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17D-012 (69) 491 BRIDGE RD BP-2019-1173 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lo:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Ramp BUILDING PERMIT Permit# BP-2019-1173 PrJect# JS-2019-001905 Est Cost: $12460.00 Fee:5100.00 PERMISSION IS HEREBY GRANTED TO: Cons[ Class: Contractor: License. Use Group: WANOR DECARVALHO 099244 Lot Size(sci.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URBHDOY"(28y Applicant. WANOR DECARVALHO AT: 491 BRIDGE RD ApplicantAddress: Phone: Insurance. 124 WESTFORD k (978) 835-1981 WC LOWELLMA01851 ISSUED ON. 0.00.00 TO PERFORM THE FOLLOWING WORK:BUILD 2 HANDICAP RAMPS NEAR POOL 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 SI®ature: FeeTWpe: Date Paid: Amount: Building 4/252019 0:00:00 5100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File k BP-2019.1173 APPLICANT/CONTACT PERSON WANOR DECARVALHO ADDRESS/PHONE 124 WESTFORD ST LOWELL (978)835-1981 PROPERTY LOCATION 491 BRIDGE RD I1 MAP 17D PARCEL 012 001 ZONE URBfl00VWPf28V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 1 tip Fee Paid Tvneof Construction: BUILD 2 HANDICAP RAMPS NEAR POOL New Construction Non Structural interior renovations Addition to Ezistine Accessory Structure Building Plans Included: Owner/Statement or License 099244 3 sets of Plans/Plot Plan THE F'O LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INATION PRESENTED: _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 Pian 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 /�Demolition Delay y-25. 2019 Si o Building Official 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. X 04a' �L0 J Versionl.7Commercial Building Permit May 15, '_000 Department use only City of Northampton Salus of Permit: Building Department Cum CWDnveway Permit 212 Main Street Sewer/Septic Availability Room 100F151 � CE lenity Northampton, MA 0lJL f St. rel Plans phone 413-587-1240 Fax 4 -1272 Plovsitetuns APO 2 Sp ity APPLICATION TO CONSTRUCT,REPAIR,REN�OVA E,CIJANGIE THE USE OR OCC PAN Y OF,OR DEMOLISH ANY BUILDING OTHER THAI AO ILYDWE LIN '.-H uMHn INnPECTIpN3 nr..�a.,.rM,p - SECTION i-SITE INFORMATION 1.1 Property Address: This section to be completed by office q A it s 1 p C R R Map 17C) Lot 04P. Unit 1 / ✓ J Zone Overlay District ------ Elm St.Del C3 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: S Yv� E !}_yr-,w 31 ool� ( (M IAA4 Name(Print) C CLt��G pI Current Mailing Address: � E _ Signature Telephone 2.2 Authorized Anent: / W /1 v -n y cu Ys rFo;49 Sof _ 4o w( y Name(Pdnq Curren Mailing Ad r SS Signature Telephm 4}Q g a r 19 % f SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a)Building Permit Fee 2. Electrical �I t _ (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Parmh Fes 4. Mechanical(HVAC) 5. Fire Protection — 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date �) Issued Signature: / / ��C/� y- Zs-zoi9 Building Commiasloriar/Inspector of Buildings Dam bjer aEffV)0DEL1u6 < NC � Yfy o. Cyn Versionl.7 Commercial Building Permit May 15,2000 SECTION a-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations [I Existing Wall Signs ❑ Demolition Repairs El Additions [I Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signa❑ Roofing El Change of Use❑ Otherr Brief Description Enter a brief description here. Of Proposed Work: r v .O A ILI t C „/� �Q r� SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly11A-1 ❑ A-2 ❑ A-3 ❑ 1A El A-4 ❑ A-5 ❑ is ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S Storage ❑ S7 ❑ 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(sf) 1" 2 nd 2' 3" P 4. 4. Total Area(so Total Proposed New Construction (so Total Height(it) Total Height it 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Info. am on: 7.3 Sawege Disposal System: Public 0 Private ❑ Zone Outside Flood Zone Municipal ❑ On site disposal system[] Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Esiscing Proposed Required by Zoning This column to be rdkd N by Building D yunment Lot Size Frontage Setbacks Front Side L R: L: R: -- Rear -......