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HomeMy WebLinkAboutBuilding Permit #142-12 - 315 TURNPIKE STREET 5/1/2018 BUILDING PERMIT ° �t``° "o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATB �JPermit NO• L4 Date Received :: 4'RAT[o • i Date Issued IMPORTANT Applicant must complete all items on this page Ac.. raY c`3'�' r,,,py " "3�w:,�'°tsYss°""' 'v�"'�.`+.�rv.. "'•" :-'''v. 3'�y» i� a;,.:•s...�..c+p }-bc +,- ,t,-�sT G.trtt'';'.�i Y<l ..,;, y+y, ,� #x ! 3 s 5 -��.z.-,,t �x . k NN ys..'w° gw r s ••;''"'^--y'p"'H _ ,aar�'w'*� .u- £ vA^ " �4- g••,y.,, 7°� �. Sd3" RE MON RROP j) Yy-0, Sr+ta". S '. sa.:.- ,ceek ^---tom c, xz:' •m.-r^r rd-'+ i E.,,..aF , eCr „`" dlagete�`���� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition El Two or more family . ❑ Industrial El Alteration No. of units: El Commercial ❑ Repair, replacement ❑Assessory Bldg B-Others:1—� 1 ❑ Demolition ❑ Other t7: /�. +'. .c ® f�c� �Ul(ell`; raj tloi. ]amX r� ®Wetlan ,s � r sv Ill(afersfietl®�s�triox, �� r r + rF�, '�.r�a*ti" •"�-3'ti"'+.� `hxt r& ; z. r ��` i t. ^� �.�c�, t fV N DESCRIPTION OF WORK TO BE PREFORMED: Ze-eh3 K2 �,rJeI t T7�! - /J�rlllGl'��trr%� ®dJ o� d bOZII I-q) 2- Identification Identification Please Type or Print Clearly) _ 3 T-ZQ , OWNER: Name: /�G�i~`'/ �� �� Phone. Address: ANN, .BP 't'� �`+sj ;7�� w6P �f',�`sJ:,� +�.,-` axy: Phone{ � �� %ONTURARGTOWfidme x s y r f� 4 43 4 5v t tr.'t n y, x •c t .'+F r t -+.e°r e`^5�. -. ,�c. 1 .z "� 'r..n asa.,,A-tt�- ars sx fi "r�'``sr `�`',- 'Y "i�T+•t ,•+- S,� Address 'stn :.y,.r � x rs� �!' tx �"� nc�s�. �,� EXI?�'��ate ittaX'as4-��� a�" � -`�a•� Fr a+F yf f .xc, g. ;,.Svc-r¢ -• 'n'' `,aE" `�'� �Fiorne�lrriprovem"ent�cense`���'� �.��`� f,� x:�r -`��.��:,��>�'-"�Exp�;�Dae��� �. ��,�.,_.�-. 4b^,�• ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEDON$125.00 PER S.F. Total Project Cost: $ 2 Roo FEE: A T� �- Check No.: C.fl to Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agen /Owner ': . .._:4 Signature of contractor 0. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans p ❑ 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 Located at 384 Osgood Street IREizDEPi*TMENT Temp Dum ster ori=siter� esu 4 o 'M T' ➢ C C {v,. 'h r bea 'sr' V .y i'x 1"' _ � 'S'v.,. r. _L :a.•}' '�,� 8p )i.-{ t?-F 4g ms's.7''a t- 'rs.3x „,.� ....r +,. t S 'z.i-'•. .. 'E, .a+.. �f,tio-„ ,„-.q, :.` "�d..a��"'�r�:,�kd �„� .� j-'� �.'� s_ „� t �-�t-rir+ rof� �`A�r `r`` ��`'?.:" ..S.t .� 3�... ��r�A'�'��,.gf� ,{•�'� `k,�r � "C`f .� -, �yw 3 z". ..a �x..rs4=.�.'r"'�'fesa;�.r•�-x°""e.- p r �'-` *� �'-a3n �- � :a cam" 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 I f Doc.Building Permit Revised 2007 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 11 - ❑ 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 a ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location ► "n`��t' l j No. Date 0 - L--- TOWN OF NORTH ANDOVER � T rIlk I � Certificate of Occupancy $ Building/Frame Permit Fee r ` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#.-J�o ( 25631 Building Inspector NORTH Town of ' ? E ,, Andover 0 0 No. * -142. - 13 i y o�h ver, Mass, A COC NIct1l WIC.c A. S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. ........................................ BUILDING INSPECTOR has permission to erec gV ��� 1 Foundation ......................... buildings ......3-T...... ..... Rough #o be occupied .... ...... ....... ..�.. .'i..'. ........�......... �.1..�..� 1 Chimney provided that the person acce ting 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 TH ELECTRICAL INSPECTOR UNLESS CONSTRUC TAR Rough 43 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 NORTH own of EAndover "t 142. - 13 i ti hver, Mass, - Lt CoCMICMl WICK �1. �•9 ADRAreD 01VC> S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System OA— _ THIS CERTIFIES THAT .. .. . �. ,,,,,,,,,„ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR ........ ...... ....... ..... . has permission to erec .............. buildings on Foundation ........... ...... ....... ............. ..... Rough u h to be occupied .... . ......T"- Immv....... ..�.. .,�..�. ........ ......... �.'..�..? ' Chimney provided that the person acce ting 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 TH ELECTRICAL INSPECTOR 0 I” UNLESS CONSTRUC TAR Rough Service ....................................................................... .... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 Google Maps Page 1 of 1 To see all the details that are visible on the screen,use the"Print"link next to the map. NO AAAF it •.. ,# R r UVJ Com . f Fi,. �4s .`:'.mac. .i°',•t, ��„ � ,ta ! k � - '' � t 'r Qom\ � t' > f t s k To \ a. - a � 4 b�,eaklil S � ve 3/1?- t 2 https://maps.google.com/maps?hl=en&ie=UTF-8&q=merrimack+college&fb=1&g1=us&... 08/20/2012 Certificate of ,frame Re5k;tance REGISTERED ISSUED BY, Data treated or APPLICATION AZTEC TENTS manufactured • CONCERN NO. 490 ALASKA AVENUE 022M TORRANCE,CA 80603 CAL COM"IS." (310)328.5060 This is to certify that the materials described below hereof have been!lame retardant treated(or are lnher- endy nonflammable). Foot CHROTIARPARTY RWALS ADDRESS 1dMfiffONDRIVE CITY HOLM STATE NH, 05040 Certification is hereby made that:{check"a"or"by (a) The articles described below this certificate have been treated with a flame retardant chemical approved a and registered by the State Fire Marshal and that the application of said chemical was done in confor- mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used.._.._...»._.»...».»...._........Chem.Reg.No.........._...» ._... Meathod of application...».»»..»..».»...........„,».».........-......»».».»...».- »».-.»».. (b) The articles described below hereof are made from a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. Trade name of flame-reaistant fabric or material used..L—%3ftdF*ft .Reg.No.......f ttfiRt...... The Flame Retardant Process Used INIu:NOT.... Be Removed by Washing (wN or+vir not David Bradley Chuck Miller-President Wo o< swm Oft CUSTOMER ORDER NO. R159657 ITEMS MANUFACTURED: i-1009040'(2 PC.)SERIES 2000 TP ULTRA WHRP 2.20Y40'(I PG)QWIK TOP ONLY-ULTRA WERE 2-20W(!PC.)QWtKTOP ONLY-ULTRA WHITE PDF created with pdfFactory trial version www.Offactory.com Google Maps Page 1 of 1 1 To see all the details that are visible on the screen,use the"Pent"link next to the map. a ; :_ IN let vA All i RI Ir a - t-q k �.. I tn E�17i7 , . Arrl htttvs://maus.p-oop-le.com/maps?hl=en&ie=UTF-8&q=rnerrimack+college&fb=1&e1=us&... 08/20/2012 Certif itate o f 11ame Re.5wance REGWMM AZTEC TENTS Dat*troeted or � 2866 COLUMBIA ST MWWbGbxW rm Ha TORRANCE,CA 90503 0212008 CAL tCrs F41101 (800)228.9687 This/s to MWOWthe materials*Wgiedbalow hereof haw beers Ianre ts�ratvrt(reefed(orate inherenfrYrataramnrsb�al. FOR CHRIS UN PARTYRENTAL 1S CLINTON DRIVE HOLDS,NH 03049 Cwtftadon Is hereby made that(check`yrs or"b") 6�,sw§ (a) The articles described below this cerditate have been treaded with a!lame retardant chemical approved and registered by the State Fire Marshal and that the applicationof said chemical was done In confor- mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Nameof chemical used...-................_...-.........» Chem.Reg.No.........»._»..»..... Meathodof application........_........_.........�...............».....»»..»».»...».W........».. (b) The articles described below hereof are made from a flame-resistant fabric or material reghdared and approved be the State Fire Marshal for such use;Fabric has been tested and passes NFPATOt-96. i Trade name of fame-reaistant fabric or material used_ Reg.No...... .�.»». The Flame Retardant Process Used..w1LL.Nor.......Be Removed by Washing t avAnu4 David Bradley Chuck Miller-President CUSTOMER ORDER NO. R168629 ITEMS MANUFACTURED: 2-20bd0 Fssilval Top UW wO Double Valance 2-211x40 Fesllral Top UIN with Double valance 3-40x40 2pc Jumbo Trac Top UW a-4WO JumboTrarc Middle Top UW 1-100br30 Series 2000 Middle UW 2.2Ox2O Serres 15001pc.Top UW 2-20x30 Series 1SOO ipC6 Top UW 2-20x40 Serres 13001pr.Top UIV f � PDF created with pdfFactory trial version www.pdffactory.com Certificate of 11ame Rem'�tancje cam REGISTERED ISSUED BY. Date treated or APPLICATION AZTEC TENTS manufactured +C CONCERN No. 490 ALASKA AVENUE OZIZOO6 CAl.COMB FttO.ei TORRANCE,CA 90603 (310)328-MO This is to aerafy that the materials described below hereof have been/lame retardant treated(or are inhem entry nonflammable). FOR CHRISTIAN PAWRENTALS ADDRESS 1d C WON DRIVE CITY HOLLIIS STATE NH, 03049 Certification is hereby made that.