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23B-014 (14) 125 LOCUST ST BP-2020-0410 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23B-014 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:NEW GAS FIXT BUILDING PERMIT Permit# BP-2020-0410 Project# JS-2020-000695 Est.Cost: $600000.00 Fee:$0.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LEMELIN ENVIRONMENTAL SERVICES INC 063124 Lot Size(sq.ft.): 730501.20 Owner: NORTHAMPTON CITY OF BOARD OF PUBLIC WORKS Zoning: SI(100)/ Applicant: LEMELIN ENVIRONMENTAL SERVICES INC AT. 125 LOCUST ST Applicant Address: Phone: Insurance: 477 CHICOPEE ST (413) 598-8555 WC CHICOPEEMA01013 ISSUED ON.10/3/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW FUELING STATION 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: 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 Sig(nature: FeeType: Date Paid: Amount: Building 10/3/2019 0:00:00 $0.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0410 APPLICANT/CONTACT PERSON LEMELIN ENVIRONMENTAL SERVICES INC ADDRESS/PHONE 477 CHICOPEE ST CHICOPEE (413)598-8555 PROPERTY LOCATION 125 LOCUST.ST MAP 23B PARCEL 014 001 ZONE SI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid Typeof Construction: NEW FUELING STATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 063124 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF *MATION PRESENTED: V Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Qe�:�n, / ,e — i4 z Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. C" - � Versionl.7 Commercial Building Permit May 15. 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/ Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plct/Site Plans Other Specify ������, APPLICATION TO CONSTRUCT, REPAIR, RE TOHAN VATE, ONE OR H FUSEAM LY D i� v --"�M LISH ANY BUILDING SECTION 1 -SITE INFORMATION 7 19 SCI 1.1 Property Address Th section to be complete by o ice /v ori2mpfon 1�1✓ Map �' GTIONS nit ia5 Locust S+ �` �nr?� �` ' °IrI�ItJ ,oeo f1RTF1AVAi 1"') MA I �ofa�np�nn MA Zone `-IIverlayDistrict 0 (UCoO - Elm St.District— CB District - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: i Signature Telephone 2.2 Authorized Agent: /DoXAA �pK�c i Name(Print) Current Mailing Address: Signatur Telephone ( 3 '.S lj 7 (S / SECTb'9 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (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 6. Total =0 +2 +3 +4 + 5) 00/0 J: ' Check Number /v This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building F_^_h Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description Enter a brief description here. c �� A-C a N Of Proposed Work: NCw r SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) St 2nd 2nd 3 d 3rd 4th 4t" Total Area(sf) Total Proposed New Construction (sf m Total Height(ft) Total Height ft 7.Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW C) YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® 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 ® NO 0 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required, t \ Vcrsion1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Eric Bernardin Civil Name Area of Responsibility 1550 Main Street Springfield, MA 01103 37950 Address � .I Registration Number 413-452-0445 6/30/2020 Signature Telephone Expiration Date Elizabeth Landry Mechanical Name Area of Responsibility 146 Hartford Road Manchester,CT 06040 54069 Address Registration Number 860-646-2469 6/30/2020 Signature Telephone Expiration Date Richard Boggs Structural Name Area of Responsibility 56 Quarry Road Trumbull, CT 06611 42477 Address (2-f x �l Registration Number t J/Imo' 203-374-3748 6/30/2020 Signature Telephone Expiration Date Kevin Sullivan Electrical Name Area of Responsibility 108 Myrtle Street Quincy, MA 02171 47127 Address Registration Number 617-282-4675 6/30/2020 Signature Telephone Expiration Date 9.3 General Contractor �PIYI�i n �h✓i�D n/rlc�n-� a �eN/ CPS �/1 c. Not Applicable ❑ Company Name: Daniel 1_er ell , Responsible In Charge of Construction ir ./V A A 1 O Ck t c n tae e S+ Chj�opee /AA Address O� 71j59�-�55 Signature Telephone CL 413.-2114 941,5 Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS 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. Signature of Owner Date I, as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties„of pe jury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: /� /C// d,_,l �em License Number 5a U/C✓ L y�►,n n% � Ch%C Q,�e.e_.G`!��1.. c z � s� __.. �'S C�Li .l a`� Address Expiration Date A711-3 `�C^9 12'/-1 S &/2.7/�D�d Signature Telephone SECTION 13-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 b ding permit. Signed Affidavit Attached Yes & No 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: /,�� ,oc- AA o ►o(�p The debris will be transported by: 9� The debris will be received by: Building permit number: Name of Permit Applicant L�rr�/,,, f,,,�,��rnP;,�� /� )��,�� c es /.,C-. 5 Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents s 1 Congress Street,Suite 100 Boston,MA 02114-2017 b 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/Organization/Individual): .L Ci�'»P �/�rG�,mP ,fcz SP�Vi LLS ✓n c- Address: '7() /,/ City/State/Zip: C,V�,G c p e-e- M A0 X0,2 o Phone#: 3 — 5.5 5 Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with f employees(full and/or part-time).* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have worker;'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.fZOther /0 n 152,§1(4),and we have no employees.[No workers'comp.insurance required.] O e-X,5b-7 rrn *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: L� —Snp C -1z v /i2 S Policy#or Self-ins.Lic.#: tic /,)Qg —(?3 Expiration Date: Job Site Address: 105 LockA51 E4 City/State/Zip: � 1A 6%occo Attach a copy of the workers' 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 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 be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerrtttify under the pains andpenalti/et 's ofperjury that the information provided above is true and correct. Signature: ( /yl9 P /,live �.riY!Q�✓L_ 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia LEMEENV-01 NICOLE A`URO CERTIFICATE OF LIABILITY INSURANCE F °`�'M""°°"""' 8/22/2019 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 eCi2NMEAcT Angela DiAugustino Phillips Insurance Agency,Inc. PHONE 413 594-5984 FAX 97 Center Street ac,No,Ext):( ) (ac,No):(413) 592$499 Chicopee,MA 01013 14DrAss:angela@phillipsinsurance.com INSURERS AFFORDING COVERAGE NAIC k INSURER A:Capital Specialty Ins Corp _ INSURED INSURER B:EMC Insurance Companies 21415 Lemelin Environmental Services INSURER c:Granite State Ins Co 70 North Chicopee Street INSURER D: Chicopee,MA 01020 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 010790 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 CONTRACTOR 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 SUBRI POLICY EFF i POLIC TR TYPE OF INSURANCE INSD WVD i POLICY NUMBER ININDR IMMIDE= OMITS A X COMMERCIAL GENERAL LIABILnYEACH OCCURRENCE $ 1,000'000 CLAIMS-MADE FX]OCCUR ENV20181613-025/3112019 5/31/2020 DAMAGE TO RENTED 100,000 X Per Project AggrEegat MED EXP EMESES An onee arson Ea occurrence) $$ 10,000 PERSONAL&ADV INJURY $ 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000'000 POLICY[7X %COT F7�LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 1,000,000 accident $ j X ANY AUTO 4=3W 10/29/2018 10/29/2019 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ _ HIRED NON-AWNED PgqOPERTY AMAGE AUTOS ONLY AUTOS ONLY Peracadent $ $ AUMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAR CLAIMS-MADE EX20181614-02 5/3112019 15/31/2020 !AGGREGATE $ 5'000,000 DED X RETENTION$ 10,000 Prod/Completed $ 5,000,000 C WORKERS COMPENSATION X I PER OTH- ANDEMPLOYERS'LIABILITY STATLITE WC 009-93-6626 11/3/2018 i 11/3/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA E.L.EACH ACCIDENT $ _ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1'000'000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1'000'000 A :Pollution ENV20181613-02 5/31/2019 5131/2020 1,000,000 A Professional Liabili ENV20181613-02 5/31/2019 5/31/2020 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I 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, City of Northampton ACCORDANCE WITH THE POLICY PROVIS ONSCE WILL BE DELIVERED IN 125 Locust St Northampton,MA AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD