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Home My WebLink AboutBuilding Permit #190 - 573 SALEM STREET 9/9/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I V Date Received Date Issued: I PORTANT:Applicant must complete all items on this page LOCATION 579 �t J }/ 1 h t"Irl Clue Print; PROPERTY OWNER J667 940,r J� Print MAP N PARCEL","" ZONING DISTRICT: Historic District yes no 4>3iFiv /l . Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne f Addition Two or more family Industrial Alteration No. of units: Commercial epair, replacemen Assessory Bldg Others: emo i ion Other Septic Wolf Floodplain Wetlands Watershed District Water/Sewer DE4CRIPTION OF WORK TO BE PERFORMED n �, ✓V 111 t - /�iI u , .�) /,� �` `` Identification Please Type or Print Clearly) OWNER: Name: U o�, Phone: Address: �{ S-./ems, s�— -..---. -----_'---� CONTRACTOR Name: tv+, Phone.: Address: Bvf` v, ' Supervisor's Construction=License: 9 3 Exp: Date:_ � 7 Home Improvement License: /S 7 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ G �� FEE: $ � ; Check No.: 4 �6 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature oI A ent/Owner '` � �g� g _ ��-, Signature of contractor , Plans Submitted Plans Waived Certified Plot Plan Stamped Plans 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 ❑ 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.Building Permit Revised 2008 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 I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i t 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 lat 124 Maas Street j Fire-,Department signature/date I COMMENTS i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL:C RICAL: 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 2008 Location s 1.1ey, No. Date ' "011T" TOWN OF NORTH ANDOVER O:tr�°o ,•,1•C F R P a Certificate of Occupancy $ Building/Frame Permit Fee $ s�►CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2240 Building Inspector Mas�uchusctts - Department oi'Public Saim Board of Building �, Regulations and Standards Construction Supervisor License .License: Cs 93734 Restricted to: 00 ADAM D LAPOINTE " 200 BUTTERFIELD DR STE I ASHLAND, MA 01721 Expiration: 7/4/2011 ('ummisiuner Tr#: 1307 NORT#i ® of 4Andover C% dover, Mass., T O Y' LAKE �. COCHIC HE WICK ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System I-to 4 o-,, 4', r. BUILDING INSPECTOR THISCERTIFIES THAT............................................................................................................................................................... Foundation �? . �r— as permission to erect........................................ buildings on ...... .......... ............ ...................................................... Rough . to be occupied as.......U�. .G..�rr.�+f�....... ... ........ ✓3—L Chimney .. . . . . . ....................................................................... provided that the person accepting this per d shall ievery 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 3 L PERMIT, EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ST TS 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 Until Inspected and Approved by the Building Inspector. BurnerFlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at /cam, SN v.pis that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: (Location of Facility) i Sig re of Permit Applicant /Ij/7 Date 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 Please Print Legibly Name(Business/Organization/Individual): i VC4 46.,_ me-;b Address: 7.6J f3if, F-AeId Pr City/State/Zip: �lltk� r� Phone#: S a �� Are you an employer?Check the appropriate box: Type of project(required): 1.[�I am a employer with /' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 7.6. ❑New construction 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. 9. ❑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.F]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � r Insurance Company Name: Q-b�l� /�►�W�h C..� Policy#or Self-ins.Lic.