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HomeMy WebLinkAboutBuilding Permit #579 - 103 PUTNAM ROAD 3/29/2010 BUILDING PERMIT Ot NO oT 6'97• TOWN OF NORTH ANDOVER 4 - APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 11,9 q�Rwreo�Pa�15 SSiCHUS� Date Issued: ` ;d IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER A)Irlt�ll I/So P nt MAP 210 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New Building OneJamil Addition Two or more family Industrial o No. of units: Commercial Re air replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WOR BE PR FORMED: entifi ation PeJase Type or Print Clearly) OWNER: Name: �� � 11 P1p Phone: :7;0 Address: l CONTRACTOR Name::- roc Phone: Address: Supervisor's Construction License: -'� " Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING 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 t e ara fund Signature of n A ent/Ower 6j4,,::j,,j gg Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMtNTS i V Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT _ Temp Dumpster on site yes no Located at 124 Main 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 NOTES and DATA— (For department use) i ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 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 ❑ 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 r ❑ 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 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 2008 Location /1-) A— s v No. Date �O�T►, TOWN OF NORTH ANDOVER • ; ; Certificate of Occupancy $ s'uMusE.�' Building/Frame Permit Fee $ `fy Foundation Permit Fee $ Other Permit Fee $ TOTAL $ _�— Check # 9 22UUi Building Inspector � NORTIy Town 0 : s _ over No.s? 9 'r C, - - - dover, Mass., 3 •dq �!� T O l A 1 Co CHIC ME WICK V ORATED Cl�C 7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .............6777..L.V..�..�.�! .! ....................... D.4.0.4 ..................................... .......... Foundation 16 has permission to erect........................................ buildings on ...�.V ..........Y. .."0...4N.�r�...... ................. Rough I. dv to be occupied as Chimney provided that the person ac pting this permd shall in every respect conform to the terms of the application on file in Final 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 0 - PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC TARTS Rough ................ . .......................................................................................... Service BUILDING INSPECTOR Final Occupancy' Permit Required to Occupy Building GAS INSPECTOR 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. r i - _ Board of Building Rrguda>iaos asd St2adards :} \ 1 Cons#ivction Supervisor LicensOKA e ' Office License: CS 88756k -� -: of Consumer Affairs and usiness Regulation Expiration: 3/2w2o10 T? 20262 r _E-r 10 Park Plaza.- Suite 5170 ..N Restriction: oo �`. Boston, M saQ14usetts 02116 SCOTT A MACMILLANI Tome Improvement JQDnfiuctor Registration 10 PARK AVE Registration: 158 SALEM,KH 03079 Commissioner `r TY.= i___- aae= lndi MACMILLAN `< _,_a' LAN CONTRACTING SCOTT MACMILLAN - 10 PARK AVE. SALEM, NH 03079 'i=--= - --- Update Address and recurs a Address J Remewal j UPS-G1/ d Yg40aKts u70t21B --' �� � tOoaaerr�s� � amo�vcrae6G - ' _ OcCre of COBlouecr AfTaim&Basiocra ReZjjB,9os Umosepr►e*"tiou veld for im i idol use 91 MUM MPF4WEIIENT CONTRACTOR exA+�tiro®date U foamd return fm` Regbhabci- .A563E)6 Office 01F Affairs and ftsisess RePL 1t0 Park Plans-S-ke 5170� `::;3.f!l�2 Tri 291290 Boston,MA 02116 hIl111h1 COQ` _ SCOTT AAKCJiAlEp�d:' f;i'` _ 10 PARK AVE- SALEDA,NH 03079 ry --- - - Nof vand wit)saat signatare Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License# 88756 Restriction 00 Name Scott A Macmillan City,State,Zip Salem, NH,03079 Expiration Date 3/29/2012 Status Current No complaints found for this Licensee. Back To Search f http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL88756 3/26/2010 03-25-2010 12:00 FROIMHOADEPOT2685 +919789466421 T-961 P-001/005 F-534 rLLAWL KLAD 17141 Sold,Furnished and Installed by: Branch Name: Boston Dot... THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Branch Numnber:31 Toll Free(800)657-5182; Fax(508)756-8823 Federal ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 CT Lie#565522;MA Home improvement ConnLraetor Reg.#126893 Installation Address: City State Zip Purchaser(s): Work Phone: home Phone: Cell Phone: Houle Address: ),1 (If different from installation Address) City State Zip UV E-mail Address(to receive project communications and Horne Depot updates): ❑T Do NOT wish to receive any marketing emails from The Home Depot Project information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation( Installadon'l of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: omn4s M-r—i ts: Sec Sheets #: Project Amount Roofing ❑Siding indows ❑insulation ❑Cnntcrs/Covers ❑Entry Doors ❑ � . $ —bt-z�(Q Roofing ❑Siding ❑Windows LJ Insulation $ ❑Gutters/Covers ❑Entry Doors ❑ Roofing Siding ❑Windows L3 Imulatiun ❑Gutters/Covers []Entry Doors❑ []Roofing ❑Siding WindowsInsulation $ ❑Gutters I Covers ❑Entry Doors ❑ Minimum 25%Deposit of Conavrct Amount due upon execution of this atntroer Total Contract Amount S � Mame Pmshabers tray not deposit more than one third of the ContractAmount. / W Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or'its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary #�7`^� ( , included a-s part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each luted Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Accei tante and Authorization: Custotncr agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has receiv a y of this Agreement. r s t7 xT;� Customer's Signature Date Sales Consultant's Signature Date X Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER. MAY CANCEL THiS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SiGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE.SIDE AND ARE PART OF THIS CONTRACT 7-15x09 GSC White-Branch File Yellow-Customer Pink-Sales Consultant a —���—� —� U-Fa�(�r . . Solar�le�GainCoet:nciznt .� Fs�rU cnAC GWV,,Cada Ersrgia molar 'Or . 32 1 . 6 C� ' 29 . D.DOMON L PERFORN"CE FRATNGS ' " . �H 3LCL.i�rErr-;.•�oe aa+c>�xTo • VisiblcTransnitonce Tranur blan&L aVLAla 0 . 52 V7 dmr>Tlr'�cd NY[,tad wK d CN4z"(rW-cx0tub and a m cft Pfd�:?iPC das rot recrnona d.sT7 a ad d=m rot,.aavrt zv n Wt d r*r fU14:+7 m I*k a Qraat n,r eda'°3�raan bC ad z{?fin —— -—--= -. � a :. i�^'�&'fit Mn t�'"'}`•� CY��T tJ��+• . Els, t 4A ha m c9Ca m Jrrfllarii�s Y uri>8 rary m ,,.. p6ctic14 t!y 'a Siad=a oc+•:j;C.m aRarrr�;a LP mW� in .4.acA- c3vft ax,d . tF�G ro racer 5w c*4w;�'f "'>v aasoo,far° . eb�del Stxtsro?rid:�aQ 9� elf podia wwtcap •' UnLt q-_a LLC :oc e?{ERCY .3C1R c¢yi�;"�i1'. uo'c eRt cn, 00 Crl - t:.n_.�i_ lo.tha-n. .Ci.�nLG1d o�LCiLca "pl•� 1J(•) .• - ' «•�lOn(��� Q11Gl�GL �L)..lt: u•oct�_ . . - Noctc CanCcal,'4.c CanCcal, 9�c_ ' 14P: Re In. 40/CLII )/JI-/K-RJ) P INO: B2f.ccso oafYldcLo 2"3t J) j:L-A pcoDado: 1L.i cn De - 44773 , N3 Ko2))1110. ,• L.p rfia lob.l for pnm6h QILtcT 51 z abata.To lawn mon V ww.maIrl-ttm4m cu�da zits ��aN d°pan q I:Sl a r"M&bT,r OJUS.T%r1 hn cDrzcu rrm 00a bI afi.1�11a'r•�rn r QfttoLQoc . -- 1� Board or Building Regulations and Standards ; HOME IMPROVEMENT CONTRACTOR Registration:. 126893 Expiration: U3120 10 i Type: Supplement Card . The Home Depot'.P' -Home'.ervice- '-------.. _.. _ b,r`La apn ;:m KINE The Cont in on wealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 °�M s eyoe wivw.