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35-286 (13) BP-2023-1747 34 SYLVAN LN COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-286-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-1747 PERMISSION IS HEREBY GRANTED TO: Project# DOOR 2023 Contractor: License: Est. Cost: 5859 RENEWAL BY ANDERSEN 090125 Const.Class: Exp.Date: 10/06/2024 Use Group: Owner: E PETERSON BILLY Lot Size (sq.ft.) Zoning: WP/WSP Applicant: RENEWAL BY ANDERSEN Applicant Address Phone: Insurance: 30 FORBES RD 508-351-227 WLRC50668058 NORTHBOROUGH, MA 01532 ISSUED ON: 12/13/2023 TO PERFORM THE FOLLOWING WORK: INSTALL DOOR 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: n . , . Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner LA petM;/ ;s Cp V ,, Aget.re- l rrerr„✓,l d y a'de/,5 @ ,a perwra .S, ,may . ►ik -. . The Commonwealth of Massachusetts ). Board of Building Regulations and Standards FOR (•, ;�� Massachusetts State Building Code, 780 CMR Il MUNICIPALITY ' USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: P' —/ 7 r./ 7 Date Applied: i Vik1 ass ; /Z-13-ZOZ3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3y .Sy beet--1 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 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❑ Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 5 ii Pe`'!O a 0/06 Zr Name(Print) City,State,Z .3'1 Sy/v4.1 I*AZ- y13-3w- 16k6 berkrs e sM%A ,ed.% 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 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 2"Specify: irpn� shot Brief Description of Proposed Work': ((e,nokt 'i '41 ,Pte/Qse / t'# i t ,,L1'/ /tie 0...44 00 j��vfsf�•� c,Gt a ors c l i<tt- e7:! J) SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 6141.0 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ 00 Suppression) Total All Fees: $ I Check NoWIA5 Check Amount: Cash Amount: 6. Total Project Cost: $ 5157.cp, Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 90 /2 5` /o%6/zir jRunt Moe i n License Number Expiration Date Name of CSL Holder !NS i% List CSL Type(see below) 3o ,'be s No.and Street Type Description � U Unrestricted(Buildings up to 35,000 Cu.ft.) N°r�'�"�O � 0 ,? Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofmg Covering (2$) Window and Siding SI Solid Fuel Burning Appliances 84o'9SZ - «exr✓a 1 iN anoieiscn g 30pe✓ni 7)3be I Insulation Telephone Email address J D Demolition 5.2 Registered Home Improvement Contractor(HIC) / /10 �'l O /�Z Z/Z3 �e�.�,✓� �j I ff✓JnF!/,fin G L� HIC Registration Number Expiration Date HIC CompanyName or Mc Registrant Name 3O ti/4 J IS /trews. Q-tdecie eyo pef,;,,4s..09 No.and Street Email address 4/0/%440,0641 4 MA- o t 5 32, ({/t 2- City/Town, State,ZIP 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 Lr3 No 0 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 this application is true and ac te�o the best of my knowledge and understanding. &add1 • C� '�ti It - air- e-3 Print Owner's or Authorized Agent's Name( lectr iic Sig e) 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.gov/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" City of Northampton a tHAM 6.r, Massachusetts iw X-- <<'. l . DEPARTMENT OF BUILDING INSPECTIONS 4 .. 212 Main Street • Municipal Building vt,, C1. b' \ 'k .� Northampton, MA 01060 '�sh 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: 3n ,iks f) //o./i kwouJl. M/f of 53 2- The debris will be transported by: Name of Hauler: GtiaTtc, mctila mICllf / 7tu eorit Signature of Applicant: iti‘"1 Crja Date: /2 63 \t I ne commonweattn of Massachusetts Department of Industrial Accidents P T Office of Investigations � Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 '" ji _: www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Renewal by Andersen Name (Business/Organization/Individual): _ Address: 30 Forbes Rd. City/State/Zip: Northborough, MA 01532 Phone #:508-351-2277 x 6 Are you an employer? Check the appropriate box: Type of project (required): 1.NI I am a employer with 30 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.