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HomeMy WebLinkAboutBuilding Permit #151-15 - 101 CROSSBOW LANE 8/23/2012 BUILDING PERMIT °F N°RTF q tt�ti,eD �6� tiO TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION by n e Permit N0: Date Received °RATED gSSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page Print# PROPERTY/®WNERI. .7/��_ /'"�IIGI . 'MAPJ24 PARCEL.; O 0,NING IS DC R_(Q% Histori c Qist'rict yes noa __ — �� - Machirie;Shop,Village: yes) not 10 ,1Year;Old Structure, 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 epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑;Septic m Welly f []`Floodplain; ❑Wetlands, ' ❑ WatershedlDistr(t, ❑Water/,Sewed � t,_ - DESCRIP ION OF WORK TO BE PERFORMED: AIS7/—�L, 1%_oCl.4 Identification Please Type or Print Clearly) 1 OWNER: Name: %/Al/ Phone: Address: C,ONiTRACTOR? Name:: G/- ' .L Address : /3iEi� t Supervisor Coristructioni License: �__3.x`0 �..- Exp Date' { JJ, Homed Irnpro'yem°entrLicense . I/2 .��l -_ _ n._._ Exp, Date:, Z 9/3_ - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ D u— FEE: $ Check No.: Receipt No.: NOTE: Persons contrac ng with unregistered contractors do not have access to the guaranty fund Location No. Date —, /�► • • TOWN OF NORTH ANDOVER • 5�f�TI�1"sti x��' � • Certificate of Occupancy $ Building/Frame Permit Fee 4; 2Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �'Z 25642 Building Inspector i ignature�of;Agent%®,wnerr� +Signaturo►of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL i Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ ❑ i Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I CONSERVATION Reviewed on Signature i COMMENTS 41 HEALTH Reviewed on Signature I 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 DPW Town Engineer: Signature: Located at 384 Osgood Street—978-685-0950 FIRE DERAR I ENT' Temp)Dumpster�on*site? yes no. LFoc'raetae`dja1243MS6881'9590;aft7, ' Departrnent?signaturo/date 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 NOTES and DATA— For department use f ❑ Notified'for pickup - Date Doe.Building Permit Revised 2012 i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit Li Photo Copy of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I Addition Or Decks o Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass Check Energy Compliance Report (If Applicable) u 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) L3 Building Permit Application L3 Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass! check Energy Compliance Report Li Engineering Affidavits for Engineered products VOTE: 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2012 NORTH Town of . t _ Andover p ,� o �A�f h ver, Mass, CX1 ILd COCHIC«.WICK �'►• �,9 A°R�rEv ►�Pa,�'�5 S U BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THAT LOM.... ..... ..1. .... BUILDING INSPECTOR has permission to erect .......................... buildings on ...................�. ...6.,0.04)................ Foundation rRough to be occupied as ....93 ....... . -IN...... ..:....... T..... .... .........A.................................. 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 UNLESS CONSTRUC TA 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. Smoke Det. SEE REVERSE SIDE _ Massachusetts- Department of Public SafetN _ Board of Suildinl- Re!-ulations and Standards Construction Supervisor License License: CS 53506 _ i GARY E LISS 13 STONEWALL TERR ATKINSON, NH 03811 Expiration: 3/30/2013 ('ouunissio��cr Tr#: 13129 o - - -- —- ,Caelalaasaapun y�•�.^ .L' SCO HN 'NOSNIN-LV 2131Ilb'M3NO1S£L - j SSII A. JVJ r ; -�t _ in SSI-I'3 J .� en ini uj ' l067t+ ':uol;ejidx3 :od�C1 ` S6SZlG :uol;e�;slBaa b010"IN001N3W3A021dW1 3WO14, uaoge m sns �amnsuo o'aa93o'q i Gary Liss General Contractor lWo tome motleRce ell beats mqubmteata of die aWs flow InVmvtmw=nbujur Lttw(MOL dMPW 14Ud W400 tW b*k% Ittngup8p to ft it Co t hantttaantoat. 149 � P� tett ea weak an your maidumktww�. You rt�abWa a Aye�bar all fie dlAA Ms�ahusa�Coomma(faidc to attune t � 01400 VCw9U~4ffdbV and 8wimw RaWMA t:C4m=~hfowat"Had4m at 617.473.9181 ar 1 20-3111 ar asauwwaWla HORt9411t1Sr Istermlaillm �:QA lfll�Qle' Nemo: 99th Malwy G'Oalp!@llr Wto+a Cirnyr Lim(latera!cum afar SNO hddata~ l8l tmsbowLeae C r/9tt1e unw Owns wore: t]ery L.las ;CWTown: Naft Mdww Smew tlddi=(Matt itohtda s asst Wdnm)- 138 IT Dqufho Pham OW/TwwStd �R SS6. *insdn N.H. 03tti UslOng A dude(lfQilllomt ltam ebo a) SLOhm now F4021 SPO'U): Ura�rdwsmirar Fiwat�.rr�lbwwiryti.