5 LARKIN LN - BUILDING INSPECTION (2) 'l
I/ 7 The C'omnonw'eakh of Massachusens
Board of Building Regulations and Standards CI'I')'OF
Massachusetts State Building Code, 780 C NIR SALLAI
'Lug• Rr ri.ee,/.1 bu all/
Building Permit Application To Construct, Repair, Renovate Or Demolish u
One- or Tu•u-Furnilr Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
`
I, iKi L,VT'2Z1
Building Official(Print N;une) , iyt Date
SEC ION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
.6 �RrL/5/iv 6,/t
I.Ia is this an accepted street?yes no Map Numher Parccl Nunttkr
1.3 Zoning Information: 1.4 Property Dimensions:
s, :/ - ;cy
Zoning District Pmpo. •J Use Lot Area(sy tt) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal O On site disposal s stcm ❑
Checkif ycs❑ >
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
--Tt-8..�p Cp/,o L617 S.U /,m
N;une(Print) City.Slate,ZIP
Nu. and Street Telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existiltg Building❑ Owner-Occupied ❑ Repairs(s)X Alterations) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed \York':_._ ,S^ '� a/mac r/- yvsT�rj L�
SECTION a: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs:
Labor and .\laterials) Official Use Only
I. Building S 1Sai rZ I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier _ x
1. 1'lumhi°g S 2. Other Fees: S
a. .\lech;mical III1':\('1 5 List:_
i i. \Icchunic:d IFirc a1-
Ru�tression) S e Total \It Fees: S_ --__ -------- --------Total Project Cost: -
G/�d` C� Cheek No. _('heck A,00unt:
n. S 0 Paid in Full 0 Outstanding ilalmtce Due:
f ,
SECTION 5: CONSTRUCTION SERVI('F:S
5.1 Construction Supervisor License(C'SL)
License Number Igiiratinn Date
N;umc ot'C'.SI. Iloldcr
Li
T St CSI.'I'.PC(sechelow)
liitl r[C_U ___�`fiL UPrrl _ /i� .LS pe Dcecriplion
No. :aid street p/
,/J U UnrestnctcJ I IhtilJin gs killto 19,0110 cu. It.)
/� Izo�f _ . _Z7 __._. . It Restricted I,2 Family MwIlin+
Cinifoe n..State.L l P Nt klasunr
wS Window
and Sin
.._ R RC Rooll me and Siding
SF Solid Fuel Miming Appliances
I Insulation
'felt hone Enmil address D Demolition
5.2Registered IIume ImprovementtC Con tractor(11IC)
-44/,"6, . er l 4 IIR: Registration Number Expiration Date
IIIC',eC;.'�omp;uly N;unc or I IIC' I(egistrant Name
red Slacel limail address
City/Town. State,ZIP fele hone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. 4 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 ..........J- No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nutne(Electronic Signature) Date
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
contained in this application is true and accurate to the
/best of may knowledge and understanding.
692��o�r�e� / /ef //GY�AyvCo, cb
Print Osuur's or:\uthorizeJ.\gent's N;une 0:1&tronic Signature) Date
NOTES:
I. 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 Hume Improvement Contractor(HIC) Programl.will mr have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be limnd at
\%\t,% ,,.i Information on the Construction Supervisor License can be found at „o\ dp,
2 \Then substantial work is planned, provide the information below:
Total floor ,area(sy. tt.l _ _-__t including garage. finished basement'attics,decks or porch)
Gross living area 1 sq. fl.) ---- Habitable room count
Number offireplaces.--_- . _ Number ofbedrooms
Number of bathrooms _ Number of half hats _
