11C-004 (7) 122 FLORENCE ST BP-2018-1333
GIS n: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 1IC-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category INSULATION BUILDING PERMIT
permit SP-2018-1333
Proiect# JS-2018-002371
Est.Cost $2900.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License.
Use Group AMERICAN INSTALLATIONS LLC 106178
Lot Size(so. ft.): 8407.08 Owner. ELLIOTT RAYMOND S&CLAIRE MR LAROCHELLE&M ELLIOTT&L
DUNN&J MARTIN&C ELL
zonine:URA000)/ Applicant. AMERICAN INSTALLATIONS LLC
AT: 122 FLORENCE ST
ApplicantAddress: Phone., Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.6114/20180:00.00
TO PERFORM THE FOLLOWING WORK.ATTIC AND BASEMENT INSULATION AND AIR
SEALING THROUGHOUT
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 ft 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 s e t re•
FeeTvoe: Date Paid: Amount:
Building 6/1420180:00:00 $65.00
212 Main Street,Phone(413)587-1140,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
fiECEIVED ,� ( �cdfoh
` Department use only
JUN 1 4 201tity fN ampton Status of Permit
Buil ng pertinent CurbCuvorivWmy Permit
Me Street SeweriSepticAvellab2iry
DEPT OF BUILDING INSPEC
NOFTHHMPTON,
NIB
100 WaterAVell AvallebAlty
ort ampton, MLA 01060 T. oBeis of SWdural:Plarce
phone 413-567-1240 Fax 413-567-1272 Plot/Site Plans_
Pear, P.
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION tip-
1.1 Property Address: This section to be completed
byeffrce
(LL rloren CI[.
Map_ Lot D— I unit.
Zone Overlay District
She SL ofstrkt. CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDgGENT
2.1 Owner of Record:
_Raymond Elliott 122 Florence Street Leeds, MA
Name(Print) Current Mailing Address:
413-584-1372
See attached TdWtene
Signature
2.2 Authorized Agent
American Installations 130 College St., Ste 100 South Hadley,MA 01075
Nam(PrinQ Current Mailing Address:
413-552-0200
SlgmWre Tdepiwrla
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollam)to be Olfldal Use Only
COMID10ted IN Permita lidm
1. Building 2,900.00 (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
8. Total= 1+2+3+4+5 2900.00 Check Number
This Section For Official Use ON
Building Permit r. Data
Issued:
Signa e: 1-6161 1z
Brlddh9 hsianw8nepecOord Bugtlings Date
Section 4. ZONING Mi Information Must Be Completed.Pennit Can Be Denied Due To Incomplete lnfnmatbn
Existing Proposed Required by Zoning
]id£rniamn mbefdlM ivby
�. avtdiog t)epehlmevt
Lot Size
Floorage
Setbacks Front O
Side L= R:= I--=R= 0
Rear
u
Building Height
Bldg.SgaereFootage
Open SpaceWilds& %
U r.
Qd ane rats.bkg&paved
#of Parking Spaces
Fill:
Nolan.&luudoo
A. Has a Special PermittVariance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:) �I
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONTKNOW YES O
IF YES: enter Book F � Page and/or Document#i
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 O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size, type and location: I J— I
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: I '1
E. Will the construction activity disturb(dea ft,grading,excavation,or filling)over 1 etre or Is K pan of a Demon plan
that wit rtsarlb over 7 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteratbn(s) ❑ Roofing
ar Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs ipj Deeks )[] Sming iO] Other]o
Brief Description ofpro Posed
Work: Attic and basement insulation and airsealing throughout
Alteration ofexdsting bedmom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plane Attached Roll -Sheet
6a.If New house and or addition to ezistina housing cornolete the followinm
a. Use of building:One Family Twc Family Other
b. Number of rooms in each family unk: Number of Bathrooms
C. Is there a garage attached?
d. Proposed Square footage of new constmction. Dimensions
a. Number of stories?
f. Method of heating? Fireplaces or Woodslaves Number of earn
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of consouction
1. is wmtrurd on within i0O ft.of wegands?_Yes —No. Is construction wkhln 100 yr. floodplain—Yes—No
j. Depth of basement or cellarflow below finished grade
k. Will building conform to the Building and Zoning regulations? Yes 'No.
