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HomeMy WebLinkAboutBuilding Permit #727-2016 - 461 SUMMER STREET 12/14/2015BUILDING PERMIT ��'t'i-EDNo TH 2 ..•t6 qy Q TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION ~y T tl Permit No#:-1;�I' '� Date Received 7RADRITED PP`y Ly cgSSACHUS�( Date Issued: 1 44141-i-IMORTANT: Applicant must complete all items on this page LOCATION UC`tt Print PROPERTY OWNER i�.suSc-GL 1 G 1 10 d Cit" -- Print 100 Year Structure MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building o -n -e family ❑ Yclition El Two or more family ❑ Industrial E � teration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑ Well ❑ Floodplain ❑ Wetlands 0 Watershed District n Water/Sewer _ DESCRIP I IUN Ul �VVUMM C U tsrcr�rvrtinr-u. ISG �� ��- nlv� o� ; S E- Cvl l � � a.� ►h o� cj l�r^"91 Identification - Please Type or Print Clearly OWNER: Name: Q Sc-� Phone: �Z-� ' S n-3 Address: �4 U l Contractor Name: v" 0,JJN\` Gr - Email: w,J�irl nsvl,a-1:� Address °01 ox 3414 1 OM,,C ✓k Supervisor's Construction License: \OLSI9 �- Home Improvement License: C k 3 l l O qI­t 3%`�o 3`Ab3 ((LSA �. Exp. Date: I Exp. Date: Ik ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST��B//ASED ON $125.00 PER S.F. Total Project Cost: $S 1-- _FEE: $ VJ� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund J�� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafer & Sewer Connection/Signature & Dato Driveway Permit DPW Town ]Engineer: Signature: 4 d Located 38 Osgood Street FIRE DEPARTMENT;Tkemp D`Qrfi ster on sitep =yes s' =�t.. ' no Y LocFedl—"al124MainStreetk:' ,'�.= "`' " partments gnaturEe/,date orf , r � 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 ®ANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No Doc.Building Pennit Revised 2014 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 4, Building Permit Application 4.. Workers Comp Affidavit 4 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 TE: 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/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4, 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 2012 I ECC Energy code Engineering Affidavits for Engineered products TOTE: 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 2014 Location ' {Al/1/1VN ( G No. t 24 Date Check om 2999 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ J� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector U) 0 �r Q �. to 0 0CD v C 0 U) n' 0 CD cr CD 0CD Co O T a7 T V1 CD Z co vCD CD y v ZCD Z n 0� 0 7v 1 C CD O a O S. O j =rO O N CD 0O N < CD N CD, C 0 m n Q rn �o =r =r �. 3 y rt CD TI O O — Q. 0 m W D N o CD CA CD CD 2 G N (O Q '�' y, O c rt n n : S CD CD CD O <(O: O vi L rrrt D `D:� CL O Q. CQ 0 CL N AD CD(D U) CL *,4110 CD y rt � 4 U3 =� rt0 °CD CD "0 (n -° CDo D° CD '0 @� 0 � o O N N Co T a7 T V1 ;;a TM T 3 1 C 3 O (D O S. O j =rO O N O O O 77 N UCO VOq OOq pOq Q (D —D (( 3 n ? S 7 S O_ (1 Z (DN N N � O O C K � fy O N S ;-r r, rD m C 3 (D ' C W G) N v v zD Z C M D H r _ O 7o m z z Z m r m O rrn m m D O 2 M W Federal ID # RISE Engineering Rl Contractor Registration No VA ContractorRoglstration No A di visioo of Thicisch Engineering ineering CT Contractor Registration No 60 Shawinut Unit {f2, € anton, MA 112021 CONTRACT 0, ` . 339-502-633.5 FAX 339-502-634a Page i IS EITRfJEiRAi4l �, ... THi5 eORITRACi tS EnTEREO iHio aEnWEEN RISE CMA-HES ENCINEERINC Arta THE CUSTOW FOR WOW AS lw-tlGINEERINC, 4. %,q� t DESCRISE00Er.OVr CUSTOMER . HONE DATE CLIENT a WORK OROER Russell Bilodeau� � 978)729-5173 06130/2015 407530 00002 � ...._ _ __... _..... ...... _,,,,. _ _._ _ . ........ _ ...SERVICE STREET �. HIS STRUT ..._..._ 461 Summer Street 1 Summer Street .......... SERVICE CITY. STATE W 8 INS CITY, STATE, XIP North Andover, MA 0184 1 ortit Andover, MA 01845 JOB DESCRIPTION AIR SCALING: Provide labor and materials to scat areas of your home against wasteful, cxccss air leakage. '1116. work will he performed in concert with the use or special toots turd diagnostic tests loassure that your home will be ]ell with a healthful level of air exchange and indoor air quality. Materials to be used to seat your home can include caulks, foams and other products. Primary areas for scaling include air leakage to attics, basements, attached garages and other unheated arcas (windonss arc not generally addressed.) This will require (8) working hours, A reduction in cubic feet per minute (cfnt) of air infiltration will occur. but the actual number ofcfm is not guaranteed; At the completion ordic weuthetintion work, and at no additional cost to the homeowner, a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure the sallety of the indoor pair quality. $680,00 AIR SCALING A13DER< (2) working hours: $170,00 ATTIC FLAT: Provide labor and materials to install ar 10" layer (if R-35 Class I Cellulose added it) (1) squaw fccl of floored attic space, $1.95 DAMMING: Provide labor and materials to insudl'a I2" layer of R-38 unfaced fiticrglitss baits to (1 t6) square felt for damming purposes. 5237.80 WrTIC FLAT: Provide labor and materials to miscall a 4" layer of R- 14 Class I Cellulose added to (290) square fent of open attic space. S30i.10 ATTIC FLAT: Provide labor and materials to install in S" layer of R-28 Class t Cellulose added to (7 t5) square feet of open attic spacc,KEEP IOX12 STORAGE! $.>K92 STORAGE BARRIER: Homcowuer is r rimitilc for the removal of the stored items blocking the installation of wcathcrizrition %work in the attic. Removal must occur prior to the scheduled work start. $0.00 A17IC ACCESS: Provide labor and materials to install €13 easily moved, insulating cover for the attic access folding stair: A mail tint surface of ptywood will be crsatedawlind the opening wit.hirt the aWG This will allose the Covens integral weather-stripping to restrict air leakage. 5237,55 VENTILATION: Provide labor and materials to install ventilation chutes in (32) rafter bays TO maintain air flow. $64.00 BASET EENT CEHING. Provide labor and materials to install (32) linear feet ofR-f 9 untaced fiberglass insulation to the perimeter ofthe basement Ceiling at lite house sill, 554.00 OVERIdANCr': Provide labor and materials to install 10" R-37 densely packed Glass f C+ ttrdose insulation to (32) square feel of exterior overhang, located below a heated floor area, by drilling holes in the overhang from below, holes drilled NWI he plugged. Plugs will be scaled with exterior guide spackle and lett in a relatively smooth condition, Finish sanding and touch-up priming/painting will be the custamces responsibility. Federal ID 11 RISE Engineering RI Contractor Registration No NA Contractor Registration No A division ofThicisch Engineering CT Contractor Registration No 4,111 '2 60 Shawmut Unit #2. Canton, ,MA 02421 C O'N'T R Am C T 339-502-633i FAX 33 5 Page 2 R I S E 1, PROGRAM S CMA-IIES Wei CONTRACT IS ENTERED MTO 80WEEN IE NS E=MECRM AM THE VATOMER FOR WORK AS ENGINEERING . . . . . . ........ . ..... .... ...... .... CUSTOMER NE DAYS CLrEMT# VIORK ORDER Russell Bilodeau 79)729-5173 06/30/2015 407530 00002 . .... .. . ..... A�k SERVICE STREET 110 ST R EET 461 Summer Street Summer Street SERVICE CITY' STAM zip ORLING CITY, STATE, ZIP North Andover, MA 01845 North Andover, MA 01845 ,JOB DESCRIPTION RISE Lneinecring will apply all applicable, eligible incentives to this contract. You will only be billed !lie lslet arnount- Currently, for eligible mcaiures, Columbia Gas of 75% incentive, not to exceed $2'000 per calendar year, and an incentive or 100% for the Air Scaling measures up to the first $680 and an additional 5340 ifsavin-es irciustified by (lie auditor. For the safety and hath of your homes indoor air quality, we will be conducting a blower door diagnostic ofilte available air now in your home both berate the work is begun, and aticr.the wouthcri=tion work is complctc, We will also conduct It full assessment of the combustion solely ofyour heating system and -,vater hooter, This has a value of $90 and is at no cost to you. Taudallm2ble wcatherWition incentive is 53.110, $128.00 $90.00 Total* $2,951.42 Program Incentive: $2,309.10 Customer Total: $642.32 WE AGREE HEREBY TO FURNISH SERVICES COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ***Six Hundred Forty -Two & 32/100 Dollars $64232 UPON rof" BS Ci[Ot APPROVAL ISE ENGINEERING. CUSTOMER AGREES To REMIT AMOUNT DUE 04 FULL INTEREST Or 1%VALL BE CHARGED MONTHLY ON ANY UNPAID E FOR IMPORTANT INFORMATION ON GUARANT ERIGHTS OF RECISION . UCHEOUUNO. AND CONTRACTOR REGISTRATION. 00 NOT SIGN THIS CONTRACT IF THERE Aki�A�NY BLANK SPACES C, AUTIiORD:ED SI -TURF EEAglnoatirtD uM:TRIS CONTRACT MAY 89 %WTHaRAV04 By US IF NOT EXECUTED VATHIN GATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT -THE' ABOVE PRICES. SPECIFICATIONS AND CONDITIONS ARC 0 ZATISFACTORY To US AND ARE HEREBY ACCEPTED..YOU ARE AUTHORIZED TO DO nfe WORK DAYS 3, AS SPECIFIED. PAYMENT V011 BE MADE AS OUTLINED ABOVE r m owner or the property located at , tqkpo ver., !v'cA_ C hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behal to obtain a building pennitt and to pedo m wofk on my property. The Common wealth of Massachusetts Department of Industrial Accidents Office of Ianesdgalioni .1 Congress Street, Suite 100 Boston, MA 021142017 www massgorldia Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers Aunficant hilormation Plea.w.Print L4ei!ihlv Name Ad&css: $0 eoX 344 UkQ123S Phone#: - I TLo - 34qS' 3 Are you an ctnploytv�? Chock the appropriate box: Type of project (required), 1. 8 1 am a employer with 5 4. [3 1 am a general contractor anti 1 & (3 New com-anictio n trip ce-s. (full and/or PM1 -time).* 213 1 -am a -wlc proprietor or partner- have hired. the sub -,contractors listed on tht attached sheet. ?>e Remodcling ship acrd have no employees rhow have S. Dernolition working for = in any capacity. employees and have workers 9- [3 Building addition [No workers' comp. insurawe required.) comp, inswatiet'. 5- [3 we are a corporation and its M13 Electrical repairs or additions 1 C3 I am a homeowner doing all work ofliem have exercised their I I,[) Phunbing repairs oi-additions Myself. thio workcW c tight of exemption pa MGL 12.[] Roof repairs insurance Toorcd,j t c, 1'S2, § 1 (4), and we have no 1-1930ther employees. [No work -m' eonr_insufance required] *Any appfi=0Wcbcck-5Wx Olm.uoalw fill etas the kviiia below policy infomwion, I Hmmm= who sulnit this a se at irrdaa nz thsy an doing all %vkArad *= him :Cwtmcim am cbo& this b" win anac*d an additimW shoname state wtreater ornos dwsc entities have enVbYco&, if the sub-contractm hew tVVl0Y=' dwy num protide this wotkbW ca a. pdhcitamber, I an an employer th or is pnmiding workerVedwponerr insuramejor my, exployem Below is thepaticy andjob site i0mmation. I - insurance Company Name.