I)pe of heaving s)steal . .. ... . _. Number of decks, porches
1)pe of anding S\Slenl _ _ .. . Inclosed _ .. . - - Open
1. -I'otal Project Square Footage-men be substituted for"lblal Project Cost'
CITY OF S,U-&NI, �SS.�CHL'SETTS
3LILDLNG DEP.IRTEY IT
I_'O W ksjl GTON 5TRE", J,FZOOR LtiL
T IM (979) 743-9599
KIJ®EALEY ON13COLL FAX(978) 744.9&"
MAYOR T 14O.."ST.PtaA"
D IAF_C MIL OF PL SUC PWPFA7Y/8C QDLYG COSMISSION E R
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.3
Debris, and the provisions of MGL a 40, S 34;
Building Permit M I I work shall be disposed of in a p is issued with the condition that the debris resulting from
l 1f, S I SOA. roperly licensed waste disposal facility as defined by hIGL c
The debris will be transported by:
z?" Z
(name of hauler)
The debris will be disposed of in
LTZ
(name oP tardily)
Cerf/P/Z
(�Jdrt»aY frcili�y)
�iynamre of permit �pphc�nr
.lore
y a ` CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tlx:. e:1 Y'�e1N r n I
\I ter e
t!: IttANll.\ea U.\ilalaa• • 3,111'N,h1.1\h.LJII a I Iv,i177,',
I'r.l.v)Lllyvi'+J r I'i.e v)M•'tC•'r.tM
Workers' Cumpensation insuruncle 1i0duvit: IlulidervContractors/Electriclens/plumben
� 1 Rican In unnrilo
Int a 'AI
Vd1r1C I lhnnr¢ay1)rpylrriiinrvfnJlr�duull:���k � � ����
+
I hone N: 9 7,F - 77
I .�rv)np as uaglloyer7 Cheek the appraprlule bas:
1.❑ I:un i ampluyat with a, Q 1 am a�uncral couuaelor and 1 l)M idproJeel(ruqulrrd);
mnpluycce(full amYur pirmil 1le).r huve hlrcd iha.suh•cunfractun h Cl Keith,cm+etructiun
'.oft" 1 ant a sole prnpriufnr or partner• Wiled on the.inched sheet ) y ❑ Remodeling
ship and have no atnpluycers Tliem aub•confnctore have
Lurking fiu Inv In any capauily, tvorken'cmnp• Insurance. e' Q Demoliriun
I No workuri'cutup, ilu n ponginn and urance J. Q We a o enl 9• ❑0aild)ng addniun
nyuirud.) ite
ofylcan have usunireW their 10.0 Electric')repein or additions
).Q 1 and a hulrwuiI doing all work "ilhr o/eacmptioe par h1Gle 11.0 Plumbing rupairs of ad n ditio
nywlf.(n'o Lprkare'comp, C. 152.41(4),and we h I a no
in.urance required.) t anpluycuiti Will waken' 12'0 Ruufmpairs
eaglet Insurance mquind.J 13.[3 uglier
•1 ip.•,gtLa'url Iha/:beers ens el mop.dw till ua IM wclwa blow agruee I'I IuIelylrrYwn why 1oolien a this en�Jsrir indleuine thy iem wwkur'cunresraaltwe Jruliey Iunulrnuwl►�n Juine all wurY nee Ihaw Atro au+aier suNrnslws mul.111.r11r a nets alnasrlr inalawlne.w�.
T'•nrinwrun IAp abed rhq hq relW auaAee.�n aJauirey).half durrine IAr n,twM II/nr eue.rler _
her
/tu n me ouplayep/I he prnl•ldeer barker,'cuinpr/etadon hr.rurnner�ar my sine/ ♦e.IhihBduWirt�r rhr pv//y an%a1 s
ire`4rnrwlarle.
Insurancu C•unlpany .Vent /2 A- ' P �T/fJ-P
Ihdicy a ur SvfGine. Lic.rh�y_�'f,S`/n� — • ----
Eapirmwn D;ut G
)ub Silo Ailllres.r,� L.pd/!ai✓ LAy,P . . . �+
C1tyl�laterLlp: J tpj O/p7a
�ttauh a 111011 workers' eurnpuneatlue pulley dac)urullun page(showing the pol)cy nuofbur and cigpl►atlue dote),
till w wcura coverage as required under Sactiun:Jr\ ul'31OL o. I J]tea lead to the Imposition arc ieninal penoltieea a/a
Ana up nI 1'I 3110.01).4Jy 144itut III* Vi latori.ermmunr, as `11 d.s civil penahlus in ihu tunn agb STOP WORK ORDER ind s Bne
up m i!3A M,f Jay yuinvt the v6Hanv. Ire advlwd thin a copy of the% "alemeill may bu IurwurdcJ to the 011ice ur
"it uYaw DIA :or nivur.u'ce alcra�u iania atom.
/du hereby 1, 011114•0.fhe p,rinr nnel prn,r/tier u
o /prr/ary their Ihor ilef'urmi'llon prurie/eel uryuve is true nnrl correct:i.•. li +
—1alu,
r)//leiul me on/y. /)J nnr'write ire t/tie are•rr, lu Ar rouse/a•teJ Dy eiry ar/Dien,a/�/aiuL
i
/ ilY elf I4wn;
yurnit/l.lcenee
Ruing .l uihnrily (ciralo nnu):
I Ifl,erJ •,(Ilv.rhb !. Ihuhhny Ua)r.vrlllcl+l 1. 1:it), I'unnC'lerk J. C•'luvfrieal IuytcYWr ;, plumbing Imyctvor
G. I)ihar
.I 1'• ai Ice View":
f
Information and Instructions
v t.tson in the sarvtce of anuther owlet arty cuntirct of hits.
�I,t»,tcitu.etts li :Ocfjl Laws utute,an empleYN is JvIituJ a#"lle Lary P cis m provide wurkcta �JlOpentattlm fQ( their ctlo hYea].
I'u f?a Jtll to Into
N.press or unphcJ. oral or omen ..
�n .•mpluper ma JetineJ>f"aa individual, partnership,.IYYaC1a11Jn,COfpJratdl,or ,the(II del eased. of any two r mart
�mershmp, assoetaltoo or other le j11 enaty,cmpluytnl{employees. However the
N the plug r j4 enin:d to a lame enterpr'se, and utcludills the Wyral represeuutives of 1 deceased amp s t tav�it °
acmver or ousted ul'.m individual. p
sons w do tnnntanunca.can+traction or repair work on >uch dwelling ha ire
owner of a dwelling house having not mare than three apartmenu and who resides therms.ut t e Occupant
.Iwclhn j house of another who employ"N
or on the,rounds jr building appunsnant thereto shall not because of such employnont be decnteJ to be an employer.'
state or local Ileenslnl)aReaey had widthold the Issuance or
�IGL chapter 132. 425CM also states chat''ev#ry far
20Y
renesrsl of a Ilca,a or penult to uperoto a boil,#"et to ton Uro:wick theinsaranc�coverage
any
+ �]C 11 cotes"Neither the canunonwcalth nut any of iu political subdivisions shall
appllcttnt who has not prnduad leeeptable erldeithe of eump
lddiliunally, %IGL chapter I S_• 5- I
enter into any cuntroel for the perfomlan eventaula the eonvact Y 1luthortilyvidanc#ui wntpliastce with the uuurone$
reyuinmenls of this chapter have been p'
•.kppllcuNt checking the boxes the apply to your situation and,if
es cad hone nunsber(s) 11001 with their canificule(s)of
Plea.# rill out the workers' cumpensaeion al8davit completely,by t,ts other shoe the
necessary,supply cul►contrUldif(s)nufne(t), address( )' D
workare' compensation insurance. If a,LLC or LLP do"have
insurance: Limited Liability Companies(LLC)or Limited Liability Pantunhipe(LLP)with no emp oY
wind. it advised that thin alTidavit may to submitted to the Department of Industrial
netnbers ur passes,are not required to carry
employees,a policy is req
headon rot the permit or license is bain4 requested. ,ol the L>•sPonmant of
\ccidanta for contlrmatiun of insursrteo coveroje. Also bt sort to skin aaJ Jute the ul'llJnrlb Tau atlldevit s u
he remelted to the city or town that the upD ueuions regarding the low ur if you ad required 1O obtain A workers'
aaies should enter thek
I ndustriul,\ccidenu. Should ynfs have unY 4.
cutnpensation policy,pleas°call the Department st the nutnbar lasted below. Self ins comp
elf•insurance license number an the appropriate line.
('Iry or Tow,Offlelets
"The Department has provided u sptsce at the'uc�m
the app '
Ptcosc he+ore that the affidavit is cumplate and printed legibly. hcant
4 di#afliduvit fur you to till jut in the avant the Ofllce of Inveni jatio.1 has to nce itut you regarding
Applications in any given ya;v, need only submit unit atlidu n indicating to ieur
I'I:usa be sera to till in the purtnit/license nusniwr which will be uaed as a reference number. In addition,an aPD
that mast submit null penni) Indnae app ' ' be rovideJ to the
policy lurormatijn I it necessary) and under"lob 5ilil AJart or marrkedmby+die city oraown tnay be p o Y
town!..It copy of the u111davit that has bans officially sump'
Applicant as proof that a valid affidavit is un file rot Pulute Pet ur licenses. Anew at]1Juvit Host m tilled nut each
y ear. `antes$a home owner of anima is s on I'lin{a license or permit nor relaled to any business a comm#reial vastest$
duli I cease tit permit to burn leave$cte,)said person is NOT required to complete thl+arfidsuthave,a,Y yuesttans,
t h. ')tile$ td Inveaiyatiuns would hire w thank you in advance fur your coupenuou and should y
I+lua.e du out hevtaro to jive us a call.