I. Septic Tank_ CitySewer_ Pdvatewreg_ Ckywatw Suppty_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED=
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING
1, Raymond Elliott ,as Owner of the subject
Property
herebyauthorize American Installations
to act on my behalf,m all matlere relative to work authorized by Oft building permit application.
See attached 6/6/2018
Signature M Owner Data
1, American Installations as OwnadAuthorized
Agent hereby declare that the statements and Information on the foregoing application are true and accurate,to Me best of my ImoMedge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Print Name
WA�ret n �. �6 St n 6/6/2018
Signa
ture of art/Agmd Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoendsor. Not Applicable ❑
Name ofu HoldHoldw, WesleyK. Couture 106178
Umnse Number
130 College SL, Ste 100 South Hadley, MA 01075 9129119
Address Fxplretion Dale
S�. Cm�k un>✓ 413-552-0200
b�Ipnalure Telephone
9.Registered Nome Improvement Contractor. _ - _ Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6/26/79
Address Expiration Date
130 College St., Ste 100 South Radley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,$25C(B))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide tlJs affgav8 will result
In the denial of the Issuance of the building permit.
S dAOldavilAttached Yes....... IN No...... ❑
11..-Home Owner Egemation
The cannot exemption for"homeowners"was exceeded to include Owner-occupied Dwellines of well) m twu(2)families
and to allow such honseowaer to engage an individual for hire who does not pansies a lkxx ae,provided that the owner acts
as sovervlser.CMR 780, Sirth Edition Section 108351.
Definition of Homeawner:Person(a)who own a parcel of land on which he/she resides or hitends to reside on which there
is,or is intended to be,a one or two family dwelling,attached in detached structures accessory to suchuse ape//or farm
struehues.A name who constructs more than one home in a two e r varied shall not be considered a hominowner.
Such"ho ncovmer"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
nisnousible for all such work Performed under the build a Permit,
As acting Construction Supervisor yourpresence on the job site will be required from time to time,duringand upon
completion ofthe work for which this permit is issued
Also be advised that with reference to Chapter 152(Workers'Compeasation) and Chapter 153(LiabilityrifEmployers to
Employees for injuries not resulting in Death)ofthe Massachusetts Genual Taws Annotated,you may be liable forpenton(s)
you hire to perform work for you under this permit
The undersigned"homeowner'certifies and assumes responsibility forcomplisnce with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State ofMassachusets General Laws Annotated.
Homeowner Signature
L
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 property
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 122 Florence Street Leeds, MA 01053
The debris will be transported by: American Installations
Chicopee Landfill
The debris will be received by: Waste Management of New England
Building permit number:
Name of Permit Applicant Raymond Elliott
(, ),,ldj �Y C&.=
Date Signature of Permit Applicant
i_'`,� www.Mnen[anMibllalnns.[am
BBB' /L1LLJ\ • Licensed E
\ ma Mrl CSL p:1,0051
5982
American Installations Reyermnssazban4
1MColleka SbeT wal kW.SpuJl H,011.F`HanS.Ol 1 Htn5l.1c.013155DOID2.EmNkry essfeamerbnlnNlWln—en
Elliott,Raymond
122 Florence Street rm Leeds MA 01053
1(413)5U-1372
465 D17 rcn nr 18-1582
n Quantity Unit Unit Cost en Total
Ah Sealing
AIR SEALING 1 6 jnsan hour 1$ 8500 1$ 510.00
WEATHERSTRIP DOOR&ADD SWEEP 1 2 le.,M1 $ 80.00 $ 160.00
WEATHERSTRIP DOOR 1 1 leach 1$ 5801$ 58.00
Air Sealing $ 728.00
Air Sealing Incentive $ (728,00)
Air Selaing W%Balance $ -
WeatherieaHon
ATTIC DOOR-INSULATE&WS 1 each $ 12000 $ 110.00
CRAWLSPACE WALL RIO RIGID BOARD 40 each $ 405 $ 162.00
KNEEWALL SLOPE-2-RIGID BOARD 198 sqd $ 3.85 $ 762.30
ATTIC FLAT-8"OPEN R-30 CELLULOSE 390 sold $ I0" $ 561.60
FINISHED CEILING ACCESS 1 each $ 135.00 $ 135.00
VENTILATION CHUTES 57 each $ 2.50 $ 142.50
ATTIC DAMMING-R-38 FIBERGLASS 88 sqd $ 2.05 $ 180.40
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00
Total Weatherization $ 2,113.00
Weatherizationlncentive $ 1,505.35
TOtal Prolecl $ 2,841.80
Total UYlity Contribution $ 2,313.35
Total Customer Contribution $ 528.45
n moron mu nwna, wllvmnanMxmruxa Mmeowrc.wnnaiwerwewnmxlpw.mnry.
m"s.,—sv propvn nial tll ma sn..,d hm,mmm...xeebrc w"pe MsnM1ln reegmeerN[Makwe ape(M[xw aNtlllmlanaeuu
epmwl.rw.unem.m.Tx.l�nw.nr.m.a.ed�ee M.In.
ACCEVcANCEOFPBOPoUL:Thealuepkes,—r.Uonaano TmALCONTRACIVALUE= $ 528.45
[.na�u.n[.re waanory aneare h.nay a[:m.a.vm,,..
awMneeam4nwnk asepe[Ihe. ymmlwal be Ua9nwn P.lo. Down Payment= $ 176.00 ❑
anW
n
ry 4kabrce Me v W 1O
Balance Due Upon Completion= $ 352.45 v
City of Northampton
Massachusetts
DEPAROHENT or aoraorNc rNEPELTIONs
zvz Min eteaet . Municipal euiltl W v Y/pC
Noct4ampton, W. 01060 4'lr
Property Address:
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley,MA
Phone: 43-552-0200
Property Owner
Name: Raymond Elliot
Address: 122 Florence Street
City, State: Leeds,MA
I, American Installations (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner wth a copy of this affidavit
Contractor signature % /eL
� I / (S
tip
Date
_`-- -
Attic Slope-Open AtticRat-Floored Attic Flat-Open
Existing Existing Existing .
R Value R Value R-Value
Upgrade Upgrade Upgrade
R-Value R-Value RValue
Attic Cap-Dense Pack Kneewail-Open Kneewall-Enclosed
Existing Existing R13 Fiberglass Existing
R-Value R-Value 10 R-Value
Upgrade Upgrade Y'Rigid Board Upgrade
R Value R-Value 20 RValue
-�� Q
T
KneewallFloor-Floored KneewallFloor-Open Kneewall-Gable End
Existing Exlsttng c .. - Existing .
R-Value R-Value_Lg R Value
Upgrade Upgrade 7"Celulose Upgrade
R-Value R-Value 36 R-Value
KneewallSlope-Open KneewallSlope-Enclosed Interior Slope
Existing Existing Existing
RValue R-Value R Value
Upgrade Upgrade Upgrade
R Value R-Valor
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
www.maes.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legible
Name OlusinesyOrgwii. tioNindividuap: American Installations, LLC
Address: 130 College Street, Suite 100
City/Slate/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
Are you an employer?Check the appropriate box: Type ofproject(required)..
L U I am a emplover with 46 _ 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or pan-lime).' have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.r 7. ❑ Remodeling
ship and have no employees These sub-contractors have IL ❑ Demolition
working for me in any capacity. workers'camp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.L] Electrical repairs or additions
1❑ I am a homeowner doing all work right ofexemption per MGI. 11.❑ Plumbing repairs or additions
myself [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roofrepairs
insurance required.I employees. [No workers' 11"A Other Insulation —
comp. insurance required.)
'Any applionl IM1aI eM1eUs box HI must also fill am rM1u section blow showing ILeir wodeb'wmpmsalion policy infonnalion.
a Itomeowners who mhmil bis amdevil indicwine dn. o¢duin6 all nark end a.i Lime saide cunrr. mull ,,w,ak new all. fi mdicming such.
:Conindors bra cLcxk lM1a to.must mbched an eddilionel sheer showing lM1c name of lLc sub<ammcmn anJ heir wnrken comp.policy infonnvfmn.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies _ __ _
Policy#or Self-iris. Lie.
it-AMWC897387 ,, - ` Expiration Date: 09/04/2018
Job Site Address:_1 a F161-erlt�.e, SK'�X.�s' -City/State/Zip:L f4t,&,M A 01053
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dale).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ora STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido barely certify,under the pains and peeraltiLes ofperfury that the information provided above is true and correct.
Signature: x,19 �S1-- _ Date �a _
Phone ll: 413-552//0200
Official use only. Do not write to this area,to be completed by city or town offrefail
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts Com urLoo Supsr e
®� Divfaion of Professional Licensure UnrssdI-aukdings ofany use group which contain
board of gilding Regulations and standards less Mae 98,000mbic fed(991 cublemeters)of enclosed
Construction Supervisor sluice.
CS-106178 E6pires: 09/29/2019 -
WESLEY COUTURE
218 LATHR(W--11MET if
SOUTH HAOI.EY MA 01876
Feam to possess a eurtent a Um Of Me Massachusetts
Slane swa00p coda M cause for revoca0m 01 Use license.
For Information about M!,acanes
Commissioner Call(617)727-3200 or vlsk www.mass4ov/dpl
tv. Office of Consumer Affairs and Business Regulation
- 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Reg>graaOn: 175982
130 COLLEGE STREET SUITE 100 EAraaon. 08/28/2019
SOUTH HADLEY,MA 01075
Update Address and return rand. Merle reason for change.
$CA 1 b
n Add::s n n.,..__i L.EmptOymaat S]!AsS&Pro
Oak.of Gnsumx A6Yn a W.I. .n.aunca.n
j8 NOME IMMOVEMENT CONTRACTOR Regl"Im velkl for Individual use only
ILI' �(/L,i TYPE:LLC before M.Winalon date. a round mum M:
/ Realstretiln E6Gk6I19O Office of Consumer Af im and Business Regulation
3 : 175082 062=19 10 Park Rwa-Suke 5170
AMERICAN INSTALLATIONS,LLC. Soeton,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary t valid without signature
aCC)Rb CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDYYYyI
8/14/2019
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: It the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. N 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 MME. Linda POaeT6
Webber, d Grinnell 'Nom, (4131 586-0111 AIC No:1a131586-6.81
8 North Ring Street AMEsa,lPG.iry Nebberandgrinnell.G.
INSURE SAFFORDINO COVERAGE NAICY
Northampton INC 01060 INSURERAE to era Mutual Casualty
INSURED INSURERSISEckahlre Hat4.p GOARD Ing. CO.
Aelerican Installations, LLC INSURER
Attn: Nes 6 Svaanne Doctor. INSURER O:
130 College Street, Suite 100 INSURER E:
South Hadley M 01095 1 INSURER IF
COVERAGES CERTIFICATENUMBERHaeter SKID 9-2018 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 WTH 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 CiAIMS.
INSmR TYPE OF INSURANCE Son" POLICY NUMBER MPoLVDOY VF MMIDDY P LIMIT
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000
A X CIAIMS.MADE OCCUR PREMISES As occurrence) $ 500,000
503535227 9/e/4010 9/4/2016 MED FUR(Airy one penin) 9 10,000
PERSONAL B ADV INJURY E 1,000,000
GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE 5 2,000,OOO
R POLICY�JERe —1NODPRODUCTS-COMRaPAGG $ 2,000,000
OTHER 3
AVTOMOBILE WBILItt Ea son IN L LI $ 1,000,000
A ANY AUTO BODILY INJURY(Per PoAoni 3
ALL OS*ED X AUTOS LEO SZ3535217 9/4/4011 9/./2018 III INJURY(Per a¢IOer $
R HIRED AUTOS R NON. G pROPEvnm 10.4MAGE 3
�JAUTOS
PIP-Baan $ 8,000
R UMBRELLA LIAR OCCUR EACHOCCURRENCE 3 1,000,000
A ERCF93 UAN CVJMEMACf AGGRE.E 5 1,000,000
OED I R I RETENTIONS 10 000 1 5]35 3521] 9/4/2017 9/1/2018 $
VIOR MCOMPENSATIONPER DTX.
AND EMPLOYERS'LIABI DRY a $LATUTE ER
YIN
ANY PROPRIRMRIPARTNENE%ECUTIVE ❑ NIA EL.EACNACCIDEM $ 500,000
B nearesiIn MX�E%CLVOEDi ORNC609917 9/4/2017 9/4/2018 E In DISEASEEAEMPLOYE E 500,000
1 OaeoNbellmer
DESCRIPTION OE OPERATIONS IS. EL DISEASE-POLICY LIMIT $ 500,000
A Commercial Property SM535217 9/1/2017 9/a/4018 amocOde$1 PA'
DESCRIPTION OF OMMTIMS I LMATIONSI VEHICLES BOOM 101,AEEMonal RemeM Schema ,maybe MlecMtl amore pace is regal NI
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence OP Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESENTATIVE
Kevin Joyce/LMP 3 ��
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
INS025rnmnn