Loading...
HomeMy WebLinkAboutBuilding Permit #1117-15 - 53 BEAR HILL ROAD 6/29/2015 NORTH 1 I !1I BUILDING PERMIT ,tLFD ,bgto 11 TOWN OF NORTHANDOVER o APPLICATION FOR PLAN EXAMINATION A F . Permit No#: 1� —� Date Received 7RADRATED Feat `y AC US Date Issued: (e EVIPORTANT: Applicant must complete all items on this page LOCATION f?69x- hl)k RD - PROPERTY OWNER J1/_V Print 100 Year Structure yes no MAP _PARCEL..tb ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi tial Non- Residential ❑ New Building ne family [Ell Add- ❑Two or more family ❑ Industrial ❑ ration No. of units: [i Commercial Fir, replacement ❑Assessory Bldg_ ❑ Others: ❑ Demolition ❑ Other _ ( Septic 0 Wells oFlo�dplam. Y WetlandsWatersheds®®rstnct, a 3 �. D IPTION OF WORK TO BEP ORMED' 6C 6T) L c Identification- P ease Type or Print Clearly �� ���d� OWNER: Name: 9199K � 0Phone: Address: �Jq Contractor Name: Phone: d< � Email: d/ Address: !r'1 Supervisor's Construction License: f.�7L' 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: $ 3� Check No.: ` 1 �0_L_ Receipt No.: � � 1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of AQPnt/®wnPr a Location -D ' No. Date . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ ,R r, r , Building/Frame Permit Fee � Foundation Permit Fee $ �. Other Permit Fee $� TOTAL $ Check" 8 59 89 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunming 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS ys 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 DEPAIDT-11 IENT , >Temp —unsite yes Located at14 MainStieet" t -,!Fir" pa rt;ment�signature/date ti !` 4 zwrc.��i .;`�` -4 { f COMMENTS° i 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 Call Email Date Time Contact Name Doc.Building Permit 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 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4- Building Permit Application 4; Certified Surveyed Plot Plan .4. 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 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 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doe:Building Permit Revised 2014 NORTN Town 1 �2 .. : ��.� Andover O No. � I � � * :_T 26 ,� oh ver, Mass,3 t. COCMICH&WICK y1' �d A00wTED ►' �� _ - LU) BOARD OF HEALTH Food/Kitchen PERMIT L D Septic System 7 THIS CERTIFIES THAT ............ ;4A.... BUILDING INSPECTOR --44 Foundation has permission to erect .......................... buildings on ... ................. .................�....... Rough to be occupied as .......... ...... e. � ...... O.�........................ 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_ CONSTRUCTION STA Rough Service .............................................t.................................... 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. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston North&South Date/ THD At-Home.Services,Inc. d/b/a The Hoyte Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,.. A 01545 Toll.Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lie#16427 Lie#HIC.0565522;MAA Home Improvement Contractor Reg:#126893 Installation Address: City State Zip Purchaser(s): Work Phone: Home'Phone: Cell Phone: Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing entails from The Horne 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 ("Installation")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#: (internal,Reference) oducts S eC Sheet(S)'#: Project Amount FIRoofing L.JSidingPWindows El Insulation / []Gutters/Covers ❑Entry Doors ❑ ! /( Roofing Siding U'Windows. Insulation ❑Gutters l Covers ❑Entry Doors Roofing OSiding Windows,El Insulation ❑Gutters/Covers ❑Entry'boors❑ Roofing .LjSiding FJ Windows Insulation ❑Gutters l Covers []Entry Doors ❑ $ Minimum 25%Deposit of Contract Amountdue upon execution of this contract. t Amount $ Maine Purchasers may not deposit more than one-third of the Contract Amount Total Contracz q 1 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 tbe.right to issue aChange Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Rome 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 workrequired complete the job was not included in the Contract. Payment Summary The Payment Summary #` / / 5101 included as 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 ffiled-lit copy of the Contract at the time you.sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed 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 applicablelaw. 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. Acceptance and Authorization: Customer 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 received a copy of this Agreement. A�cV :,bL �: 1.4tr/ Submitted by: __ ® Work area will be contained a•. . Pre-Renovation Form ®ate: / • ,,��„'' NAT=19276- -� This form is used to document compliance with the requirements of the Federal Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. r Customer Address Job Number(s) t iv .ten ...�:.....a.n.-...mom-,�.-.,.«—,........c;..�.�.. .ems.-....-,.,•,..,�.- - OCCUPANT CONFIRMATION Dust will be minimized Pamphlet Receipt r - a I have received a copy of the lead hazard information pamphlet irtforming me of r the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit.-I.received this pamphlet before work began. . }} 1 .� h i Hoene Year Suitt >n Enter the year my home was built. If my Home Year Built is Pre-1978,my home requires lead paint testing to determine B, whether Lead-Safe Work Practices are necessary per EPA or State regulations. Work oral area will be cleaned U n If my Home Year Built is 1978 or after,Lead-Safe Work Practices are.not required. thoroughly L � v ti= , Printed!Jame of Owner-occupant Signature of Owner-occupant I {, Signature on ng L amphlet Delivery f EES AT SPECIFIG FORMS ON REVERSE SIDE 0 Work area wi I .be contained Pre-Renovation Farm Date:1�- . .•.4 NAT-19276 This form is used to document compliance with the requirements of the Federal lead-Based Paint Renovation,Repair,and Painting Program atter April 2010. t Customer Address Job Number(s) OCCUPANT CONFIRMATION 0 Dust will be minimized Pamphlet Receipt 41 ve me copy f the Iead hazard pamphlet ccity me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began. ° T itHome Year Built I r x a ° ,. ' Enter the year my home was built. v If my Home Year Buill is Pre-1978,my home requires lead paint testing to determine +� p whether Lead-Safe Work Practices are necessary per EPA or State regulations. Work C7 ork area will e c l eanedu u p If my Home Year Built is 1978 or after,Lead-Safe Work Practices are not required. thoroughly Printed Name of Owner-occupant k Signature of Ownenoccupanr s SignaturerEE on mg L amphlet Delivery am S ATE SPECIFIC FORMS ON REVERSE SIDE • • � .. • f' , eneiSY>Itr.nran—thea 9 lion; �AV:: 1or luluro • ':� . lzbel.oh""-f (�tal ince' �•s;;iev• loll h�i•�� ----- L"�od_I 6tiD6 Double Nung Alum clad the a al Frame ��.