22-026 (4) 56 SPRUCE HILL AVE BP-2018-1144
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22-026 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv' ROOF BUILDING PERMIT
Permit# BP-2018-1144
Project# JS-2018-002060
Est. Cost: $8200.00
Fec: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BRADFORD J MOREAU 1175408
Lot Size(sa. ft.): 14287.68 Owner: BELL VICKI A&RICHARD W RILEY
zoo Applicant: BRADFORD J MOREAU II
AT: 56 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
9 HARLOW CLARK RD (413) 358-7946
HUNTINGTONMA01050 ISSUED ON:5/4/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 5/4/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
-- pfo Status of Permit
..� " tl�eBuildinDp en Curb Cut/Driveway Permit
A 21a S et Sewer/Septic Availability
see Room 10 WatertWell Availability
�R
oic 30 Two Sets of Structural Plans
—Al587-1272 Plot(Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION go (} i //Vv
1.1 Property Address: This section to be completed by office
S6pev��v�� �il� �/��E' Map_dA Lot G.;' & Unit
7
Zone Overlay District
Elm SL District CB district
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2A Owner o7
Record=
c E S�SPQa/cF/✓irr <La�F�lr a
ame(Print)
Current Mailing Adtlress'
✓2 , 1�t F—ane?= 195, - 6S �
Telephone
Signature
2.2 Authorized Agent:
Namee((PlrPring
,Bu tcl T. ///a/!FA/. 7L I/✓A/11IJWCC4/�2D N/1n rni/_� N /fin.
Current Mailing Address: 01U�
�/Z?- ..352-
Signature Signature Telephone
SECTION 3.ES M TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ly
5. Fire Protection
6. Total=(1 +2+3+4+ 5) 1 .2.00 Check Number 1/0
This Section For Official Use Only
Budding Permit Number: Date
Issued:
Signature: 3
Building 4missioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
i
Section 4. ZONING All Information Must Be completed. Permit n Be niedDue To Incomplete Info ma[i
Existing Propsed I Bgte irEd"ni
��hh��, hhlumn filto in by
Buddin.Department
QiMR� Nr 'mnMM'D tV11
Lot Size
Frontage ... ... _... _.
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage % -
(Lot arta minus bldg&paved --
rkm
#of Parkin S aces
Fill:
ivalumc&Lacenonl
A. Has a/S'�pe(�Ta t Permit/Variance/Finding ever been issued for/on the site?
Cl
NO DON'T KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW C) YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO �ON'T KNOW ® YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES "`���"JJJ O/NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Wil the construction activity disturb(clearing,gredinc, exc abon, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O VO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check II applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
gr Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [[7] Decks [q Siding(0J Other[O]
Brief Description of Proposed _
Work'J %L 17r, '7—m ./V,�qA"
Alteration of existing bedroom_Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Nc
Plans Attached Roll -Sheet
Sa. If New house and or addition to existing housing- complete the following.
a. Use of building One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In, Type of construction
i. Is construction within 100 ft, of wetlands? Yes No. Is construction within 100 yr floodplain_Yes No
I. Depth of basement or cellar Floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,property as Owner of the subject
hereby authorize ,6/l.,Q/'FG/u7 /3(/ G(' F/J,S —r/JG
to act on my behalf, in all matters relative to work authorized by tKs building permit application.
Signature of Owner
Data
I, /,�2,�1C�0/IQ T, /j'I6//FAl2 as Owner/Authorized
Agent hereby declare that the s atement�s and information on the foregoing application are true and
and belief. accurate,to the best of my knowledge
Signed under the pains and penalties of perjury.
SWA'Doan ,T, ('4-
Print Name
T�
Signature of /Agen Dat
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 15//. .19,7 [,O S7
License Number
9 HqC Lju e«P'A- AeblIVItl 70 A4 lrc a /9
Address Expiaoig6 Date
Sign.t.reV Vl Telephone —
9. Registered dHHolme/Improvement Contractor: Not Applicable ❑
Company Name Registration Number
a/1frsrr %v;�DFns LNC 8�si �l�
Address � r' / Expi anon D to
/L/A?L6w eLA/,. 9N///Jjt'E/,-x✓///�. Te ephoney/3-,(rf-/1)
b
SECTION 70-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...... ❑
' City of Northampton
( Massachusetts
C A .
I DEPMTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
t Northan ton, um 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est. Cost:
Address of Work:
Date of Permit Application.
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under 51,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner: -
`y�a/yADl�t07. Na/ZFGJt fi/!ll�ODrdi�BC;[tK��s /%-� 7W��
Date Contractor Name L HIC Re g1stration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
MasB.acnusetts �-
'I DEPARTMENT OF BDZLDSNG INSPECTIONS
212 Main Street a Hunicipal Building CJs C`
\ ., Northampton, MA 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/ or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner ;hall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time, during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS i r
212 Mein Sweet •Municipal BDilding
NDithamp[Dn, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(Please print house numb and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Aa/' Al 5 /70//
(Company Name and Address)
/ LOain;s �ti�Ay
F/'srgAmQ7un/, 47� 41��7
Signature c&1 e t plicant or Owner Date
If, for any i on, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth ofMassachuseus
r., Department oflndustrialAccidents
I Congress Street,Suite 100
7
Boston,MA 02714-1017
rvwly.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Informationppnn,,,, _ Please Print Legibly
Business/Organization Name:�e W,4J j/zo A fIll t, TAc
Address: 9 CLA?/l RG_
City/State/Zip: rl 'il <' _ Phone#: ZZ k/
Are you an employer?Check the appropriate box: Busin s Type(required):
1,❑ I am a employer with employees(full aid/ 5. Retail
or Part-lime).` 6. ❑Restaurant/Bar/Ealing Establishment
2.El I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales Qnel,real estate,caro,etc.)
employees working for me in any capacity.
