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HomeMy WebLinkAboutBuilding Permit #1056-15 - 90 LANCASTER ROAD 6/16/2015 �., - L 05- lel > BUILDING PERMIT OF NOE D q E.tt LD.,64 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y H T Permit No#: 0 '`� Date Received SSAC H�1`����� Date Issued: /I /(/ kr . IMPORTANT: Applicant must complete all items on this page LOCATION; I?nnt PROPERTY -Z- '4--6!L—_ RTY OWNS 1A flly y-, _ not 100 Year structure yes no MAP _=PARCEL: ZONING: DISTRICT: _.Historic District yes no Machine Shop Vilhage yes f no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetland's ❑ Watershed- District U Water/Sewer x DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: l '62��_S'_ar� Phone: Address:-Nt jT2_J Contractor Name Bone: 1 "j Address:- Supervisor's _� Construction License � 1-� ;Exp. bate:, Home ImprovernerltLicense: . ___ _ _.__ Exp. Date: . JW-117-T. 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: $ �� Check No.: 6)0&1 Receipt No.: NOTE: Persons contracting with d contractors do not have access to t fund Signature of Agent/Ovvner __ _ Signature of contractor 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/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 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 i Doc:Building Permit Revised 2014 � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiimning 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 I PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ' HEALTH Reviewed on Signature COMMENTS r 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 Tern Dum .ster on site - p p yes no, Located at 124 Main Street - -- Fire be signature/date - - COMMENTSr _ - 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) 3 i f I II i ❑ Notified for pickup Call Email Date + _ Time __ Contact Name Doc.Building Permit Revised 2014 Location q0 No. l Date ��J • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ R `^ Other Permit Fee TOTAL $ Check# 7i9 Building Inspector OORTH Town of 2 E ndover h ver, Mass, row �!- COCHICHEWICK y1' S V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT . Vft s BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ....... .fel........1-a-&ejqts4-4&�. .... , 1 Rough to be occupied as ...........14.IV.-.'...4n&-.... ....':''...D�... .. :rl!►. ►..�........................ Chimney provided that the person accepting this permit sh 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 CONSTRUC T Rough S TS g 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. (I v� next step Living, home energy solutions This agreement its made by and among Next Step Living,Inc.("NSL") Bili Porteous 21 Drydock Avenue,2nd floor 90 Lancaster Rd Boston,MA 02210 North Andover, MA 01845 phone: (866)867-6729 Site ID: 417356 20 Apr-15 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customer's address above,In a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the'Work")which are incorporated herein by reference: 7777770 0scriptiotV, nvestment RecommendationsAir Sealing 1 / Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 $85.00 Hr $1,020.00 Initial Investinent: $1,020.00 100%Airseaitng fncerltiv.e up to;Program Max '$1;020:00> Total $0.00 Estimated Annt�ai�netgy Savings tram th�'Above lmprovementt3 $75:04; ,. 2. PAYMENT CUSTOMER agrees to pay NSL for the work as follows: Payment#1: $0.00 -Credit Card or E-check deposit is due at the time the Work is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed 1/3 of the total retail costs. (Note:Mastercard,Visa,and Discover aocepted) Additional Payments and Final Invoice: $0,00 -Additional RMnts for the Works all}t2 due Moon completion of The Work. If the final Invoice is being paid by check,credit card information will still be required at the time of scheduling. Notify the customer service representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. -5 ' Customer Signature 4� r— 20 Apr 2015 Leonard Earnshaw SL Signature Date Name of NSL Representative A986769 The Terms of this Agreement are contained on both sides of this page Next Step Living o 21 Drydock Avenue 2nd floor a Boston,MA 02210 a(866)867-8729 a inquiry@nextsteplivinginc.com o www.nextstepliving.com TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time,subject io the availability of subcontractors or materials,or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170,Boston,MA 02 116.617-973-8700. 5. PERMITS NSL will be responsible for obtaining any necessary permits as the Customers agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented,amended,or modified only by the mutual agreement of the parties.No supplement,amendment,or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times,our weatherization team discovers situations in the structure during the course of the Work that indicates a_risk for a health or safety concern for residents.Such concerns can include but are not limited to ventilation,potentially hazardous materials such as mold or asbestos,or structural concerns. In the case of health or safety concerns being identified,NSL reserves the right,per section 9.2 of this contract,to communicate concerns to the Customer and halt work unfit such concerns have been addressed. 