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3 10 OLIVE ST BP-2017-1327 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-242 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit# BP-2017-1327 Project# JS-2017-002197 Est.Cost: $4001.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo: HOME DEPOT AT HOME SERVICES 105953 Lot siae(so. ft.): 8232.84 Owner: SINGH MAHAN Zoning: URB(I00)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 10 OLIVE ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROV I DENCERI02908 ISSUED ON::S/16/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS 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 It Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTepe: Date Paid: Amount: Building 5/16/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner • Department use only ;City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street SewerdSeptic Availability I_ J Room 100 WaternNell Availability orthampton, MA 01060 Two Sets of Strudural Plans +••- 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONEORTWOgFAMILY DWELLING SECTION 1 -SITE INFORMATION AP' f7- / 3AJ 1.1 Property Address: se This section to be completed by office /v D /iV€- Map r/ Lot h" Unit L Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i✓Da( 4),d# /P NIYr - Name(/Pr�int)) �//� �/�- Current agiNtliCG/1.,,, _ '/� 4Z n `1iD V '�f •'7 c Telco 4ii. l��r// ZZ/ C / (1 Signature [ �� 2�J yy 2.2 Authori A e ' - Name(P . Current ding Address Mit 40 J- Z/1- Sig•aure Telephone U) J.te f SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 922 / „�/O (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 14 6. Total= (1 +2+3+4+5) Pg/-J' ) Check Number a f afl fclo This Section For Official Use Only Building Permit Number: Date Signature: !/// / ��I' _/�_/9 Building Commissioner/Inspector of Buildings Dale Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column re he filled in by Building Dcpanment Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg_Square Footage Open Space Footage (lot area minus bldg&paved par in¢) F of Parking Spaces Fill: (volumeherad,m) _. . A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YEs O IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation.or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) I I I� I� New House I Addition CI 'Replacement ows Alteration(s) I Roofing I I Or Doors LL9� Accessory Bldg. ❑ Demolition� El New Signs [D] Decks iQ Siding[D] Other[D] Brief Descriptio of � //r i `, n / �/,_ f 44 /�' Work: ptio /l�//y// (r/�l/ijj�,J F' �/ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? L Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No I. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR'AP/PLIIES FOR BUILDING PERMIT a'J I, 6 ON' /D `7. LI -.< J.41 , as Owner of the subject property �f/i� �,. f� �/� hereby authorize ) Y-ALI 720) - to act on my behalf, in yYpialll�era live tow orized y this building permit application. Signature`reof Owner Date C Date I. L//r1ectni � 2-6519...4,1— ,as Owner/Authorized Agent hereby de are that he statements and imation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under t s aid penalties of peri ,. PDr.FN'd at , A Signature n Owner/.gent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisorya:� Notot/Applicable 0 Name of License Holder: T�a// ? / !/ _////� License Number ,) e & Lrrtr� /6�6 AddressExpiration Date ,p, -A% A1 491126. Signature Telephone ) z> 135 9.Res istered Home I • •roveme Contractor: Not Applicable ❑ /12743-- Compan Name T'� Registration Number •.tl -ss Expiration Date / Telephone 4% SECTION 10-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 qd No . 0 11. - Home Owner Exemption The current exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(11 or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own 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 homeowner. Such"homeowner shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will he required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 {Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated.you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code.City of Northampton Ordinances State and Local Zoning laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: E.) 292114- 21 T /1/Sp' The debris will be transported by:"(4112.-C- -- - / �4 ,�"/1y— The debris will be received by: "(jlyl�YC� / Building permit number: y� Name of Permit Applicant r1 '1> �%/, Date Signature of Permit Applicant *40 IL Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg.#126893 Salesperson Name and Registration Number: Timothy Drost : HIS 0553710, R-R-073-15-00005 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: SANDEEP SINGH Boston North 10016523 First Name Last Name Branch Name Lead 10 OLIVE STREET LNorthampton MA 01060 Customer Address ity late Zip (413) 923-8519 Home Phone# Work Phones Cell Phone# deep03877@gmail.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address Citytar ZIP or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOTS EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: X 04/30/2017 Customers Signature -- Date 1 Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. Includes all applicable discounts, rebates, and , taxes. Contract Price $ 4001.00 Excludes finance charges.* Minimum °/deposit$ Due Immediately Remaining balance $ Due upon completion Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will❑will not v be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date I Installation Schedule Approximate Start Date: 06/25/2017 Approximate Finish Date: 07/23/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. L Initial Acceptance and Authorization; By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. XI _- - _ 04/30/2017 lCustomers Signature Date X Coagre, if applicable) Date X -- �- - 04/30/2017 Sales Consultant's Signature Oate License number(s) held by or on behalf of the Home Depot: 2 WINDOW SPECIFICATION SHEET - Specsheet p'. 10016523 Sheet 1 of 1 Customer. SANDEEP SINGH Job N'. 10016523 Consultant. Timothy Drost Dale. 04/30/2017 New Window Hinge Locations Existing Window Measurements Grids Pmduc1 Optans Lahr Options From outside. Leu to Right Bays.Bowls Location Color Rough Opening 4 oL bars N of Dare Csmms.1 Pm use L.R or S Gla„ Mme hems Hardware Code Screens For doors use g n 3 Mull 'S"e stationary or w Style Wraps _ `" r Eh_ _ _ p 6_ %=operating P Room FI Code (YIN) SlyieCode BenesCode w 3 x o r w o a s E > m STD.Classame Same.' WRAP.rsu STD Glasseask Slandara *RAP.LSH 2 LIV Isl OH y OH 6100 SIG Ian 3F F2 54 Fe F5 SPECIAL CONSIDERATIONS'. wrap color t While 2:Wbne 3:White.4'.Mute M.SCA.Budd bulla arm Oak off laoulsay windows ntenor Casing Type Bay or Bow window Seatboard material(vinyl onlydl rv8 or oak) Say Protech Angle In°r45) Say Flanker Type{DH.Stu.on camnt Top of window to soffit(inches) 'tied to soffit.cola of sect material I nave reviewed and agree with all the lob specifications above and Oe Construct Roof(Yes or Not Speoal Terms and Conddiare on the Lollowlng page Garden Window Seatboard Materia I(vinyl only-White Fbnite.B itch or Oak( Wall Thickness undies) Customer Signature Additional Shell(Yes or Net •There is no guarantee IMl new shingles will match existing color. ,04 , d t r14nc1mq ketikiLltl (MS Whi 31 IC iV cC n S 4: : CSS L-105953 , . , • IGOR GUSEV :,14'4, • 21 KIBBE LANE HAMPDEN MA 01036 • f 05/ 18/2018 • • • li 11 i !;;FOCOOt9_ — - mz;•LH �'r. 2£E^_b :G/CSi3`E'n^- li , Id¢tS S^.l.7 "Som j; ii " 0,.r:'rr-sv:`JLYSONINU'cir P:Il''s r VES�;LC. I '1 .S3NR JWJebtt"ie—t J:OL'YC.idl AKIVNV!ISt4V ::S! �^.usfi`1"-'-_s!4�_ r it 17 . if I III II I� JI 11 0 j H Iiiit cartipwoSmd sse;',�/OOurt�:0i4i - - f_L='-_f f i II 1Tut ,QA .eEPte% -- :J.1 . , 11 I W3J!-C$ LCf -� 12E1ian LE!N$1 '° �o! Ft%ll " T;:+T &'f • _ � ',Zs"- a • n:- i s-- elME_FI. . ii OLMIWOW Vt2O WVIlialtbrtaig wor_mmere io Balli MOMVindOda-,d ;�-tgeaIajvr !_ _ rte- ii 'i 0= '�. 1. ._ II r ii . sista i ySIdii'dc 592JCiNd©_raz i.'=;moi-!_7+7 it Jo<S--0 Z]^_OPS?'dZ '�'.1eg-GrD ( • SEL@JJO✓.aa3JGC�-cf , - a:.:=1: -'mo▪ i. 1 - S-a-.;aL! 1- att'.oipla,su S�2-opyl.—'.4oilinS gp"as -=aK _r..v_-__ ii ii . ' `-- o-a __o.. of lar: is'-:J ,.LL. •u, _ ! r▪i - ji . . L - - r; e f_ o in mo net/ea/tie Jac ee.selt Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC 2455 PACES FERRY RD C-11 HSC --- -. ,. Expiration: 04/22/2079 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. a . vi oPM1•a. ❑ Address 0 Renewal 0 Employment El Lost Card Office of Consumer Affairs&Business Regulation -.<.. ..:.. HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. If found return to: _ Registration Expiration Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 RICHARD TROIA ALC'GC�F--� I/ f� „ 2455 PACES FERRY RD C-11 HSC Y ATLANTA,GA 30339 Undersecretary Not valid Niihau signature ACORD D CERTIFICATE OF LIABILITY INSURANCE DATE "TE„IMM/00IMM/00/11111Y ' 3(117 30...---- 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 pollcyfies)must 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 net confer rights to the certificate holder In lieu of such endonementls). PRODUCER thNTACT MARSH USA,INC. PHON: I`WO ALLIANCE CENTER PIC.NNo Esti, '(NC.Nog 350 LENOX ACAD.SUI IE 24W SMAB ATLANTA,GA 30325 Amass ..� INSURER'S'AFFORDING COVERAGE I Nile 1Ce493Has,(80A'N'-17-08 ]SUPER A:OA Rambla Insurance Co 12414TINSURES .� .�. THE HOME DEPOT PAG NSURERe=A4e(idnptal Minns CgNdp,4gy $2)5? HOME DEPOT U.S A.INC I PuvuxC:ILYw HdR9sBiH Ms Co INSURERS.;2455 PACES PERRY ROAD INSURERS.: BUILDING 1140 INSURER E: ATLANTA,GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER: AT1-803746381.14 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VJRtI RESPECT TO AMICH 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, ILSRRI me OF INSURANC-Io11<SyUryByR PCLICYNUMHER raget.S.41 IpaoUyYER A X CGMYERcaL Gel<ERALOAISILMEm91(310022 0 10 12014 1Aa1TS 03212018 DAMAGE TORSXGP !s 1007.8]'9 1 CIA MSMAGE X....OCCUR PROSSER.TO EMARMt S EXCLUDED LIMITS GFPOLICY XS I MED EXP Ray ale Amon) S EXCLUDED r .. ICF SIR:SIM PER CCC PERSONAL ACV INJURY 11 9.90.000 GEMS AUOREGATE LIM i APPLIES PER GENERAL AGGREGATE I s 9,900200 X tOLICY -_.. wr LOC aROOUC c-CDYPOFAGG S 42n07700 OEM_' { I s A AUTOMOBILEUAOLUTY IMWi811W21 i01D12911 031012010 L,Cp:Fe s:N[IL.;Nit IIs 1.309.000 X I ANY Auto I ROPILY INJURY]Per person) 5 IALLOV40 -' ^,CNEDULec SELF INSURED AUTO PHYDMG f $ cel OS LI AUTOS 1 HIaE41AUTOi i AAUTOSAmEO I N D est! wf arm.nl�'I 3 I - s ._ UMBRELLA LIPS OCCUR EACH OCCURRENCE $ IL Exuma UAB I CLAIMSUAOE • AGGREGATE IS DEO IRETENL:ONf Is B 'WORRERS COMPENSATION 8W1$C491129391TN) I93ICs8097 `83912010 XII PSi 1 IWH- • D MPLOYERS'LAHIUTY y aiiNTE WYPRO+RRSCRFPARTMEGEXECNTE 1`NNI NIA 00923192923(AK,NH.NJ,VT) ,0Ai2011 9bDt24f8 iTC,iC6 CF;ICERIME!eaEP EXCL'UOEO$ EL:ACHACCT.EN! 1 {Mandate In NH) I [INC 023102424 MI) '0310,12017 [9319112918 LEL DISEASE-EA EMPWYEdi 1,fX:9,000 V ]lay dni„nheuMer 1CpniimJLH no AtltliI ndl Page ! LEL DISEASE•POSICY LIMIT s 100.90 I ESCRIPN)N OF OPERATIONS B&Les I 1 DESCRIPTION OF OPER/MONS I4OCAr1oNs I VFL1CLEa(ACORO/al.A44111nnal Remarks Salida Ery M aN[Md If mon space le rMu'md) DICENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION ROME DEPOT USA.NO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH TIE POLICY PROVISIONS. AUTRORPED REPRESENTATIVE of Man USA Inc. ManasNN 51uU,erjee LTATALLAncoai •SFAHAAoL.4tA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A'IS ENG[GLS TOMER.ID: 1 36.132 LOC I: Atlanta ACOROe ADDITIONAL REMARKS SCHEDULE Page 22 ar 3 1AGE I AMiO Neue=_D ...]n,. 'c -‘0&:;M? is SO :MP sILS-CNC 32PM FitiCY NUMBER 21) ?AeES ;p''CAC 312113t1.. 3Ta A i! SMS tC3ReiER :SCCF i_ DAR: ADCISICNAL REMARKS THIS ADDITIONAL RBMARK3 i ORM 13 A SCHEDULE TO ACORD FORM, i ORM NUMBER: 25 FORM TITLs, Certificate Of tiabliitr Frsurance 'homers'1mytK3Nl Cal,muM Caow-*immt(rs&3nc4:amass Yl sort l nerca P,41matr XI. alapm_,0.A:a,l`1_A MS 4.1C'lEe1.1,`19:14 a,3C.'I N"I €ts[.e9ale:PJC1401? 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