(check "a"or`b') El (a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the Shite Fire Marshal and that the application of said chemical was done In confor- mance with the laws of the State of California and the Rules and Regulations of the State l=ire Marshal. Name of chemical used.............»._........„_.............Chem.Reg.No....... ...»...» .».. Meathod of application...»._...»»».».......».... ».»...„....»...... » ....»...»..»« ... » (b) The articles described below hereof are made from a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. Trade name of flame-resistant fabric or material used.. F+f .Reg.No.......f.411 t......The Flame Retardant Process Used WILL NOT.... Be Removed by Washing (wNt or will/not) David Bradley Chuck Miller-President TIM low Im . CUSTOMER ORDER NO. R159657 ITEMS MANUFACTURED: t-IWX40'(2 PC)SERIES 2000 TP ULTRA WHRE 2.20x40'fi PC.)Q07KTOP ONLY-ULTRA W M 2-Z05t20'(I PCJ QWIK TOP ONLY-ULTRA WWBE 2 a �C�O PDF created with pdfFactory trial version www.odffactoly.com 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 Information PIease Print Legibly h r �r ABA Name Name(Business/Org�lan/ization/Individual):(h V'i 5f'N'1 W iyeky t u7Gil v Te,, y+ccS,X4 _C_hkx l 1A_,I� pdH4Y 444 Address: 8 (Ct i�fUYI _Priye, City/State/Zip: Phone#: (P 2- Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 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 partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.-Other "T1=/\ITS '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. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer tltat is providing)porkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Cwimeme nsui-an4 Policy#or Self-ins.Lic.#: WC 0093-70533 Expiration Date: Q�'17-Z 2- Job Site Address: City/State/Zip: /*40 i Attach a copy of the workers'compensation pollcy 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 Investig4tions of the DIA for insurance coverage verification- Ido hereby cert nder the ins a d pena ie of perjury that the information provided above is true and correct Si aforeaVZDA— te: Phone M D �—c�Y _S3Z4P 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#: ACORO CERTIFICATE OF LIABILITY INSURANCEF8/31/2011 DATE(M f 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 LUC' Fitzpatrick Tebbetts Insurance Agency PHONE {603}465-3333 F (603)465-6800 P.O. Box 848 E-MAIL S.luci@tebbettsins.com 3 Village Marketplace INSURE AFFORDING COVERAGE NAIL M Hollis NH 03049 INSURER A:Citizens Insurance C2ppany of 31534 INSURED INSURER B;Hanover Insurance C 22292 Christian Delivery & Chair Services, Inc. INSURER C:Commerce and Industry Insurance 15172 D/B/A Christian Party Rental INSUWR0: 18 Clinton Drive INSURERE; Hollis NH 03049 1 INSURER E.' COVERAGES CERTIFICATE NUMBER-CL1183101187 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. ITER TYPE OF INSURANCE POLICY NUMBER AIXX 5U581 POLICY EFF MWDPOLICY EXP LIMITS GENERAL LIABILITY �� EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREM S MeDAMAGE76-R-EITFoccirrance) $ 100,000 A CLAIMS-MADE x_ OCCUR ZWO844363 /1/2011 /1/2012 MED Exp Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GFITL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICYPRO- El LOC $ AUTOMOBILE LIABILnYffaaBBIINdEm SINGLE LIM 11000,000 X ANY AUTO BODILY INJURY(Per person) $ A ALLOSMED SCHEDULED V0716909 /112011 /1/2012 BODILY INJURY(Per accident) $ HIRED AUTOS NOI-OVVNED PROPERTY AUTOS $ Uffirwzadmotaistcombined $ 11000,000 X UMBRELLA UABOCCUR EACH OCCURRENCE $ 4,000,000 B EXCESS LULB CLAIMS-MADE AGGREGATE $ 4,000,000 DED I X I RETENTION 10,DOC 0844365 /1/2011 /1/2012 $ C WORKERS COMPENSATION X I WC STATU- X 577 AND EMPLOYERS'LIABILITY rR ANY PROPRIETOR/PARTNER/EXECL VE Y t k E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED9 E NIA 009870539 /1/2012 /1/2012 IMandatory In NH) EL DISEASE-EA EMPLOYE $ 1,000,000 !r yes,d8%Cdbe under DESCRIPTION OFQP:RATIONSbelow E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It 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. AUTHORIZED REPRESENTATIVE Seth Tebbetts/LUCI rsrsa ACORD 26(2010105) ©1988.2010 ACORD CORPORATION. All rights reserved. INS025 igninnsi m Tho AP.ARr)nam&an,i lAnA aro mntafara,i marke of Al A0n