,,,,��,,II [No workers' comp, insurance required] 8. ❑Non-profit
3.LI We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,pl(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]"
4.❑ We are a non-profit organization,staffed by volunteers, I1.❑Health Care
with no employees. [No workers' comp.insurance 'eq.] 12.0 Other
'Anyappncantdmchecksbox#Imust also fillom thesection below,hosmiheuwmiwo compensationpolic formsomi.
"'lithe ro...is mr.c.have axempred themselves I.the corpoa i a las Mier employees,a workerscompensation policy is required and such an
.,—..,am should check box#1
I am an employer that is providing workers'campensatiun insjumnce for my employees. Below is the policy information.
Insurance Company Name: _
Insurer's Address:
City/State,Zip:
Policy#ar Self ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation policy declamation 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 c,vil 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 ofthe DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties ofperju y that the information provided above is true and correct
Signature e s � _ Date z1�3b/1��
is
Phone#' y/.f-J3.J�—V
Official use only. Do not write in this area,to be compreted by city or town ojlieiak
City or Town: _F'ermit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City//Pown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www x,gMy/dig
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as--every person in the service of another under any contract of hire,
express or implied, oral or written"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,525C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please bo ame that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permu license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe provided to the applicant zi proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Departments address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSA-FE
Fax# 617-727-7749
www.mass.gov/dia
Pim,Rc,-d02'3-15
HIC 170018 CSL 75408
Bradford Builders, Inc.
9 Harlow Clark Rd
Huntington, MA 01050
Tel 413.358.7946
Customer:
i
Vick* ell �S (�
56 pruce Hill�N.� (,��b� "--
Florence, MA UU
Scope of work:
Remove existing layer of shingles that are on the roof. If at that time any rotted wood or any
problem is detected, Bradford Builders will contact customer and discuss problem and options.
This would result in a $55 per man hour.
Apply 2 rows of ice barrier along eaves and in the valleys.
Apply roof guard over the rest of the roof so in the end you will have 2 layers of roof.
Apply a 30 year architectural shingles over the whole roof.
Install a continuous ridge vent and cap on peak of roof.
Install a new boot over the stack pipe
Install a new drip edge (white)
Bradford Builders will pull permit
Bradford Builders will get a dumpster and have it delivered to site, we make sure that the
dumpster company puts guards under it but sometimes the lawn will compress, but not our
responsibility to repair.
Owner will supply power and access to it for project
Bradford Builders loves shrubberies and flowers so we will be as careful as possible to not
disrupt any ,of it but some damage could occur.
Total cost: $8200
$5,000 due upon signing of contract �C 'J ow
$3200 due upon completion _/ J
X_-� _Q`---------- x-I�-`i� --------
_r
4Co CERTIFICATE OF LIABILITY INSURANCE
05/02/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement's).
PRODUCER CONTACT HANE AdlRa Edgetl
Webber&Grinnell PNx"Ea_ (413)588-0111 aG He, (013)5867481
8 Noun King Street ADOFEsE-. aedgett ebew d,nnoII ad.
INSURERCH AFFORDING COVERAGE HAIL.
Northampton MA 01060 INSURER Main Street America/MSA 29939
INSURED INSURERS. Commerce Insurance 34754
Bradford Sunder$,Inc INSUMENC
ART Bradford Moreau INSURER
9 Har[°Clark Read INSUNERE
Huntington MA 010509799 INSURER F:
COVERAGES CERTIFICATE NUMBER: Exp OD18 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 CLAIMSHER POLICY NIFF Try .
PE OF INSURANCE NED WYa POLICY NUMBER MMNOMYY MMODYE%P LIMITS
X COMMERCIAL GENERAL LIABILITY EAOry OOOURRENCE 5 1.000.000
DLAIMS-MADE O OCCUR PREMISE$ E 5 500,000
PCce
ME°EXP(Ary one eio) s 10.000
A MPT9550S 08/04/2017 NVGE2018 PERSONAL S ADV INJURY s 1.00a000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 Z000 000
X POLICY ❑�Ea' 1-1 U. PRODUCTS-COMPIOP A. 5 2,'C-0
OTHER
AUTOMOBILE LIABILITY CEO MBI eEDI SINGLE LI Rl a 1,000,000
ANY AUTO BODILY INJURY(Per,penon) 5
B OWNED x SCHEDULED BCDR20 07/13/2017 07/13/2018 BODILY INJURY ryeremden° $
AUTOS ONLY Aul
HIREDNON9WNE0 ANEGIC
PROPERn
x AUTOS ONLY x AUTOS ONLY P.'='O5
Undenroured motorist S 100,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE 5
EXCESS LIPS GLAIMs-MADE AGGREGATE s
OED RETENTION 5 S
ROMPERS COMPENSATION PER OTH
AND EMPLOYERS'LIABILITY ,.IN STATUTE ER
ANY
f CEP)MEMPOER EXCf UDEO+Ecu11vE ❑ N EL EACH AGO DENT s
niuseorvin NH) E L DISEASE.EA EMPLOYEE $
If Arr once eds
OEscwPnoN OF OPERanONs eelpw EL DISEASE POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACONO I.I.Adair anel Remerkn BCRe4un,mry be aNCRed Nmort apace[a repulntl)
Regarding_56 Spruce Hill Ave.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
0198&2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD