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32A-092 (3) BP-2022-0772 25 MARKET ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-092-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0772 PERMISSION IS HEREBY GRANTIM TO: Project# RENO APMT Contractor: License: Est. Cost: 27000 BRAMUCCI CONSTRUCTION 110834 Const.Class: Exp.Date:09/03/2022 Use Group: Owner: 300 ELM ST LLC Lot Size (sq.ft.) Zoning: CB Applicant: BRAMUCCI CONSTRUCTION Applicant Address Phone: Insurance: 17 MT WARNER RD (413)221-3942 656OUB1K70974321 HADLEY, MA 01035 ISSUED ON:07/08/2022 TO PERFORM THE FOLLO WING WORK: RENOVATIONS TO COMBINE 2 APARTMENTS INTO 1 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: yg if . Cgt/ • Fees Paid: $189.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED JUN 2 9 2022 Th Commonwealth of Massachusetts Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) ("FPI OF p sApp ication for any Building other than a One-or Two-Family Dwelling NORTHAMf ruty, AA 01060 _.._ This Section For Official Use Only) Building Permit Number: -la-7 7 . Date Applied: Building Official: SECTION 1:LOCATION I� - ZSIAA i- S1" 0 ( 060 No.and Street City/Town Zip Code Name of Building(if applicable) LA 0 - Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building F( Repair❑ Alteration ❑ Addition❑ Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No L� Brief Description of Proposed Work:r,{rs j+g1(i�� a� tw;.^d a z✓ are ka.) exiS+(i4 b ‘::NY` LIS Leisjlake rbv% eX�Sr,nr^'). f ✓jD eLeG Co....b:v.z . ad .67 op ev,;LAj & s k�d`{-d �nrAil, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB 0 IIA 0 IIB ❑ IIIA 0 IIIB 0 IV ❑ VA 0 VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system❑ required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: • ".-,/ City of Northampton,io err r# • `'> At � Massachusetts �_ DEPARTMENT OF BUILDING INSPECTIONS ;-_,,, Li ' ''"' �`""' 212 Main Street • Municipal Building Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL & MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work (Digital & Hard copy). 3. Site Plan with location of proposed structure(s) and setbacks. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CSL and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (if applicable). 8. Note any Conservation and/or Special Permit requirements (if applicable). 9. Driveway Permit (if applicable). 10. Proof of Water and Sewer entry fees paid (if applicable). 11.Trench Permit (if applicable). 12. Initial Construction Control Documents filled out and signed by the Registered Design Professional in responsible charge. 13. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 300 E1wt Str at1 SR Fiat Mu /4-0,0 d- /WI- 0 0 o-1...- Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �p ties . - - q13-ZLL is-,I Detersefe 1 9 vN•u1•co Title Telephone No.(business) Telephone No. (cell) f1 e-mail address If pplicable,the property owner hereby authorizes: �e+tr "jcscop 371 fLLs41 sf SUS. •)a.,.rl mA 01 o5`t Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor _ g•rav u c: CO"St e v-t{'I O Company Name P,c k avrawtc.A.Z.L.4 - • - )1 O 83 L{ GS L- Eip. 9/3 a. Name of Person Responsible for Construction License No. and Type if Applicable 3- wit. W,urnev- ..l_ 14 Adl.ey ,vim o lb 3 S Street Address City/Town State Zip t//3 .2 Z1- 3 elL _ 1prArvtiA iGotns('rK.c.tiavtea ►•ntaa , u Telephone No.(business) Telephone No.(cell) e-mail addrt s SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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 Is a signed Affidavit submitted with this application? Yes❑ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 4-to b 0 1.Building $ 1 S D 0 v Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ ,- Da v appropriate municipal factor)=$ . 3.Plumbing $ �. a 0 0 l ( p ty) 4.Mechanical (HVAC) $ Note:Minimum fee- O 1 contact munici ali 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 2,4- 0 (contact municipality)and write check number here 12 I 1 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this ap, lication is true and accurate to the best of my knowledge and understanding. rI t-c-if S' f r-iLL( ere). 413 -in- 1514 12.i1 LL Please print and sip na Titl Telephone No. Date s-6( F�o►F i it f A'^"At+r'�' " P( O(D 6 7 e_£tcaetGraw a d•Ce`'-' Street Address City/Town State Zip Email Address A51 Municipal Inspector to fill out this section upon application approval: Y �,,, j/gPQ Name te CITY OF NORTHAMPTON SETBACK PLAN (\� MAP: LOT: f LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS �- 212 Main Street • Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: /1/6 rfkottAltb,i 4 avtdev 51 t7 v\ The debris will be transported by: Name of Hauler: Tot, Cave l Signature of Applicant: Date: 6 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 - WisIstmass.govldia • IlOrkers'Compensation Insurance Affidavit:Builders/ContractursiElectrielansIgurnbers. 11)HE FILED VS ITII AUTIIORITI. Applicant Information Please Print Legibly Name illusiness.Organization.individual): 3 DO 1140N ST. L C Address: 5-g EP-4 *I; (24 City'StateiZip: jb_il.,k_6-f5t; MA 01 Ob-Z- Phone#: Are,cou an rmptuyer?I heti.tire appropriate but: Type of project(required 1.0 I am a cm(ale'pa. AII1enapi,e:r es dull;anitut part-tune,.• 7. CI New construction 20 I am a aole in•Upneitm in partnership and haVe CalpitNye+ 1. Aking forme In S. 3 Remodeling 1u-Aurkers'comp.insurance regained I 9. Or Demolition 30 Lam a liunteussiars doing all twill:nr.iself.[No workers'cutup 112sUraiu;e rootted I 0 0 Building addition 1.C3 I arn a homeowner and wall bluniatxrutracturs ne-tinduet altstork an my property I ensure than all contratiurs either hne vt,arkers-eurnpubattun insuran,e or are sole 110 Electrical repairs or additions pruprieturs nu enapluyee. I 2.E1 Plumbing repairs or,idditions I am awneral cuntesetur and I ha e hued the mbmaantracturs had un the atiatned sheet These tub-contraeturs have empluyeet anti has e ikurkers'comp.insurarne.., I 10 Roof repairs 14.C3 Other We are a curporanota:anti its officers have exercised their right of esetripuun per NCI_C. I 432.. It-D.Limi Ne have 114)CZnpktret3.'No*Mien' Lary,Insurance required.' applicant that checks box 41 mint 160 fin uui th.N..:CANNI IC‘V 31.kr.ving their workers compensation pulley infornantion, HUrno.rAthers who subtrat this affithrt it indicating they are/wig all gieOrk and theta hire+Ansi&contnactort most submit a orn fdaa inditmion%11,101. 4..."ontractors that check this but must attached an additional abet shim nig the name of the subAcontructurs and oat.'Whether IX nut those cruises hiN.e cL, Ii Ibc,LIS-curacadvirs 6101: i ICC,il lc-.id,aa,e policy number.. I um an employer that is providing workers'compensation insurance fur my employees. Below is the policy and job site information. Insurance Corripany Name: (t t1/4 Policy or Self-ins.Lie.#: Expiration Date: Job Site Address: City'State,Zip: 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 51,500.00 andor one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a tine of up to 5250.00 a day against the violator.A copy of this.,,t.it.211:...rat may be forwarded to the Office of Investigations of the DIA for insurance •kerlitiri. I do hereby ce nder the pains and penalties of perjury that the information provided above is true and correct. Sitmature: 4—r,•16") Date: Phone#: qi 3222 - S-.( 1 Official use only. Do not write In this area,to be completed by,city or town City or Town: Permit/License •Issuing Authority(circle one): I. Board of Health 2. Building Department 3.CkyfTown Clerk 4-Electrical I nspector 5. Plumbini! Iipetiir 6.Other Contact Person: ribose#: AC� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/06/2022 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). PRODUCER CONTACT NAME: Erin Knechtel _ AMHERST INSURANCE AGENCY INC tac°.No.Extl: (413)253-5555 /c,No): ADDRESS: eknechtel©nathanagencies.com PO BOX 48 INSURER(S)AFFORDING COVERAGE NAIC M AMHERST MA 01004 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B BRAMUCCI RICHARD JR INSURERC: DBA BRAMUCCI CONSTRUCTION INSURERD: 17 MT WARNER RD INSURERE: HADLEY MA 01035 INSURERF: COVERAGES CERTIFICATE NUMBER: 791172 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 �gp SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDD/YYYY1 (MM/DDIYYY'Y)_ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence)' _ $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per persof) $ AWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER EH R AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y N( E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? n WA WA 6S60UB1K70974321 11/16/2021 11/16/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Croin/Jby,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORCP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/06/2022 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). PRODUCER CONTACT Erin Knechtel NAME: Amherst Insurance Agency Inc PH NN,Extl: (413)253-5555 FAX No): (413)256-8354 20 Gatehouse Rd. E-MAIL eknechtel@nathanagencies.com ADDRESS: P.O.Box 48 INSURER(S)AFFORDING COVERAGE NAIC# Amherst MA 01002 INSURER A: Preferred Mutual 15024 INSURED INSURER B: Commerce Insurance 34754 Richard Bramucci Jr DBA Bramucci Construction INSURER C: 17 Mt Warner Rd INSURER D: INSURER E: _ Hadley MA 01035 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21111503700 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. LTR TYPE OF INSURANCE IA SD DDL WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDD/YYW) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 10,000 A BOP0100730136 11/01/2021 11/01/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 B OWNED Ne SCHEDULED BCNJ50 10/31/2021 10/31/2022 BODILY INJURY(Per accident) $ 300,000 AUTOS ONLY /N AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Job site:17-25 Market St Northampton MA 01060 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ' 4K0-7 .p.0 t "Ic' vS,Ilk , t -- -- __ _ ___ t )LIkrirJ uNit icti3 DopQ� 4.-•4. 1z c > to Ay i Jili. ,,i, 2 ii ri NI izeo)11‘ 1 -t -.4Z4 . " - , ev.V*0 ( 4 fir . Nti , . ii 4-le ge e-Z �`• _ ` EN- lS7 t 4- U1 ZT t51)sii 1 < aiiK 9 59 Ica` ". - ..---�--�;i tt- �r - ‘‘ . . r--)k VT.i C\ V4"'‘‘,0c. 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