nc� U.p•uunatt'e adJra+s, talcphune aTh aA number:
Commonwealth of Mamchusatn
Deputment of Industrial Accidents
Oflles of Isvadisdans
600 Washl+t8tOn Street
Bolton, MA 02111
fal. d 617.727-1900 ext 406 or 1.877•MASSAFE
Fax N 617-727.7749
„d .vww.mass.8ov/dis
♦. V
HID 126-356
fib Cotoup �-.Piui[brr�, 3111c.
13 SEWALL STREET
PEABODY, MA 01960
OFFICE: 978-922-6120
SPECIFICATION SHEET Q 7 �7 ^7
. . . . . . . . . . . . . Home Phone:F /.Y. ` . . �' 1 7LY
Owners 11'ame . t7�
t/17��. Mork Phone: . . . . . . : .
. . . . . . . . . . City . . . State . .Job Address . . . . . . . ! 1�. . .y. 1. . . .�o%fGL �TU. . . . . . . . . : �i/-{. . . . . . . . . ! . . . . . . .
SMING -- -- --
l. Siding Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . It'icltl . . . . . . . . . . . . Colorr. . . . . . ... . . . . . . . .
2. Area t0 re c - in House. . . . . . . . . . . . . . Br-eezer+:a_v . . . . . . . . . . . . . Garage . . . . . . . . . . . . . Additions . .'; . . . . . . . .
Dnrmets . . . . . . . . . . . . . . . . . . . . . . . . . . . Other . . _... . . . . . . . ;
3. Insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .� . . . . . . . .
4. Trim cover ❑ Yes ❑Ago Color. . . . . . . . . . . . . . . . . . . o be dome: Soffits. . . . . . . . . . . . Fascia. . . . . . . . . . .
. . .
Rakes . . . . . . . . . . . . . . . . . . . . . . . Ceilings. . .
,i. YYiridow and Door Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,, .`
6. Glitters and spouts Sig Use heavy gauge seamless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Color. . . . . .:' :-..,..<._
7.Shutters es ❑No' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .< . . . . . . . .
S. fruloa-sand Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:4
ROOFING , � J�i�
MaterialTvpe . ,. . . . Color.-f'y �.. . . . . . .
Arens to be done . . . . l . . . . . . . . . . . . . . . . . .
Remove Misting shingles TYYr� ❑A'o IS 11).felt. . . . . .. . . . . . . . Metal Eclging t/ . . . . . . . . .
p
Chimney and vents, ch . ./QeSys.�L�w -�i�,�. .�!-�! -T - .iyt� :.
NOTES.
L . . . ..•r �. . . .y . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . .
/' . . . .Deposit .
tMaterial mid labor to cost v4'. .(f_ -�. . . . . .. . . .pavable.as follows: .S'���Ralallce
.. .Ist Jnstct/Lnent
DO NOT SIGN THIS DOCUIVENT IF THERE ARE ANY BLANK SPACES. .2nd Lrstallment
on courp Lion
Contrcretur mi/l do al/said+rnr6'ilia 2on:l wnrknrnndrip urmmer: 3brr aver i easel l7ris ngreemetu if it Las heerr amsaonurtterl lry a pngv 77utrd : at a place
Gllr•r[Iron ou nc[.h'en njt/ra srJler, n•/viz lr mql'be hrc rrtaiu nffite or!-r:urch thereuj provided v0tt noti6 the seller in writiu, it his trr aill offiA or brnneh
br onlDrum wall/roped, br rele_granr sent er(•1•deliver.e act Inter than midni lu ol•the/hire?brrsine.cc din fJ7/owing the si,rling of this a,re't reni.//
11N VYITNES HEREOF, the pm ties have herewtto signed their names this. . . . . . . . _/�. L . . . . .den A.
'. �. . .
Acrcpi
b I 101u ItOtrs, i11c. urr•r
c°Lu�.c � � . . . . . . . . . .
s;o,ied. . . .
Pert
O,rner
Represenkriiv Aatlly .ed -.ri Rep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sirlk•e,. labor disputes. in, enrenr we.tthco: 01 nmteri.tl supplier decals razAting in+rurk sl%•ppngr are hevond tfie cvufrol of the rontp•iny.
OP ID: DH
DATEprMIDONYYY)
CERTIFICATE OF LIABILITY INSURANCE o1,
THIS CERTIFICATE IS ISSUED AS A TIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER.THIS
BELOWC THISOCERTIFl CERTIFICATE O IF NS LANCE DOES NOT CO SNSTMITEIX CONTRACTD OR TBETWEEN TH THE ERISSU G INSURER(S AUTHORGE AFFORDED BY THE IZED
REPRESENTATIVE OR PRODUCER, THE CERTIFICATE HOLDER• sub'eot to
IMPORTANT= H the certi0eate holder an ADDITIONAL INSURED,the li ('res)must be endorsed. if SUBROGATION IS WANED. J
the terms and conditions of the policy,certain policies may require an endoreamed. A Statement on this certiheate tlnes not ceTlh!r rights to the
Certificate holder in lieu of such endo s)•
PRODUCER 97s-777-9:94 NAMIR F
Dan Hurley Insurance A 976-7n-M �Or� °o
ChestrlUt Grewn,Suite 24 -
Seven Federal Street ADD
PRO VJLEYBR
CUSTOM $
Danvers,IIAA 01923-3620 -
Daniel J Hurley um AFFWHWVM COVERAGE .MAICC
INSURED IN
lomew f aUISRA.Preferted Mutual 15024
56 Co
56 Conant Street
LNSTIReRe:Granite State
Danvers,MA 01923 INS°RERC:
INSURER D:
WSURERE:
INSURER F:
CE FICATENUMBER: RE NAMED ABOVE
FOR
:
COVERAGES _
ITHIS IS TO NDICATED.CNOTTWITHSTANDING ANY E QUIREMFNT,CTERM OR CONDITION OF ANY CONTRACT OR ONTHER DOCUMENT WITH RESP CT TOUWHICH CY PERIOD
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 SUG POLICIES.LIMITS SOWN MAY HAVE BEEN RED0UCCEDEBY PAI��EMS. UNIT
I�TR TYPE OF INSURANCE ° POLICY NUMBER W0 EACH OCCURRENCE MID S 300,00
GENERAL LAABIUTY 1a6o 10/16M7 P ® omre
CPPO170564252 -- S 100,00
A .X COMMERCIAL GENERAL LIABILITY NED FJP(AM mre Pei l S 5,00
CLAIMS4AADE [K OCCUR PERSONAL SAW INJURY S 300,00
GENERAL AGGREGATE - N$ 60 ,
PRODUCTS-COWOPAGG GENL AGGREGATE UNIT APPLIES PER !POLICY Pfta .LOC COM094ED SINGLE LIMIT AUTOMOBILE LIABLITY (EBaoDdsm)
BODRYDUURYIPePp )%ANY AVTOBODILYQUURV(PwwMderd)ALL OWNED AUTOSSCHEDULED AUTOS PROPERTY DAMAGE
(Perealdesd)
HIRED AUTOS S
NON-0WNEDAUTOS - $
EACH OCCURRENCE $
UMBRELLA LIAM OCCUR
AGGREGATE S
EXCESS LIAR $
DEDUCTIBLE $
RETENTION S _ X WC STA�TU- 071E
WORNERSCOMPERSATION 100,00
AND EMPLOYER•LIABILITY YI �r96_ . 06IYON1 09/20H2 EL EACH ACCIDENT $
B ANY PROPRIETORIPART N!A ELnrccecF-EAEMPLO S 1O0,000
D HCEwL EeaFR EXCLUDED? EE ATTACHED NOTE 500,000
(Me^de�r NDI) EL DISEASE-POLICY LED E
M yes,desvme,omeD
DESCR�TION OF OPERATIONS beta
DESCRIPTION OF OPERATIONS T LOCATIONS VE oCLrS(Aaazh ACORD 101.AdABad Runts SLR.IT more sPRae is mmuleai
Sole proprietor not covered by worke IS compensation.
CANCELLATION
CERTIFICATE HOLDER
TOWNIPS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISION&
AUTHOR REPRESENTATIVE
Daniel J Hurley
(D1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD