Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
23C-082
BP-2023-0256 54 BLISS ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23C-082-001 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-2023-0256 PERMISSION IS HEREBY GRANTED TO: Project# WATER DAMAGE 2023 Contractor: License: Est. Cost: 6500 24 RESTORE NE LLC 103111 Const.Class: Exp.Date: 05/13/2024 Use Group: Owner: SCHEEL SCHEEL GERALDINE M &MARK B Lot Size (sq.ft.) Zoning: WSP Applicant: 24 RESTORE NE LLC Applicant Address Phone: Insurance: 10 CHURCH ST 508-238-3060 30504218 S EASTON, MA 02375 ISSUED ON: 03/02/2023 TO PERFORM THE FOLLOWING WORK: INTERIOR DEMO DUE TO WATER DAMAGE 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: ill • ti Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner E� <f .l°z a ` 1- ,,, Yam' The Commonwealth of Mas achu etts AV . It , 7 / FO --.*: Board of Building Regulations nd S andards 7423 MiNICI ITY Massachusetts State Building ode r o� R US Building Permit Application To Construct,Repait-R� h}rc tel• h a Rpvised Mar 2011 One-or Two-Family Dwelling °N.Mq�oi�T,°Ns This Section For Official Use Only Building Permit Number:6 D. j » .Z 5- / Date Applied: Ie ► %'i ' . 34 �3 Building Official(Print Name) Signature it 1 to SECTION 1:SITE INFORMATION 1.1 Property Addrress: _�k�w �j 1.2 Assessors Map&Parcel Numbers 1.1 a Is thisan acceptedstreet?yes>(�1~�noY Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 1 Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PRIOPEERjTY�OWNERSHIP1 2r 1 Owner'of Record \J Y,�rl<n�S d . Q/0Y. ' G ame(Pnnt) City,State,ZIP -i.1 T JSS. '` megek 31/3 S84 4g07 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addi ion 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:l 1 , T...4,4) BriefBrieffiDescription of Proposed Work2: L 'T 6.I�L .-so vf4 1 i&, �103o f l 6wvl, F/( J .l-t„�It6..., SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List. - 5.Mechanical (Fire $ Suppression) Total Fees: $ ____,lf_()6 C No. C ck Amount: 6.Total Project Cost: $ Pai in 11 0 Outstanding Balance Due: City of Northampton Massachusetts °14.1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ,) ?fi - f!r Northampton, MA 01060 ��} ., PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC. 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 and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new /replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements(if applicable). 9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. 4 tuhc'ii �ppmvc -- -t=5-/-opp 60 2 resfo re-ne vm SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C.,S-1013/)/ 54� _c7Z4 �,t F t✓} S License Number Expiration Date Name of CSL Holder /2 ,/O z List CSL Type(see below) No.and Street Type Description G 1.}-� y �2 U Unrestricted(Buildings up to 35,000 cu.ft.) 1 �U 'Tt R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding _ q SF Solid Fuel Burning Appliances _S28b- i_� —� C1_ I Insulation Telephone Email address D Demolition 5.2 Registered Home Improveement Contractor(HIC) A W.46418 HIC Registration Number xpiration Date HIC Compa y Nam or 11..I95egistrant Name • �C•� 424SC -�.L`'''1 No.a d Street Email address sioia cers„ Isce City/Town,State,ZLP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 ❑ No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S 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 permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in is application is true and accurate to the best of my knowledge and understanding. 2/Z-7/2.4 Print wner's or Auth ized Age Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.cov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ft\ ....,.