2 HOLLY ST - BUILDING INSPECTION (2) � The Commonwealth of Massachusetts
/I Board of Building Regulations and Standards CITY OF
VW Massachusetts State Building Code, 780 CMR SALEM
', Revised Mar 2011
ol
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Useftly
Building Permit Number: Date App ed:
Building Official(Print Name) Signature. bato
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�1JGil..i
ame(Print)
N 1 City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of ProposedWorl�: -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I.Building $ S. I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ r Cb ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Vej 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ression $ Total All Fees: $
Check No. Check Amount: ' Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) � — 77 nl
-T✓Vt,P c�riy r�ItG, License Number t{, Expirati nDat
Name of CSL Holder
7 t List CSL Type(see below)
No.and Street —� Type Description
��� 1l U Unrestricted(Buildings u to 35,000 cu.ft.
City/Town,Stat ,ZIP/r lLP V Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
IiMga"Stt ro. 9 1 Insulation
Telephone mad ddress D Demolition
5-.-2t-Registered
/Home
('I Improvement Contractor(HIC) .7 �5•�13
Hl - Registration Number Expiration Date
HIC Company NWe or HIC Registrant Name c
3
No.1n Street J) �/ �r �f
lLI /" - �.5 Em i s
City/Town, Sta[ ,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
RR-APPPLIES FOR BUILDING PERMIT
X1,as Owner of the subject property,hereby authorize Cu r�ype, �� A J r
/ to act on my behalf, in all matters relative tow authorized by this building permit application.
l
c
Zr Z ,A t1L z ,-
Print Owner's Name(EI' tronic Signature pa '..
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containV in this application is true and accurate to the best of my knowledge and understanding.
_ Z Zo] '
Print Ow is or A orized Agent's Name(Electronic Signature) D e
NOTES:
L An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system - Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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All home improvement contractors and subcontractors engaged in home improvement contracting,
unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be
registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be
made to the Director, Home Improvement Contractor Reeistration,One Ashburton PI, Room 1301,
Boston MA 02108(617)727-8598
J.M. Gaddis
Fine Homebuilding and Kemodeling
581 Lafayette jt.
Salem, Ma. O 1 J JO
Proposal/Contract
Job Name: Date: 4-25-2013
Pike Kitchen and Bath
"Contractor Information:
Submitted to:
Owners Lucine Pike jei,} I� Co. Name: JM Caddis
Address 2 Holly S . Salem, Address: 381 Lafayeette St. Salem, Ma 01970
Telephone Telephone: 617-839-3351
Email: Fax:
E-Mail: jimgaddis@gmaii.com
Job Address:Same Pro'ect Development: JG
Desi ner : DOP: CS#: 97276 Exp. Date: 10-27-2012
Specifications For New Kitchen and Bathroom
All work will be performed on a fixed price basis. Additional work or changes to the plans may be
added and performed upon request by Owner. The parties shall execute a written Additional Work
Order for such additional work or change in plans,which will define the work or changes,and any
increase or decrease in costs associated with it. Where noted either in the Scope of work or the Cost
Breakdown,certain `Allowances' may be specified. These`Allowances' constitute a budget number
based on certain assumptions and may change depending on scope or selections or both.
Job has been estimated and described in the ADDENDUMS below.
ADDENDUM A Cost Breakdown
Contractor hereby proposes to furnish labor& materials,complete, in accordance with
specifications and fixed costs,noted above for the sum of. $ 69,686.49 DOLLARS
All allowance work and time and material work will be performed as follows if contracted by
Additional Work order:
1. All carpentry related labor and supervision will be charged at$55.00 per hour.
2. All other subcontractors and materials will be charged at Contractor's cost.
3. 10% for profit and overhead will be added to 1. and 2. to arrive at the final cost to Owner.
4. Products and services purchased by others,which must be installed or otherwise handled or
supervised, may be subject to some charge to defray potential costs and liabilities,this charge
will not exceed 10%,and may be less depending upon exposure and liability.
Customer may order changes in the work to reduce or enlarge the scope of work,
and hence the costs associated,through written Change Orders at either a specific fixed cost or on a time
and materials basis.
Payment to be made as follows: 10% upon agreement. (6968.64)
Requests for payments will be submitted as needed for line items completed.There
will be partial requests made on some items requiring deposits for either materials or
sub-contractors as well as tasks that require material and labor payments on a
regular basis.
"Punch List: The Owner may not hold up the final payment because of punch list items.
However,if some items need adjustment or need to be re-done,the Owner may hold up to
150%of the value of this work from the Final Payment until the work has been completed
or corrected satisfactorily.