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no Replacement employees. [No workers' 13.181 Other comp. insurance required.] *Any applicant that checks box#1 must also fill 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. tContractors 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: Old Republic Insurance Co. Policy# or Self-ins. Lic. #: MWC 314158 23 Expiration Date: 10/01/2024 Job Site Address: 34 Sylvan Lane City/State/Zip: Northhampton, MA 01062 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: �'u Date: 12/06/2023 Phone #: 5 -351-2277 x 6 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (check one): 1❑Board of Health 20 Building Department 3.0City/Town Clerk 4.❑Electrical Inspector 5.0Plumbing Inspector 6.0Other Contact Person: Phone #: C4 / Agreement Document and Payment Terms �� t• � DBA:RENEWAL BY ANDERSEN OF BOSTON Bill Peterson e RENEWAL Legal Name:Renewal by Andersen LLC 34 Sylvan Lane HIC#170810 Northampton,MA 01062 byANDERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)320-1816 It/LOWE WON(DOOR R[RWINIlf Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmail.com Bill Peterson 12/04/23 BUYER(S)NAME CONTRACT DATE 34 Sylvan Lane,Northampton,MA 01062 (413)320-1816 BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER bpeterso@smith.edu PRIMARY EMAIL SECONDARY EMAIL NOTES: No HOA Restrictions/ Approval Required Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen LLC d/b/a Renewal By Andersen of Boston("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this "Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. TOTAL JOB AMOUNT: $5,859 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. DEPOSIT RECEIVED: $1,993 BALANCE DUE: $3,866 Estimated Start: Estimated Completion: 9-13 Weeks 1 Day AMOUNT FINANCED: $0 We schedule installations based on the date of the signed contract and secondarily on the date METHOD OF PAYMENT: Credit Card in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. NOTES: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank. You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 12/07/2023 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. 60._\_,_______ SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Christopher Johanson Bill Peterson PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 12/04/23 Page 2/ 23 MAU If Using a Builder DBA:RENEWAL BY ANDERSEN OF BOSTON Bill Peterson Legal Name:Renewal by Andersen LLC 34 Sylvan Lane RENEWAL HIC#170810 Northampton,MA 01062 by ANDERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)320-1816 Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmail.com Property Owner Must Complete & Sign This Section If Using A Builder I, as Owner of the said property, hereby authorize Renewal by Andersen LLC to act on my behalf, in all matters relative to building permit application for the property/address indicated on this agreement. SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Christopher Johanson Bill Peterson PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 12/04/23 Page 17/ 23 r 2.46AM Moo Ore 4 ce+9Ahaa1 i media.provia.com Y OUR PROFESSIONAL-CLASS PRODUCT opt, ' ..�, mit riafEfftooML RA!' Legacy 20•Gauge Smooth Steel Entry Door with Clear Glass ' / QUOTE INFORMATION Job 34 Sylvan Tag: Back Door DETAILS Legacy Single Entry Door to FrameSaver cram* t Unit Size.31 WIC'a El t 1116' Frame Depth 4 16' No at kiutwki Pot Hand inswing-Inside LDuktN flat II et460 Style 20-Gauge Smooth Steel Doi Comforlech DIA ! i ' 4130 Snow Mist White inside and Outside Ail Hardware in Lifetime ar gnat Grass Finish Georgian Lott Thuturra Deatittott 1 ii Fromm 2, Teretured Snow Mist Whet Alsantirttttn Frame CLadding l Separate Sox Snow Mot White Inside frame 1 I i i Mil!Finish ZAC Auto Usti rg Threshold e5 Ste"Depth) r,04 01 w Zinc Chromate WO Sea=!. —yes tComplierrients aright and Antique Wass) Security Platt WAG HANDING i Sell Price:$6.167.00 1 Gz ----�- _ . --•-.*1 O oes**t ; 1 Total:S6,167.00 1111.. 0.29 0.16ii is a *E MIS ,a, .eKoo o s t] r.'Q <= 0.04 a`il`",,, ' iiv I L. 4-..msi.t ,..c ui 1011 i Ow tit-.a leer tad,-at* xar Proctor, sr., .r.. _ ;,� Go Permits, LLC 105 Buttonball Lane GO In Glastonbury, CT 06033 i' PERMITS i Scott Doughman Phone: 860-952-4112 Fax 860-430-6719 _ scottdoughman@gopermits.org Re: Building Permit Application - Licenses Good day, Please find attached permit application, licenses and supporting documents. Renewal by Andersen sold the job and is the G.C. and CSL - CSL #CS-090125 -- Exp. 10/06/24 - HIC #170810 -- Exp 12/22/23 - Workers Comp -#MWC 314158 23 — Exp. 10/01/24 Old Republic Insurance Co All licenses and insurances are attached. Once the permit is ready: • Please fax or e-mail a copy of the permit and receipt to the below address and mail the original to the homeowner: Fax: 860-430-6719 Email: renewalbyandersen0gopermits.orq • If you unable to mail the permit to the homeowner please send to the below address and we will ensure the permit is at the home posted at the time of installation: Go Permits, LLC 105 Buttonball Lane Glastonbury, CT 06033 If we are required to pick up the permit in at the building department, please call 860-952- 4112 once it's ready and we will come to get it. Thank you, Go Permits Unice of Uonsumer Attat S ana I3uslness Kegulatlon 1000 Washingtreet - Suite 710 Boston,-Atlassachusetts 02118 Home Improve- • tractor Registration 1im ;w vit Type: Supplement Card RENEWAL BY ANDERSEN LLC to .-- , ' "".=` atiort: 170810 30 FORBES ROAD '} :' E �iration: 12/22/2025 NORTHBOROUGH, MA 01532 _` w k,,2; "= r .4. Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Regjstttati90 Expiratj4Lt 1000 Washington Street -Suite 710 170810 12122/204 Boston,MA 02118 tENEWAL BY ANDERSEN LLC 1 '.. ',...‘,. t-- A ,----, s„,..._____0/...leimA___. ' ‘ s S AIMS SIN *- 0 FORBES ROAD � / 4 � H'''� `' JORTHBOROUGH,MA 0t5st / '. Undersecretary Not valid without signature 11 Commonwealth ot Massachusetts C14"cliUn Division of Occupational Licensure Unrestricted*6.61$ s at asPigrs "?which c°r".1 Board of Budding Regulations and Standards less tban 3$,000 cubic feet(let cubic meters)of enclosed Vt Const 1 k. 4113118‘14)erumor silacrs,. N. I CS-090 125 -, etpires 10/0612024 JAIME I_MOON 64 NOTTINGHAM RD -RAYMOND tifi 03077 'I t r,I i%»I It' Failure to possess s cornett abbot)of the Massachusetts .,1,- • State&adding Cods is cause tot ravooslion of this dowse. Commissioner daetz, if s./.7d, For mformation about Otis Scone Cob(sin 727-3200 or visit veww.moss.govfdpi Page 1 of 1 ACORO� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/21/2023 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 CONTACT Willis Towers Watson Certificate Center NAME: Willis Towers Watson Midwest, Inc. (NC. �); 1-877-995-7378 A/C.No): 1-888-467-2378 c/o 26 century Blvd E-MAIL certificates P.O. Box 305191 ADDRESS: ertificates@Willis.co Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAICS INSURERA: Old Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC -- -- - _ 30 Forbes Road INSURER C: Northborough, M4 01532 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W30224860 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS-MADE Xi OCCUR DAMAGE ED PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 MHZY 314161 23 10/01/2023 10/01/2024 PERSONAL BADVINJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 6,000,000 X POLICY L_JCO&- LOC PRODUCTS-COMP/OP AGG $ 6,000,000 OTHER- $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED MWTB 314159 23 10/01/2023 10/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ , DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N A ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? No N/A MWC 31415E 23 10/01/2023 10/01/2024 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance egnn4, 4 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 24 694 639 BATCH: 3138744