6,4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However,at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations,NSL will communicate such changes to the Customer,including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment,or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that(a)the materials and equipment furnished under this Agreement will be of good quality and new, (b)that the Work will be free from defects,and(c)that the Work will conform with the description of the Work described In Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration(No;162111)and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field,including,but not limited to,Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner,and that NSL will repair and replace,at its own expense,and promptly upon Customer's request,any defects in workmanship and materials provided by NSL which appear up to one year after completion of the Work or within any longer period as permitted or required under applicable few,provided NSL has received final payment as provided herein, 9. PRE-EXISTING CONDITIONS&PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall,moisture damage,non-code construction,cracked or fragile siding or shingles,old pipes and fittings,rotting wood,etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos,mold,or any other potential health risk to the Customer. In this event,the Customer is responsible for remedying the at-risk situation,including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect,including dust protection,any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not property protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law,to have,file or maintain a mechanic's or material men's lien,or to file a notice of intention to lien,and to take any other steps to perfect and enforce such a lien,if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. _ 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement,they are not relying on any representations,warranties or terms other than as expressly contained herein.This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. 11. ENERGY BENEFITS. The Sponsoring Utility Company(the Utility)is entitled to 100%of the energy benefits associated with all Energy Conservation Measures,excluding the value of energy cost savings by the Customer,but including all rights to all associated ISO-NE Energy,Capacity and Reserves Products.NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. 12.1 Customer understands and acknowledges that NSL is not an agent,vendor or sub-vendor of The Sponsoring Utility Company(the Utility)with respect to the installation of an energy efficiency measures.In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to Conservation Services Group(CSG)or to the Utility.The Utility and its operating companies shall not maintain,remove or perform any work whatsoever on the energy conservation measures installed. 12.2 Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. 12.3 Customer agrees that it shall not hold CSG,the Utility,their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement,forfeiture of the energy conservation measures to function,for any damage to Customer's Premises caused by Contractor orfor any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law,you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof,provided you notify the seller in writing at his main office or branch by ordinary mail posted, by far.,or by e-mail sent or by delivery,not later than midnight of the third business day following the signing of this agreement. I Mass Save Planview Diagram Customer ' a Advisor Name: k-eav� yd C&.vw�c -' Address 90 �� �?�_ Advisor Number: Sg c--L(97 , Town Al, A Any limitations to access by truck? Site ID ,�(�, )6 NOTES II © `a✓- cq V 1 Z 4•✓— CID 2C—) The Commonwealth of Massachusetts Department of Industrial Accidents p M Office of Investigations W ' d I Congress Street, Suite 100 FW eW Boston,MA 02114-2017 www.massagov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Les_ibly Name (Business/Organization/Individual): Next Step Living Address: 21 Drydock Ave Ci /State/Zi : Boston, MA 02210 Phone#:(866)867-8729 Are you an employer?Check the appropriate box: Type of project(required): 1.8 I am a employer with 850 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. F]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ®Demolition working for me in any capacity. employees and have workers' (No workers' comp. insurance comp.insurance. $ 9. Building addition required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no l3.