_ _.. Building Height Bldg.Square Footage Open Space Footage ttm nice minus bldg a,v #Of Parking Spaces Filluml: voe&Locamn A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO_-3C5, DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO �J& DON'T KNOW O YES O IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO 'a 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: 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 theconstruction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan that will disturb over 1 acre? YES O NO IF YES,men a Northampton Storm Water Management Permit from the DPW is required. Versiori Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 750 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant)'. Registration Number Morass Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Data 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 Not Applicable ❑ Company Name Responsible In Charge of Construction Morass Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER RENEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No O SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building pennN application. Signature of Owner Date FU SNP ' CF}ekVp4 I, ,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 pen a;enury. Print Name Signature of Ow*gr/Ag M Dale SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor. (� �r Not Applicable ❑ Name of License Holder'. IaNPe\ X11- �-fA,n•'l'`Ll"i cense Number )6L if W f T- �o 9 S? - �w� mA - olgN Li ; a v Address Expiration Data 9coq/orl Ig Sig Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152, 525C(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 O 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�/1111, S 150A. Address of the work: i i ,I 5 r ( 9 Ct c- ILD . - / !D nFA'-CC - /"iF The debris will be transported by: U rMOS% A-g' W oAK S 1 The debris will be received by: T)U Mil U/0fu<- S k Pr Building permit number: �p !1� Name of Permit Applicant (A/Wtip^• Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builden/Cont netors/Electriciens/Plumben. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Informationa printLegibly Name(Business/Organixadodlndividual): /Y✓b0N' N (i Address: ) am M-"— 1i01�-9 �T Q City/State/Zip: 1$O Phone#: Are You an employer?Check the Appropriate box: Type of project(required): llm aa employer with y amployas(fisll and M part-tamale 7. ❑New construction 2 am a sok propriaturmpanocrship and have no employees worlong for ma m 8. Remodeling wry,capacity.[No workers'comp.uumance required.] .t.❑I am a homeawnar doing all work mymLE[No workers comp,insurance w,mund.] 9. ❑Demolition 4.❑1 am a Immcowner and will be hung contractors to wnducr all work an my Foamy. 1 will 10❑Building addition smethw all cooaacmrs eithn have wooers'compamauw immame err am sole 11.❑Electrical repairs or additions propromm with.amplay«s 12.❑Plumbing repairs or additions 5 711 am a vncml contractor and I have hired the sub-contractors luted an on,avached sh«t 13.❑ROOF repairs These subeonawwrs have wncas ployand have workers'camp.insurance: I 6,C] re maF wa wt aa cooawan and in have mormaed thea right ofexampeon per MGL c. 14.DOthery—uj 152.§1(4),and wa have m employers.[No workers'comp.unworn aonmand.I M eA onappaca a thw checks box al man also fill out Ute union below work and floorworkers' ouc'company nrm policy lmomudon. a Ninum,W erswhosubmit this atTsdovitslodaing day am doing allwork and then hire out side contractors mustsubmitamw ma am,, indicatingsuch. tConaagors that check Nis sox must —lflk) an addi�iunal sheet showing the name of the .b-.m nmeu+rs anJ sine whether or not Nose emitias have empinyacs. Irthe wbcontrecmrs hove employees,that must pmvih their workers'wrap.policy nwvR++. I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy andjob site information. Insurance Company Name: lN � f� NF Policy#m Self-ins.Lic.ik. BO r�I.1 A imtion Date: % } — 15 Job Site Address: ��A �i�Q.I �CE � .r/ , ��l City/St�/Zip Attach a copy of the worken'compensatloD podey declaratlon page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,p25A 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 farm 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 certify under the pains an na/ies ofperjury that the information provided above is�&me and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermiULicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City?own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone N: 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,§25C(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 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),addresses)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,am 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 be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bonom 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 most submit multiple pennit/license applications in any given year,need only submit ode 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 proofthat 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 Departments address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CONTRACT This contract Forms an agreement between MAN C000r,ad les I Meadowbmoh Apartments), U.address M 491 Bridge Rad Florence fee,and Wpc Ramodellag Its borne and business address at 120 Westford 5t Lowell Ma,being g,mwn Ise rrefter as-contractor ,,The contractor agree to notarin all work at 491 arid,Road Florence Me to start and complete on the - agreed dates for the agreed total amount as stated below. Dewiption Job ao0d two.handicap ramps,First ramp 22 foot long by 5 If wide with a Sit by Sh Landlny. All material made to be pressure•treated 9.01.9 In both sides guild to Massachusetts code required tar handicap accessibility Second ramp 10 ft long 5 ft wide with a 51t by 5 it Landing All bulli Wilt pressure treated material Handrail an both clde5 Amount tun this project Is------•--$12.960.80 Payment Method 50% $6.230.90tastart SOPc $6.23000whenbdone Acceppuce R A, POAHCOMMUNITIES Mete Wpc Rer•- eling Date 01 I Commnnweatth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrgC&A $op;rvisor CS-099244 �'pi tea:99/05/2019 y WANORDECARVALHOD' j - 124 WESTFORD ST / LOWELL MA OMI C Commissioner ✓"� `� 4� CERTIFICATE OF LIABILITY INSURANCE DATE /19 YI 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 le an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condltlons 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(a). PRODUCER " EDINA BRAGA NAY E: Alpha Insurance Agency PI1oH: 978-439.4547 FAY xP 97131 BAB Carmel St ADDREae: BUSINESS@ALPHAINSURANCEINC.COM Lowell,MA 01852 Ixsux s ArFosMND covERAaE HNce DISURERA: WESTERN WORLD INSURED IxeURERB: SAFETY WPC Remodeling Inc .x NRC: AIM MUTUAL 124 Westford Sl Apt 1 INNIRER D: Lowell,MA 01851 INaURER E: RIDURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW MNVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED CR MAY PERTAIN.THE INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS. UCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INNIRANCE Asian POLICY MIMBER MMDDAYYY MMIDD MM18 X COMMERCMLGEIEAALLMINUTY EACHOCCURRENCE A 1,000,000 CLAINBlMDE ©OCCUR P Eass S 100,000 MED EXP E 51000 A NPPB316M5 09117118 OW17119 PERSDNALSADVIUArr L 1,000,000 pENLAGOREGATE LIMITPPRIEB PFR: GENERALAGGREGATE $ 2,000,000 FOLICYOJ LOC PRODUCTS-COMRWAGG E 1,000,000 OTHER: COMems S AUTpMIMLE UABILRY M IN LI fu Osot) A B BDDILYINJURYIani s 100,000 OVINED N1r 0ANYAUTO AVIC)S AUToa ACHEOUIEO6235526 90120118 10120119 BODILY INJURY IPa P«Pam4esy s 300,000 HIRED X NONAYNEO PROPERTY DAMAGE f 100,000 AUTOSAUTOSONLY S UM LLA OCCUR. EACH OCCURRENCE E UCEBB LW l,TE CWMA,AMpE A(sam F GED I RETEWION$ A HOTIRERSCOMPENSATION X TE ER AND EMPLOYERS UABILIIY ANY PROPRIETORTARTNERIFXECUTIVEYIN ELFACHACCIDENT E 1,000,000 C orTICERMEMeeR Exa00ED1 ❑N Nu WCC5005o151082o18A 00117116 OW7]I70 IMFrgFn,In Nd) EL.DISEASE-FAEMPLOYE A 11000,000 xyr. sods u.IIESCRIPTpNaOPF1UTpNS peow EL.DISBASE-POUCYUMIT S 1,000,000 DESCRI MKIN OF OPERATIONS LOCATION I VEHICLES(ACORD 101,AtlJRIaW limseds SCMd,M,ss,W Ami xnom q—M"Insi) Preservation of Affordable Housing,Inc.and Posh Communities,LLC are listed as additional Insureds on the General Liability policy required per written Contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Preservation of Affordable Housing,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. Posh Communities,LLC 491 Bridge Road AUTHDRUEDREPREY TAINS Florence,NA 01082 ®1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2010103) The ACORD name and logo are registered marks of ACORD