- i tawlf --A4 X'3 J)LU" "A "A-^ ExpirationDate: 0 Job Site Address: k-lu t S'Jrr'm L'r- S city"'StateiziliN, Atiaclt a copN of the workers' compensation polity declaraction page (showing the poho, number and expiration date). Failure to see= coverage as required under Section 25A of GL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 Wid/or one-yzar imp 6soar omi,ws well as dAl perialtics in the form ota STOP WORK ORDER and a fine of up to $250M a day against the violator. Be advkcd that an copy of this statement may be, forwarded to the Office of investigations of the DIA for inqurtince coverage verification - I do hereby cerdfy under the paias and penafties of pedtoy that the information provided above is trees and tonvct. i ' I b25t-� - k I 'Q I 5 4 CL�— Official use only. Do rid write, in this area $ to be completed 6y ror town official, (Ity or Town: permit/License 9 Issuing Authority (drde one): 1. rel of Health Z. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Othtr Contact Person: phone #-, CERTIFICATE OF LIABILITY INSURANCE �- AC<>RL> _:� ThIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION 014Y AND CONFERS NO RIGWS RBTME PTIFICALE 4fOLLWR. THIS CERTIFICATE DOES NOT Air`MkAlWrLY OR NEGATINEVY AMEND, "ND OR. ALTER Tk* CO AM POW A tiOW BY THE POLICIES bEW i T CERTIFICATE Of IIaS tAINCE DOES NOT CONSTMI E A CONTRACT BETWEEN TELE INSURER (S), AIITtItA2Et ASWV .#iTATWE OR PRODUCER, AND Tits cignFItATt HDLDCP. IMPORTANT-, W rw m7m; ss sta ¢�t3iT3t %AL tNW D, W XZ7(w-S) rye O DO t"04MO, It ifMOGATION IS WAIVED. _ )w to t toms arw rotadite s5 of he Atter, r.Aat n pokles may *A w,, rsbi rk. A rwtmem on " oeftftm dos not confer 60ft to Vw MgftaW hdder tn Itto of SvCh a z( >. J60 Nordl& hon St PO Box 989 ,� r •I Ate. :i t866 7I5-81le H t ts�caa GatitilNir lnr6i �� PO Box Sd4 : "widij VA elm V: W 15 t:EitT`fEiC:Ai� Nt1YlBER: � tltC1 IS 9 CERNY TRA7 7 R P M i MS 0 F I N uuIIWE USTED 6 a OIN I0,AV15Si8s'ii T4 TfrfE to tM T79 ' w.ICT PEMM CATER NOT6+MSTANV ANS? PEC ti TEW OR CONDRION OF ANY CONTRACT OR 07HER DOCJMENi' WITH REPECT TO W*QH TMS MTIFrATE MAY eE MWED € RWAY PERTAIN, TME WSURANCE AFPOF&ED BY THE P .IGIES DEEMS ~EB HEREN PS SUWECT TO ALL T)i E TERMS, E-XW MOM AND COW M 5 09 SU CH POL10T5,LUTS MYNMAY E SEED REL, E0BYAAtIC L 7'x'D k4k VAIJ DE ;x sickx5dav`i' t S 4'swNq sAwr AOTOMOKI UAMLM a e E AW A00 raaxa s wa+ x; +gig W w. �www.ta"Im bgCr.r,#a.�sl+�'gw:.rs+eea� �$ ac*aaswta s. rys_e .w,W d £7" UAO de f $. kSsreiiELiJG:' $ Jam Li RRTI-X14"s A -W iPAiE Yx ED P3327 ?lr t�tit6il:R �`.Gki#1 ClCat .�i1tC! ACCORDAN'm wax THE PO CY PROM OWS, 3mature, ACM 25 20) eta 3139 ACORN0 �� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 7/7/2015 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 Martin J Clayton Insurance Agency; Inc. 1649 Northampton Street P. 0. BOX 989 Holyoke MA 01041-0989 CONTACT Nancy Usher AICONN Ext: (413)536-0804 FAX No: (413)534=7874 ADDRESS: INSURERS) AFFORDING COVERAGE NAIC # INSURERA:Nationwide Mutual -Harleysville NATIO INSURED Gauthier Insulation 44 ESSEX ROAD IPSWICH MA 01938 INSURERB:Allied World Natl Assurance Cc INSURER C : INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE IX OCCUR DAMAGE TO TE PREM SES (Ea occurre) $ 50,000 MED EXP (Any one person) $ 5,000 X GL43487F 7/6/2015 7/6/2016 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY E JECOT- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ B EXCESS LIAB CLAIMS -MADE DED RETENTION ___1J000'000 g BE020792125-194985 10/18/2014 10/18/2015 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PEROTH- STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSUREDS) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MF?brd§tbd with pdfFactory trial version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MF?brd§tbd with pdfFactory trial version www.pdffactory.com 13 m ;a umi 0�>hm gtft�4� AC7= U m x s 0 c0 f ;ma N m o v. 0'0 o�z � ML, � 0 R A n c m ^ i a m c i c 000D Mill C�? 00 in tA m' a 020 ... i Qt � jf