HomeMy WebLinkAbout0336 BISHOPS TERRACE ��slw�s�ae�
Town of Barnstable *Permit#
~per Expires 6 montinfrona issue date .
Regulatory Services Fee
Richard V.Scali Interim Director
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601 T 'A'V MAY 19 ?0i6
www.town.bamstableams TO OF
Office: 508-8ti2-4038 .m Fax:/ 0`880,- 30
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property?Address 3 3f� �i S h o 7 e rA e / S
[Residential Value of Work$ 7 y I Minimum fee of S35.00 for work under 56000.00
Owner's Name&Address Mar,w✓1 �a fl P,n f i�
336, e rWIR- i s
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Contractor's Name i 0 t W5 A /SOtj Telephone Number'1d/-Zzr-foft
Home Improvement Contractor License#(if applicable)__732�{� Email:
Construction Supervisor's License#(if applicable) 0 FT 7d 7
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
.I have Worker's Compensation Insurance
Insurance Company Name t�DNAt�'/ IUCj
Workman's Comp.Policy# W�iQoZ
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going,over existing layers of roof)
❑ Re-side
[Replacement Windows/doors/sliders.U Value_ 0. (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
"Note: Property Owner must sign Property Owner Letter of Permission.
A-copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
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YOU, `i`[1 : MAY WOM '7'mm T)lEitrNIUCipOS AT ANY.TIME PRIOR TO MXDNIGHT OF HE HIMID
NOUCE OF CELL
OF THIS)RUIGHT.
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t�Fl •�
Southern New England Windows
dabea
Renewal by Andersen of SNE
liassachuset:s-Department of Public S2"-
Board of 3aiic:in_Rev
Ui2bons and S.2ndards E
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�is.eriSE:
7 LAMBS POND
Chariton MA 915b'Y
Expirabos
GO?fLT1S55107"P? � ��
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Office of Consumer Affairs d Business Reglatzon
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement.Contractor Registratian
Registration: 173245
Type: Supplement Card
Expiration: 911912016
SOUTHERN NEW ENGLAND WMDOWS L.. —-—-
DENNISON BRIAN
26 ALBION RD
LINCOLN,R102865
'Crate Address and amen card.Msrts resaoa for dmgr-
._Address E Renewal !Fj Employment r'Lou Card
S:A1
r.�"�r' a+meswx .c�C- a�srmlle
!LQ of Coaaemv Alfaia&Bosmrss 11ceu1e6oa Lieease or re;;is=tioo valid for indireto ttse only
E rRtPROYEMBtT CONTRACTOR before the expiation date.irfoond atotn to:
r- OfFeo-orcoasnmer AjWrs and Sadness Regafattoe
eBiabadon: 173245 TYR 10 Part:Pfnmm-Suite 5170
Etpfratlon 9119I2076 �SupPkanerm'-ard Bouon MA02116
SOUTHERN NEW ENGLAND WINDOWS LLC.
RENEWAL By ANDERSON
DENNISON BRIAN
26 ALBION RD _ ���----------
LINCOLN.RI C2865 Uodrrsecrstarr Not valid without signamm
r =
The Commonwealth of Massachusetts
pa Department of°Industrial Accidents
Off Ice of'Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www maass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Legibly
Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS
Address:26 Albion Rd
City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800
Are you an employer? Check the appropriate box:
Type of project(required):
1. 10 I Ai a employer with 20+ 4_ I am a general contractor and I
employees(full and/or part time). _ have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7_ ❑Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp.insurance comp. insurance
a corporation and its 10.❑Electrical repairs or additions
required.] 5. We are
3.❑ I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required] c. 152, §1(4),and we have no Door Replacement
employees. [No workers' 13. Other p
comp.insurance required.]
*Any applicant thatchecks box 91 must also fill out the section below showing their worke&compensation policy information.
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:ARGONAUT INS. CO. _
Policy#or Self-ins. Lic.#:WC 928058352394 Expiration Date:8/21/2016
Job Site Address: `3 (P �15 � City/State/Zip: `S
Attach a copy of the workers' compensation policy declaration page(showing the policy n ber and expiration date):
Failure to secure coverage as required under Section 25A-efMGL 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$250.00 a day against the violator. Be advised that a-copy of this statement may be forwarded to the Office of
Investigations of the DIA fbi insurance coverage verification.
I do hereby cert4$under th ains and penalties ofperjury that the information provided above 's tru and correct.
r
Si ature. Date:
Phone#: 4012289800
Official use only. Do not write ih this area,to be completed by city or town official
City or'Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SOUTNEW-01 SHETTYSHT
CERTIFICATE ®F LIABILITY INSURANCE aAa�r19�UNDIN1
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 holier is an ADDITIONAL INSURED,the policy(ies)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terns 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).
PRODWillisuCER of New Jersey,Inc. NAMES IIVlliis CettNitrete Center F
c/o 26 CenturyBlvd .(877 945-7378 No ("M 467 2378
P.O.Box 305191 5411M certifi ilis.com
Nashville,TN 37230-5191 "
AFFORDING COVERAGE NAIL R
wsURERA:SelectiVO Insurance Company of Southeast 39926
INSURED 0.4SURER a:OneBacon Insurance Compan 21970
Southern New England Windows LLC INSURER cArgonaut Insurance Company 19801
DIBIA Renewal by Andersen INSURER D
26 Albion Road
Lincoln,RI 02665 PasURER 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.
LTR TYPE OF INSURANCE POLICY NUMBER LIIUis
A X couNERctAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.
CLAIMS-MADE ®OCCUR S 2029459 0811012015. 01IM012016 g 100,004
MED EV(Any are person) $ 10
PERSONALS ADV INJURY $ 1,000,00
GENtAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3.000.00
POLICY Q JECTT a LOC PRODUCTS-COMP/OP AGG $ 3,000,00(
OTHER $
AUTOMOBILE LIABILITY COMO►NED SINGLE LIMIT $ 19000.00
AX awten _,
ANYAUTO 2029459 08M0/2015 08MG12016 BODILY IWURY(Perpersan) is7— ALL OWNED
"
AUTOS AUTOS SCHEDULED BODILY INJURY(Per aoddwd)1$
X HIRED AUTOS X AUTOS Pe a�IDAMAGE $
$
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE s k000l000
A . EXCE.SSuAB" CLAIMS-MADE S 2029459 08M012015 08(10=16 AGGFEGATE $ 51000100
DELI RETENTION$ is
ANDw LOOS LIABILITY ER
X STATUTE �
B ANY PROPwETOR/e%TNEwExECUTIVE Yin 0000068028 08/21/2015 08121/2016 E.L.EACH ACCIDENT $ 1,000,00
OFFICERiMEMBER EXCLUDED? ®N/A
(Mende"In ELL DISEASE-EA EMPLOYEE $ 11000,00
VDE$cRla Pr ON of OPERATIONS below E.L.DISEASE-POLICY Einar $ 11000,00
C JWorkers Compensation C928058352394 0812112015 08/21/2016 See Attached
DESCRUiTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.AdMa,a►Remarks Schedule,may be attadwd N mare space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
ACCORDANCE WITH THE POLICY PROVIS�NS.
AUTHORIZED REPRESENTATIVE
videnca of Insurance
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
r
af�
Town of Barnstable Per�t# "I-T
Expires 6 months from t�ae dat,e -
g
Regulatory Services Fee
• BA&N8rA8tS. -
'tA9'
619. Thomas F.Geller,Director
���
MA't
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-8624038 Fax:508-790-6230
EXPRESS PERMIT APPLICATION_ RESIDE L ONLY
Not Yalid without Red X--Press lmprlrrt
Map/parcel Numb?e :�L
Property Address 3
S Residential Value of Wor 0i Q13 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Mh
Contractor's Name 5 E. N elephone Number
Home Improvement Contractor License#(if applicable)_ l a�3 c-�Z ��7�
Construction Supervisor's License#(if applicable)
dworkman's Compensation Insurance X-PRESS
Check one: PERMIT
❑ I am a sole proprietor
�❑ I am the Homeowner DEC 1 9.2013
I have Worker's Compensation Insurance
Insurance Company Name E41 1
�- .A .
Workman's Comp.Policy##..l,Cr �� / ��93 6,;2 3 / ^F EARNSTABLE
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
0 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
3 #of doors
Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
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Renewal by Andersen of SNE
Massachusetts -Department of Public Safety
i� Board of Building Regulations and Standards
C'ons"Ction Sfpen fsor
License. CS-09S707
s ;.
BRIAN D DE '
7 LAMBS POND Ei1RC
Chariton MA 01507
Expiration
Cofnmissioner 09/08/2014
�-�,./�l,P� ��'f�71?/I?'GO�ir/..(.�.CZ'Gf.�Z• � �.GL
Office of Consumer Affairs d W Business ie on
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Rellishation: 173245
Type: Supplement Card
ExpSOUTHERN NEW ENGLAND WINDOWS LL1a°O" 911912014
DENNISON BRIAN -- -----"-
1137 PARK EAST DRIVE -- ---- ~ ——
WOONSOCKET,RI 02895
Update Addresr avid return card.Marl:rt—aa for change.
x.r a _1 Address C3 Renewal i—Employment last Card
\^:`—ofCaasaa—ARafrs&Duel—Knatati.. l.icett nrregistratioovalidforindiridulme Daly
EMENT CONTRACTOR bellm the espintioa dam if toned return m:
Office of Consumer Almin and Boeiaex Regulation
173245 Type: 16 Park Pura-Suite 5170
V:E.XE-P-:IrffiZ=- B lSM14 Suppienenl::ard Boston,MA 02116
SOUTHERN NEW ENGLAND WINDOWS LLC.
RENEWAL BY ANDERSON -
DENNISON BRUIN
1137 PARK EAST DRIVE
WOONSOCKET.R102895 Underserretary Not valid wit6om sigweture
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgovfdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Auplicant Information Please Print Lezibly
Name(Businessiorganintion/lndividuai):
Address: 2 & hwok) �L1
City/State/Zip: bPC01IVi 026450"Phone#: A-101-ZZ S'- gD 0
Are you an employer?Check the appropria-box: Type of project(required):
1.[91 am a employer with 20 4• �_J I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- . listed on the attached sheet. - 7 ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'
insurance.♦ ❑Building addition
comp.[No workers'comp.insurance P•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.[KOther WWI,W , -
comp.insurance required.] 4 l
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy' formation.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors 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
informatiom
Insurance Company Name: C/
Policy#or Self-ins.Lic.#:�1 t^,_9Z 7�l� r��� Expiration Date: 21 1
Job Site Address: 3�5 1 S Yw p S ��, City/State/Zip: ut S ln
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 pom
Ty Werthepains and penalties of pE:jury that the information provided abov is true and correct
Sip-nature: Date: l� S
Phone#: —2Z I
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
01011M :30124 SOUTNEW `
ACORD CERTIFICATE OF LIABILITY INSURANCE- DA106/2DD/YYYY)
8/06/2013
THIS CliRTIFiCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CkRTirICATE 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:It the c011 tic to huldnr Is nn ADDITIO~NSURED,the policy(los)must be endorsed.If SUBROGATION IS WAIVED,subject to
the 101•1110 and c0iidiUoncs Of the policy,cortain Policies may require an endorsement.A statement on this certificate does not confer rights to the
cert111CAN holder In Ileu Of such mtdoraemmilt(s).
PNclln)cI.H '
Willis of Now Jorsety,Inc. NAME._Anita Little _
1015 BrI00s Road,PO Box 5005 lac°°,"o,E,856 9144660 ii A/C 856.914.1881
PO Box 5005 EMAIL anita.little@wiliis.com
4-
ADDRESS: _
Mount Laurel,NJ 08054 _ - INSURER(S)AFFORDING COVERAGE _ NAIC 8
INSUN►t) INSURER A:Selective Insurance Co of the S 39926
Soutliorn Now England Windows LLC INSURER a Argonaut Insurance Co. 119801
DIBIA Ronowni by Anderson INSURER C'Beacon Mutual Ins.Co. 24017
26 Albion Road i INSURER D;
Lincoln,RI 02865 !INSURER E:` `
INSURER F!t _
COVERAGES CERTIFICATE NUMBER: . REVISION NUMBER:
'"IS IS TO CERTIFY THA•I' TILE POLICIES OF INSURANCE LISPED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NO'IVYI.11STANOINC ANY REQUIREMENT'. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAN' LIE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
LXCLOSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADULISUtlR`_:•.,.'..�""'. ...— .. -
LT►1 TYPE OF INSURANCE POLICYnY�[4,� POLICY NUMBER kP1MO/LD10Y MAD LIMBS
A GENERAL L1Al11LITY ! S202945900 8/10/2013 08MO/2014'EEACM�H��OEECTCURRENCE $1,0010
�l00
X COMMERCIAL GI'NrrA1,LIABILITY � PREhAItSES Ea NTErrynco $10000
CIAIMJ k1At11i Gil AOCCUROCCu
` MEO EXP(Any one person) s10,000
-- s 1 PERSONAL S AOV INJURY S 1 000.000
AGGGGRIA'-"- GENERAL AGGREGATE s3,000,000
GENtAEGA'TELIMITAPI'I.tESPf:R: t PRODUCTS-COMPIOPAGG 53,000,000
POt.tcV 1� �ndEGT� LOC s
A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/2014 X COMBINE 0 SINGLE LIMIT
ANY AUTO BODILY Y INJURY1,0001000
(POT S
ALL OWNEO SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) S
NON• __ `
X HIRED AUTOS X AUTOSOWNED ,. PeernOA GE. 4 xident
IQ X UMBRELLA O ocCUR S202945900 8/10/2013 08/10/201 I EACH OCCURRENCE
ExcEse LIA6 S5 000 000
_ GLAIMS•A1A®E AGGREGATE '<
RETENTIONS $5 000 000
WORKERS COMPENSATION .C AND EMPLOYERS'LIABILMY 0000068028-RI 8/21/2013 08/21/2014 X JOTH. s
g ANY
PROPRIrrORIPARTNERIEIIECUTNE Y I" WC STATU•AIC927818352394 8/21/2013 08/21/20141 E.L.EACH ACCIDENT s1 000 000
OPFtCERJMEMBER O. LUUE09 N I A
(Mandstory In NN) t
d a.desotDo unAa E.L.DISEASE.EA EMPLOYEE 41 000 000
0 SCRIPTION OP OPE TIONS Wow +
E.L.OISEASE-POLICY-MIT S1,000 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AUsch ACORD 101.Addldonol Remarks Schedule,M more apace Is squired)
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CER FICATE HOLDER CANCELLATION
SHOUL9q ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Southern NE LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS.
Lincoln,RI 02865
A M REPRESENTATWE
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.' ®1988-2010 AC0RD CORPORATION.Ail
S►eserved, i
ACORD 25(2010105) 1 Of 1 The ACORD name end logo are registered marks of ACORD
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