+. ttwwetstt,�r.fer twiw+•�w . ck..li+r rta•� uns~s�tz3�yS' ataotS"o The Coattwctor agrees to do an tbihrtftg ww t fbr t tb H#Mmm (t�cetee m AetsR drt aorto b ba o ryeeitylr��ham►t�aad�q f ya Qe taa�,ero aAdMtow Ott ttae�po�uy} Sea AKadied ftegttlr�d bet+rtit►'tho tblbwtt�buiidla pal aw SM tIdtla.ria tsoiQ;w adg be to kW and will beSODAW by die a Nsclut raft a�tteerrda►ttaWsdua�e�r,aesbgaondstteaw,e�aricmuraniMee �e (C)urAenwhoeegmstbelta�tmpt t 8-�8.ts Oft wbai+onntndm will NO aannfed wade wlil batooeblded fttt ftQX dWFWdpt id=dMGL � 14211.] q�3-t3 teaaroeniteotedwatwlitbsraebpt..a T+Dht C4att�l�eite�ihllrelHut 8ehedale The CattaeotortdporstapetibumptcwaukAxahfttlfetnuMerleitndlNDarepecilhdt�ha+rmlbtdralo�ixettot:.�I��0�. f�' >'arunatuta wilt tie rs�t eopettilt�fu ih0 eC�0u1a f 32tidAf) uponu oouuW l(suerbatraaW 112 o!'du mutasomploepr tbtt ooRadrpnW ardortmtul►wtttkt:erbpotroor) g32WOO _ wbanwi*jmat=,,rQet-4 -bind gebeft upat aamp>etmtt er"ouxmtiet(iittr Ibtttlt4e a mmft iw pay� autttl am&m is oartpkttrrf b tt O Ow"atdiaergt" �dbeJbleftoaatwtrr>dtagikta�iasiaae�r 5�,,,,,,,,,,_,bbepuidtr inrtsatiootedtedukrC� !.,�,,,,,,,�„_t►t+epafdbr MUM Gapptttcpfdp0a�[a►douuaptpa+enttlq�tMdbf►taaadtr t rru�aru�¢i ��io�obo�ta�tfo�n telepadtda�uip�m�are� milatd dv- &ttbeowb�tora-Theeaaatctoerg�bb.�r �. �� ���o�r��Otiff�tJl�o'Si�t IN IN Moll udibWbytlteoonmm'li come etntLe w bhe regadleeirafttiall, rteafrs�ttl�d � a�$►tsrptredbirihrattpaaaneasoa��sieanAraelortrl6r CaatrettAesappoes•tfpar�dt�►pdens0eeotAeE• ttouoe�tttwdar4arrr. atiteftei�uaneledw�ttbiet6e amaeot dtbl+gt ianpl,►fbet�tiatt�adter:oautfljr luttetuailht<rbeotpflaoadan daetddonme.iia*lewtba�sa�aade�atlOmtane4tifs Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.The seine right is t10t automatically afforded to a contractor,however.Tie oontrwtor would have to resolve any dispute hddw has with a homeowner in court milers both parties agree to the optional claire provided below.This clause would give the contractor the sane right to arbitration as is aff Hoorded to the homeowner by the Hoare Improvement Conuw"Law. e WhWor and the homeowner hereby mutually agree in advance that in the event the contractor has a the contrsator may submit the ��ming this tfisputs a private arbihT60n firm which has been approved by the Swetuy of the Rxecutive Office of Consumer Affairs and Busirtess Regulation and the consumer shall be required to su it to such arbit atiott as ded in Massschtasetts General Laws,chapter 142X t Hryrrreawnea's S' Cot+>ractoa's Signature. NOTICE: The sigrtabtnes of the above apply only to the agreement of the parties to albmm ive initiated by the conbam r.The homeowner map,ink ahenadve dispute resolution even where this Section s not separately signed by the parties. Homeowner's!tights A homeowner's rights rmde,r the Home tmprovanent Conb acan Law(MOL chapter 142A and other MGL chapter 93A)may not be waived in any way,even b ) be excluded MM t at laws(ire. the contractor they choose is not y H *}>omsowners may be eucluded them gain rights if msaibad automatically excluded from all Guaranty by law.Homeowners who secure their own building pauffa aro for completing the work as all provisions ofthe Home Improvement Contractor Law.The contractor is rrtoo>b1e bed,in a timely and wor�rlilm manual:Homeowners may be entitled to other spedfic rigin if th6 c onuactor guarantees or provides an express qty for workmanship or materials.In addition to gttaraattees orWETanties provided by the contractor,all goods sold inMaSSUC11USMS carry an implied wMMty of merrhantabitity and finless for a particular ticular PWS•An enumeration of other naftrs on which the homeowner and contractor idly agree may be added to the term of the oonuw as long as they do not rat,ict it homeowners basic consutrter tights,tf you have quesdons about your onnsum Aum m rights,comet the Core Information Hotline(listed belowk Execution of Contract 'the contract Rust be executed in dMISM and should not be signed unfit a copy of all exhibits and refe enc ed documents have been attainted.Parties are also advised not to sign the doctuncrtf until all blank salons have been filled in or marked as void,deleted,or not applicable.One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any moMcation to the original oomract must be in writing And agreed to by both parties.Ccortbacwd walk may not until both PM=have received a fully executed copy of the contrack and the three day rescission period has expired. Accelerated Payments A contractor may not demand paymams in advance of the dates�ecified on the payrrrent schedule hi caste where the homeowner deetos,Mm/herselfto be financially insecure,However,in instances whore a contractor deans him�fto be snanciaity bactue, the eontta t may require that the balance of funds net yet due be placed in a joint escrow account as a prerequisite to emdinuing the cunbaaed work Withdrawal of funds from said amount would require the signatures of both parties. Additional Information i If you have gmaW 4ucstions or tread additional mar►about the Home � tmprovemerrt Contracxor taw or other cxMsratter rights,or ifyou wish to obtain a fim copy of"A MUSSOCIRISM C.anauner Guide to Home tmprowment"contact: e msurner Information Hotline office of Consumer Affairs and Business Regulation 10 Pads Placer,Room 5170,Boston.MA 02116 617-973.$7$7,89&283-3757 or visit the OCABR website at P J;�gov/o%br/ If you want to verify the fegistration of a coriftciar or if You have questions or need xWorral infotmation Cmcomponent offhe Home I spec&dy about the rr�pnavemerrt Goiitracto�[raw*ornrtyci; Director of Horse Improvement Cmrtractw Rggbmdm Office ofConsunter Affairs and Bumess Regulation 10 Park Ph^Room 5170,Boston,MA 02116 617-973-8787.988-293-3757 or visit the H1C website at h�Ep f/www _ v/ abr CONTRACT GaryLiss General Contractor Mr. Tim Mellody Date: 7/12112 10 101 Crossbow Lane 603-36 N. Andover,MA 13 Stonemli terrace Atkinson,NH 03811 MA.LICENSE#53506 HIC# 112595 www4arilbwbuildem.com I/�.IIIMr���/�i�l����*II w.l l�-1 I • M���Illi Wi.i� Quote mcluues labor and matenat for replacement windows,which entails: - Remove existing windows and storm windows Install thirty-two Harvey"Classic"double hung white vinyl windows with grids between glass and"Energy Star Package";full screen Install two Harvey white vinyl sliding windows with"Energy Star Package"in basement Repair damaged window sills - Fill holes and paint area where old storm windows were attached - Dispose of old windows and storms Includes taxes and permit costs Install new textured Masonite siding as discussed Install new trim at front entry bottom and gage door bottom - Paint new siding and trim Payment Schedule: $ 5.200.00 Deposit $5,200.00 Windows delivered $ 5,.200.00 Upon completion $15.500.00 Total Price `All workmanship guaranteed for one year Acceptance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. 7 /Z / Z- 10, Z- ? t Submitted by: Guy Liss Accepted by: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant ladtifikl6h Please Print Legibly Name (Business/Organization/Individual): Address: /.3 -5;2/9Z_ VVAJL L 7,_ 1e�e14L f Ci /State/Zip: /J, 03 / Phone#: X0-9 --?Zz Are yon-an employer? Check the appropriate box: Type of project(required): 1. I am a employer with E 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition. [No workers' comp.insurance comp.insurance.$ ❑ g required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance'required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that:c6cks box 41 must also fill out the section below showing their..workers'compens ation policy infor:.;aticr.. 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. A 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.#: " lily 63 9Yj Expiration Date: Job Site Address: ��� �T���-S' O�`� ✓`7�� City/State/Zip-,24 A_1f0�,�� 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. 152 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 fine 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. I do hereby cernfthe pains andpenalties o erJu that the information provided above is true and correct Signature: 7:�:: Date: / Z, Phone#:-66 -3 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#• AC R® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F 8/22/2012 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 CONTNAME:CT Marialana Costa INSURANCE SOLUTIONS CORPORATION PHONE (603)382-4600 FAX 0. (603)382-2034 60 Westville 'Rd E-MAIL .mcosta@iscinsures.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERA-MG Insurance Company 15997 INSURED INSURER B.NorGUARD Insurance Company Gary Liss General Contractor INSURERC: 13 Stonewall Terrace INSURER D: INSURER E: Atkinson NH 03811-2148 [INSURER F: COVERAGES CERTIFICATE NUMBER:CL1262905276 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 EFF POLICY EXP LTR TYPE OF INSURANCE AD BR POLICY NUMBER MM/DY/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 250,000 A CLAIMS-MADE ❑X OCCUR SCO117891 /20/2012 /20/2013 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NI ER ORYANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) �WC326396 /15/2012 /15/2013 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 Tim Mellody ACCORDANCE WITH THE POLICY PROVISIONS. 1elCrossbow In N. Andover, MA AUTHORIZED REP ESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD 8R ORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD