23C-072 63 WILLOW ST BP-2017-0587
Gls#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:23C-072 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2017-0587
Project# JS-2017-000950
Est.Cost:$13742.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class; Contractor: License:
Ilse Group VISTA HOME IMPROVEMENT 110285
Lot Size(sq,ft.): 17685.36 Owner: SWEENEY JAME
Zoninr:URA 100 S' 100 Applicant: VISTA HOME IMPROVEMENT
AT: 63 WILLOW ST
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (413)382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:I0/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.:REMOVE 2 LAYERS OF ASPHALT & REPLACE
WITH OWEN CORNING 30 YR - 15 SQRS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector f 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 10/27/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
S�
Department use only
\City of Northampton Status of Permit:
l YuBuilding Department Curb Cut/Driveway Permit
G�It \ 212 Main Street Sender/SepticAvagaCiYty
b /' Room 100 waternvell Availabdey
Northampton, MA 01060
Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: L This section to be completed by office
(033 wrll� 5s Map Lot Unit
A!orerce 'MA ciCA07--
Zone Overlay Dstrict
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
`carne Sweeiae. 63 Wil(x) 54- riotaiee 04)4
Name(Print) Current Mailing Addr s r"
SS SS�fS
Telephone
Signature
/Ira
2.2 Authorized Agent:
44 .i:til . 13t1' Ma).s IPA (C.-SA (d 0-t,
Name(Print) fY Current Mailing Address: 0‘2099 3
/ �_-- • '�y 0-
Signature telephone
SECTION d-ESTIMATED CONSTRUCTION COSTA
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Coat of
Construction torn(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection ,(/
6. Total=(1 *2+3+4+5) I 3-,,(ZP° Check Number 413 -/y 14.70
This Section For Official Use Only
Building Permit Number: Date
/,�///J ' Issued: /d,V1
et
Signature: ^. 7e...
A /!/j, 1
Bulking Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
lel�� RequiredThiscolumn by Zoni61teng
robed in by
Building Department
Frontage
Setbacks Fiont
Side
ElliMiraill
Rear
IlliallIMIIIESIMINIIIIMMO
Bldg.Square Footage _®__-
Open Space Footage -®--_
(tut area minus bldg&paved
raiku t _
--iiii�-
FilC EMI.
Fill:voturree Location) _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO O
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 O
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
ll
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW a required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all amalleable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Rooting V`a
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs ICH Decks [q Siding(Oj Other(C1j
Brief Description of Proposedd
Work. remove ex:sii oc6 2logcc Wsekti-a-e✓I(ace co Wal cars 3ckinot �ryCe1-works`
in el ISgS
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of building:One Family X 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 Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
<5a.4e S 5p.Jeeneti,L ,as Owner of the subject
property �1,,
hereby authorize pl(Lx G J v.,---)
to act on my heir in all matters rel a to work authorized by this building permit application.
t of Omer Date
.as QwnerlAuthonzed
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 a enalties of perjury.
�4;
Print Name /fl
Signature of Ownermgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
�11Supervisor
�� Not Applicable 0
Name of License Holder ?'.ICv - Ytts:s+c� 110225
License Number
W CJO teen-1- kik-Skserk Cr 0604 IA/20
Address Expiration Date
1e $750' age?
ignature Telephone
p.Registered Home Improvement Centred= Not Applicable 0
l/fgJA J'kb$ ta.( nies cAk— /62dC g
Coma me Registration Number
2b03 'JCS—eta 51- W. dpri 0 Yid abr? Ih417 ...
Address �� 7Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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 bu�ilding permit.
Signed Affidavit Attached Yes �, xNo 0
II. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(0 or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
es supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of 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.
Such"homeowner"shalt submit lo 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.
The undersigned"homeowner'certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 6,3 ( ;(CSf c'foCe ce iivkA
The debris will be transported by: 0571
The debris will be received by:
Building permit number:
Name of Permit ApplicantKe—CE 9
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
=silt= l Office of Investigations
C _"l= .lE
=la=_
I Congress Street, Suite 100
' PE a Boston,MA 02114-2017
'a,-=.'
im•
'vwww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): }(�jrye CL4!h(c .cEyed\-]'
Address: o w5 P.:(46-Sate (a.J
City/State/Zip:jj l , 1 N � MA ") 29j Phone#: LI r3-3-72-1 c(7
Are you an employer? deck t appropriate box: Type of project(required):
1. I am a employer with 9 4. ❑ I am a general contractor and I
employees(full and/or part-time).
• have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.ill I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. [' Demolition
working for me in any capacity. employees and have workers' y ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE Plumbing repairs or additions
myself [No workers' right of exemption per MGL
Y comp. 12.0 Roof repairs
insurance required] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box d I must also till 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.
IContmetors 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: (C'ax/e I cr3
Policy#or Self-ins. Lic. #: UQ- 20O"121S3-It. Expiration Date: 311 z1 i 7
Job Site Address:4.t.3 (AA t I I Oo-) 54- City/State/Zip:f!orUice /MW o104:::1
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 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 insurance coverage verification.