`. W4LOW Inch Gl�Zing rtArr.;G ,,:I� Z o in Alt sPaye n u n�Ln Fill Griil_ SGS >�- LWcRCY IA ADD Ip'CRr�R`Yt -41cn P,:tI11L�-- ICrn�:cs. ''I O,t?O rif FL P�ccty ict b_. ncbrtl is ai Pn s,ylt l,tt nant'Dbrl pts: nu•; HFLL ntnst xFFY Cos C nvltcv ui '.j,p t htl Utir;rt�a. t.ts rietnq .1,�s pr.:t:l tn't r,i P tn! n�11t pprsdss't G:*'j• J! � rndlv.t of v-{)rod any tsv tnn. r � Vrd cl el tr,nrntT bnn+^'t • ' v7 pi>lu�u.C[�[t rai rtrnst h', e LLj�d cl pn sols ' LnL:rt UI tr.T "v Is ,,,v.r.ttlr=•onut lnlgtn Cyon A•cu L.C. N'i(v pl IVLS.1-t7 'IYY.t11s of e::esCt Y,.��. C._.C.' I 1soeLlt 1KSt'11L'.0 pJL=[l LI ,n-- N_L::t tl,s:-Motu-sem . t1e�s�u?lt}vS n _ - � I The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 ' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le 'bl Name(Business/Organization/lndividual): Address: City/State/Zip: Phone t Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(frill and/or part-time). 7, E]New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8, Remodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.F-][am a bomeowner doing all work myself.[No workers'comp.insurance required.]t 10 F-1 Building addition 4.7[am a homeowner and will be hung contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions p netors with no employees. 12.7 Plumbing repairs or additions 5. l am a general contractor and I have hired the sub-contractors fisted on the attached sheet 13.Vother_�4 f repairs These sub-contractors have employees and have workers'comp.insurance.:. 66.F-]lNe are a corporation and its officers have exercised their right of exemption per MGL c. 14. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowmers 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. IV /W /UL� /V� ' ' Insurance Company Name: /' J Policy r or Self-ins.Lic.r: �(i 0 12— Expiration Date: Job Site Address: / City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date .��`'/✓ Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci and naltie erjury that the information provided above is true and correct Signa / Date: t Phone n: � ^ i Official use only. Do not write in this area,to be completed by city or town official. i City or Town: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.CitvfTo,%m Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persons Phone n: t r 7 ! NerRVt Jervices / 4U1 •L40 ZOOO p.2 10i, Office Vit% C7L G� Office of Consumer Affairs and Business Regulation 10 Parr Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement-Contractor'Registration R.eg istration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: Bt312016 RICHARD TROIA ------ 2690 CUMBERLAND PARKWAY SUITE 30.0 . -- ATLANTA, GA 30339 _.....__. ........_.___ Update Address and return card.Mark mason for change. SCAt 204.1-0-111 - Address I J Renewal ...mploym: r:', :an Erse. O. r7i/,•i_i!/J/lil(i///'('//1./J/'�^l,i/�;I'f,�,/;ri� Office of Cunsuracr Nrbirs&Busiur_ss RcgulatiD❑ License or registration valid for individul use only before the ex iration date- Cf found return to: 110ME IMPROVEMENT CONTRACTOR P Office of Consumer Affairs and Business Regulation Registration: .1265.93 TYpa: 10 Pant?laza-Suite 5170 Expiration.:.8!9!2016 - Supplement Card W Boston,MA 02216 , THD AT HOME SERVICES,INC. THE HOME DEPOTAT HOME SERVICES RICHARD TROY{ 2690 CUMBERLAND PARKWAYS /� A`T t GA 30339 Undersecretary Tdotvalidwi out signature .e y.. j t t � 9 ^Aassachusetts Department of Public S f tyt 302rd, of Building Regulation and Standgtd�- ,?