32C-078 14 CONZ ST BP-2016-1206
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 32C-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1206
Project# JS-2016-002073
Est. Cost: $2000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITER BUILDERS 102457
Lot Size(sq. ft.): 7579.44 Owner: KOLB BARBARA K&AUGUST 2009 REVOCABLE TRUST
Zoning: URC(100)/ Applicant: KEITER BUILDERS
AT. 14 CONZ ST
Applicant Address: Phone: Insurance:
35 MAIN ST (413)586-8600 () WC
FLORENCEMA01062 ISSUED ON.-412112016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW POST & PIER
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:
FeeType: Date Paid: Amount:
Building 4/21/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1206
APPLICANT/CONTACT PERSON KEITER BUILDERS
ADDRESS/PHONE 35 MAIN ST FLORENCE01062(413)586-8600()
PROPERTY LOCATION 14 CONZ ST
MAP 32C PARCEL 078 001 ZONE URC(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee PaidIle
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL NEW POST&PIER
New Construction
Non Structural interior renovations
Addition to Existine
Accessory Structure
Building Plans Included:
Owner/Statement or License 102457
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
_t,<�Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolit' Delay
41e� Z4, rA41�17
Sig e of Bui di g Officia Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Version 1.7 Commercial Building Permit May 15,2000
Department use only
11 ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway,Permit, -
�� 212 Main Street Sewer/Septic Availability
�! Room 100 Water/Well Avaitahility
-- ampton, MA 01060 Two Sets of Structural Plans
- -hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 --SITE INFORMATION
1.1 Property Address: This section to be completed by office
14 Conz Street Map Lot Unit
Northampton, MA zone Overlay District
Elm St.District CO District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Barbara Kolb 14 Conz Street Northampton, MA 01060
Name(Print) Current Mailing Address:
413-584-2593
Signature X &n5 f I As Telephone
2.2 Authorized Aaent: trdat
t n+``r14t
Keiter Builders, Inc 35 Main St Florence, MA
Name(Print) Current Mailing Address:
4135868600
Signature f1t President,Keiter Builders,Inc. Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building $2,000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 16 (s
5. Fire Protection
X2,000
6. Total=(1 +2+3+4 +5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signator
Buil " missioner/inspector of Buildings Date
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other m
Brief Description Install new post& pier
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE Please see attached control Docs
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
1st 131
2nd 2nd
3rd aro
4th 4th
Total Area(so Total Proposed New Construction(so
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 1 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commerc'al Building Permit May 15,2000
S. NORTHAMPTON ZONING j
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L R: L: R: _
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever!been issued for/on the site?
NO O DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 0 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,excavation,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.
Versionl.7 Commerc;al Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant),
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
David Vreeland Structural
Name Area of Responsibility
46317
Address Registration Number
See attached control doc 413-624-0126 06/30/16
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Keiter Builders, Inc.
Company Name:
Not Applicable ❑
Scott Keiter
Responsible In Charge of Construction
35 Main Street Northampton MA
ess
A
President,Keiter Builders,Inc. 4135868600
Signature Telephone
Version 1.7 Commerciral Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Barbara Kolb as Owner of the subject property
hereby authorize Keiter Builders, Inc. to
act on my behalf, in all matters relative to work authorized by this buioigg permit application.
Xt --.......... /
Signature wner Date
Keiter Builders, Inc. as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Scott Keiter
Print Npge
President,Keiter Builders,Inc.
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Scott Keiter CS-102457
License Number
5 1 A Hatfield St 06/20/16
;7k
Expiration Date
President,Keiter Builders,Inc. 4135868600
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,g 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 Q No O
The Commonwealth of Massachusetts
Department of ItidustrialAccidents
Office of Investigations
kv I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Auulicant Information Please Print Legibly
Name (Business'OrganizationIndividual): Keiter Builders, Inc.
Address: 35 Main St
City/State/Zip: Florence, MA 01062 Phone #:413-586-8600
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 15 4. ❑ I am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have
8. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.t 9. E] Building addition
com
[No workers' comp. insurance P•
required.] 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(#),and we have no
employees. [No workers' 13.0 Other new post & pier
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 work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the Mame 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 insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:Arbella Insurance
Policy#or Self-ins. Lic. #: 9127440615 Expiration Date:6/11/2016
Job Site Address: 14 Cont Street City/State/Zip: Northampton, MA
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL 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 insurance coverage verification.
I do hereby rtafy under the pains and penalties of perjury that the information provided above is true and correct.
Siknna,ture. Date:
04.06.16
Phone#: 4135868600
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 Klerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of IVIGL 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.
Address of the work: 14 Conz Street
The debris will be transported by: [fuseau Trucking
The debris will be received by: Valley Recycling
Building permit number:
Name of Permit Applicant Keiter Builders, Inc
z7
t 4;zr�President,Keiter Builders,Inc.
Date Signature of Permit Applicant
Initial Construction Control Document
i
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Enclosed Second Floor Entry Porch Pier and Post Replacement Date:4/6/16
Property Address: 14 Conz Street,Northampton,MA 01060
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Temporarily support second floor entry porch,temporarily remove stair,remove existing 6x6 post,
excavate and remove existing concrete pier, install new precast pier(24"x 24" footing intergrated with tampered 12"
square to 8"square pier) with the base of the footing 4' below grade, install new 6x6 P.T.post with Simpson#ABU66Z
post base anchor,top of post secured to entry porch floor framing with a minimum of 3 - 'i."carriage bolts,reinstall and
secure stair,and remove temporary entry porch supports.
1,David Vreeland, MA Registration Number:46317, Expiration date:6/30/16, am a registered design professional, and
hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Entire Project Architectural X Structural Mechanical
Fire Protection Electrical X Other:Construction Control
for the above named project and that such plans,computations and specifications meet the applicable provisions of the
Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee)shall perform the necessary professional services and be present on the
construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a *Final Construction Control Document .
Enter in the space to the right a"wet"or 1vt OF
electronic sip-nature and seal: DAVID A.
VREELAND
CIVIL -4
No.48317
Qt P
Phone number:413-624-0126 Email: dvreeland@verizon.net_
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised.if'other' is chosen,
provide a description.
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LIMITED POWER OF ATTORNEY
1, Barbara K. Kolb, Individually and as Successor Trustee of The August 2009 Revocable
Trust. of Northampton,Massachusetts, do hereby make, constitute and appoint Thomas R.Reidy,
Esquire, of BACON & WILSON P.C, of 6 South East Street, Amherst, Massachusetts, my true
and lawful attorney, for me in my name to make any corrections and additions needed to
effectuate a transaction relative to a conveyance from Barbara K. Kolb, Individually and
Successor Trustee of The August 2009 Revocable Trust to Scott Keiter, or his nominee/assignee,
of the real estate known and designated as 14 Conz Street, Northampton, Hampshire County,
Massachusetts, and to sign the necessary City documents, including building permits and the like
for underground storage tank removal, to further the transaction.
Giving and granting to said attorney full power and authority to sign all documents
required by Buyers' mortgage lender in order to facilitate the sale of said real estate, including,
but not limited to, government forms concerning the transaction and the reporting of the sale to
the Internal Revenue Service; to receive and disburse, on our behalf, the proceeds of the sale; and
to do all other things necessary or convenient to accomplish the sale of said real estate as I might
or could do if personally present.
This Limited Power of Attorney shall not be affected by the subsequent disability or
incapacity of the principals).
EXECUTED as a sealed instrument this 7th day of April , 2016.
Witnessed by.
lJ�
Barbara K. Kolb, Individually and
Successor Trustee of The August
2009 Revocable Trust
AC40 a CERTIFICATE OF LIABILITY INSURANCE OATE(MMrODiYYYY)
ilk 7/10/2415
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(les)must 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 Ileu of such endorsement(s).
PRODUCER NAN A Cynthia Henderson, CISH
Webber A Grinnell PHONEEztl' (413)586-0111 FAX (41])586-6681
.2#v_ (AIC•H2}__.e.
E-MAIL
8 North King Street A DRESs:chen$arson@webberandgrinnell.com
INSURE S)AFFORDING COVERAGE ...........
Northampton MA 01460 INSURER A Arbella Insurance Group __ 17000
INSURED INSURER 8:
Keiter Builders, Inc. INSURERG___ _.._._.._.__ ___ __......._.__.
Attn: Scott Keiter INSURER D:
35 Main Street INSURER E:
Florence MA 01462 1 INSURER F:
COVERAGES CERTIFICATE NUMBERAaster Exp 2016 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 CLAIMS.
INSR TYPE OF INSURANCE DL S POLICY NUMBER POLICY YYF �L�WYYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A ' CLAIMS-MADE X ,OCCURPR MSS a rrence S 300,000
8500068396 61112015 6/1/2016 MED EXp(Any ane parson) S,OOO
s PERSONALS ADV INJURY 3 1,000,000
0
GEN'L AGGREGATE LIMIT APPLIES PER i GENERAL AGGREGATE S 2,000,000
PRO- PRODUCTS-COMP/OP AGG $ 2,000,OOO
X I POLICY_.. JECT LOC _ _
OTHER
AUTOMOBILE LIABILITY CO I IN L LIMrr $ 1,000,000
{_{Ea aeddenp __._.
A ANY AUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED 1020039381 6/1/2015 6/1/2016 BODILY INJURY(Per accident) $
AUTOS AUTOS — --
NON-OWNED PR PER DAMAGE S
X .HIRED AUTOS X AUTOS
I Medical Payments $ 5,000
X UMBRELLA LIAR j OCCUREACH OCCURRENCE i 1 000 000
A EXCESS LIAR mss1 CLAIMS-MADE' AGGREGATE $ 1,000,000
DED I X I RETENTION 10,000 6600066399 6/1/2015 6/1/2016 S
WORKERS COMPENSATION ! - STAT 7E R
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETORtPARTNERiEXECUTIVE Er L EACH ACCIDENT $ 19 ,O00
OFFICER/MEMBER EXCLUDED? N N/A
A (Mandatory to NH) 9127440615 6/11/2015 6/11/2016 E.L DISEASE-EA EMPLOYE $ T_ 100,000
Kes,describe under
DESCRIPTION OF OPERATIONS below (E.L DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS/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
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
IC Henderson, CISR/CIN "" _ 'r-w.rtc�r.s.-�_r
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 12OIA01 s