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HomeMy WebLinkAboutBLDC-24-12 ' - ' f f f I. of''''.4R BUILDING PERMIT APPLICATION • . . •F 4 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. �. 'k l Town oI larmouth Building Department M�TTACNtC3 %A"4•44..«f••"60, 1146 Route 28 • Yarmouth, MA 02664-1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Office Use Only Planning Board Information Assessors Department Information: Permit No. `�2 -1L Date Plan Type Map Lot Permit Fee $)0 Endorsement Date / Recording Date New Deposit Rec'd. $(0d A'V Date Plan No. 1.4 Property Dimensions: Net Due $ 3 4 Other Lot Area(sf) Frontage(ft) Lot Coverage • This Section for Office Use Only Building Permit Number: 2 Date Issued: Signature: --V' Certificate of Occupancy-f� d�J/1 Building Official Date is Is nal _ 77-1 Section 1 - Site Information $ s , 1.1 Propirty Addy ss: r �1 ro r� 1.2 Zoning Information: FEB o 7 2 02 Zoning Distnct . r Proposed'UseJ 1.3 Building Setbacks(ft) ' ..• Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Water Supply(M.n.L.a.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BFE: • Section 2- Property Ownership/Authorized Agent 2.1 Owner rt Re ord: �( Ct e ,'vl vk.le Z ` g cc Name(print) 9,t ___ Mailing Address: 7(74. -2_`�� _ ( 2 6 Signature Telephone Telep one Email Address: 2.2 Authorized Agent +e ✓ t 0 8-e-z. 439_ Ot•cc4, Hams(print) Mailing Address: Signature Telephone Fax Ernait Address: Section 3 - Construction Services . 1 3.1 Lie ns Const tion Supervisor- Not Applicable License Number Addre S"O- 77G I 66 6675-6- LAd $ /,� raonDategnature lephone ` r/ 2 4' Section 6-Description of Proposed Work(check at applicable) New Construction ❑ (tor multiple family only) No.of Bedrooms for multiple family t� 1 ( D yonly) No.of Bathrooms Existing Bldg. ❑ I Repair(s) ❑ I Alterations D'�, I Addition ❑ Accessory Bldg. 0 Type Demolition Other Specify: P fY: Brief Description of Proposed rk: ) 4,0/2-11S / Section 7-Use Group and Construction Type I Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ 0.t ❑ A•2 ❑ A-3 ❑ 1A ❑ - B BUSINESS ❑ Ad A to❑ S ❑ ❑ E EDUCATIONAL ❑ ❑ F FACTORY 0 El H HIGH HAZARD ❑ F t ❑ F 2 ❑ 2C K ❑ _ I INSTITUTIONAL 3A ❑ M MERCHANTILE ❑ I_t ❑ I-2 ❑ l.9 ❑ — :I R RESIDENTIAL 4 ❑ S STORAGE ❑ R ❑ R 2 laR-3 ❑ SAra ❑ U UTILITY ❑ 5-t ❑ 5_a ❑ se ❑ SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE Cl SPECIFY: Complete this.section if existing building undergoing renovations;additions and/or change Iri use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area I Building Area Existing(it applicable) Number of floors or stories Proposed include basement levels Floor Area per Floor(sf) Total Area AU Floors(sf) Total Height(ft) Section 9-STRUCTURAL PEER REVIEW(7BOCMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ��4?rtccc( ¶e�nor��lPZ ,as Owner of the subject property, hereby authorize /1 1 L I I�L JJ to act on my behalf,in all matters relativ work authorized by thiS.tiuilding permit application. Signature of Owner O"' t 1 2-e-/ Dale 4 r r of•Nr.9,4, BUILDING PERMIT APPLICATION • . ...;*c` '� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE,OCCUPANCY OF, ' _; �, OA DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. �l Z`'t Town 01 Yarmouth Building Department �TT.Z... f �,T+•.�•.",Cd' 1 146 Route 28 • Yarmouth, MA 02E56-1- 492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Office Use Only Planning Board Information Assessors Department Information: Permit No. 1)1-1`,:2 g-1L Date Plan Type Map Lot Permit Fee $ Endorsement Date / Recording Date New Deposit Rec'd. $4d LC Date Plan No. 1.4 Property Dimensions: Net Due $ e- 3 7 oh Other Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number: 2 Date Issued: `_- Certificate of Occupancy- „—_______....._ Signature: ._ ' ilk/,4 /Building Official ' Date is :1st*r~• r., .._ �•__._.__ Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: (n `7 �o�t� 2 ; FEB o 71014 I i i `/I I I i : - - Zoning Districtt ____Proposed Use . 1.3 Building Setbacks(ft) ' Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Water Supply MULL.e.40.S 54) 1.5 Flood Zone Information: '0 Commentx �/ Public Private Zone: ` gFE: . 14\?' Section 2- Property Ownership/Authorized Agent 21 Owner of Re orth 0 V? (A e ,,,,4.,vel_e2.___ q 6--ki,La,„( 17 (Q.4_,,,,_ (0 v„.€ . Name(print) Mailing Address: 71cr -zoo - ( 2 6 Signature Telephone Telephone Email Address: 2.2 Authorized Agent C >lq.Q►i c e z u 3g __4(Liot•43 Name(print) Mailing Address: Signature Telephone Fax email Address: '1Section 3 - Construction Services . 3.1 Ue need Const tlon Supervisort Not Applicable l] I Li" q b,-- - \ l i - License Number Add I SV 77(1 ' 7 // 2 6b 756— iration Date Signature lephone Email AdltPr — .Z j q(JJA Pa.-/v n A 4-lnl �; I ,l mU ' • , Section 6 - Description of Proposed Work(check all applicable)1 New Construction 0 I (for multiple family only) No.of Bedrooms I (for multiple family only) No.of Bathrooms ' Existing Bldg. ❑ 1 Repair(s) ❑ 1 Alterations A I Addition ❑ 1 Accessory Bldg. ❑ Type Demolition Other Specify: P fY: Brief Description of Proposed rk: AJ e-td cz 16 u ,.p-,72.-----i-iS iN.. k( -0a_.----i-ti-outa Section 7- Use Group and Construction Type I Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS El ❑ _ 2A -E EDUCATIONAL ❑ 213 0 F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ - 3A ❑ I INSTITUTIONAL ❑ • I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M MERCHANTILE ❑ ❑ _ 4 Ft RESIDENTIAL ❑ R-I ❑ R-2 ❑ R-3 ❑ 5A ❑ s STORAGE ❑ S-1 ❑ S-2 ❑ se ❑ u UTILITY ❑ SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this-section if existing building undergoing.renovations;additions and/or change hi use.' Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Areal • Building Area Existing (if applicable) . Proposed Number of floors or stories include basement levels Floor Area per Floor(st) Total Area All Floors (sf) , Total Height(ft) Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No I SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ifr(mot.wu e 1 "e cet c:t►1 mil- eZ , as Owner of the subject property, ,�/ hereby authorize I" t< l-464-+e- I f G. 11' to act on my behalf, in all matters relativ- • work authorized by thi uilding permit application. diffiXiMP K..% CI. / ‘ /2oi€,/. Signature of Owner Date The Conunonwealth of Massachusetts _=ram i Department oflndustrialAccidents =�1= 1 Congress Street,Suite 100 c•Siffil Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organ'zation/Individual): Address: 7,2 tM,lj-w f C- • �i9-2'wef/" City/State/Zip: 14"y, �66lf Phone#: GC ' 776I76•6 Are you an employer?Check the appropriate box: Type of project(required): am a employer with employees(full and/or part-time).• 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in ca act 8. Remodeling an y p ty.[No workers'comp.insurance required.) 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] .Any applicant that checks box it 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_ :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 po' and job site information. Insurance Company Name: Vpro. (�.. 1 v i2— Policy#or Self-ins.Lic.#: (�0 � (� /2.-3. Expiration Date: 7-I- Job Site Address: I tr?? 2 o 14-e, a.2? City/State/Zip: Attach a copy of the workers'compensation policy declaration ge(showing the policy num r and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify r the ins and nalties of p jury that the information provided above is tr e and correct. Signature: 4'i P� c , Date: Phone#: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: §TOWN OF YARMOUTH 1 146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR - Section 105.3. 1 . #4. I hereby certify that the debris resulting from the proposed workldemolition to be conducted at 7i2„N -1-ce Work Address Is to be disposed of oat the following location: 4246)4 ) 1-A-c, F Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111 , § 150A. q_102.4 Si na u g e of p ication Date Permit No. n Commonwealth ot Massachusetts , . ,..., 1 i, - Division of OccIipational Licensure %... ) . ,.. Board of Budding R ulations and Standards .. . - Cons ton S. ,10eirvisor .....:"Y. ,f• . . , - . S 06t1855 e5p i r es: 11/2212024 _.. MICHAEL A ALY Z aft* '401 ' -,..—, ": • 72 OLD NIA T SOUTH YAROpUlftt 4 1 i r .4 . . ,r y •,'''A t 1 •',0, ,4 • ot. 0, - - ,..-•:_,,, ;v., mliri +62 , Id.... •;i1 •t•t / '' ts,IP , It A , . *-4V0 4 • ,S) , -1. • , .,• . ,f.,,,, , .. - . , et- n • Jot- 4 j 144.4. / 1. t.,00 // • i• , lb , 1,11'1S/it. 4P 1 7 1*' : ,./1.. .....,. c , - . . . . . . . • . . . . . . . _ . • . . . • . . ., . . . . . . . . . --. . . . . ..• , . . 4 • • • . r . . 4. . . . . . . . . . . - . . . . , i . . . • , . . •. . . . . . . ..._ . . . • , .. . ' . p . . . . • .. . . , . v , . . . 7* ® DATE(MMIDD/YYYY)AC� CERTIFICATE OF LIABILITY INSURANCE 02/06/2024 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 Marshall Lovelette NAME: MARSHALL K LOVELETTE INSURANCE AGENCY INC PHONE No.Ext): (508)775-4559 FAX No): ADDRESS: marshall@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 975404 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 (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT 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 STATUTE ERH AND EMPLOYERS'LIABILITY Y/N A OFFICER MEMBER XCLUDED?ECUTIVE N/A N/A N/A 6S60UB0W65672423 08/19/2023 08/19/2024 E.L.EACH ACCIDENT $ 100,000 (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/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/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Four Seasons Trattoria Inc ACCORDANCE WITH THE POLICY PROVISIONS. 1077 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 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 ACCPRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/06/2024 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 Marshall K.Lovelette Marshall K Lovelette Insurance Agency Inc PHONE FAX 396 Main St (NC.No,Exn: (508)775-4559 (A/C,No): West Yamouth,MA 02673 ADDRESS: marshall@loveletteins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Co 17370J INSURED Healy Brothers Construction, Inc. INSURER B: 72 Old Main Street INSURER C South Yarmouth,MA 02664 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. INTRR TYPE OF INSURANCE ONCE SUBR POLICY NUMBER /YPOLICY EFF POLICY EXP LIMITS (MMIDDYYY) (MM/DD/YYYY) A (COMMERCIAL GENERAL LIABILITY NN1637497 01/09/2024 01/09/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED 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 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBEREXCLUDED? N/A $ (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/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 EXPITIONFour Seasons Trattoria,Inc. ACCORDANCE WITH TATE HEREOF, POLICY PROVISIONS.E WILL BE DELIVERED IN 1077 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE K// .O — ACORD 25 2016/03 ©1988-2015 ACORD CORPORATION. All rights reserved ) The ACORD name and logo are registered marks of ACORD