�31'��s�it L ren CSSL-106006 BENJAMIN BARKER JR. Y 43 GREENOUGII ItOAI� z , Plaistow NH 03865 i.....x p r t L i c R 4 02111/201&-.- "'71 21111201& s Y t� ^2 f '� y ..i.s. Y` ya ' ,� e y�'�+ t: hp�n "�'. �h ,'.,iu .s ' t.g � s'? �' -.'s +,�°•. t Permit Services 401 246 2868 P.1 ACOR& CERTIFICATE OF LIABILITY INSURANCE i °;z25;,�;5°"YYY' THIS CERTIFICATE 15 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 SLISROGATION IS WAIVED,subject t0 the terms and condliions of the policy,certain Pclic(ec may require an endorsement. A statemont on this certiflcaw dons not confer rights to the certificate hoider in lieu of such endomement(s). PRODUCER CONTACT HARSH USA,CVC. N AM E: -.— TNOALLIASIarC C:CENTER PHONE )[.._.... FA% 1-' :- 356D L'cNOk RI�AD,SCUTE 2E00 �o, IL ATLANTA,GA 30326 INSURER!SI AFFORdNG COVERAGE 1004 -}+OrICC'•uAVr`•ifi-16 INSURER A:Steadfast Im"r-xii,uotper:y 2E ' LYSUJ7Fd INSURER B:ZUrttt AlreLtar!ASuf3RCe Co ., ;16 5 THE H�6.cr DEPQT.:NC. .... _.......----...._... HGIAEDEPOT U.S.A,INC. !NSURERC!New Fixro:JurehSCc 23M; 2455 PACES FERRY ROAD:NYy —-- -- BULLING C•20 _IN_SURER D:Ulros Nawria!h rrance CCmpary ATLANTA,GA JD_JS INSURER INSURER F: — COVERAGES CERTIFICATENUMEER: ATL-MM553010 REVISIONNUMSERA THIS:S TO CERTIFY THAT THE POLICIES 0--INSJRANCE LISTED BROW HAVE SEEN ISSUED TO THE INSURED NAM50 A80VE FOR THE RDUCY PERICD INDICATED. NOT,aATHSTANOING ANY RECWREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO'AHICH THIS CcRTIFICATE rAAY OE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE -ERVS, EKCLLISICNS AND CCNDITIONS OF SUCH POLICIES.UhIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CL AINIS. T — -� - TYPE Oi — — .. .— ....... _...__.___,_._._._....,_ r i POLICY NUMBER --- I MMIDDIYYFr i MM;DDrYVYY I LTIT q$URANCE LIMITS A I DFRERALLIAaILTY Gt.048E771<C5 ;?;,12D'S C3,0VA-16 Ca c n'w I ,ADH OCCURRENCE 5 X f COMIIERCIALGEN ERALUASILITY .....-__._�...__�____.._.' X l.JI -R—EM S C:AMS.MADE OCCUR OF?OL)C5XS O MED FXP;A:r c"XCIJDED OF SIR:SIM SFR SCC '- I'—�I _°ERSONAL d AOV INJURY j S — SADO•Co0 L• .. f CENERALA13-3R£GATS $ S,DDD.000 GEMLAGGREGATEULIJAPPLIESPER: t—� (�'��y (_BCDUCT$-COMPrO?AMG i S .�JO.FMiO i X POLICY I 1 ,,'i I I LCC 9 AUTONOBILEUASILITY BAP 23 PFb3.11 DMU2315 030123BINED SINGLE LAIi CDDlx� X ANY A'JTO !110CILY INJURY!Por owsoc7 S ALLOYYNED '''^SCMEDULED SELF INSURE 0 AD TO PHY DMG ------• AUTOS u AUTOS I I eOG.:Y IrWRY cPcraxkrl) S HIREOAIJTO$ NON'OVNED ! PRO?ERir'�A:aaGE S Ir AUTOS I UMBRELLALAB OCCUR i I I EACH OCCURRENCE S —� ' EXCESS LIAB�.-" CLA ASAIADE '.DEC RETENTIONS i 5 C WORKERS COMPENSATION I YaC0t7731d93 TADS; !D3.'1rzD1s O;L3t 20114 :( WC 5'ATU• jOTH AND EMPLOYERS 4ABILITY I YAj4L1S.:.-.I P : __ C' -ANY PROPPoETOR,PaRTNE•R,EXECUMVE Y!N I �YVCD1773i45S(AY,,KY..`iH,Nd.'JT) 2.10112015 ,G3r01.2016 � 1•DDQ,tinD OFFICE"CIJBEq 00.U0E°' A: I =i EACS1 hCC10E•';T S D (Mandatory in HH) I TIG Il)73T4E4(FL) 0.1*1015 D331,23Tfi E.L. c- EMPLOYEE! �ISEAS.. EA S _ tt yeS.eetL�bo uder I D-'SCRJ'TOn OF OPKRAr�•+S oelcw iCarinued OR Add".Of`31 Page L.DI$Eii.E•POLICY IM17 is 1 rr+ it f I DESCMPTICN OF OPCRATIOVS f LOCATIONS!VEHICLES IAeach ACORD Lel,Addith-1 R—arlaa Schedules if morosp..la mquirrel CERTIFICATE HOLDER CANCELLATION TOWV OF NO.ITHOD S1.aN�ti'ER i60005S000StSHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTHANOOVnR.SIA 01844 ACCORDANCE'ARTH THE POLICY PROVISIONS- AUTHORIZED REPS ESENTATIVE o1 Marsh USA Ina Mznasn.4lu:chpr;oo _Mw�.anow •�""'k_a`A�� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD