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31A-055 (4) 250 CRESCENT ST BP-2020-1231 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31 A-055 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2020-1231 Project# JS-2020-002076 Est.Cost: $28523.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO.- Const. O:Const.Class: Contractor: License: Use Group: TEAGNO CONSTRUCTION INC 034716 Lot Size(sg.ft.): 8581.32 Owner: NELSON ARVID Zoning: URB(100)/URC(0)/ Applicant. TEAGNO CONSTRUCTION INC AT: 250 CR SCENT ST Applicant Address: Phone: Insurance: 228 TRIANGLE ST ! (413)549-0803 Workers Compensation AMHERSTMA01002 ISSUED ON.-411212020 0:00:00 TO PERFORM THE FOLLOWING ORK:SIDING AND ROOF REPAIRS 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 TUE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS Certificate of Occupancy s; nature: Feer e: Date Paid: A ount: Building 6/12/2020 0:00:00 $ 00.00 212 Main Street,Phone(413)587-1240,.Fax:(413)587-1272 Louis Hasbr uck—Building Commissioner Department use only City of Northampton. � Status of Permit: r Building Departmen �C Curb Cut/Driveway Permit 212 Main Street \ ewer/Septic Availability 'k Room 100 V1/6terMlell Availability Northampton;-M 60 lyo,�ets of Structural Plans phone 413-587-1240 Fa" f 7-1272%0 ;ther Site Plans 10'�> t Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, R )q- DEMbLISH A ONE OR TWO FAMILY DWELLING s SECTION 1 -SITE INFORMATION 1.1 Property Address: rr ww11 -( This section to be completed by office 15 O CK V VRT 1 Map Loty SS Unit 1V X1 &T (�K- A K^ DW 110 0 Zone Overlay District CVS, H Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Own%ofRecord: X _ ti So C(��SC��1Z S T Ok ObName(PrCurrent l A dressyY r x 1'r ' T � Signature Telephone 2.2 Authorized pent: Df&-aS K o O fe-a5no co W S+94-C-�10 TeAed>,� (-t-� ZZg -M L A-t,) a NaCurrent Mailing Address: 2R)r-z� : t 3 S`E-cr -O Fro3 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) 5. Fire Protection 6. Total= (1 +2 +3+4+5) ,Crz Check Number This Section For Official Use Only Building Permit Numb r:-6 � Date Issued: Signature: G �2 ZU2(J Building Commissioner/Inspector of Buildings L Date K.6 @ l e CL5 K 0 GSI h-S fIR-kC1.0�4 . CO VA EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size ' Frontage Setbacks Front Side L:' R:1_ L:' R x. I Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved j d parking) #of Parking Spaces I - Fill: volume(,,1 ,7Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page, and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO ®' DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading,exc ation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 71 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[7 Siding Other[Cl] Brief Description of Proposed / Work: iIJ*UR.4-#J(.E 1>4"YKIC' VKLe 75 Rn'Zt-itil�LL1M8' SIy1rJG� '� QeV F/'JG` d�-6 Pt1," I (2-17, � Alteration of existing bedroom Yes 0< No Adding new bedroom Yes K No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a. 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 d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Com liance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 f. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cella floor below finished grade k. Will building conform to thE Building and Zoning regulations? Yes No . I. Septic Tank City ewer Private well _ City water Supply SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTR CTOR APPLIES FOR BUILDING PERMIT Vv as Owner of the subject property hereby autho ize (A 1 ?U to act on my ehalf, in all mattes elative to work authorized by this building permit application. x r-> • 1\ - lb Signature Own Date I, �� ti� � 'J L as GwQQ4Authorized Agent hereby declare that the s atements and information on the foregoing application are true and accurate, to the best of myTknowledge an—Tc Gelief. Signed under the pains and per alties of perjury. 16 N � T Pri t Name Signature of w er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: jF-1 Rcz,D rhe. CS ^ o 314 -7 License Number 5Z) W L. -A F-� eTx-- - fL BOX_ Z-?_q Agkess 04 of LOO 7/ Expiration Date Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ �tA�o s u i►�� to c b Company Name Registration Number JR If ATJ Address Expiration Date Telephone SECTION 10-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 buildi g permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS , 212 Main Street • Municipal Building Northampton, MA 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 tn such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, rem val, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but nod more than four dwelling units....or to structures which are adjacent to such residence or building"be done by register contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered Type of Work: S tO(aC` /r-r. R �'1°ctetw�es�v V Est. Cost: , ?$3• vo Address of Work:} C Kz-y� 5-T' N C)-F, P Tb,y wt yt— Date of Permit Application:-- I pplication:_I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _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.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: l C- CG ADZ) CM " c-TZ-dX:) t lV L Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: i Date Owner Name and Signature Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation TEAGNO CONSTRUCTION INC. Registration: 108109 228 TRIANGLE ST. Expiration: 08/17/2020 AMHERST,MA 01002 4) 20M•05/17 Update Address and Return Card. C�7e 1pooyrincararnealf�o��laaaar.�uaella ----- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration. EKIZImmum Office of Consumer Affairs and Business Regulation 108100 08/17/2020 1000 Washington Street-Suite 710 TEAGNO CONSTRUCTION INC. Boston,MA 02118 DONALD J.TEAGNO 228 TRIANGLE ST. 7 AMHERST,MA 01002 Undersecretary Not valid Nthout signature City of Northampton Massachusetts ,4* DEPARTMENT OF BUILDING INSPECTIONS �+ . y 212 Main Street •Municipal Building \\ Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 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: ')-5b CA t SCtMj 7- S5 � (Please print house number 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: (Company Name and Address) 5-71( Signature bj Permit Applicant or Owner Date If, for any reason, 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 of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLilblV Name (Business/Organization/Individual): T�l� u C'-O►AJ GThx cA—zq&D &D L Address: '--Z 1jr- 'r2a AW CA4,(_' S,�- City/State/Zip: i�&t:;_ -9 WIXA7— Phone#: 4L3 6"'-0�3 Are you an employer?Check the appropriate box: Type of project(required): 1.[011 am a employer with otr employees(full and/or part-time).* 7. E]New construction J1 I am a sole proprietor or partnership and have no employees working for me in 8. [] Remodeling any capacity.[No workers'comp.insurance required.] 3.[31 am a homeowner doingall work myself t 9. ❑Demolition y [No workers'com ,insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.D4 of repairs 6.[]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other S 1 dlAJ4 f2.G'Ptrj g_sf 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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 hwork 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: 04rt IAt, ( 1,j S CC) Policy#or Self-ins.Lic.#: B-OU(o 2-z-501 Z 020 A Expiration Date:_ �`1 t72I Job Site Address: 2-4-0 Cftf:5Sctru-:S City/State/Zip: lJtk1,1VVt'1h,P -Qr)J Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce 'y t er the pains air alties of perjury that the information pro *d d above is true and correct. Signature: Date: /r Phone M 3(0 Y Official use only. :Do not write in this area,to be completed by city or town officiar< City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cl own Clerk 4.Electrical Ins ector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 a joint 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 busin ss 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, §25C(7)states"N ither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of publit work until acceptable evidence of compliance with the insurance requirements of this 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or I�mited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry work rs'comp,hnsation 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 f r the permit or license is being requested,not the Department of Industrial Accidents. Should you have any question regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at t ie number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lin . City or Town Officials Please be sure that the affidavit is complete and prin ed 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;e used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Departmet of Industrial Accidents 1 Con ess Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fa # 617.727-7749 Revised 02-23-15 .mass.gov/dia NOTICE x NOTICE TOTOr w � EMPLOYEES ` �y4� EMPLOYEES o ay b�ev The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WMZ-800-8006223-2020A 04/01/2020- 04/01/2021 POLICY NUMBER EFFECTIVE DATES 97 Center Street Phillips Insurance Agency Inc Chicopee, MA 01013 (413)594-5984 NAME OF INSURANCE AGENT ADDRESS PHONE Teagno Construction Inc 228 Triangle Street Amherst, MA 01002-0000 EMPLOYER ADDRESS 03/09/2020 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER TEAGCON-01 LAUR ACORO' CERTIFICATE OF LIABILITY INSURANCE 27/2020 DATE 2712020 3/ 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). CONTACT Laura Misseri PRODUCER NAM `HONE 413 594-5984 Phillips Insurance Agency,Inc. ac,No,Ext): ( ) FAX,No):(413)592-8499 97 Center Street E-MAILE Chicopee,MA 01013 ./aura phillipsinsurance.com INSURERS AFFORDING COVERAGE I NAIC# INSURER A:Ohio Security Insurance Co 124082 INSURED INSURER B:Ohio Casualty 124074 Teagno Construction,Inc. INSURERC:A. 1. M. Mutual Ins. Co. 33758 Mr.Donald Teagno . 228 Triangle Street INSURER" r, Amherst,MA 01002 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REV3SION 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 IADDL:SUBRI POLICY NUMBER PM ICY EA--T POLICY EXP LIMITS T TYPE OF INSURANCE IN WV A X1 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE I $ 1,000,0( DAMAGE TO RENTED 500,0( CLAIMS MADE ❑X OCCUR EsCS57750627 4/1/2020 4/1/2021 PR MI o- r n $ MED EXP(An one oerscn $ 10,OC PERSONAL&ACV INJURY $ 1,000,01 GENERAL AGGREGATE $ 2,000,01 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,0( X POLICY a jECT [7 LOC I PRODUCTS-COMP/OP AGG $ I $ OTHER: COMBINED SINGLE LIMIT I $ 1,000,0( A AUTOMOBILE LIABILITY, = cid n ANY AUTO BASS7750627 4/112020 411/2021 , BODILY INJURY(Per^erson1 $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS I PROPERTY DAMAGE X HIRED I `�( I NON-OWNEp Per accident $ AUTOS ONLY AUTOS ONLY S X UMBRELLA LIAB X OCCUR I EACH OCCURRENCE I S 1'000'0( Excess uAB CLAIMS MADE US057750627 41112020 I 4/1;2021 nGGREGATe $ 1'000'01 DED I X RETENTION$ 10,000I $ C WORKERS COMPENSATION X I STATUTE I ERH AND EMPLOYERS'LIABILITY YIN WMZ8006223012020A 4/1/2020 4/1/2021 ' 1'000'0( ANY PROPRIETCR/PARTNER/EXECUTIVE [ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $ 1,000,0( (Mandatory In NH) 10'Ey describe under 1,000,0( DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES (ACORD 101,Additional Remarks schedule,may be attached 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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved