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HomeMy WebLinkAboutBuilding Permit #359 - 21 JETWOOD STREET 11/1/2012 L r ttORTH BUILDING PERMIT Of�t4ac �ti° TOWN OF NORTH ANDOVER p APPLICATION FOR PLAN EXAMINATION Permit NO: Date ReceivedToo A . �9SS4c►+us�� Date Issued: s �'" IMPORTANT:.Applicant must complete all items on this page 2 LOCATION / `JF_rw©0L ST j S �� -,-.,Print E I PROPERTY OWNER ULd K S Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes na Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential D New Building D One family D Addition D Two or more family 0 Industrial D Alteration No. of units: D Commercial Repair, replacement D Assessory Bldg i D Others: D Demolition D Other D Septic D Well D Floodplain ❑Wetlands C Watershed District D Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: k-ca.- ttgAl— Identification Please Type or Print Clearly) OWNER: Name: 7,40-0 S , �?&/S Phonel7t--26_r� 7s& Address: CONTRACTOR Name: Phone: 101- Q3 f`263 3 Address: N- O Supervisor's Construction License: > gKo Exp. Date: 312,Z Home Improvement License: l?16 X9-3 Exp. Date: 3 2dI ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINGG PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. cl- Total Project Cost: $ 014,1,5-1 FEE: $ 161 Check No.. Receipt No.: NOTE: Persons contrac n4WWregistered contractors do not have acce's to g ranty fund Signature of Agent/Owner Signature of contractor 1 Building Department s The fohowing 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 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: Doc.Builfling Permit Revised 2012 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 ® Notified for pickup - Date Doc.Building Permit Revised 2010 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ l TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑ . 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 Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 4servation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow, Fngineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Departinerit signatureldate *; 1 COMMENTS Location No. Date ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ q Building/Frame Permit Fee Foundation Permit Fee ' Other Permit Fee $ TOTAL $ Check#✓ 1 J l/ 25898 uilding Inspector NORTH ` own of E ��� ndover o to No. T - o .AK. h ver, Mass, coc NICHIWICK 1' S U BOARD OF HEALTH Food/Kitchen PER IT T Septic System LD THIS CERTIFIES THAT .Q ...�i�.............. ..��.:�......... BUILDING INSPECTOR ............ ... ...... .. ................... .......................... Foundation has permission to erect .......................... buildings on .. .(........ ....*...................... ♦ Rough to be occupied as .......... •- .........+...... .......... .... .. ............ ..... .............. ......... Chimney provided that the person accepting this permit shall in every respe t conform to the ter s 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 CONSTRUCT S TS 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 �ORTh Town of E 1, Andover O - to No. 3 4-4;h ver, Mass, o COCKICMNWICK y1. p�RATED S U BOARD OF HEALTH PER Food/Kitchen Septic System IT T LD BUILDING INSPECTOR THIS CERTIFIES THAT .a ............ .. �. ........... . Foundation has permission to erect .......................... buildings on .. t........ ...*...................... Rough to be occupied as ..........S-t7q.0........'......... .......... .... .. ............� ".... Chimney provided that the person accepting this permit shall in every respe t conform to the ter s 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S TS 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 FIONIL IMPROV AIENT CONMRAC"r PLEASE REA DTMS SoiLL Funikh,%]'Intl 111%tall"Al t\v: .11ranch Name- Ruston Date: 1111)At-Florae Services,JnL:. IaLNLA _ d/b/a The Ho"Ic Ucpol At-flowc service, 4W Boston Turnpike.Unit 1.Shruwshury.MA 01545 '17441 ITT;eth()(06.W-5182;I:lx 612:I X45_0(j17 Branch Number.3t Fcd�_l ID ff 75_6TW&),XjH'Lic h CO2439:R1 Com U0 16427 Cr Ljv a HIC-065sz-, MA ticvic br4trr;,,.,ncm Corttroowr Rq�It 1268.13 Installation Addresti: jNj- Citv Statc Zip IlormPlarne: 11604 Florae Address: t If diffierent from Installaim Addrctqs) City State Zip E-tuail Addm-z(toreceive prqjcc1 rANroniunictitiouh and El I DO Nor wish to rexxive any markcsing emai6 from The Hone Depot I-nijectinfortruition: and'12HD 1t-Home St:rviccs.Inc.(-0e riume m1mr)ag to fumih,d-ativermitt zuTarigre for the inslaabon Ir]nstA;&on7j of all ntntcri3ls described on the betaw and tin the referenced 5mc Shect(s),all of which ate inco"vawd into this Czxaruci by thi., reference,along,%vilh any applicuble Susie Suppleniclu and ftyrnent Sumnlaly allaclied hereto and any C*.b;ine Ofdcrs(C01I1CTiVe1yL "Contr2ct-)- Job#;n-,"i-_. SJt."-11.i A: Prt xt,'irnozoa DG-AtussICAners[1Eutry0wr% 0-- nt, 0"tm I Cc—Oaay lk-5 0autte __�Txrtiiq, E,Windm%,%Uhi'Lilatict, t 0 ClEntryDma, 0_.. y-- I KhArnrun15%1kVvx5t nrCAmkract.An"mf due opm mccudanafthis cura=L TOC21 Contracl Amo,�13 44R- 6 Nkiine Purclawn�vow nit depmA rwav 11rm onL-0drd ef Ow Cuxdvxt,%n�t. I Cmtorner tip Lcs ihaL inintediatcIv upon cocop!ciien of the wtv),for itch PaXJUCt,CMILMICF NOR CACkMIC A CORIP106011 CCWJ14:31: (onc rex each Pvxluct as defined by an individual Spec Sheet)and jiny any halarim due. J4..applicable,each Customer uuj,T this Ccritruci agr=_%to N-jointly and%cvcrally obligated and iiaWc,hereundcx. The Ronie Depot reserves the riLiht in issuca Cimngc OvdLr or cenninate this C.OnIFUtt 4W.V)y individual I'miluci(N.)included herein.ut its di.TvtiLm%if 17he Home Deput 4x*its authorized%,riLA:prt)N;idc--deLcrmiru!s that it cannot pLrLirjn its kibligations du;;to a structural prubleni with tho1ioinc,cnvirornmental haiArd,such its Intaid.asbusit's(x tuad 1xiinT.otlicr.q.,dety L:tmerus_nrian,error or bcc:.ase wod,"oi"l in curnpicle dn:job was not included in die Crintrat;L Pavrnmit Suntmary- Tb,-V-.syruent Sunuixtry 4 (;a 7) AM -is Forgo the(owl joclutled.a,jxwt of this C* oraci. %, Ccixtracl amount and paytucnt,required for the deposits and final pay-awnt,,by Produti(.isappfiur.blo. NO(IIMTO flicre is one Curuptetion Cerlifiscatc for each listed Product as defined Inv individual Spec%hczL,;)lxrum evorit on thaPruill;_1 is comptele. In the event of termination nrthis C-ontr4cl.C.mlorricraggrem to pay'Flie Honic Ur-pot Cie rost,of Inaterkti".juhur.exjwjts,. and services provided by The Horne Depot or Authorized Service f1rovider Lbrough the Baty or tterrvivatavnpits any whcr unumnLsset forth in this N-greculcutor allowed under applicable law. THE 11ONIC DEPOT-MAT-v1'5TV*x_)LD AMOVINiMS (TWFID TO TIRE, HOW DEPOT MOM T11F 0?t7OS­j-u Pj'LV%,;FNT OR OTHER FAVINTCNTS MADE. WAMIOUT L!'%UTING I'M lJOIKE UEAOT'S OTHER REWDIMS r!OR REXMVERY OF SUCH INIGUNTS. Acce»Longe:tad ands timit this Ag Ve Authorization. Cust4nn-zi �tgrces and undu-1, .cement is]he entire aut and--utIlen,"Ics all prior d istru..sions and arrcc lcwx either nt with regara to[ire net.%and Imjal lalion servicN oral wr written.relaijug to sual Products and IrWallatkut.Tbi-.,Agreement canak-4 J-.e a5%qjiej or�rn,::ndotl except by a writing signed by CvstornLt and The Home Depot.4Cu-aimrtr aelaKAdedges;end aggret�_ that Ctistotner has ieul.kw&rslands.voluntarily acceltiN the je.nj.;,jr anct bas received a ctipv of[:itisAgrecinent- I .- A"+1rd by: 1� bv. X C,js1LAt1Lr,_N Sig paturc Date SajeS COn.%Ulttanj'S Si&FUIIUFC TO el ih nirz'q o. T Cusicuncr'sSignalluc a-tic i Sales Con-wilant LiccrLse t%kv. CUSTOMER MAY CANCM THIS AGREEMENT BVI f[IOL'f PFNAI.TV OR OBLIGATION BY I)FLIVIKIUNG VVRITTEN N0710E TO THE 1-10*-%11-', Dl,*I-OT BY MIDNIGIrr ON THE THIRD BUSINESS DAV Ak-IT.R SIGNING TIM AGREE-,%-1FNT_ THE STAIT" SUIPPI.C.NIENT ATTAC1110) HFIXIE-170 CONiAINS A 1,0rho 'ril UsE, III SX71FICA1.1LY PRE-SCRIBED BY LW KI CU'1;"j'ONjFWS.STATE. NWICY:ADTIONA,TERMS A'0f0NWTJ01SAKVS AT'DO"'111hKFWKIV5SW 1 2%^iDXKE PAR "rl! 0NrKA r MLIC-12 C-SC White--era-.:h File Ye!w—k;ustamv, L-d 6669-C9Z-009 d8C:Z0 Z 96 100 Oct 31 12 07: 45p Richard Fallone 4014531367 p. l -LU 1 1.U1 J `/1411 uuo .4JL Ly�v /kJ�j�. L V�•I - 4' �t:F��ii�11l1�CCF� • I)l'II.H'Cp1�e1[ ur'{�1,i1}14' �:II'CFt • Bt�artl ��!' Eluiltfin•„ R+:�tiluciuiia an,I �t�uld:;rrl. voti '�O.�G� $L'�Jet�IiSGL' U. e.,1 Licensh: CS 104880 JAMES LEMIRE 6 MOUNTAIN HOMe ROAD LONDONDERRY, NH 03053 _~ p 3014 i`x ,ration: f •gfill I `Lil«•p Tr=: 104880 J O ice o onsumer a an usmess Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 802014 The Home Depot At-Home Servlrles. ANDREW SWEET 2690 CUMBERLAND PARKWAY SUt-TE'i300 ATLANTA, GA 30339 — Update Address and return card.Mark reason for change. Address R Renewal 0 Employment E] Lost Card DPS-CAt 5OM-04104-461701216 OfficeoYsiYi 'r� usess egu atio License or registration valid for individui use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to,.- Office a:Office of Consumer Affairs and Business Regulation Registration: 121.6893 Type: 10 Park Plaza-Suite 5170 Expiration:,.8/3/2014 Supplement Card Boston,MA 02116 TTome Depot.A# rnik Setv�Fes ANDREW SWE8T. 2690 CUMBERLAIdf Fei4KWAY:S A"1'`Ai `A,GA 30339 Undersecretary al ithoul siguature The Commonwealth of Massachusetts =nntForm- Department of Industrial Accidents POffice of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letibly Name(Business/Organization/Individual): Address: 2Y6:r Adzs_ FeRk y j Q City/State/Zip: (�� 3 0338 Phone#: 800 Are you an employer?Check the appropriate bog: Type of project(required): I�I am a employer with ;,;o 0 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]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 g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. Building addition required.] 5. ❑ We are a corporation and its 10.C] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.XRoof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 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. tContractors 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 formy employees. Below is the policy and job site information. Insurance Company Name:_ GW ,fl1'>bSiNlT�F Policy#or Self-ins. Lic.#: _W VQ 17 736Q4!!� Expiration Date: Job Site Address:--? J r�Gyl3 p ,& S l City/State/Zip:,k/ ��d dP,{ MA 0&y5' 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 c era4 verification. 1 do hereby ELM.&under the pains and n 1 es ofpg1urthat the in ormation provided above is trrt and correct Si afore: Date: a L Q L Phone#: Official use only. Do not write in this area,to be completed by city or town officiat 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#: A CERT_Irif"�%=-n i" !S SIJET'j AS A OF IHFORAV�1`101N L ,tEfffi-FiCAIE rjl:;ES NOT AFiIRMATI'VELY OR NEGATIVELY AM BELOW. T'I'lit CERTIFICATE OF INSUFANCE DOES NOT CONS7117UT= A CCi TRACT T'HE' ISSUNIi 10. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 77777= 1777, IIAPORTAN117 is If ih,- v�y'd Mcata hold,?r is an ADD17IGNAL RNSURED, the D03w0lezi Slis–ROGA7 iT�N' 1"'. 'he terms and Conditions al lha policy,CsYtain 190i1CW5 MY r quIl' dOf e a oq�; 3pi-nent A on'tlilri, wdfhnta di.:zia no';rirlv Cer'41-ficat8 ho'146f In Nei.)of sucth PRODUCER Marsh USA Inc. v" E-MAIL homedepot.cartrequastilmarsh.com EDOM: Two Alliance Canter, 3560 Lenox Road, Suite ?400 Atlanta, CA 30326 INSURER(S)ArFOR01MG COVE'RAGE— NAIC 9 Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26307 INSURED INSURER 3: Zurich American Ins Co 16-535 The Rome Depot, Inc. INSURER C: NOW Ham shire Ins Cc 123841 Rome Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co, 23817 Building C-20 INSURER I-: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanti, CIA 30339 27960 I., _.. -INSURER IF-. Illinois Union Ins CO COVERAGES CERTIFICATE NUMBER: 25776028 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. D INSR CY EFF I( OLI C LTR TYPE OF INSURANCE WVI) POLICY NUMBER wwPOLIoomrn M0TfEA LIMITS I A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE S 9,000,000 DAMAGE TO RENTED -Y COMMERCIAL GENERAL LIABILITY PREMISES(Ea Occurrence) 1 1,000,000 CLAIMS-MADE M OCCUR MED EXP An one person) S EXCLUDED X LIMITS OF POLICY X3 PERSONAL&ADV INJURY $ 9,000,000 IX -OF SIR- $1114 PER OCC GENERAL AGGREGATE S 9,000,000 PRODUCTS-COMP/OP AGG S 9,000,000 GEWL AGGREGATE LIMIT APPLIES PEFL' :i�j POLICY PRO.F-1 JECT LOC B BAP 2938863-09 03101114 03/01/13 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (go accident) 1,000,000 -X ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NONAUTOSWNED PROPERTY DAMAG9_ -O (Per occident) HIRED AUTOS AUTOS X SELF INS PRY PRY DXG UMBRELLA UAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR 'CLAIMS4AADE AGGREGATE. DED I I RETENTION$ I — . WORKERS COMPENSATION WC019736915 (AOS) 03/01/1, 03/01113 X I TWC'STAT'U;I M JOTH C AND EMPLOYERS'LIABILITYYIN WC019736917 (FL) 03/01/1, 03/01/13 E.L.EACH ACCIDENT ER $ 1,000,000 D ANY PROPRIETORIPARTNERIEXECUTIVENfA OFFICERIMEMBER EXCLUDED? FN-1 WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE q$ 1,0001000 3 (Mandatory In NH) Ifdescribe under E.L.DISEASE-POLICY LIMIT S 11000,000 DESCRIPTION OF OPERATIONS bet. E Workers Compensation WC 1192494 (QSI) /'01/1: 03/01/13 SIR (AOS)/SIR (GA) IN/750,000 C workers Compensation WC019736918 (WI) =03/01/1: 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/11 03/01/13,Occurrence/SIR 30N/1N DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Iternafka Schedule.If more specs Is required) RE: EVIDENCE OF COVERAGE v CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ROME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA l@l 198&2_010 ACCORD CORPORATION.- All rights reserved.