#: 1/cm- o zL�( 7q q l / Expiration Date: Job Site Address:��'l d�c/ S�le"s-14 � City/State/Zip: - •W✓� 0�1 n jdj,� 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 coverage verification. Ido hereby cern under the pains andpenalties ofperjury that the information provided above istrueand correct Si ature: Date: U l ert ocr Phone#: d _ 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia ��fifTon~sumWetroAefair#san usinessegu anon 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 157108 Type: DBA Expiration: 9/5/2011 Tr# 287273 UNITED HOME EXPERTS JOHN DUDLEY ------------- - -- -- ----- 200 BUTTERFIELD DR STE I - --------- - -- -- ASHLAND, MA 01721 Update Address and return card.Mark reason for change. j-1 Address Renewal ❑ Employment F_1 Lost Card PS-CA1 as 50M-04/04-G101216 � !�(.CLddClCltUdP,�.td ,� 6II74)tfJJrt.I.U6 d.�; . -� Office of Consumer Affairs& usiness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 157108 Office of Consumer Affairs and Business Regulation Expiration: 9/5/2011 Tr# 287273 10 Park Plaza-Suite 5170 Boston,MA 02116 Type: ` DBA UNITED HOME EXPERTS JOHN DUDLEY 200 BUTTERFIELD DR STE I ASHLAND, MA 01721 Undersecretary —�C•- -- - —- — Not valid without signature Vinyl Siding Scope of Work Project Name r Area for work to be erformed: Excluded Areas and Surfaces: Building Y Permit:. es E' No[] rDumpster .%(if needed)& Rubbish Removal: Yes No Location: Surface Preparation& Details Yes No Yes. No Removal of Existing Lavers of siding: �I Mitered J-Channel Remove/Reinstall Electrical Meter(if needed): ' Hand-Nailed Galvanized Nails Remove/Reinstall Light Fixtures where needed : Notes: (t,,:;, i Moisture Barrier Installation: Type: s f I Insulation Installation: Type: Steel Starter Stri : �' Sheathing rot replacement priced at$ > per 4x8 ft.section or$ per board ft. Siding 1 to be installed: L" f:1- .sir �. r (i Size:V Color: Siding 2 to be installed; = " i'r �. n;•f- 17r .(s ,X, Size: 0 Color;"rU-P It r1/2" Features and Accents er osts Window Frames Door Frames Garage a Door Frames Flat 5 Bend PVC Coated 5 Bend PVC Coated 5 Bend PVC Coated ✓� Flat Flat PVC Coated Flat PVC Coated Flat.PVC Coated 5 1/2"Fluted Frame Color: ,; � �, Frame Color: lf;� Frame Color: Finish: �1 J-Channel Color:�frirrl Body J-Channel Color:,; rim J Body J-Channel Color:� m Body Other: Other: Sv 1 ��GaK Other; Other: Color: .,� .�t. Fascia&Rakeboards r5H Porch Ceilings Shutters PVC Coated Custom Bend den Ridge Vent f Triple 3 Beaded r inyl Louvered finish: (', ted Vent Cellular PVC T&G Vinyl Raised'Panel Color. '^'''`_ �' —C `e �-+, t Openings; of Pairs: p Other: �'.� Color. Color: 3 " theOther Other s Gurs A=reas be installed: e: Color: Gutter Size: Downs out Size: Guards: Notes and Options: U Specific Exclusions: We understand the following surfaces are to receive no work: ��i j` r • Any additional permitting required by the town or city 0 All areas and surfaces not mentioned.above Clarifications: Basic clean up will be observed at the end of each working day,thorough al project completion. We understand that if needed.iandscaping will be cut back away from the house by the homeowner or others prior to starting the work. See Definitions and Conditions on the back of this contract set for explanations of terms. A United Hom � , � e Experts & M HOME United Painting Co. Inc. elm TM 200 Butterfield Dr. Suite I Ashland, MA 01721 MM HIC License#130101 Full Worker's Compensation Coverage 508-881-8555 FAX 508-881-5584 P $2,000,000+Liability Insurance Coverage MA Constr. Supervisors License Warranteed work wWw.UnitedHomeExperts.com RI REG#22948 Excellent Financing Plans available PROPOSAL PAGE 1 Project: Bid Date: Attn: Phone#: Company: Work#: Address: Fax#: Email: City, St. Zip: Heard of us by: Base proposal as per attached scope of work: Alternates: Any additional customer requested carpentry work will be billed at per hour+materials. Prices good for 14 days PAYMENT: A non-refundable deposit of 1/3 of ALL ACCEPTED PROJECTS is due upon authorization in the amount of$ ,with 1/3 of EACH PROJECT due upon half of completion of EACH PROJECT, and the balance of EACH PROJECT due upon completion of EACH PROJECT along with any additional work requested by customer. DISCLOSURE: State law requires us to inform you of contract liens. Any contractor, supplier, or subcontractor may lien your real property if you or the general contractor fail to pay for goods or services delivered or installed at the work location. Some contractors and suppliers automatically send letters of notification similar to this notice. At your request, we will provide original lien release documents from anyone who provides said materials or service. Please call if you have any questions regarding liens. ACCEPTANCE: The signature on this proposal reflects acceptance of the proposal as per the attached scope of work, authorizes commencement of the work, and hereby guarantees payment as outlined above. Any amounts not paid within thirty days of invoice are subject to service charges of 1 %Z%per month(18%APR). All costs of collection, including reasonable attorney fees are to be paid by the customer. You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract. United reserves the right to assess a service charge equal to 25%of the contract amount if the job is cancelled by customer AFTER three business days. i�I.�r4 IIS Contractor signature Date Customer signature Date BBB Great People, Quality Service, Fair Prices, That's United! t _ CUSTOMER COPY Fear internal use Job type Scheduled $Price Notes Material l Forecast Date � r' S1;z�; 3._4 4 S ,- i S000 W -- Dumpster size location date < < , 00d y/�;�� Project: }� Bid Date: � S , d, �ti -� Attn: -�A A G r c Phone#: -7 P= (v D'3 . " %3). Company: Work#: Address: — Fax#: 7 �� P -, �� Email: J,T2,e ah q;- City, ?City, St. Zip: Heard of us by: i�,M r ;,I. �(. Base proposal as per attached scope of work: Alternates: Any additional customer requested carpentry work will be billed at (/ per hours m-aleriais / p r d-) 1�U V1 yl S/ i'J f:,i, 1 Si Prices good for 30 days PAYMENT: A non-refundable deposit of 1/3 of ALL ACCEPTED PROJECTS is due upon authorization in the amount of$.ice, L1440 ,with 1/3 of EACH PROJECT due upon half of completion of EACH PROJECT, and the balance of EACH PROJECT due upon completion of EACH PROJECT along with any additional work requested by customer. r— � S Notes to Production: IN P�10i VJSA' Contractor signature Date C�stome'r signature Dates BBB Great People, Quality Service, Fair Prices, That's United! ■_ ncnrfIr rinDv Client#: 27859 UNITE ACORD- CERTIFICATE OF LIABILITY INSURANCE 0DATE(MM/D 8/12/09DmYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Herlihy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 51 Pullman Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester, MA 01606 508 756-5159 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance Company United Painting Company, Inc. 200 Butterfield Drive, Unit I INSURER e:INSURER C: Ashland, MA 01721 INSURER D: INSURER E: 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. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DDIYY LIMITS A GENERAL LIABILITY CPA011338715 04/15/09 04/15/10 EACH OCCURRENCE $1,00 000 X COMMA MERCIAL GENERAL LIABILITY DAGE TO RENTED PREMISES Ea occurrence $250,000 CLAIMS MADE 51 OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s21000,000 POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY MAA011338815 04/15/09 04/15/10 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUA011339114 04/15/09 04/15/10 EACH OCCURRENCE s4,000,000 X OCCUR FICLAIMS MADE AGGREGATE s4,000,000 ADEDUCTIBLE $ X RETENTION $0 $ A WORKERS COMPENSATION AND WCA026478911 08/15/09 08/15/10 X WC STATURY 0ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS United Painting Company, Inc. United Painting Company, Inc.dba United Home Experts CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION United Painting Company, Inc. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10_ DAYS WRITTEN 200 Butterfield Drive, Unit 1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Ashland, MA 01721 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 Of 2 #S38752/M38751 RLK 0 ACORD CORPORATION 1988,