I do hereby certify�lder the pains and penalties r injury that the information provided above is true and correct.
Signature: / / p Date: l0 % Co
'I
Phone#: V90 rp30 - I lin
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#:
C-Dul2e fonoltevea/lA oiCilazadeneitt
Office of Consumer Affairs and Business Regulation
0; 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration 152058
Type: LLC
Expiration: 1/122017 Tr/ 262537
SAMBRICO LLC dba VISTA HOME IMPROV
BRIAN RUDD
2003 RIVERDALE ST - -- - -WEST SPRINGFIELD, MA 01089 - -
Update Address and return card.Mark reason for change.
scar 0 , C5/11 Address Renewal Employment Lost Card
'-92.- 6€,.ml.anda I-fti ,,Artsi/,
LI Office of Consenter Affairs&liminess Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before theexpiration date. If found titian to:
Tkg
titration: 102058 Type: Office of Consumer Affairs and Business Regulation
piratlon: 1/122017 LLL 10 Park Plaza-Suite 5170
Boston,MA 02116
SAMBRICO LW dha VISTA HOME IMPROVEMENT
BRIAN RUDD jT�� —r.2003 RIVERDALE ST '�r
WEST SPRINGFIELD.MA 01089 � - - —h- - -- -
Undersecretary . valid without signature
AST ....a • • • •• • AA .j • tiA • • • •,.• . ✓ air a • 1• • • • .' as
e.
1 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION ''
( Be it known that t
e ,
4) SAMBRICO LLC ."
1 2003 RIVERDALE ST ,
a, W SPRINGFIELD,MA 010894060
r
A
{ f.
la i
is certified by the Department of Consumer Protection as a registered
HOME IMPROVEMENT CONTRACTOR ))
( a:
Registration # HIC.0621848
.a VISTA HOME IMPROVEMENT a
{ e
a Effective: 12/01/2015 /1
Expiration: 11/30/2016 4. .•OC • s
J adman A.Ilania,Cominissiooet p
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0-4 3/15/2016 5;36;45 AM PAGE 2/002 Fax Server
,A1r'r art CERTIFICATE OF LIABILITY INSURANCE I DATE IMINDDNYYY)
rniT s.crnois
HOLDER. This
TIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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 ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRDDUGFAN AND TME GERTIFIGATE HOLDER
IMPORTANT:lithe certificate holder is an ADDITIONAL INSURED,the poliey(les)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
the certificate holder in lieu of such endoraeawnys).
PRODUCER CONTACT
NAME:
SOUTH WICK INS AGENCY INC PHONE FAX
562 COI I FGE HIGHWAY IAti,Na,Eat): INC,No):
EMAIL
SOiTFHWICK,MA 01077 ADDRESS;
28TKt
INYJR9A(Sj AFFORDING COVERAGE WUCp
INSURED INSURER A: TRAVELERSPROPERTY CASUALTY COMPANY OF AMERICA
SAMBRICO LLC DBA VISTA HOME IMPROVEMENT INSURER e:
INSURER c:
INSURER is;
2003 RIVERDALE ST INSURER E:
WEST SPRINGEIFI D,MA 01089 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
This B To CMi1FT THAT THE FOLtias or NSNRANCe MST®BROW NAVY BEEN SWW TO THE nuns NACHO ASOVEFOR THE PRET NET®o INMATE.RWTWRNSTANDNO
ANY RLVUN61Rr,T91M OR 00/10(0 31.OF AER CONTRACT OR(Ma WmTENr won RfVER TO IWIGN SHS EMBER-ATE MAY EE amassOR RRT POnAN.TIF NHmANCE
AROffi,®RY TNHPoti tES OP NI=scum 6&B.e¢TTO ALL THE TARE,ERC348ONS AND CONIXymNs OF suss("OLIES.LICTS ISOtlN MIT Rem SEEN RO}VC®6Y
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NSR ADO SOB POLICY 9T DATE FOLEY SFr DATE
LIR TYPE OF INSURANCE L It roLOY NUMBER ISMLNYTYYI IMMOTYYVY) I,Errs
GENERAL LABILNY _ACEI OCCURRENCE S
CCMMGMAAL GENERA.EAGLET
CLAIMS MADE 0 OCCUR PREMISEScHTLAM S
PREMISES(Ea NTEO
ce)
MEG EXP(Any OMF4BOn) S
PERSONAL&AOV INJURY S
GENT AGGREGATE EMT APPLIES PER
WEER/AWEER/A AGGREGATE
0 POLICY f - EDT El LOC -£OERCT$-COMP/OP
S
AGO S
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANT AUTO LIMIT(Ea amtlert)
'__ ALL GINNED AUTOS BODILY musty $
SCHEDULE AUTOS (PBT Per(PM
HIRED AUTOSe0DLY INA.RT S
ATIS
NOILLOMAED AUTOS iPNTac Rrt
PROPERTY DAMAGE
LPH McdcleMl
UMBRELLA LAB [1OSCUR 'EACH OCCURRENCE S
E%CES$LIAR CLAMS-MADE AGGREGATE e
DEDUCTIBLE
RETENTION S
A WORKER'S COMPENSAI1ON AND vM STAMtV GOTHER
EMPLOYER'S LIABILITY YIN UB-2E072163.16 03/12/2016 03/122017ITS
WEAGurive V FDA E.L EACH ACCIDENT S 100,000
N rEcERMEMSEREACLMO:V?
