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HomeMy WebLinkAboutBuilding Permit #501-13 - 640 Great Pond Road 1/7/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 1 Date Received Date Issued: I -!a - ( ? F - ---� IMPORTANT: Applicant must complete all items on this page -7 rl iLOC°P;TI®N_// iPROPERTiY®�1NNER v _C�!t ..w, Prat 10Yea Ol�tl Struture� yes p MA NOS 'PAF2CEL „ _ Z;®NING ®ISTRI0TFF-.�..._..; Hist rJ 39 tract yep . n �MaclimSliopVll`age� yes t TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial VRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 1._ IWe p etladj n ©Watershed Dista �; : t❑�1Nater/S,ewer�_ bi _W®lSc -w. . � /DESCRIPTION)QF WOI K TP E PERFORMED;,// m v awl. t'fi�.' �,, dr�1 r �/�,orw, , OWNER: Name: h4? Print 7? 4-��4791 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: $ 17 7g FEE: $ Q0 I Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 u Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract u Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) a Building Permit Application u Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report Li Engineering Affidavits for Engineered products VOTE: 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 submAted with the building application Doc: Doc.Building Permit Revised 2012 b Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Tanning/MassageBody Art ❑ 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA — (For department use B Notified for pickup - Date I E Doc.Building Permit Revised 2010 Location 64d -77j6W& v No. � Date / TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #7 26071 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 6,778.00 m $ - $ 201.34 Plumbing Fee $ 25.17 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 25.17 Total fees collected $ 351.67 640 Great Pond Road 501-13 on 1/7/2013 Remodel 2 existing bathrooms • ot v 'a O � o •�L Q ai �a Q L � E L _ (� L d U) J L >+ m 0 o = � 0 c m Oz n. c o E- CL �H L Q w v ++ C I— v�m 0 'N O = _ N O co O 2 m W = M - O O ui P:LL '�R N = .= t O N 0 — = w CD 0 N Q d> d N y. EE CO) o LO = O F- t +O+ CL 0 C.) O w m V/ 2 z O yrm z CO O CL Z rn W 0cf) . c X Z o W O � U DC uj LLI —i {� Z CD L O c O N O t O O J O �v H LS 9 2 '�1 w 4U O H N W W 19 W N cz O~ O Ow J W H Z Z a LL ? O Q Z V W ccLU m C J J LL t y m C 4 W v ti O +' Y N Z U ."O t C t L v U t v 41to 41 E to to CU o v o O � O o ;v o .� LL VI LL d' U LL d' LL d' : N LL LL m N N 'a O � o •�L Q ai �a Q L � E L _ (� L d U) J L >+ m 0 o = � 0 c m Oz n. c o E- CL �H L Q w v ++ C I— v�m 0 'N O = _ N O co O 2 m W = M - O O ui P:LL '�R N = .= t O N 0 — = w CD 0 N Q d> d N y. EE CO) o LO = O F- t +O+ CL 0 C.) O w m V/ 2 z O yrm z CO O CL Z rn W 0cf) . c X Z o W O � U DC uj LLI —i {� Z CD L O c O N O t O O J O �v H LS 9 2 '�1 w 4U O H N W W 19 W N 1patm ENO�SURES" BY GREAT DAY IMPROVEMENTS, LLC MYLES STANDISH BLVD., TAUNTON, MASSACHUSETTS 02780 Taunton, MA 508-822-1966 Toll Free 888-333-1966 Fax 508-821-9339 www.patioenclosures.com HOME IMPROVEMENT CONTRACT MASSACHUSETTS REGISTRATION #168562 Page 1: I, we hereby accept your proposal to furnish the premises of the Owner N F, w located at (o 4f D & (Z FaT oto DATE: Dc— )-20__L,�, labor and material necessary to perform the following work on in the City of 4N 1)nt/�, State of M Zip 0►a q.9— Tele: Customer E-mail address: This contract shall be considered non -cancelable after legal cancellation period has expired. THE WORK TO CONSIST OF: ' r Ii v A r. •l Single Glazed AIIView and all non -thermally broken sunrooms with insulated glass ARE NOT designed to be heated or air conditioned. N 14= (initials) Any inquiries about a contractor or subcontractor relating to a registration should be directed: Director • Home Improvement Contractor kegistration • One Ashburton Place, Room 1301 • Boston, MA 02108 or call (617) 727-8598. --go to page 2-- �►� �% ENCLOSURES" BY GREAT DAY IMPROVEMENTS, LLC 500 MYLES STANDISH BLVD., TAUNTON, MASSACHUSETTS 02780 Taunton, MA 508-822-1966 Toll Free 888-333-1966 Fax 508-821-9339 www.patioenc.com HOME IMPROVEMENT CONTRACT MASSACHUSETTS REGISTRATION #168562 Date: 20 Page #2: Seller agrees to furnish labor and materials at Buyer's request, and for the contract amount, to complete the work described above, subject to the terms and conditions which appear on both Page 1 & Page 2 and on the REVERSE sides of this contract. Work to start approximately S!(e weeks from the date of this contract and to be completed approximately-3—weeks after commencement if not delayed by building permit, delivery of materials, weather, strikes, fires, or other conditions beyond Seller's cona comp e n date is not of the essence. Buyer representf and w ant t gal titp to the property, which is to be improved, is in the following owner(s): 04 NOTICES 1. Seller and/orall sub ontractors, if any, who perform on this contract, and who are not paid, may have a claim against you which may b ced against the property being improved in accordance with the applicable lien laws. 2. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE TRANSACTION DATE (THE DATE ON WHICH YOU SIGN THIS CONTRACT). SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. THIS RIGHT IS IN ADDITION TO ANY RIGHT YOU OTHERWISE MAY HAVE TO REVOKE YOUR OFFER. The contractor and the homeowner hereby mutually agree, in advance, that in the event the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary ofAhe Executive Office of Consumer Affairs and Busines ons an the consumer shall be required to sub to such arbitration as provided in MGLC. 142A. G %l Contr9ctor Owner NOTICE: The signatures of the parties above apply ONLY to the agreemenZute pa ties to alternative dispute settlement initiated by the contractor. The owner may initiate alternative die ution even where this section is not separately signed by the parties. WHERE REQUIRED HOMEOWNER TO GET PERMIT. Source of Sale: SV t✓ Contract Price $ Down Payment $ ,!�:S'ptq / I sr P4ay SkQ$ S�190 �— f o r-Pwrci ihvt *rod Sa a $ coA%,O(Ci-f Balance Due ' 5-3Upon Installation $ THE DOWN PAYMENT SHALL BE A NONREFUNDABLE DEPOSIT ONCE THE THREE DAY CANCELLATION PERIOD HAS EXPIRED. THIS CONTRACT CONSTITUTES THE ENTIRE UNDERSTANDING OF THE PARTIES. Customer acknowledges receipt of a copy of this contract, product w ra ty n_ du tcate ces ancellation. DO NOT SIGN THIS CONTRACT IF THERE RE K S C Date Down P ment Received: (Customer Signature) By: A �DIL (Signature of Sales Representative) ( (Customer Signature) Subject to the terms and conditions which appear on both Page 1 & Page 2 and REVERSE sides of this contract. Revised 10/18/2011 % ADDITMNAI WOPK 01ITHOP17ATIMI PATIO ENCLOSURES 500 Myles Standish Blvd. TAUNTON, MA 02780 Taunton (508) 822-1966 TOLL FREE: (888) 333-1966 Customer E -Mail: OWNER'S 14C u ( NAME PHONE DATE Q STREET JOB NAME JOB NUMBER CITY N 0 o--rq u0v STATE /"4 - STREET EXISTING CONTRACT NUMBER DATE OF EXISTING CONTRACT CITY STATE You are authorized to perform the following specifically described additional work: PER t(Ai Tom S i o c 7? IV D Sin2 Al bL r >z 1 13 1 1,j F fF t4TRY ^(j uta Lin S1 I//< rt P91C9 i u c r W S rzSu c fi fl Oaf GfK L A & vl ,y N7- It K3� rrZ ADDITIONAL. CHARGE FOR ABOVE WORK IS: $ la 7' Payment will be made as follows: p uc trD F/Zm-\ F/ o c P4Y Oji tyy % Above additional work to be performed under same conditions as specified in original contract unless otherwise stipulated. Date Authorizing Signature (OWNER SIGNS HERE) Date Authorizing Signature (OWNER SIGNS HERE) We hereby agree to furnish labor and materials - com ete in accordanc ith the above specifications, at above stated price. Authorized Signature Date (CONTRACTOR SIGNS HERE) THIS IS CHANGE ORDER NO. \NOTE: This Revision becomes part of, and in conformance with, the existing contract. 14 A ry /to 0 1,44 1* 41 r GREAT DAY I'M 11R0V G\I l:\'1'S. I.I.0 MA Reg. # 168562; RI Reg. # 16788 PROJECT QUOTE #1 Client: Anne Broyles Address: 640 Great Pond Road North Andover, MA Proposed Project Description: Date: December 12, 2012 Update Hall Bathroom - Remove tub and surround, overhead shower fan, sinks, medicine cabinets, wall light fixture, wallboard with tiles affixed, and finished flooring. - Replace tub with cast iron Kohler 5' white fixture. - Ceramic 4" tile installed surrounding tub area to a height of approx. 5' above rim. - Replace removed wallboard with green board. - Replace shower valve with new temperature control shower valve. - Install double vanity with twin sinks, faucets, and new drain plumbing. - Install new overhead fan/light exhaust unit vented to exterior. - Install new wall light fixture, including wall switch and GFI outlet to code. - Remove existing toilet and replace with new unit. - Install new tile flooring including new subfloor. - One coat of primer wall paint for exposed interior walls - All plumbing, electrical, and finish trim included. - Paint bathroom ceiling, flat latex white and paint non -tiled wall surfaces one coat primer and one coat of finish latex paint of customer selected color. Installed floor the allowance $6 per sq. ft., Installed wall tile allowance $5 per sq. ft., faucets, medicine cabinet, light fixtures, toilet, vanity, vanity tops, sinks, shower valve, and exhaust vent are customer supplied items. Approximate tile square footage, walls 66, floor 44. Quote for Project: $9788. Exhibit: C ` Intials: 500 Myles Standish Blvd., Taunton, MA 02780 1 Phone 508.822.1966 1 Fax 508.821.9339 www. patioencl osu res. com _Pout 2� o GREAT DAY IN11'R0VFN11i\"I'S. 1.1. C. MA Reg. # 168562; RI Reg. # 16788 PROJECT QUOTE #2 Client: Anne Broyles Address: 640 Great Pond Road North Andover, MA Proposed Project Description: Date: December 12, 2012 Update Master Bathroom - Remove tub, tub surround, overhead shower fan, vanity, medicine cabinet, wall light fixture, wallboard with tiles affixed, and finished flooring. - Replace removed wallboard with green board. - Replace shower valve with new temperature control shower valve. - Install 60" x 34" shower base with tile flange. - Install 4" ceramic tile surrounding shower to an approximate height of 7'. - Install new vanity with sink, faucet, and new drain plumbing. - Install new overhead fan/light exhaust unit vented to exterior. - Install new wall light fixture, including wall switch and GFI outlet to code. - Remove existing toilet and replace with new unit. - Install new tile flooring including new subfloor. - One coat of primer wall paint for exposed interior walls - All plumbing, electrical, and finish trim included. - Paint bathroom ceiling, flat latex white and paint non -tiled wall surfaces one coat primer and one coat of finish latex paint of customer selected color. Installed floor tile allowance $6 per sq. ft., Installed wall the allowance $5 per sq. ft., faucets, medicine cabinet, light fixtures, toilet, vanity, vanity tops, sinks, shower valve, and exhaust vent are customer supplied items. Approximate tile square footage, walls 96, floor 36. Quote for Project: $6,990. Exhibit: B 0, Intials: 500 Myles Standish Blvd., Taunton, MA 02780 1 Phone 508.822.1966 1 Fax 508.821.9339 www.patioenclosures.com /� . Id ds-,I,ddp The Commonwealth of Massachusetts Print Form Department of Industrial Accidents i Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): Address:. �W City/S d�-7Ad Phone #: (,5_e) i') �.,_7a "�1��� pu an employer? Check the appropriate box: I am a employer with /L/,) 4. ❑ I am a general contractor and I emplovees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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: Lw'� r� Policy # or Self -ins. Lic. #: _ I'7�o� Expiration Date: Job Site Address: 6/� �✓'- ��� City/State/Zip:&/ awj 1 • 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifyAnder the pains and penalties of perjury that the information provided above is pue and correct. 9ZZ /qa Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # //'7/WV13 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Q � ENICLOSURE$' Jim McCormack Installation Supervisor jimmccormack@patioenc.com 500 Myles Standish Blvd, Taunton, MA 02780 Main: 508.822.1966 Toll free: 888.333.1966 Direct: 508.967.0105 Cell: 508.345.0112 Fax: 508.821.9339 patioenclosures.com Ask us about financing MA Reg #16856P:RI Reg #16788 Massachusetts -Department of Public Safety iBoard of Building Regulations and Standards t'onstruction Supcn isor 4° . ,License: CS -076261 �•y r' xr�i. JAMES MCC04�NACK' -p Y� 73 FEARING4ML RD West Ware6yn M 01576 Pr►: ,�, Expiration commissioner 11 /13!2013 PATIO -3 OP ID: J8 ,4� o* CERTIFICATE OF LIABILITY INSURANCE DATE01/0 D/YYYY) 01 /03/13 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(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 certificate holder in lieu of such endorsement(s). PRODUCER 216-328-8080 The Fedeli Group P.O. Box 318003 216-328-8081 Inde Rocksendence, Road Independence, OH 44131-8003 CNTACT NAME: Jeanne Moscarillo PHONE FAX AIC No Ext): A/C, No): ADDRESS: jmoscarillo@thefedeligroup.com INSURER(S) AFFORDING COVERAGE NAIC # David Pease INSURER A: Cincinnati Insurance Company 10677 EACH OCCURRENCE $ 1,000,000 INSURED Great Day Improvements, LLC dba Patio Enclosures INSURER B: Berkshire Hathaway Homestate 20044 PERSONAL &ADV INJURY $ 1,000,000 500 Myles Standish Blvd. INSURER C INSURER D Taunton, MA 02780 INSURER E: A INSURER F: LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS Ix AUTOS COVERAGES CERTIFICATE NUMBER: 3MA 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 OkDDL FOR PROOF ONLY POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CPP1074823 01101/13 01101114 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS Ix AUTOS CPP1074823 01/01113 01/01114 COEaMBINED accidentSINGLE LIMIT 11000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CPP1074823 01/01113 01101114 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 51000,000 DED I X I RETENTION$ 0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YI N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A TNW001460 01/01113 01101114 WC STATU- I OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION 0000-00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR PROOF ONLY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD