464 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
' Board of Building Regulations and Start} CITY OF
�. � Massachusetts State Building Cod,. $E 'VS SALEM
Rq$) —Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or ?o 'S}� a.
v
One-or Two-Family Dw VJ0L.A 3. AD'1 t' �'G
1 This Section For Official Use Only
Building Permit Number: `- Date plied:
Building Official.(Print Name
1 lb
( ) Signature
ate
SECTION,1: SITE INFORMATION
1.1 Property Add ess 1.2 Assessors Map&Parcel Numbers
Lla Is thisM an accepted street. a Number
no Par
cel cel Num
ber
tuber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage($)
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'
21 Otme ''o Rec d
Name(Pn ) )I Z $'
City, tare,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ{cheek that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) " Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. El I Number of Units ther ❑ Specify:
Brief Description of Proposed Workz:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use only
Labor and Materials - - - y
L Building $ 1. Building Permit Fee: Indicate how.fee is determined:
2. Electrical $ ❑Standard City/Town ApplicationTee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:.$
4.Mechanical (INAC) $ List:
5.Mechanical (Fire -
Suppression) $ Total All Fees: $ - - -
Check No. Check-Amount: Cash Amount
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
� �•L� ,"1J S RSA '1 � l S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
����� Lic nse N e Ex ton Date
Name of CSL Holder
�( �� _ List CSL Type(see below)
No.an eet Type - - Description
y� U Unrestncted(Buildin s u to 35,000cu.ft.
City/Town, to t IZ P R Restricted 1&2 FamilyDwelling
M Masonry
RC RoofingCovering
WS Window and Siding
�- SF Solid Fuel Burning Appliances
I Insulation
ele one Email address D Demolition
5.2 Registered Ho elm ovemen Con ctor(HIC)
HIC Co N or egis HIC Rer , i imber Ex t' n ate
No.an t
Email address
City/Town,State, It' ele hone
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 ..........❑ Ne.....,..,.❑
SECTION 7a: OWNERAUTHORIZATION TO BE COMPLETED WHEN '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject proper�h�erebyuthorize
to act on my behalf, in all
m��-atters relative to work authorized by this building permit application.
Print Owner's Name ec nic Signature) Date
SECTION 7b:OWNERt_OR AUTHORIZED AGENT DECLARATION .
By entering my name below,I hereby attest under the p ' sand penalties of perjury that all of the information
contained in this application is true and accurate!to! est kn a and und
erstanding.
derstandin .
g
-- t
Print Owner's or Authorized Agent's Name t a at
NOTES: . .
1. An Owner who obtains a buildi pemilt 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 halffbaths
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'
CITY OF S,,ULEINI, 11WSACHUSETTS
BUILDING DEPAmEENT
130 W ASHLIIGTON STREET, 3' FLOOR
) TEL (978) 745-9595
KIa1BERLEY DRISCOLL FAx.(978) 740-9846
MAYOR T HONUS ST.PIERR&
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMM Section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transportcd by:
(��`oname f haC_l�;' ' / —
The debris will be disposed of in
(name of facility)
1Jo ,�Y
(address of facility)
e errnit applicant
date
JcbriulLdx:
° Window World of Boston, LLC MA HIC Registration
° Offices & Showrooms Number:
❑15A Cummings Park O 295 Old Oak Street 166025
Woburn, MA 01801 Pembroke, MA 02359 Federal ID #
(781) 932-4805 (781) 826-6281 27-1481665
"Simply the Best for Less" www.WindowWorldofBoston.com
3z
Customer: l� /J -�r..�a ! a�r,�, C O c�, fig Phone(h) ? -
Install Address: 4{w 49aef c 44yf __ Phone (w)
City: Sr //t/e u r State: MA Zip G/F76 E-mail
WINDOW WORLD GLASS OPTIONS
_1000 Series Single-hung All-Weld $189 SolarZone Elite $99
2000 Series DH Mech/Welded Sash $195 Triple Glazed T02* $175
4000 Series DH All-Weld $205 (-Series 6000 Only)
6000 Series DH All-Weld $240 WINDOW OPTIONS
2 Lite Slider $334 Glass Breakage Warranty $151NCLUDED
_3 Lite Slider (its.w.im) nr4.u2,114) $525 1/2 Screens $9 INCLUDED
_Picture/Fixed Lite $334 Foam Insulation on Jambs and Head $11 INCLUDED
_Awning $260 Double Strength Glass $15 INCLUDED
_Casement $290 Double Locks (> 26") $5 INCLUDED
_2 Lite Casement $575 Full Screens $22
_3 Lite Casement (im im w) (114.1/2.1r4) $860 Colonial Grids (Contoured/Flat) $45
4L Basement Hopper $334 Prairie Grids $51
69
T Bay Window-Soffit Mount/INS Seat $2660 Diamond Grids Simulated Divided Lite $182182
_Bow Window-Soffit Mount/INS Seat$2785 Tempered DH Sash (BSO) (TSO) $65
_Garden Window $1880 Obscure Glass (BSO) (TSO) $35
_Specialty Window $ Oriel Style (40/60 or 60/40) $30
_Beige/Almond $40 Foam Enhanced Frame $35
_Wood Grain Interior(Series 4000 16000 only) $100 p E 1978 BUILT HOMES (Federal Lead Containment Law)
(Light Oak/Dark Oakl Cherry/ Fox Wood Lead Safe Practices Required $257
Rich Maple) MY HOME WAS BUILT IN THE YEAR Initial ..
_Brown Exterior(Arch.Bronze/American Terra)$100
—Designer Color Exterior $155 MISCELLANEOUS
Custom Exterior Aluminum Cladding
Window Color p/ ❑Textured$75 O Smooth G-8 $75 $
—� G.v'e / `^� Facing Color
inside oursrae Metal Window Removal $50
NON CUSTOM DOORS New Construction Vinyl Removal $175
_ inyl Rolling Patio Door 5ft. or Eft. $995 Specialty Window Exterior Trim $
Rolling Patio Door Bit. $109 Mull to Form Multi Unit $30
_Add>r-h
price for Custom Rolling Patio Door $ 0 Install Interior/Exterior Stops $50
_Fren tiding Patio Door 5ft.or Eft. $1295 Install Interior Casing Starts At $95
_Fren ]SI! ' Patio Door aft. $1395 Insulate Weight Boxes $20
_Frenl Sliding do Door 9ft $1495 Roof for Bay/Bow Windows $500
_Custerior Clad $150 Existing New Const. Ext. Retro Fit $150
_SolaElite or ETC GI $175 Removal of Existing Bay/Bow $250
_Grid Door $129 Repair Sill, Jamb or replace sill nosing $50
Woo Interio $295 Full Sub-Sill (Single) replacement $150
Extes! r Colors $395 Mullion Removal $30
_Inte ' g 21n 31M $175 gay/Bow Conversion Ext. Petro Fit $350
Han Options $ (New Siding Will Not Match)
$ Building Permit $150
Door •olor / .• ROUND-UP FOR WINDOW WORLD CARES
Inside OutsideV St.Jude Childron's Research Hospital $
vumvurG! VOVw,GJ pALaIIUI Map a11V UllVGIJIaIiVO pall ItlllJ at wi V1 I aliall I I Jay VO I W41.411C4 rrlilrar �n/j
Customer declines grids on �windows/doors Initial
DISCLAIMER:Customer is responsible forthe following in connection with this contract:Painting,Staining,Alarm System disconnectlreconnect Building Permit fees in
excess of$25.00,Homeowner and or Condo Association Approval,Historic District Approval.City of Boston parking&sidewalk Permit fees in connection with installation.
NO EXTRA WORK IF NOT IN WRITINGI Customer agrees to the terms of payment as follows:
Extra labor&Materials $
Site Set Up, Disposal &Delivery Fee $ $195.00
Total Amount $ o2
Custom Order Deposit 50% $ C k# It7
Balance Paid to Installer upon Completion $ l
Amount Financed $
Window Word of Boston anticipates starting this work on !=/-G °'`-*and being substantially completed in_days.Security Interest:Yes No
Any deposit required in advance of the start of the work SHALL NOT exceed 331/3%of the total contract price or the actual cost of any material or equlpment of a
special order or custom made nature,which must be ordered in advance of the start of the work to assure that the project will proceed on schedule.No final payment
shall be demanded until the contract is completed to the satisfaction of both parties.
All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be
directed to:Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170 Boston,MA 02116.Phone:(617)973.8700
No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract.
Window World of Boston under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.Window Word of
Boston shall not be deemed responsible for delays in the work described in this agreement caused by regulatory;permit grantng agencies,authorities or individuals.
Notice:If the PURCHASER(S)obtains his own construction related permits for the work described under this agreement or deals with unregistered contractors,
the PURCHASER(S) is hereby advised that In the event of a dispute,judgement and nonpayment,the PURCHASER(S)will not be entitled to make a claim or
collection from the guaranty fund established by chapter142A,M.G.L.
You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.
Notice of cancellation must be in writing postmarked no later than midnight of the following third business day.
This Window Wodd®Franchise is independea owned and operated bv Window Word of Boston,LLC.under license tram Window Wodd Inc.
Owner:Do A06ign N there are any blank spaces. Oats II
t1ifesman: Do not sign it there Are any blank spaces. DVe Owner:Do not sign if there are any blank spaces. Date
6o=n o7-is White Copy-Original Yellow Copy-File Pink Copy-Customer Hayes annwgeeecsr-u!s
48m eley uugdullOul d41 ui i!es rim Owrt I.0 JV}owµ idnwd yoWvuwd dyi}u uvn oolnyd tale onn oeml,l,vo.yeaoV.yak p.....y p
,goals padeospuel io sgni4s'slueld
of o6ewap Aue jot alcilsuodeai lou ale aM'Aliedad inoA uo 6ultliom al!t4m gales ono pus smopulm moA'iliom ino uo snoo;of ale saguoud
ino inq 'uollt,ia6aA punoie 6uliliom uaym in;ateo aq 01 anuls aM-wa4l aniassid of tuem noA pus uo pacidals 6ulaq sAlAins iouueo Aa43
;I p81e0010i Agieiodwat aq ptnoys mopulm a molaq 14611 seals Ill sgnigs pus slueld aieallep 'smopulm moA of ssaooe sn sA0 of Mosq
paunid aq of peeu segsnq snoi061A puts seed aw0S •swalgoid leiluelod lot>ool pus 6ulAuie sn of loud pieA jnoA Aanins elseeld'sioop pug
smopulm ay3 of 1ue0e1pe ale leyl awoy inoA to seals padeospugl iaylo pug sialueld Jul>fiom of peeu am AgeuolssODO•sagsne pug slueld'b
•wa43lielsulea.of paitnbau aq Aew Lout suogeialle
6UIiaA00 MopulM Aug jot alcilsuodsaii lou aim osle aM'uopetlelsulai pus I8A0Wai ayt ul SulHnseu a6ewep jot algisuodsai lou aim pus
swan a9841;0 uoµellelsulai io BUTAOwaJ io;elcilsuodsout lout aim am uoilelletsut ino of iopd penowei 5u1i8n0o moputm iaylo Aug put,
sedeip'sialinys 'sepgys do-got 'sputiq!eolllaA'spullq !ulw its paau am'smopulm ayl10 lopawl aql of ssaooe ule6 01'961,111an03 MoputM'£
-noA isisse Alpel6 film am'Allsee anow of AAe84 ool ale swell a ntiwny Aue
if Miom ino to Aem gulf w ale leull s6ulyslwnl Aue epics anow aseald -Alueaodwal pale3olei io paienoo eq pinoys luawdinbe oluoipele ieul10
put,sialndwoo we4l eleaofel pus pu!m out Act paginlslp aq ueo le41 swell flews iaylo pug'sioded lueyodwn leyle6ol iayle6 of aiggslnpe sl
11 'awoy inoA y6noiyl moll AlleoldAl pulm to slsn5'panowai ale smopulm plo e4l uayM'8iom ino wiopad of Aiessaosu slool pus sulolo dap
ino aoeld ueo am os 'awoy inoA aptsu! 'mopu!m yoea to lust u! last Z Alatewlxoidde paau film am *sloop pug smopulM suit of ssaootl Z
•s%99m,eaiyl ueyl slow si lsenbei noA Aelep egl it uogegelsui aioleq aouelaq 6u!ulgwai eyl ioelloD of peeu ti!m
eM,noA yl!m Blom of Addsy eq film am iapio inoA getsu!of Apse,ale am te41 uogeol;llou iatte s>eem to eldno0 a uegl slow jot uolie fielsu!moA
Aelap of paau nor uoseai ewos jot A 'atep uogggt,lsui us lee of noA geo g!m am lu!od le41 IV'sAesm 9 ol9.AlleDldAl at peolut,ien6 lout y6noull
'pefielsui eq of Aplaw ale smopuim ayl uaym pus peoeld si iapio inoA uaym usemiaq guilt ayl•Suogt,001 plioM MopulM DOE leA0 ino to Aug of
paddlys pue Allunoo suit punoie pateool slueld 6ulintoelnuew ino to auo is spew wolsno sit-smoputm ino to gV•awLL AieAllaa paloadx3 't
'anuae siagefsul ino uayM loedxa 011e4m 411m noA
;ulenboe of Inopuey s1411 PaleaJO OAey am'algissod se Alyboows se aaeld w1el of uoflellefsul 04f sicieue pus 1u8wlsanuj
inoA aaiwlxew ol'awo4 inciA;o aouaiaadde pus anjeA 'janai No;woo 041 esea,11oul of uolsloap moA uo suo1lelntei6uoC)
SH®®® ®N V SflA®®N OM M3N enoA u®:i 0N1UVd3Hd
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MM 01111
www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-A,pplicalat Information Please Print Le;dbly
Name (Business/Orpnization/[ vidual): � \
Address: 1.4
City/State/Zip: Lt�t24iljap( 7 ( Phone #:
Are yo employer?Check the appropriate box: Type of project(required):
1, am a employer with ? 4. 0 I am a general contractor and I 6 New construction
employees (full and/or part-time.).* have hired the sub-contractors y Remodelling
2.0 I am a sole proprietor or partner- listed on the attached sheet I
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me is any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
right er MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all workof exemption� on p
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Rrepairs
insurance required.] t employees. [No worker' 13.�Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
r'domeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tr;mtractors that check this box must attached an additional sheet showing the name of the sub-contractors mind their workers'comp.policy inforrnatioa
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. ��
Insurance Company Name: i td I I �
Policy#or Self-ins. Lic. #: o522 ' Expiration Dated
Job Site Address: / City/State/Zip:_ �__!. Y7y_
Attach a copy of the workers' compensation p01' y 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for msurance coverage verification
I do hereby certify under pa' nd p aloes of perjury that the information provided above is true and correct
Si ature: ! Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4_Electrical Inspector 5,Plumbing Inspector
6.Other
Contact Person: Phone#•
Massachusetts Department a;Public Safety -
Board of Building R=gJlatians and Standards
_icense_ CS-072772
JEFF C STEELE
24 SHERWOOD AVE _
DANVERS MA 01923
:.cmmissioner 04/07/2018
Ofliice of Consumer Affairs&Bus near Regulation
_- - =`HOME IMPROVEMENT CONTRACTOR
-- Registration: 166025 Type:
Expiration: 411212018 LLC
WINDOW WORLD OF:BOSTON,L-C.
JEFF STEELE
24 CUMMINGS PARK SUITE 15-A!
WOBURN;MA 01801
Undersecretary
i
i
i
i
I
i
I
Li registration valid for individual use only
-, befo expiration date. If foun�return to:
of consumer Affairs and Bupiness Regulation
Plaza-Suite 5170
Boston,MA 02116
eNot valid without signature
I
I
i
i
i
CEPMFICAI - - ilABl ITY iNSURA\. 1.11 E
TH ll )11i ArID "-.Jr4r I!a R 15 3 "r0l THE -EF�Tjr-
' MATT17P !NF0Pl$fiA7 QAT=_ �Uj 7. .3
—Ana AF7SP��xn a? 7H-
aXLOIX1, :HI 3 DOES �iC�- CON37T- A 3= Va�ll 3 j,,J� ;JISI.JFZ=Rr3�. 21j-•jCP1
-7 JI -
;H OR ?RODUCE`o. AND THE--ERTIFICAT=HOLOCR.
t.'APOP. I? the -_^ivcare�Qvisr is an q'j3P.:)G4T4ON 13 q 1
che{eI-n i and C)ndii;Qrs U�-7he PoiiCY an s-a�mvnam on :N3 ` 3 -0
ca-,tjffate holder in lieu GE Such 3ndof3arnent!3;.
-RuoUC=F. C. TimorhyWard, CPCU. CliC
-Senn Dunn -05 a
1625.1.Elm SL "MCI&E,,,I,336-272-7 13 1 iA,C.nor
Greensboro.NC 27455 AO=L,,, wardiM_senndunn.com
C- Timothy Ward. CPCU, CUIC
INSURER iSi AFFORDING:OVERAGE NAiC A
INSURER A;Citizens Ins Co of America 131534
:NSUREO I/Vindow'.Vorld of Boston,LLC INSURER 3:Afterica 17 ..Cial 3.rtafft i
118 Shaver Street
North Wilkesboro, NC 29659 INSURER CwHartford Rra Insurance Co.
INSURER-
INSURER 7:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
li,ICICATED- NOTIPAT4STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1fifiTH RESPECT TO TMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
j:<CLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOW4 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE IINSD VAID! POLICY NUMBER "OUCY sF POLICY EIP.
Mjoo ?YY LIMITS
C MEItCUAL GENERAL UABILMf
A I LLI:--04OM EACH Z=URRENC-- I i 1,000!000
-LA A�.AAG '0 1 5UJS-4ADE [�X --C--"P f;R
PBG790252707 od/01j2O 1604jO1,12017
"�ecoj
3.cin..c O'n.,,a 5,000
R—.30NAL I A31 UJIF.f
GENERAL AGCR=3AT PRCDLrTB-'--"Jp cp 303 r 3 2,000,000
AUTOMOBILE UABIUr( uomn-'ED al L..';
AN(AJ70
ALL�VWIED 3CFEDIAZ:e
AIJ7��S
50DII-f.IUU� Psr1=G9m 3 AU-CS acloenn I
3
x UMBREU-A LAB X OCCUR EACH OCCURRENCE i 1,000,00C
A U41B CLAIMS-MA0E, 066790252707 04/01)2019 04/0 1/90 17 1 AGGREGATE
DEC
AND EMPLOYERS'UABILITY Al=- N
WORKERS
COMPENSATION F'C VIYPR0IaRIErCRrPAjMEHIEXECU`�1 JE YIN 2101ECLJ2635 01/27/9016 0112712017 2-1-EACH ACaDE?n 500,000
(mandatory in NMI -1 NIA 500,000
�FRCERIMEMBER EXCLUDED? EA EMP 0-=SFA.E
'109,deshe undo, 500,000
EAS_ '0' Li'IT 3
DESCRIPTION OPERAnONS ZMIO:v
1 1000 OOC
DE3CRI"IONGFOPERAnONSI LOCATIONS IVEIlCLES (ACORD 101.Additiomit Roman"Schedule may be aftachad If more space Is required)
CERTIFICATE HOLDER CANCELLATION
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 REPRESENTATIYE
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (20141011 The ACORD name and logo are registered marks of ACORD