least 20 feet away from the home during all work"in progress this is due to debris that could fall and or hit the vehicle. MGS Construction is not responsible for any damages to this pmpeuty as this should_be considered as a formal Notice.All interior wall hangings,including shelving pictures,and otherpreeious objects shoald also be removed due to heavy hammering until the project has been completed. MGS Construction takes extreme care in the setting up of the equipment,scaffoldinnA and tarps used on each project in order to protect all property and landscapes..Any exterior damages to property incurred by MGS Construction will be remedied repaired/resolved by MGS Construction.However,we cannot be held liable for damages to plaint and or flower beds,shrubbery,etc located within 15'of the perimeter of the work area. MGS Construction will not be held liable for cracked or damaged drywall or for any interior objects that may vibrate,sbake,or fall due to heavy hammering or normal constraction work. MGS Construction estimates that this projectwill be started and corapled:d within 14 business days weather permitting WARRANTY: MGS Construction will warranty their craftsmanship for 5 years from thedate of completion.This does not include acts of nature and or damages incurred by others. Manufacturer's warranty:The manufacturers all carry limited waminties on all products used(usually pro rated atter 5 years) PAYMENT TERMS: We hereby propose to furnish labor and materials to complete in ac::ordanrcc with the above specifications,for the sum of fine Hundred Fifty Three Thousand Dollars($153,000.00 )per building with payments to,be made as follows: A deposit in the amount of$76,500.00 is due upon completion of four buildings The remaining balance in the amount of 576,500.00 is due within 7 days.from the completion offinal building NOTE:A teri percent(l0%)of the ieanaiiiing balance-rmy be held:Ibi rel t4inage in the event of unusual circumstances such as nrimr . property damage incurred by MGS Construction or in the event ofliackardered materials. Please note it is unlikely that a retainagge would need to he held in most cases. All material is guaranteed to be as specified.All work to be completed in a workmanliilce manner according to standard practices. An alteration or deviation from above specifications involving extra•i:osts will be eb:coted only u on written orders, and will become an extra charge over and above the estimate.All agreements cantingcnt upon s, accident or delays beyond our control.This proposal subject to acceptance within 30 days and it is void thereafter at The•option o undersigned. Authorized Si ature (' ���-t� Q-e r Meadowview Condominiums 2 2013 Roofing project Nw. Board of Baildin r`p,<r,rrncnt t,t Bc r ut)lic S.rfct� Construction sup"'ul:�iioq.�'anc! ervisor Stand,ir.cls License: Cg 57645 License .rY'tJfN••'• _ MARK E MO 18 NEWELL DR INI �- N AT7-LEB01RO MA 02760 C'uqurussiuni r Expiration:n: 9/18/2013 Tr#: 10303 :r :9 6 I 10 iOffice of Consumer Affairs and Ifusiness Regulation `i' l 10 Park Plaza- Suite 5170 ��`' `? Boston, Massachusetts 02116 �:..: Home Improvement Contractor Registration Registration: 171254 Type: LLC 1 Emirfl— C II'MI 1 �•.0 ��a neo M GENDRON & SON CONSTRUCTION LLC MANUEL GENDRON P:O• BOX 1024 DERRY, NH 03038 Update Address and return card.Mark reason for change. [J Address [] Renewal E] Employment Lost Card )PS-CAI Co-SOM•04104•G101216 ='`• Office o onemert �uerz�IrB ljtbc�r�eelt >/� �`{'t�a�rs mess c�+u a iou License or registration valid for individul use only nh " -•HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: is Re istration: Office of Consumer Affairs and Business Regulation t (:• 9 171254 Type: - -- 1'11��71 + Ex lration: 3/1/2014 LLC lU Parlc P[aza-Suite 5170 �afL,i p. Boston,,MA 02116 M d�hbRON&SON CONSTRUCTION LLC. MANUEL GENDRON.; 6 ENGLISH RANGE RD DERRY,NH 03038 Undcrsecrcta -- O' Not v )d wi )ou ignature CERTIFICATE OF UlABIILITY INSURANCE ilE miCATEISISSUWASAMATfEROFINFORIYU►?IONpNLY w(zkr-ERSNORIGIiTSU ECERTIFICATIc HOLDER. ERTIFICATE DOES NOTAFFIRMATNELY OA NEOATIVEI-YAW110.UTERIDaRALTER THE COVERAGE AFFORDED BYTHE POLICIOW. THIS CERTIFICATE OF YISURANCE DOES N01CONSTtTI'ITEA CONTIIIACT tIETWEEN THE ISSUING UiSURMS).AUTHORIZED ICA1 N F ra MPOR7ANT:ftfhseartNicalel7oldaris an ADOGIONAL INIIURED,the policAlles)must be andorved. NSUBROGATION IS WANED.subjW to he tenor and conditions of the pollcy,canaln DoYciae aaay require and endomernanl A stAttment on this eerWicote does not confer rights to ha oerifficaU holdu in luau of such auforssnr PRODUCER IEAIIIAL ONTACT P LANWGHTINS&FWANC:jA FAILNOME2z4 MAW ST STS 2A UC.N4 t:AG. WCW;SAUK NH 03079-31.92ADDEIE24.: ?fFiAQF1 &WR8"AVF0a) Ira COV13tAQE MAIC A RLSIIR� 10 MIARETt A: BAP TFORD EI7I MR LWR[rER5 INSURANCE CokeANY M GENDRON&SON CONSTRUCTION LLC DBA 162US q awaaR o; CONSTRUCTION aitBlrREst P0BOX 1024 RSD' WSURER I- DMMY.NIA 03038 IV rSURHt F: ME RAGES COtiFICATEMtAM�t: �__� isEMSr4N IAlIBBt: EIaR7l!lZSS+I o PUT MUAl17rlKTAIbMGlU7�q.Y�iT.1i�fOt1 D01dlK1M OF AIiY Q)1rnMLt OR 0111�OCIC1iEirrN7rN RfERELT70 WICNTN6C�TTIfJTEfNY YEIEiWFDDRfMY NAVE OL i116M6UR*V AS CLAMS. 11nEPOlDC�6t1i3Cletar>oF�IBIrSEt1�16!I'TORN.AfETEII�",flOCW610R6AIptOI�IT�N6OFSMRrOLlCr�4 UMrrSsHownINY NAVE 6®I IlkDla«D aY PAS CU{�' nett o0llr V G*DATE PoIJ Cv�DATE LTR TYPEOFOW IRAMM L R POLALY M11e•!J! psillDo{YYYU} Q��YY1'Yi tom M1StALLIAINLiTY IMACE OCURRENCE S COMMERCIAL GENERAL LMILIFY CLAIMS MADE �OCCLIfR. TO RENTEDSES(En occurrenco) (P Wvorra oeraor�GEM AGGREGATE LIMIT APPLIES PER• NALRADVINJURY S POIJCY [D PROJECT O LOC AL AGGREGATE S CrS-COMPIDP AGG S AIJrDWWALE LIAGMAW ' ANY ALTO EPERTYIDAMAGE S amclelll ALL OVO ED AUTOS IVJURYSCHEDULE AUTOS rson) HIRED IWfOS INARYNON,OYYNED AUTOS kim S leer accded! UMBRELLA LIA9 OCOUR EACH OCCLIRREIVCE S EJ(CESSLIAS CLAIMS-MADE AGGlEGATIE S DEDUcnBUE S RETENTION& S . A WORKEWSCOWEN'SATLONAND —�� vuCsrwturaty Or►ER ewLaroYsuw tLlTY' TIN US-4292P3 J* 000Q 13 OW3WM4 % utilTs ANY GROPER fr0WAAITdEREJ*QIrfwe C FrrX-RpUEAIBER EXCLUOW? E L EACH ACCIDENT S 100,000 oftehawyaem9 ELUSEASE-EAEMPLOYEE S 1OO,DW If Yet de—be„nmr DEMRrPr104OF OPERATK*Z be%w EL.DISEASE-POLICY LIMIT S 500,000 DESCRPTION OF OPERATWSS40CATIONVAN OC EWPXSYFdcn0m-oisp C Ui L MIS THI3REMACW ANY PRIOR CHRTIFICATn ISSUED TO TEE CBRTM(-AHE HOLD-mR.atFPCi W O WORLM COMP CO VFRAOR. CERTIFICATE HOLDER d ANCELIJATION —_ SHOULDAKVOFTi41FABOVEOESCIWIEDPOLKAIMBECANCELLED BEFORE 7PEl[PIRAr()KDATE .ft0uM'?r—LesS:p...EgW W ACCORDANCE WITH THEPOUCY PROM L -— I [AIMTHOWEDREPFAMO INE I ACo 29(2070105) The nam®and logo are ropls I mar ACO reserved. 8'd Z8Z8Z bE09 mi mionaisuo7 Rnw dp.n:7n P.i- a7 unr 4<7"R"RU® CERTIFICATE OF LIABILITY DATE IMMIDD(YYYY) Y INSURANCE 3/19/2013 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, E:CTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NCT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),I ER(S AUTHORIZED REPRESENTATIVE )� OR PRODUCER,AND THE CERTIFICAS'E HOLDER.. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,rile Policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require art endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C(;NTACT N1IM : Qa'tr1C1a Blair Financial Insurance Services Inc P OME (603)932-6414 ac No-_(603)432-3852 PO Box 950 AIItM Ess:PblaisQfis ins.com INSURERS AFFORDING COVERAGE NAIC C Derry 11H 03038 INSURER A:Peerless Insurance Co INSURED IN!tU RER B MISS Construction, LLC 01313RERC.- PO SOX 1024 INf:URER D- IN3URER E: Derry NH 03038 211WRER F: COVERAGES CERTIFICATE NUMBEFtj3-19 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEROD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION CI ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFF(:)RDECI 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. IN6R LTR TYPE OF INSURANCE EOLICYNUMBE it (NM10 FPP MMlOD EXD uMt trs GENERAL LIAS(UTY EACH OCCURRFJICE S 11000,000 X COMMERCIAL GENERAL LIABILITY A&=TO N PREMISES(Eaoccumence 5 100,DDO A CLAIM DE a OCCUR 81035059 13/2013 /3/2014 MED JCP IAny one person) S 5,000 I PERSONAL&ADVINJURY 5 1,000,000 GENERAL AGGREGATE . $ 2,000,000 GEN'L AG GREG.ATE LIMIT APPLIES PER. PRODUCTS-COMPJtJP AGG $ 2,000,000 X- POLICY JECT PRO- LOC 5 AUTOMOBILE LIABILITY COMBINED SINGLELIM71 i t 6DED O BODILY INJURY(Pet person) $ ED SCHEDULED AUTOSNC BODILY INJURY(Peraecidenl) $ UTOS AUTOS NON-OWNED PROPERTYOAMAGil Per accident $ 3 LA LIAR OCCUR EACH OCCURRENCE 5 EXCESSlIAB CLAIMS-MADE AGGREGATE S 4 RETENTION$ WORKERS COMPENSATION 5 WC STATLI OTH- ANO EMPLOYERS'LIABILITY IT ANY PROPRIETOMPARTNER/EXECUT[VE Y J N I I ER OFSCE"EIARER EXCLUDE09 NIA E.L.EACH ACCIDENT S (MandatoryIn trader In NH) if describe E.L.DISEASE-EA EMPLOYE S yyes, OESCRIPTiON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedula,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 ACCORDANCE WITH THE POLICY PROVISIONS. nA1THOR12ED REPRESENTATIVE Ryan Fragala/PAT ACORD 25(2010105) ©4988-2010 ACORD CORPORATION. All rights reserved. INS025 mm�n�ol Thn QC(TRn nn rov+Anrl lnnr&ara ennictaroA mar4e nr ar npn d Z8ZeEM09uoo}l �l� , nJ}suoo SSW dV0:Z0 O6 97_ ung