WORK SCHEDULE:
The Contractor shall begin the work on or about: 5-6-2013,and complete the work on or
about: 7-6-2013 Variations in Scheduled Start and Completion of Work: The actual
dates that construction will commence and be completed may vary due to circumstances
beyond the control of the Contractor. These delays may include, but are not limited to:
the time to apply for and obtain necessary permits,delays caused due to necessary
inspections,delays in the scheduling of work crew(s), the presence of hidden conditions or
necessary additional work discovered during construction; or delays in the receipt of
equipment and/or materials which must be ordered and/or delivered to the site.
Certain Delays-Not Violations: The Owner(s)hereby acknowledges and agrees that the
scheduling dates are approximate and that such delays that are not avoidable by the
Contractor shall not be considered as violations of this Contract.
IMPORTANT NOTICE REQUIRED BY LAW:
If the Owner obtains his/her own construction related permits for the work described
under this contract.The Owner is hereby advised that in the event of a dispute,judgment
and nonpayment by the Contractor,the Owner will not be entitled to make a claim against
or collect from the guaranty fund established by Chapter 142A.
HIDDEN CONDITIONS& NECESSARY ADDITIONAL WORK:
Hidden conditions such as: (but not limited to)the presence of ledge, unsuitable bearing
soil,structural defects, pipes, and/or wires hidden in wall cavities,etc., may require
additional work beyond the scope of this agreement that may require an adjustment in the
overall price. In such cases the Contractor shall inform the Owner(s)of such conditions
forthwith and,where necessary,a written amendment of this agreement will be negotiated
and executed by the Contractor and Owner(s). The Contractor shall not be responsible
for additional work that may be required by Building Inspectors,or other code
enforcement officials that is not within the scope of this agreement.
INSURANCE:
The Contractor will be responsible to the Owner(s)or any third party for any property
damage or bodily injury caused by himself,his employees or his sub-contractors in the
performance of,or the result of,the work under this agreement. Contractor agrees to
carry insurance to cover such damage or injury and shall provide a certificate of
insurance to the Owner as proof there of. The Owner agrees to carry insurance to cover
damage to any newly erected structure or portion thereof or equipment that has been
installed or delivered to the site. Should the Owner directly hire any contractors to
perform Work on the property before J.M.Gaddis FHR has completed its work, the
Owner is solely responsible for all building permit,inspection, insurance,and liability
issues that may be required or arise with that Contractor
SUBCONTRACTING:
Contractor agrees that, not withstanding any agreement for materials and/or labor
between the Contractor and a third party,Contractor is responsible to the Owner(s)for
completion of all work described in a timely and workmanlike manner.
In the event that Owner(s)has subcontractors or others on the worksite during the
construction period that have not entered into a contract with Contractor for the activities
or services they are performing on the worksite; then the Owner(s)shall indemnify and
hold the Contractor, its employees, its subcontractors and other personnel harmless from
and against any claims,actions,costs and liabilities, including reasonable attorneys' fees,
arising from any act or omission, negligence or the willful misconduct of those not under
the direct control of Contractor
WARRANTIES: (Limited Warranty Provision)
The Contractor shall repair or replace, at his option and at his expense,any substantial
defects in workmanship or materials supplied by the Contractor,or his agents, under this
agreement that may occur within a one(1)year period from the date of installation. The
Contractor makes no warranty of installed equipment. All warranties for equipment
supplied by the Contractor shall only be those given by the manufacturer of such
equipment,which shall be and are hereby passed through directly to the Owner upon the
equipment installation, HOWEVER, IT WILL BE OWNER'S RESPONSIBILITY TO
REGISTER OR MAIL WARRANTY MATERIALS OR OTHERWISE TAKE ACTIONS
REQUIRED BY MANUFACTURERS TO VALIDATE A WARRANTY. The Owner(s)
failure to mail in, register or take such other required action,which failure voids the
manufacturers' warranty, shall not create any responsibility for the Contractor to
warrant such equipment. This warranty shall not apply in the case of defects or damage
resulting from,or aggravated by,any neglect or failure on the part of the
Owner(s)/Buyer(s)to properly maintain the property. The foregoing warranties shall
survive any inspection performed in connection with the work performed under this
agreement. This warranty is not transferable and any obligation hereunder shall
terminate if the property is sold or shall cease to be occupied by the original Owner/Buyer.
This warranty gives the Owner specific legal rights. THE WARRANTY PROVIDED IN
THIS SECTION IS IN LIEU OF ALL OTHER WARRANTIES EXPRESSED OR
IMPLIED AT LAW, INCLUDING MERCHANTABILITY AND FITNESS FOR A
PARTICULAR PURPOSE. Owner may have other rights, which vary from state to state.
PHOTOGRAPHIC IMAGES:
The Contractor reserves the right to take photographs of the project, including before,during
And after construction.
Contractor shall solely own all resulting images and all rights associated. At the Contractor's
Discretion the photos may be used for estimating,training, marketing,and/or other legitimate
business purposes.
WORK SITE SIGNAGE:
The Contractor reserves the right to install a company sign on the property during the
course of construction. Job site signage is a useful aid for deliverymen,and provides
neighbors who may have questions or concerns with the Contractor's contact information.
CONTRACT ACCEPTANCE:
I have read all pages of this document including any referenced attachments, and
accept the prices, specifications and conditions stated. I understand that upon signing,
this document becomes a binding contract under the law. You are authorized to do the
work as specified. Payment(s)will be made as outlined above.
Contractor: Date:
JM Ga dis
Owner: ,(6,/,r.,, J�
�u ..c c� Date:
T'
Owner{.! i Date:
01. PLANS-PERMITS-SURVEY
Expense Item Units Unit Cost Hrs I Labor Rate I Material ISubcontractod Other I Item Total
O Permit Fees & Expenses $ $
Total 0 $ - $ $ $ $
02. DEMOLITION
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
S Kitchen Demolition 2 D $ 1,750.00 $ 3,500.00 $ 3,500.00
S Bath Demolition 1 V $ 1,750.00 $ 1,750.00 $ 1,750.00
L Demospecial construction $ 55.00 12 $ 660.00 0 800 $ 1,460.00
0 $ -
Total 12 $ 660.00 $ - $ 5,250.00 $ 800.00 $ 6,710.00
06. FRAMING & STRUCTURAL WORK
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
L Kitchen ceiling $ 55.00 16 $ 880.00 300
$ 1;180.00
L flooring/wall allowance $ 55.00 20 $ 1,100.00 300 $ 1,400.00
M IMisc. Materials $ 190.00 $ 190.00
Total 36 $ 1,980.00 $ 790.00 $ - $ $ 2,770.00
09. HVAC SYSTEMS
Expense Item junits Unit Cost Hrs Labor Rate I Material ISubcontractod Item Total
S I Rough & Finish HVAC A I I I I $
Total 0 $ $ - $ $ $
10. PLUMBING
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
S lRough & Finish Plumbing $ 6,300.00 $ 6,300.00
M I Toilet 1 A $ 250.00 $ 250.00 $ 250.00
M lKitchen Sink 1 A $ 250.00 $ 250.00 $ 250.00
"11 `" 'k Faucet Kitchen 1 A S 200.00 $ 200.00 $IMFTub 1 A S 450.00 $ 450.00 $ 450.00
_weer Body & Controls 1 A $ 450.00 $ 450.00 $ 450.00
bath sink A $ 100.00 $ - $
M, bath faucet 1 $ 100.00 $ 100.00
$ 100.00
1
i
Total 0 $ $ 1,700.00 $ 6,300.00 $ - $ 8,000.00
11. LIGHTING- ELECTRICAL
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
S Rough & Finish Electric $ 4,400. 00 $ 4,400.00
M Exhaust Fan $ 230 $ 230.00
M New Main Service upgrade $ 1900 $ 1,900.00
Surface-Mounted
Fixtures (Supplied by
M Others) $ $
Total 0 $ - $ - $ 6,300.00 $ 230.00 $ 6,530.00
13. INSULATION
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
S Closed Cell Foam R-21 215 $ 2.21 $ 475.15 $ 475.15
Kitchen Floor bait 128 $ 2.90 $ 371.20 $ 371.20
L lInstall Insulation $ 55.00 6 $ 330.00 $ - $ 330.00
Total 6 $ 330.00 $ $ 846.35 $ - $ 1,176.35
15. DRYWALL
Expense Item jUnits Unit Cost Hrs Labor Rate Material Subcontracto Other Item Total
S KitchenBlueboard & Plastj 878 SF $ 2.50 $ 2,195. 0 -"$ 2,195.00
S Bath Blueboard & Plaster 192 SF $ 2.50 $ 480.00 $ 480.00
L Install Durock (1/2 hr each sh) $ 55.00 5 $ 275.00 135 $ 410.00
Total 5 $ 275.00 $ - $ 2,810.00 $ - $ 3,085.00
17. INTERIOR FINISH CARPENTRY
Exc ens:; Item Units Unit Cost Hrs labor Rate PJlaterial Subcontracto Other Item Total
L Ki chen base/case S 55.00 32 S 1'760.00 340
$ 2,100.00
L Bathroom base/case S 55.00 10 $ 550.00 95 $ 645.00
L Misc Finish $ 55.00 15 $ 825.00 $ 825.00
S $ $
I
Total 57 S 5.00 $ 435.00 1 $ $
$ 3,570.00
2
18. MILLWORK-CABINETS-VANITIES
Expense Item jUnits Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
M Kitchen Cabinets $ - $ 7500 $ 7,500.00
M Bath Vanity $ 2,500.00 $ - $ -
L lInstall Cabinets $ 55.00 60 $ 3,300.00 100 $ 3,400.00
Total 60 $ 3,300.00 $ 100.00 $ 7,500.00 $ - $ 10,900.00
19. PAINTING & STAINING
Expense Item Units Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
S lKitchen Painting $ 1,200.00 $ 1,200.00
S Bath Painting $ 600.00 $ 600.00
S Living Room prep and paint $ 2,200.00 $ 2,200.00
S Total Painting $ $ -
S Misc. Patching & Painting $ 800.00 $ 800.00
Total 0 $ - $ $ 4,800.001 $ $ 4,800.00
20. HARDWOOD FLOORING
Expense Item Units Unit Cost Hrs Labor Rate I Material ISubcontractod Other I Item Total
S I New Kitchen hardwood 320 SF $ 7.50 1 1 $ 2,400.00 1 $ 2,400.00-
S jAdditioal Sanding and fini 400 SF $ 2.50 $ 1,000.00 $ 1,000.00
Total 0 $ $ $ 3,400.00 $ $ 3,400.00
23. TILE & STONE
Expense Item jUnits Unit Cost Hrs Labor Rate Material Subcontractor Other Item Total
M Bath Tiling 60 SF $ 10.00 $ 600.00 $ 600.00
M I Bath Tile install 60 YD $ 20.00 $ 1,200.00 $ 1,200.00
M lKitchen Countertops YD $ - $ - 5000 $ 5,000.00
Total 0 $ $ 1,800.00 $ 5,000.00 $ $ 6,800.00
24. LOT AND SITEWORK
, "D„ . S i : ,.. _,. O . r m Total, n [tern
_ ' ------- -----
! : :: (Initial) S 55.00 10 $ 550.00 260 L) , rccoon $ 810.00
L 5::e . dministration 2. xoenses S 55.00 26 $ 1,430.00 $ 1,430.00
_ _._ . - -
L Tr.sh Runs S 55.00 30 $ 1,650.00 1400 $ 3,050.00
Deliveries (Accept,
L Inspect, Store) $ 55.00 0 $ - $ -
L $ 55.00 $ $ -
L' Portable Toilet 2 $ 160.00 $ - $320.00 $ 320.00
3
Dumpster
Total 66 $ 3,630.00 $ 260.00 $ $ 1,720.00 $ 5,610.00
Subtotal 242 $ 13,310.00 $ 5,085.00 $ 42,206.35 $ 2,750.00 $ 63,351.35
Total TOTAL w/Tax & OH&P $ 69,686.49
• a
ACORD `CERTIFICATE OF LIABILITY INSURANCE DATE /D
05/01/2013013
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA:ESSEX INSURANCE COMPANY
Gaddis, James M. INSURER B:Ace American
381 Lafayette Street INSURER C.
INSURER D
Salem MA 01970- 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.
INSR ADUL POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE IMM/DO/YY) DATE(MM/DD/M LIMITS
A GENERAL LIABILITY 3DJ4525 11/22/2012 11/22/2013 EACH OCCURRENCE $ 500000
X COMMERCIAL GENERAL LIABILITY PRE'SES E RE
a oavnID
ance $ 50000
CLAIMS MADE F-IOCCUR / / / / MED EXP(Any one person) $ 1000
PERSONAL S ADV INJURY $ 500000
GENERALAGGREGATE $ 1000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1000000
POLICY JECOT LOC / / / / NO
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $
ANY AUTO (Ea amdwt)
ALL OWNED AUTOS / / / / BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS / / / / BODILY INJURY $
NON-OWNED AUTOS (Per actitlenl)
PROPERTY DAMAGE
(Perac denl) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHERTHAN EAACC $
AUTO ONLY. AGG $
EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE / / / / $
RETENTION $ 1 $
A WORKERS COMPENSATION AND 6S62OB-5B50520-3 07/24/2012 07/24/2013 X T&STA STATUS
Eft
EMPLOYERS'UA81LITY 10D000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE- 100000
If yet,descbbe urMer EA EMPLOYEE$
SPECIAL PROVISIONS bel. E.L.DISEASE-POLICY LIMIT S 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLEWUCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City Of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLI TION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS REP ESENTAT
AUTHORIZED REPRES T )
4 /
ACORD 25(2001108) a ACORD CORPORATION 1988
INS025 m mw.o6 Pane'on