ManaNuyNNN EL 03EASE•EA EMPLOYEES 100,000
veA°u°Rr vqW EL DISEASE-POLICY LIMIT I 5110,000
1£OCRRTW 604MTCN6 MW
DESCRIPTION OF OPERAnONSILOCATONSNEBCLENIRRTRIGIION&SPaIAI ITEMS
TNR REPLACES ANY PRIOR CERTIFICATE ISSUEDTO THE CERTIFICATE FOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOWN OF WESTSPRINCFIELDAiA SHOULD ANY OF THEABOVEDES:ReED POLICIES BE CANCELLED
26 CENTRAL ST BEFORE THE EXPIRATION OATS THEREOF.NOrICEW L SE OSIER=
4R ACCORDANCE WIT)I THE POLICY PROVISIONS.
AUTHORIZED PE*RESEwrf
WEST SPRINGFIELD,MA 01089 Fdw
ACORD 25(201010S) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
08/23/2016 2:47PM FAX 4135729191 • WILLIAM MIS INSURANCE 2,0001/0002
CERTIFICATE OF LIABILITY INSURANCE os-rumwoOT0e/23/2 "" _-
THIS CERTIFICATE IS ISSUED AS A MATTER Cf INFORMATION ONLY AND CONFER-9 NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TIRE CERTIFICATE OF INSURANCE DCIS NOT CONS-MUTE A CONTRACT RETWEEN THE ISSUING INSURER(5), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOWER
IMPORTANT: It the cenINCat holder le an ADDITIONAL INSURED, the pollCyllee) must be endorsed. If 9GDROGATION IS WAIVED, subject to
me lams and conditions of the policy, certain policies may esquire an endorsement. A Menem on Vila certificate does not corder ng btu to the
walks*holder In INu of such emdomalmmgq.
PRODUCER NIpEC1 RM J MIS
WILLIAM J MIS INSURANCE
156 ELM ST .Su (113) 568 - 6111 II`NMnAN,y(a131 572 - 9191
ERTL
NESTPILID, HPL 01095 114suAPArsIMFORDon COVERAGE ,ERE
IESMER:HATITIAS INS CO
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INSURERS.:
SAMBA/CO LW DBA
MURRC:
VISTA NOME 221PROVEt6NT
MVIRRIU
2003 RIVERDALE STREET SERENE;
WEST SPRINGFIELD MA 01089 INWaRF1
COVERAGES CERTIFICATE RUMMER: REVISION NUMBER:
THIS IS TO CERTRY THAT THE POLIO S op INSURANCE LISTED BELOW HAW BEEN ISSUED TO THE INSURED NAMED MOVE FOR DE POLICY PFRIOn
INDICATED. ROPIER ISTANDNG ANY RgDUREMEar, TERM Oft CONDITION OG NW CONTRACT OR OTHER DOCUMENT yrr1H RESPECT TO WHICH "MO
CERTRCATE MAY EE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO NI. THE WRNS.
EXCLUSIONS AND CONDITIONS Or SUCH DO UCID&LIMITS SHOWN MAY HAVE BURROWED BY PND GAMS
M6.
Diar- P�
on rITEceedlflAI INaa WNo POLICY NEER I (NMEDVYYY) •BIM ODYN sum
uAIlun 1 EACH OCCUROCCURRENCERCE i 1,000,000
A X C0 D _ G3679203 108/01/201608/01/201'! P%o«EaI`R„.u.m,,,I a 100,000
_. ,_'CUMM
SN)C I ,OCCUR MIN,&PIR+YamNN
es 5000.
PERSONAL LADV Num i
GENERAL $ 2,000,000
�PO TEt mementoes Pf Oucia_ . . .. s 1,000,000
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AUTOLESET11ErnYI
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CERTIFICATE HOLDER CANCELLATION
SASBRICO LW DBA
VISTA NEE¢ RSRGvaii:tTT SHOWER ANY Of TOE AeOvE DESCRIBED POI%IES BE CANCELLED BEFORE
SME GCWRATDN DATE THEREOF, NOTICE WILL EE DEuvERED IN
200 3RIVERDISt ROAD ACCORDANCE WAIN THE POLICY PROVISIONS
WEST SPRINGFIELD HA 01069
AVDCASEDPIPME N
sc 4f
. .0 lad
l/ ®1S f2010 ACORD CORPORATION. All fights reserved.
ACORD 25(2010/05) The AGGRO name and logo am registered marls DYACORO V