©Other Insulation 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 I iomeowners 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 moist attached an additional sheet showing the name of the sub-contractors and state whether or rol th03e 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 insurancefor my employees Below is the policy and job site . information. Insurance Company Name: A.I.M Mutual Insurance Company Policy#or Self-ins. Lic.#:AWC-400-7030025-2014A Expiration Date: 9/30/15 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 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 v fi tion. I do hereby certify under the pains and pen es perjury that the information provided above is true and correct. Signature: Date: 10/ 11/Ll Phone#�$1otq) Official use only leo 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#: 11' eef �Gl ® ® C®trIlsumer A�ffai rte 10 ]dark Plaza o Suite 5170 .. Boston, Massachusetts 02116 Home Improvement Contractors Registration Registration: 162111 Type: Supplement Card Expiration: 1/1412017 NEXT STEP LIVING INC. ROGER OUELLETTE 21 ®RY®OCK AVE. 2TH FL BOSTON, MA 02210 Update Address and return card.Mark reason for chfinge. Address ❑ Renewal R Employment LostCard DPS-CAI as 50M-04104-GIM16 ,,, ✓/u� {omirnayuuP.�ICI of, j�.aeaa��raQ.tld �= Office of Consumer Affairs&Business ReguRa itioo ]License or registration valid for individul nese only ®It7E IMPROVEMENT CONTRACTOR Office the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 162111 Type: 10 Park Plaza-W99 5170 Expiration: 1114/2017 Supplement Card Boston,MA 0211 j NEXT STEP LIVINGS INC. k ROGER OUELLETTE f(� 21 DRYDOCK AVE.2TH FL BOSTON,MA 02210 Undersecrrettry (r/Aot�vand without signature 17 Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialt-N License SL-10281 ROGER A® LIAT o � 55 STANMORE War-wick RH 028 9 Expiration Ccxrrnllssloner Resift edd To. CSSL lC a lnsuhtion Contrauctorr Failure to possess a currrrerQ edition of the iWassachuseVs 5a,to Building Code is cause for revecau lon on tthis license. For DIES Loceming lIn ormadon vIsIt: vfflU3-M3SsA V/DP5 NEXTS-1 OP ID:EL CERTIFICATE OF LIABILITY INSURANCE DATE(M1/20 4 10/01/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THO CRRTIFICwTF HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ASTER THE COVERAGE AFFORDED BY THE POLICIES RE10111f. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZOp ROP PSENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMP RTANT: If the P,eetificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANK r flywigg Iq 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 endorsements). PRODUCER CONTACT McLaughiir)I surance Agency NAME: Erin Lyons 828 Lynnfepls ParkWpy LAIICONN.Etd:781.665.2775 A/C Ne:781-665-02QO Melrose,MA 02176 FrMAIL John E.McLaughlin Jr. ADDRESS: INSURER(S)AFFORDING COVERAGE MAIC 0 INSURER A:Nautilus Insurance INSURED 21 D Step(_wing,Inc. INSURER a:Commerce Insurance Company 3478 B ton,Mk 02210Avenue,2nd Floor INSURERC:A.I.M.Mutual Insurance Co. Boston,MA 02210 INSURERD:AXIS insurance Company 15610 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PffRIIOp INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH- 1B 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. Po CY EFF POLICY EXP LTR TYPE OF INSURANCE KV—D wvo POLICY NUMBER IffiMMIDDIVYM (MMIDDNYYYILIMITS A X COMMERCIAL GEI iERAI.LIABILITY EACH OCCURRENCE $ 000,00 CLAIMS-MADE ®OCCUR ECP2010198-12 09130/2014 0913012015 DAMAGPREMISE TO RENT U-ce $ 190,00 i MED EXP(Any one person) $ 5,901 PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ I�rQNOrMp POLICY❑JELOC PRODUCTS-COMP/OP AGG $ �,QAQ,AO OTHER: $ AUTOMOBILE LIABILITY Ewa aBI D SINGLE LIMIT $ 1,®00,00 ANY AUTO 14MMBGKKOM 09130/2014 09/30/2015 BODILY INJURY(Per person) $ ALL AUTOS ED SCHEDULED AUTOSBODILY INJURY(Per accident) $ HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D EXCESS UAB CLAIMS-MADE E�U783547012014 09/30/2014 09130/2015 AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER C ANY PROPRIETOR/PARTNERIEXECUTIVE YIN N TO BE ISSUED BY CARRIER 09/30/2014 00/30/2015 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? �N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 Dyes CAPTION OF scribe underOPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DES DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) FOR rNFORMT.Tow ONLY CERTIFICATE HOLDER CANCELLATION INFO-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information OnlyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE L Ak ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) 7-40 A�ANR 09 11 loop,ar�r9qpst0r0r f ACORI