HomeMy WebLinkAboutBuilding Permit #826 - 89 SURREY DRIVE 5/17/2012Permit NO: � Zce
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: _�, IZ'
IMPORTANT: Applicant mustcomolete all items on this Daae
LOCATION 0 % – % ww_t ca v /Vo 2-/-7-f AJ 2� d v
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PROPERTY OWNER iso L l-fi Gmd,_4�1_ � �yi � 1�U 0 t('e`—Unit #
Print
MAP NO: -if—PARCEL: ONING DISTRICT: Historic District yesn
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building"One
family
❑ Addition
U�- wo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
0 Assessory Bldg
❑ Others:
❑ Demolition
0 Other
IT.S bet � O Well'
Floodpl'aiw q, Wetlands
IDs-Watershe40*1ct
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
C)hl,
JJe
(Identification Please Type or Print Clearly)
OWNER: Name:RAP,-k ('o rn ,n--_ f CKyi s `PG -r (fer Phone:�7� / SJ oZ J(*
Address: X G - V /
q/,
CONTRACTOR Name: P b;Ay l ui n P Phone:
Address: U �U)omrn ) /A 41[�f
Supervisor's Construction License: c1 L, S (o Exp. Date:
Home Improvement License: ( U L4 S(.o � Exp. Date
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
1Z,
FEE SCHEDULE. BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ a '7(,'- o a FEE: $_ `7,� _
Check No.: t& L(y Receipt No.:. Q5,31 3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
nature of Agent/Owner,.,, _ Signature_of contractor
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑
Stamped Plans ❑
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
0
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Drivewny P---;'-
DPW
ermit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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
Doc:.Building permit Revised 2011 June/mi
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 2008mi
Location /f !7) i'T t4
No. Date
Check # G"
25313
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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DAVID CASTRICONE ylAG
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 M A Y 11 i 2
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises Belo described:
£�. Jyl u.CA.•1 �.4.... .Clt / ... Te one #..... G�.�....:..:rr.......
Owner's Name.. : e %/�
Job Address....... . ...- . 9 �... il.1.1 f` i�� ...l F?L..7.......... city ... �.L? ...44. 0...1f...eJ............. State ...... M/4.....
Specifrcalions:
..............................................
rip existing shingles!, /% ,Apply new drip edge to all edges.
.......................................................................................................................................................................................................I..............
,,Apply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house.
.....................................................................................................................
�iCnnly felt nalsermnderlavment . install ridge vent to / h p _T , . " , ., &e-6
........ ka . ^{.rre .,e. :.,... ...� ...... .. .. .....t .. ...... ... .... 'K... ......
........................... y.............•"""--------
„Reroof sing v r s ..� .x/ ..�, shingles with a L' year warranty.
....................................................................................................................................................................
�Counterltash chimney. -New vett pipe flashing. . 4!Jegal disposal of all debris. 1.
.. ......................
..................................................... j.......'................................................
Area(s) to be worked on:r(,
/.�. ..� �../... : y/ r?r'.. rj .. ...t..v...tY S..E'.c..s......
�...
.6..... .....
..�!. R....... 5...../..n.... .y ....,—t.. .................
i
...................................-..e.r...... i`.�.�.....
Roof board replacement if necessary @ LCi /sheet/foot.
................................................................................................................................................................. f�-. ..............................
Two Year Workmanship Warranty (Not Transferable) B'),iinufacturer's Warranty as specif by tt�nufacturrer-,
The contractor agrees to perform the work and furnish the materials specified above for the SU of $..... .a� �7iZ.........•••. ,>
Payable............................. on .................................
Payable ............................. on ................................. I Balance payable on completion of job
Owner or Owners arc not responsible for Property Damage or Liability whilejob is in operation.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon
completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by
contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is
agreed that, if permitted by law, contractor shall he paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by
contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There arc no representations, guaranties or
warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to an conditions not
herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108
Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................................................ Completion date .........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see n//o��tie f cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their names this .. T. ' y of .. .......... 20..)...r�.
Accepted: l
Signed ................ Owner
.. ...... ..
Signed........... ...... ...................................... Owner
David Castricone, President
�-Q— r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
kv 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): 0-417-r l C t) N& Re) f- ANG l S/b //,-1('r /,_1 C.
Address: �,2 c,, ('1 Sc: 777 /,. `
;S igz,� T
City/State/Zip: N6, A /V bo UL K
MA U/ NY Phone #: 97f
6 e3
Are you an employer? Check the appropriate box:
Type of project (required):
1. N1 I am a employer with
4. ❑ I am a general contractor and I
6. ❑New
employees (full and/or part-time).*
have hired the sub -contractors
construction
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g. ❑ Demolition
workingfor me in an capacity.
Y P h'•
employees and have workers'
9. ❑Building addition
[No workers' comp. insurance
required.]
comp. insurance.
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.ZRoof repairs
insurance required.] t
c. 152, §1(4), and we have no
13.❑ Other
employees. [No workers'
coma. 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 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.
Insurance Company Name:41 n s
Policy # or Self -ins. Lic. #: Wcv A3 9 0 924-3 Expiration Date:
Job Site Address: �q — �/ to lJ t6WC City/State/Zip:�c/ldY'-
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: ' ` 1 1%f e �"„ _ Date:
Phone
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 #:
Town of North Andover
0 itt,
. 3� h..;il .. d O
Building Department o -
27 Charles Street '' A
North Andover, Massachusetts 01845
(978) 688-9545
Fax(978)688-9542��
LSSACHU5(_
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MG.L c.l 1, sl 50a.
The debris will be disposed of in /at:
kZ't E Z/V(f
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
} llcliartmcnt ul Public .1;Ifi•n
Buartl int Buildin" Kc,ulatiun, ;Intl St:uItl;Iril
Construction Supervisor Specialty License
License: CS SL 99358
Restricted to. RF,WS
DAVID CASTRICONE
31 COURT STREET
NORTH ANDOVER, MA 01845.
Expiration: 12/16/2013
('in,niainrr
T rl;: 7924
jla. ueJr�J
OflircOtCunxtnnc, Affli,'Ss Busillc,<kigul;uiun
Illi SII HOME IMPROVEMENT CONTRACTOR
Registration: 104569
,Type:
Expiration: 7/14/2012 Private Corporafio
DAti?D CASTRICONE ROOFING, SIDING 8
David Casfricone
200 SUTTCN ST SUITE 226
NORTH ANDOVER. MA 01845
•� Llnilcrxrrcr;uy
DATE (MM
,IDDIYYYY)
ACC3R0 CERTIFICATE OF LIABILITY INSURANCE111 9/23/2011
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(Sy, AUTHORIZED
AA I.►I.t •\111 Tllr O.11TIr1A •Tr I IA -D, tf�the certiAficate holder Is an ADDITIONALP INSUREDI, the pollcy(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
certlficate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Eastern Insurance Group LLC - Main PHONE FAX
AIC No):50 -65 3-233 West Central Street E-MAIL
Natick MA 01760 ADDRESS:
ERA
INSURED 31969
David Castricone Roofing & Siding Inc
200 Sutton Street #226
North Andover MA 01845
COVERAGES CERTIFICATE NUMBER: �i ni r,-7 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
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DDLSUBR
11.rI I�VI.IDCn
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GENERAL LIABILITY
EACHOCCURRENCE $
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PREMISES tE wurre�nce $
COMMERCIAL GENERAL LIABILITY
_
MED EXP (Any oneperson) $
CLAIMS -MADE F7OCCUR
PERSONAL & ADV INJURY $
i
HGEI'L
GENERAL AGGREGATE $
AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
POLICY PRP LOC
$
A
AUTOMOBILE
LIABILITY
BCNGCV
/1/2011
/1/2012
Eaaccklera 1000000
_
BODILY INJURY (Per person) $20000
ANY AUTO
ALL OWNED SCHEDULED
AUTOS X AUTOS
BODILY IWURY(Per acckdent) $40000
X
HIR ED AUTOS X AUUT-OWNED
PROaPERTYccDAMAGE $
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UMBRELLA UAB
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EXCESS LIAB
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g
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNEMXECUTIVE Y / N
OFFICE EMBER EXCLUDED?
(Mandatory in NH)
II yes, describe under
N / A
C003989723
9/23/2011
9/23/2012
X WCSTATU• OTH-
—
E.L. EACH ACCIDENT $100000
E.L. DISEASE - EA EMPLOYEE $100000
E.L. DISEASE - POLICY LIMIT 1 $500000
DESCRIPTION OF OPERATIONS below
T
Castricone Roofing & Siding
Suite 226
200 Sutton Street
North Andover, MA 01845
............ nrmur D oure, n more apace Is requrreo)
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
® 1988-2010 ACORD CO
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
TION. All rights reserved.
A&VRHCERTIFICATE OF LIABILITY INSURANCE DR'S 2 01D°
9/9/ 21
1
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 INBURER(B), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holler Is on ADDITIONAL INSURED, the pollcy(Iss) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsoment. A statement on this certificate does not confer rights to the
PRODUCER
Willows Insurance. Agcy
51 Cochichewik Dr
North Andover MA 01845
INSURED
DAVID CASTRICONE ROOFING & BIDING INC
200 Sutton St suite 226
NORTH ANDOVER MA 01845
4 0RE U- 978 475 3414 --- _..IIIAlC,No), —
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wVr-KAUts CERTIFICATE NUMBER CL119906255 REVISION NUMBER;
THIS )S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW WAVE BEEN ISSUED TO TME INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINQ 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.
ret Well
OF INSURANCE POLICY NUYeEq ►M� ICY EFF Po �Y --- LIMITS
j GENERAL LJAeILlTY EACH OCCURRENCE _ S 100_0000
COMMERCIAL GENERAL LIABILITY PREM
�k�1r.egaro�m� (s--.._.....-50000
A h CLAIMS.MADE I x l OCCUR 00031600 9/06/2011 /6/2012 MED EXP An one on s 1000
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PER40NAL b AOv_ INJURY t 1000000
GENERAL AGGREGATE S 200000_0
GEKL AGGREGATE LIMB APPLIES PER PROOUCT3 • CDMPIOP AGG S 1 000OOO7C
POLICY
PRAF71LOC
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COMBINED SINGLE LIMIT
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ALL OWNED AUTOS
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
David CastriCone Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS.
CastriCOne Roofing
200 Sutton Street Suite 226 AUTHORMUPRUVffAME
N Andover, MA 01845 �7
ACORD 25 —(2060j
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a (z0oe0v) The ACORD name and logo are registered marks of 0 ORDORD CORPORATION. All rights reserved.