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38B-175 (4) BP-2024-0023 196 SOUTH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38B-175-001 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-2024-0023 PERMISSION IS HEREBY GRANTED TO: Project# 2023 BATH RENO Contractor: License: Est. Cost: 10500 STEVEN LEMPKE 047805 Const.Class: Exp.Date: 01/24/2024 Use Group: Owner: WEINMANN, CHARLES J. &ELLEN M. TRUSTEES Lot Size (sq.ft.) Zoning: URB Applicant: STEVEN LEMPKE dba LEMPKE CONSTRUCTION Applicant Address Phone: Insurance: 89 PITTROFF AVE (413)575-9728 6HUB8H07081 A23 SOUTH HADLEY, MA 01075 ISSUED ON: 01/08/2024 TO PERFORM THE FOLLOWING WORK: BATH RENO 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: TI Fees Paid: $68.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner AN The Commonwealth of as actfi; ettsro 15 ! Board of Building Regulations and'Sta ire ',mi4 FOR pF Massachusetts State Building Code, 780 CMR-r, "�q o,obo/ones +' USEICIPALITY Building Permit Application To Construct,Repair, Renovate Or Demolis .Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 6/I A.3-dad 3 ate lied: /E U t v (IZ / I- ?Q Z'-i Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Pro a Address: 1.2 Assessors Map&Parcel Numbers i of c/r- sT 1.1 a Is this an accepted street?yes pC 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: Zone: Outside Flood Zone? Publiciffi Private 0 Check if yes❑ Municipal tf On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ic1LN W6/nAk-A40 /Vier#4144"4// Name(Print) City,State,ZIP /96 5 -it 5r-- `f(/ No.and Street Telephone Emai Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing BuildingI Owner-Occupied Er Repairs(s)j Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: ��) Brief Description of Propose Work': c��?�„u�� -src. ���cs'l 2cx SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ .C/ �W 1. Building Permit Fee: $ Indicate how fee is determined: �vU .�� 0 Standard City/Town Application Fee o 2.Electrical $ t 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 3/ 5 03 . 00 2. Other Fees: $ 4.Mechanical (HVAC) $ List: i 5.Mechanical (Fire $ Ow Suppression) Total All Fees: $ Check No.2 4 Check Amount: 6.Total Project Cost: $1 Qs-00 0 Paid in Full 0 Outstanding Balance Due: City of Northampton 0. LTa,{ / Massachusetts d DEPARTMENT OF BUILDING INSPECTIONSt4, t 212 Main Street • Municipal Building `. 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. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) e�/ 46r9 Y /v X e UtEense Number Expiration Date Name of CSL Holder ^ry List CSL Type(see below) P/p jzUfiG No.and Street Type Description O �l Unrestricted(Buildings up to 35,000 Cu.ft._ City/Town,State,ZIP S 7 R Restricted 1&2 Family Dwelling Masonry M Mon RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances /3&_7C?7 L ' K j41 5Pe /kW- I Insulation Telephone Email address ..e°n' D Demolition 5.2 Registered Home Improvement Contractor(HIC) `` /� L,�rKd G� �'� HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 'D'�l? e"P A� f oi 1 D .r d,L_cc"-t No.and Street Email addres 50arif- 0/74-01-6'/ /144-67-1e7 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 ❑ 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 Gt�JL!5 n2 Uc-r7-o''L _ to act on my behalf,in all matters relative to work authorized by this building permit application. mt wner'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 accurate to the best my knowledge and understanding. 3Ze Print Owner's or Authorized Agent's Name( e onic S' a e) /Date NOT S: 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" The Cotnmonovealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, M40114-2017 ;01 wwrnass.gov/din M..orkers C4/1111petl%Alion Insurance Affidavit:Buildersif7ontractorslElectricians/Plumhers. 111 BE FILED WITH THIL PERMITTING ACTI1011.11'Y. Annlicant Information ritnist! Print Letibk Name(Bus incss)Organtzat ion'individual e--091V5VIRZFC/77.6 xl Address: ?et— .444.5 City'State/Zip: Ver1/71---- 1144 Phone 1,tre-/-7'713 Are you an vinploy ell Check the appropriate box: pe of project(required): I.471 I am a eisvploya•with 2. enspioyet%(full arailin part-time t.' 7. 0 New ci.nritrUCtiOn ,C]I am a sok pruprsetor or lassinerskup and base no employee tvorlong tor me in aav capacsty.(No workers'comp,insurance rtxptired.1 9. Demolition I am a honscowner doing all work myself.[No worisas'rump.ingirancr:cog usroi) ci Building addition 4.0 I am a honna and will be Intuit contractors Co conduct all work on iny property_ I will emote that all cow-moves Cutter have workers'curnivx-notion isestsramer or anc 110 Electrical repairs or addition:. propnetors with no erripkrycea_ 12_0 Plumbing repairs'or addition., It]I AIn gtlx-Tai contractor and I Isa...e hired the sub-contractor%listed on the anacherd sheet 13 Theme sAib-tuntraetors have employees and bat e workers' otattranett: .E1 Roof repairs 14.nOttti n.0 We use a evaporanon and its oakum have excn:tsed their ripbt 4.4cAernplitin per §liii.and we Itat,e no ernplo)ves.[No worker4'G:ouip..insurance required] *Any applicant that checks box 1:I most ats.0 fill OW theation bdutshow in then worl .r,'compen,al ion pota.1,informatinat. ikl,M6OWIIIC1a who submit that afinda.,,ti rikbeattnit they an doing all work and risers hire vtit-Ade,:i.mirt‘wl mast submit a new affidavit rCnrunietors that cheek this boa ilium attached an addshunal ibect ahem ing the name of the sub-eontra..-tors and state w hohiN m not those cremes ha,,e einrlop:e, If the Sub'cuinratimh Isat.e employ they must provide their orkcn'comp.17,011....y number 1 am an empluper that is providing ovorker3'compensation insurance for my employees. Below is the policy and job slit information. Insurance Company Name: Policy#or Self-ins.Lie.4: Expiration Date: Job Site Address: l 4/774-- City State/Zip: Attach a copy of the worke•re 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 tine up to S1.5(XJ.00 andior 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 statement may be forwarded to the Office of Investigations of the DIA for-insurance co‘erage verification. I du hereby certify under the and willies ofpedury that the information provided above is true and correct SA:mature: 57— Date: //3/7i Phone- 5'..7 57".7 2-et' Official use only. Do not write in this area,to he completed by city or town official City or To n: Permit/License# Issuing Autliorit, (circle one): I. Board of Health 2.Building Department 3,Chy/Town Clerk 4.Electrical Inspector 5. Plumbhig Inspector 6.Other Contact Person: Phone 4: 1 City of Northampton �, Massachusetts ,``z t iP :el j DEPARTMENT OF BUILDING INSPECTIONS 1"—is)x P Building .': ear 212 Main Street • Munici al ;, $ '-. Northampton, MA 01060 '$S!� ir.�‘1 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: ; ,r,y, ,=, _ The debris will be transported by: Name of Hauler: fr4f3xe_ sL. e`e/liti _ Signature of Applicant: �" A— Date: //3(ZY City of Northampton sty, Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ? x 212 Main Street • Municipal Building Northampton, MA 01060 V^�1� 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) STEVE13 OP ID: SP ACC)RO DATE(MMIDD/YYVY) CERTIFICATE OF LIABILITY INSURANCE 01/04/2024 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 413-788-4531 CONTACT Goss McLain Insurance Goss&McLain/Chase Clarke NAME: PHONE 413-788-4531 � FAX /C Nol: 214-6160 Physical: 59 Bobala Holyoke MA (Ale,No,Ext): (A , PO Box 9031 E-M IILSS:spremo@chaseins.com Springfield,MA 01102 - Goss McLain Insurance INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Main Street America 14788 SNSURED INSURER B teven Lempke 89 Pittroff Ave INSURER C: South Hadley,MA 01075 INSURER D: INSURER E: 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 TYPE OF INSURANCE ADM_SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS rR INSD WVD (MM/DDIYYYYI IMMIDO/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT2729Y 09/30/2023 09/30/2024 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence] $ MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (EaM acddentSINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILYO INJURY(Per accident) $ AURTOS ONLY AUTO ONLY (Pe�aEnt)p AMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER AANNYIPROPRIETORR/PARTNER E ECUTIVE N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Northampton is additonal insured on the above captioned policy, as per lease agreement; subject to policy forms, conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector Kevin Ross 212 Main St AUTHORIZED REPRESENTATIVE Goss McLain Insurance Northampton, MA 01060 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 01/04/2024 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 Sarah Premo _NAME: CHASE CLARKE STEWART&FONTANA (Ac N Extf: (413)788-4531 INC.No): E-MAIL remo ossmclain.com ADDRESS: p �g PO Box 9031 INSURER(S)AFFORDING COVERAGE _ NAIC# Springfield MA 01102 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: LEMPKE STEVEN INSURER C: INSURER D: 89 PITTROFF AVE INSURER E: SOUTH HADLEY MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: 965135 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 ADDL SUBR POLICY EFF POLICY EXPD/ LIMITS LTR INSR WVD POLICY NUMBER (MM/DYYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ 1 CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS 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 PEPERTUTE TRH- AND EMPLOYERS'LIABILITY - - A OF ICER/M MB REXCLU ED?ECUTIVE E.L.EACH ACCIDENT $ 100,000 N/A N/A N/A 6HUB8H07081A23 05/01/2023 05/01/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS I LOCATIONS/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 dale 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/IwdAvorkers-compensationhinvestigations/. LEMPKE STEVEN has elected coverage. Continuation of above Named Insured:DBA LEMPKE CONSTRUCTION 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. City of Northampton 212 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 "k C Daniel M.Cro y,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