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers Applicant Information Please Print Leaibl`• Name(Business/Organization/Individual): E Address: City/State/Zip: _t`&-L `1)n33jc- Phone#: `D 0��h l-3 g Are y an emplo}er'Check the appropriate box: Type of project(regained): 1. I am a emplover with Il_ ` � 4. ❑ I am a general contractor and I 6. ❑New construction. employees (full and/or part-time).* have hired the sub contractors 2.❑ I am a sole proprietor or pa-tcr- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Buildino addition [No workers' comp. insurance comp. insurance.$ 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 o . right of exemption per MGL y [N workers' comp. 12.❑Ro pairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other _ 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. iContractors 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. ems^ Insurance Company Name: i Policy#or Self-ins. Lic. #: s"��e�-,�� Expiration Date: Job Site Address: �QD�VL-L JI City/State/Zip: 4-,-, 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 Investieations of the DIA for insurance coverage verification. I do hereby certify and r t e p 'its a penalties of perjury that the information provided above is rue and correct R Sienature: a Date: / Phone#: ������� Official use only. Do not write in this area, to be completed by city or tows: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#: ACC) CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 02/19/10 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 Fax (212) 948-0902 - INSURERS AFFORDING COVERAGE NAIC# — --- ------ ---- -- ------- The Home Depot, Inc. INSURED – INSURER A:Steadfast Ins Co 26387 --- -----------._-�-- -------.__-_.---- Home Depot U.S.A., Inc. INSURER B:Zurich American Ins Co 16535 2455 --------- - - -- Paces Ferry Road NW ---------- INSURER C:New Hampshire Ins Cc _ 23841 Building C-20 --- — _ Atlanta, GA 30339 INSURER D:NATIONAL UNION FIRE INS CO OF PITTS 19445 INSURER E:Illinois Union Ins Co 27960 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRC TYPF OF INSURANCE POLICY NUMBER D M I /YYY DATE M / Y LIMITS A GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY OHMAGE TO RENTED ------ PREMISES(Eaoccurrence) $_1_0_0_0,000 CLAIMS MADE FxIOCCUR MED EXP(Any ant,person) $-.EXCLUDED_ PERSONAL&ADV INJURY $ 4,000,00_0_ GENERAL AGGREGATE _ $ 4,0_00,_000______ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY LOC B AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS -- ----------- -- BODILY INJURY $ SCHEDULED AUTOS _ (Per person) HIRED AUTOS ------- BODILY INJURY $ NON-OWNED AUTOS (Per accident) X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA.ACCIDENT $ ANY AUTO ------------ OTHER THAN EA ACC _-- AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 5,000,_000 X OCCUR F-1CLAIMS MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ ----__..---.. .------ RETENTION $ - $ C WORKERS COMPENSATION WC STATU• OThi- AND EMPLOYERS'LIABILITY YIN WCO20342355 (AOS) 03/01/10 03/01/11 X -._ r�RY 41M1 D ANY PROPRIETORIPARLUDE EXECUTIVE❑ WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N ________ E (yes,dory beundn NH) WCO20342357 (FL) 03/01/10 03/01/11 E.L.DISEASE-EA EMPLOYE $ 1,000,00_0____ If yes,describe under —_- _—_ _ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER E TX Employers Excess [TC10C46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation W910566 (QSI) 0.3/01/10 03/01/11 C Workers Compensation WCO20342358(KY,MO,NY,WI, ) 03/01/10 03/01/11 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY ROAD NW IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BUILDING C-20 REPRESENTATIVES. ATLANTA, GA 30339 [AUTHORIZED REPRESENTATIVE USA ACORD 25(2009/01)Jthornton_hd ©1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD name and logo are registered marks of ACORD