-- The Commonwealth of Massachusetts .. ., — 1 Department of industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.goildia ‘Irtukers'Compensation Insurance Affidavit:Buiklers/ContractorsiElectrirignsIPlumbers. IC)HE FILED WITH THE PERMITTING AUTI101111'1, Applicant Information Please Print i_efibk Name 4Business'Organizationlialividualr 24 -Fe,sieczc, io E- /a.c_. Address:/6 cJ 5.-A City/StateiZip:51-11 C)25/S_61Phone P.: '? 'S' eyo ..),•pep „..._„„.____ Arc yam itti entpky IT?Cheek tare appropriate lin': Type of project(required): 1 t I am a emplo;eer with employees(full aniler part-time t..• 7. 0 New construction 20 I am a ink prupnctur or varinerslop and ha%e nu 1.131116Stlrx working for Eric in 8. 0 Remodeling MIN'capacity.[No workers'CLAIlp,illSliraillA: required I 9. 0 Demolition 3.1:3 I JIM a humeownica doing all work myself.{NO VtOr3t29'comp,imunuice requirixi,)' 10 CI Building addition 4.0 I,ain a larnicirsixicr and will IV haute Wattrackwa to conduct all 4.urk on my property„ I will aware that all contractors either have workers'encripintsatiori insurance or anc aulc 110 Electrical repairs or additions pnaprietins with no employees, ! 12.D Plumbing repairs or additions sC3 I am a veneral contractot and I have hired the sub-contraetors listed on the anachind sheet 13.D Roof repairs These sub-curitracturs haw employees and Ism c workers'comp.insurance,: 14.00thet , 4 • ,,410 : hi:Ipli'e ans a corporation and 1i..officers have exercised their nen of CACETVIHR/per MC&c, I.1,2..t 1(41.and 4c haw no employees.(Ni,Vvtlii.Crh comp insurance required. An applicmn that duxIcA ts..”..,.;I must also fill out the section below h b i Inv then u.oricr,'..1.41;p,N,L,11,41 pul icy mientiathro Homeowners who submit this a(tidaill indicating they AM&RIM all work and then bin:outside conk:icier+intro*ablaut a 01:14 affidavit ind waling Nt.i..11 %Cuntractom that ch..1.1thi&bck,,,must anacInxi an ildthaiural sheet stunting the name of die aiih-contractors and V.A.:vliwther or not tisust entitic, haw mriployces tr(iv sub-euntractors have MIESISIll,LV!i,they must pnwide 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 thforrnatiOn. Insurance Company Name: /4-2g. 'Tj.164,/,ha)4e..„. .,,/,-_,, ) 6e.L4.94) — , Policy a or Self-ins, Lic. ;`,... ( ‘4\C_S(L6 I ci"e Expiration Dale: Job Site Address:S47L)5.5 51 . City'State!Zip10e2fi hif/ Attach a copy of the porkers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under VIGL c. 152,§25A is a crinurial t iolation punishable by a tine up to S1,500.00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification. I do hereby certify uml the pains and penalties ofpedury that the information provided above is true and correct. Signature: "We Date: 5/27/202. 1-77.. . 2.Z 7 . 6 4 41(-, -1"-Srcii,4 IA YE,.1- ker, /3c,.ci.4.-1 , i Official use only. Do not write in this area,to he completed by city or town official ('its or Town: PermitiLicense a Issuinf,Authority (circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ('ontact Person: Phone#: „_ _ City of Northampton ex*, Massachusetts ' iff. DEPARTMENT OF BUILDING INSPECTIONS ; 212 Main Street • Municipal Building Northampton, MA 01060 �s_byv r 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: The debris will be transported by: Name of Hauler: SS ��7),‘, 1 2/ /Signature of Applicant: � Date: City of Northampton t Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building f ^- Northampton, MA 01060 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born_(insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) Gina Murray From: XactAnalysis <XactAnalysis.support@xactware.com> Sent: Wednesday, February 15, 2023 2:56 PM To: Gina Murray Subject: Contact GERALDINE SCHEEL @ H(413) 584-4118 (WATER) - 24 RESTORE NE, LLC (Normal assignment) From: MAPFRE-Vendor To: 24 RESTORE NE, LLC Assignment Profile: Type: Normal Date of Loss: 02/15/2023 Claim Number: H010020338-1 Insured Name: GERALDINE SCHEEL Evening Phone: (4'1S584-41 18. Type of Loss: WATER XA ID: 058VK58 Location of Property: 54 BLISS STREET, FLORENCE, MA 01062-2606, USA Ggo_gle_Maps MapQuesi 42.327415° N, 72.67496°W 42° 19.6449' N, 72°40.4976' W Instructions: PROPERTY FIRST REPORT POLICY TYPE: HO-3 LOSS DESCRIPTION: Insured Scheel thinks a pipe burst in the second floor bathroom and caused water damage throughout the home APPLICABLE COVERAGES: Coverage A$360,000 DEDUCTIBLE: $500 DATE REQUJRED'BUILDING LETTER SENT 02-15-23 Called insured Mark(413) 586-6907 and pipe in ceiling in kitchen and upstairs is bathroom. Ceiling came down and water leaked down into unfinished basement. Insured has not contacted a plumber but will do so. Insured stated there is standing water on floor and floor below. He did not contact any mitigation company. Offered select. Insured accepted. Insured does not have contractor. Offered select for rebuild and also accepted. Explained program. Advised insured also that there was high volume of claims due do pipe freeze could be delay in mitigation. $500 deductible. Dates: Assignment Received by XactAnalysis: 02/15/2023 07:55PM GMT Notification Sent: 02/15/2023 12:55PM MT wieew detailed information for this assignment in XactAnalysis. 1 Commonwealtta of Massachusetts t t; Division of Occupational l_icensure Board of Building R ulations and Standards CGrIS tP CS-1it,13111 - fkires:0511312024 JASON R Ea' 31114 1740 JENNA' R t `:? DIGHTON Mte102 11111. —issio."Yer Cvlsnu^ J�s.,th:c. Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dp1 CPC-02 Rev 06/13 844290 STATE OF C O N N E C T I C U T LIMITED LIABILITY COMPANY DEPARTMENT OF CONSUMER PROTECTION 450 Columbus Boulevard ♦ Hartford Connecticut 06103 Attached is your Home Improvement Contractor registration. This registration is not transferable. The Department of Consumer Protection must be notified of any changes to your registration within thirty(30) days of such change. Questions regarding this registration can be emailed to the License Services Division at dcp.licenseservicesact.gov. In an effort to be more efficient and Go Green,the department asks that you keep your email information with our office current to receive correspondence. You can access your account at www.elieense,ct.gov to verify,add or change your email or address. Visit our web site at www.ct.gov/dcp to verify registrations,obtain applications and the booklet for The Connecticut Contractor for Home Improvement and New Home Construction. S' ATE OF CONyI:CTICt'T 0/ ,NI t// A/ II/ ( I1 A V I til R P/UII LC IIO A 24 RESTORE NE LLC HOME IMPROVEMENT CONTRACTOR 10 CHURCH ST 24 RESTORE NE LLC SOUTH EASTON,MA 02375-1508 10 CHURCH ST I SOUTH EASTON,MA 02375-1508 Registration# Effective Expiration HIC.0660478 12/01/2021 03/31/2023 SIGNED ✓ .' : ltJ 1 s nt .t gi.. Si ;,,• � y ;lei, �.} . i , A y _f �i\ 4 4 vM �i' * M ♦ f � 1,r t . ti° 4t f �J � , p �l 4.1� i p4p4sC `J STATE OF CONNEC Y ICUT < DEPARTMENT OF CONSUMER PROTECTION '! ;? Be it known that + ‘ ' Al24 RESTORE NE LLC 10 CHURCH ST „ , '4.. SOUTH EASTON, MA 02375-1508 •• : k has satisfied the qualifications required by law and is hereby registered as a • HOME IMPROVEMENT CONTRACTOR .. \ • C y 44 k Registration # HIC.0660478 )' Effective: 12/01/2021 d. • Expiration: 03/31/2023 e' «�i Michelle Seagull,Cotnmiasloner + 41 err W.'''. ,r . q . w . 4 . 4 4 • q .• * e � % �—.41 24RESTO-01 JLABO ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) kle.....-- 2/21/2023 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 License#1780862 CONTACT Jennifer Labo NAME: HUB International New England PHONE FAX 600 Longwater Drive (A/C,No,Eat):(781)792-3397 (A/C,No): Norwell,MA 02061-9146 ADDE-MAILESS:Jennifer.Laboa@hubintematIonal.com R INSURERS)AFFORDING COVERAGE NAIL 11 INSURER A:Everest Indemnity Insurance Company 10851 INSURED INSURER B:Arbella Protection Insurance Company 41360 24 Restore NE LLC INSURER C_Wesco Insurance Company 25011 10 Church Street INSURER D:Ohio Casualty Insurance Company 24074 South Easton,MA 02375 INSURER E:Federal Insurance Company .20281 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 I TYPE OF INSURANCE IADDL�SUBR PO Y EFF POLICY EXP L^i INS) WVD POLICY NUMBER IMMID (YMIDD/YYYYI LIMITS A 1 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR 500,000 EF4ML06641-231 2I20I2023 2120/2024 DAMAGE ro RENTED —__. I X x I PREMISES(Ea occurrence) $ —_ 10,000 MED EXP(Any one person) fi$_ DV _ PERSONAL&A INJURY I$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • GENERAL AGGREGATE i$ 4,000,000 X POLICY X PRO X LOC PRODUCTS-COMP/OP AGO $ 4,000,000 OTHER: E� I $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) _,_ ,$ ANY AUTO X X 1020094653 2/20/2023 2/20/2024 BODILY INJURJPer person) ,$ OWNED i SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per acciden),$ X HIRED X 'NON-OWNED PROPERTY DAMAGE AUTOS ONLY H .AUTOS ONLY (Peraccldont) i $ ., $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE ,$ 5,000,000 EXCESS LIAB CLAIMS-MADE X X EF4CU01684-231 2/20/2023 2/20/2024 AGGREGATE $ 5,000,000 DED RETENTIONS I $ C WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY _ STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NI x WWC3631578 2/20/2023 2/20/2024 1,000,000 OFFICER/MEMBER EXCLUDED? IV I'N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under .1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S D Bailees X x BMO 24 64385778 2/20/2023 2/20/2024 Inland Marine 250,000 E Crime Coverage 82614882 2/20/2023 2/20/2024 1,000,000 ; ; DESCRIPTION OF OPERATIONS i LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage information: Everest Insurance Company (AM Best Rating A(Superior) Policy#EF4ML06641-231 also includes the following: Contractors Pollution Liability Each Pollution Condition:$2,000,000 Contractors Pollution Liability Aggregate:$4,000,000 Transportation Pollution Liability Each Pollution Event: $2,000,000 !Transportation Pollution Liability Aggregate:$4,000,000 ;SEE ATTACHED ACORD 101 I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE HO� 4 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 241 aareeo• rNaaau 11111-21041010 Tan RORLzawNsa 11110101111TEE!OLL0WJNG nips P11111/01111113D DAMOIDIAVELYt i.-6i3 r / 6-j CL, - 004'[�l.D S • 3.„5/0/ iLize- T�ICY SITUATION EIQVI I NO TElBUIVICIES�s Homeowner's dostu a,4 I pa Rzt, =7. .fliti,e,g_ 4, 5c 64-FtL aro--, 3 tiomoomay inittnnatIon: CoeaadorIntlymottom Pigott Omen-Creel! L :oNmponeslants 24 Realora NB LW AmniaAmnia�/7Crsss �rx� j Plena V►'� • Connector `� 174� Panay Ilk Addreaa Ly4,'L) 044 , ChM it /0o z v. 3 • / MON 114. "21 42f7 tlervi oa 4 but %61zL2v kopek I bevel y employ and authorise 2411is1+o1111 N!LLC and its employees and woe to enter end exit the maims described above as nutoeeeay to provide emergeney modem Given the emeripaoy name&Etheemvieee repeated by me,1 aoknoudedse and eooeptthat the an ibr nerviest;above may be eerwon to be�p�aed* rmaay be plemented an made by eddigoael requests lhr 1