The URL can be used to link to this page

Home My WebLink About11-12121 CITY OF ZEPHYRHILLS 5335 - 8TH STREET C" Z �-9 12121 BUILDING PERMIT � Permit Number: 12121 Address: 38627 B AVE Permit Type: RE-ROOF ZEPHYRHILLS, FL. Class of Work: ROOF REPLACEMENT Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: MOORES FIRST ADDITION Est. Value: Parcel Number: 14-26-21-0010-01900-0090 Improv. Cost: 3,424.00 Date Issued: 7/20/2011 Name: SILVEREST, EDWIN R& ROBIN L Total Fees: 55.00 Address: 38627 B AVE Amount Paid: 55.00 ZEPHYRHILLS, FL. 33542 Date Paid: 7/13/2011 Phone: (813)388-0804 Work Desc: RECOVER SHINGLES OVER SHINGLES - 18 SQUARES 5. __—, ' � , � � s TAPE JOINTS ROOF INSP FINAL � — 1 ,.� • l I REINSPECTlON FEES: Reinspection fees will comply with Florida Statute 553.80 (2)(c) when extra inspection trips are necessary due to any one of the following reasons: a) wrong address b) condemned work resulting from faulty construction c) repairs or corrections not made when inspections called d) work not ready for inspection when called e) permit not posted on job site � plans not at job site g) work not accessible. NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management, state agencies or federal agencies. The payment of inspection fees shall be made before any further permits will be issued to the person owning same "Warning to owner: Your failure to record a notice of commencement may result in your paying twice for improvements to your property. If you intend to obtain financing, consult with your lender or an attorney before recording your notice of commenceme " i� a=..-es2.� ' � CONTRACTOR SIGNATURE PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER �asco County Parcel: 14-26-21-0010-01900-0090 001 Page 1 of 1 Data Current as Of: Weekly Archive - Saturday, July 09, 2011 Parcel ID 14-26-21-0010-01900-0090 (Card: 001 of 001) Classification 01 - Single Family Mailing Address Property Value SILVEREST EDWIN R& ROBIN L Ag Land �p 38627 B AVE Land $7,854 ZEPHYRHILLS FL 33542-6060 Building $44,083 Physical Address Extra Features $359 38627 B AVE ZEPHYRHILLS FL 33542-6060 Market Value �52,296 Assessed (Save Our Homes) $44,471 Leaal Descri�tion (First a �ines) Homestead 196.031 -$25,000 MOORES FIRST ADDITION PB 1 PG Non-School Additional Homestead Exemption -�p 57 EAST 66.00 FT OF LOT 9& SOUTH 2O.00 Ff OF EAST 66.00 Taxable Value #19,471 Ff LOT 10 BLOCK 19 Warning: A significant taxable value increase may occur when sold. Click here for details and info. regarding the posting of exemptions. Land Detail (Card: 001 of 001) Line Use Description Zoning Units Type Price Condition Value 1 0100 SFR OOR3 4,620.00 SF $1.70 1.00 $7,854 Additional Land Information Acres 0.10 Tax Area 30ZH FEMA Code � Residential Code ZFiLGLP7 Buildina Information - Use O1 - Single Family Residential (Card: 001 of 001) Year Built 1976 Stories 1.0 Exterior Wall 1 Concrete or Cinder Block Exterior Wall 2 None Roof Structure Gable or Hip Roof Cover Asphalt or Composition Shingle Interior Wall 1 P�astered Interior Wall 2 None Flooring i Carpet Flooring 2 None Fuei Electric Heat Forced Air - Ducted A/C Central Baths 1.0 Line Description Sq. Feet Repl. Cost New 1 � 264 $2,771 2 EA 192 $4,030 3 � � 1,200 $50,376 Extra Features (Card: 001 of 001) Line Description Year Units Value 1 DWC 1988 96 � $133 2 CLFENCE 1995 640 $226 Sales History Previous Owner BUSH DONALD N& M IRENE Year Month Book/Page Type Amount 1993 06 3159 / 1486 WD $55,000 1986 04 1498 / 0844 WD $37,000 1984 08 1357 / 1827 WD $23,500 h ttp://www.appraiser.pascogov.com/search/parcel.aspx?sec=14&twn=26&rng=21 &sbb=0... 7/13/2011 813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department Date Recelved _ / l / Phone Contact for Permltting _ Owner's Name ��? I� S� l�er�. Owner Phone Number �,3 $� �j �Q Owner's Address g6 �� Owner Phone Number Fee Simple Titleholder Name �— Owner Phone Number �— Fee Simple Titleholder Address JOB ADDRESS 3g6a� � � LOT # �� SUBDIVISION , PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED B NEW CONSTR 8 ADD/ALT � SIGN Q Q DEMOLISH INSTALL REPAIR PROPOSED USE � SFR Q COMM � OTHER TYPE OF CONSTRUCTION Q BLOCK Q FRAME C� STEEL Q DESCRIPTION OF WORK � � � � J BUILDING SIZE SQ FOOTAGE HEIGHT � BUILDING $ � �� VALUATION OF TOTAL CONSTRUCTION �ELECTRICAL $ AMP SERVICE C� PROGRESS EN�RGY Q W.R.E.C. QPLUMBING $ �� QMECHANICAL $ VALUATION OF MECHANICAL INSTALLA ON QGAS � ROOFING Q SPECIALTY [-� OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO BUILDER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address � License # ELECTRICIAN COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address , License # PLUMBER COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address License # �— MECHANICAL COMPANY SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N Address License # OTHER y! _ �� COMPANY w(�1 N C� �p �� (N SIGNATURE 'X� REGISTERED Y/ N FEE CURRE� / N Address �.�� `Q � C License# C �.-�S� ��.- RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction, Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w! Silt Fence installed, Sanitary Facilities & 1 dumpster; Site Work PeRnit for subdivisions/large projects COMMERCIAL Attach (3) complete sets of Building Plans plus a Life Safety Page; (1) set of Energy Forms. R-O-W Permit for new construc6on. Minimum ten (10) working days after submittal date. Required onsite, Constructlon Plans, Stormwater Plans w/ Silt Fence installed, Sanitary Facilitles & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet wmpliance SIGN PERMIT Attach (2) sets of Engineered Plans. "'*PROPERTY SURVEY requlred for all NEW construcUon. Directions: Fill out application completely. Owner 8 Contractor sign back of application, notarized If over;2500, a Notice of Commencement (s requlred. (A/C upgrades over;7500j " Agent (for the contractor) or Power of Attomey (for the owner) would be someone with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (Front of Application Only) Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage) Driveways-Not over Counter it on public roadways..needs ROW NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions" which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any applicable deed restrictions. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation under state law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for the intended work, they are advised to contact the Pasco County Building Inspection Division—Licensing Section at 727-847- 8009. Furthermore, ff the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign portions of the "contractor Block" of this application for which they will be responsible. If you, as the owner sign as the contractor, that may be an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco Counry. TRANSPORTATION IMPACTIUTILiTIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of use in existing buildings, or expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and 90-07, as amended. The undersigned also understands, that such fees, as may be due, will be identified at the time of permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to receiving a"certificate of occupancy" or final power release. If the project does not involve a certificate of occupancy or final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water/Sewer Impact fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances. CONSTRUCTION LIEN LAW (Chapter 713, Florida Statutes, as amended): If valuation of work is $2,500.00 or more, I certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law—Homeowner's Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone other than the "owner", I certify that I have obtained a copy of the above described document and promise in good faith to deliver it to the "owner" prior to commencement. CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the information in this application is accurate and that ail work will be done in compliance with all applicable laws regulating construction, zoning and land development. Application is hereby made to obtain a permit to do work and installation as indicated. I certify that no work or installation has commenced prior to issuance of a permit and that all work will be performed to meet standards of all laws regulating construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I aiso certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is my responsibility to identify what actions I must take to be in compliance. Such agencies include but are not limited to: - Department of Environmental Protection-Cypress Bayheads, Wetland Areas and Environmentally Sensitive Lands, Water/Wastewater Treatment. - Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas, Altering Watercourses. - Army Corps of Engineers-Seawalls, Docks, Navigable Waterways. - Department of Health 8 Rehabilitative Services/Environmental Health Unit-Wells, Wastewater Treatment, Septic Tanks. - US Environmental Protection Agency-Asbestos abatement. - Federal Aviation Authority-Runways. I understand that the following restrictions apply to the use of fill: - Use of fill is not allowed in Flood Zone "V" unless expressly permitted. - If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan addressing a "compensating volume" will be submitted at time of permitting which is prepared by a professional engineer licensed by the State of Florida. - If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wall construction, I certify that fill will be used only to fill the area within the stem wall. - If fill material is to be used in any area, I certify that use of such fill will not adversely affect adjacent properties. If use of fill is found to adversely affect adjacent properties, the owner may be cited for violating the conditions of the building permit issued under the attached permit application, for lots less than one (1) acre which are elevated by fill, an engineered drainage plan is required. If I am the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work, plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invatid unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension may be requested, in writing, from the Building Otficial for a period not to exceed ninety (90) days and will demonstrate justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR OTICE OF COMMENCEMENT. FLORIDA JURAT (F.S. 117.03) � ` OWNER OR AGENT CONTRACTOR Subscribed and swom to (or afflrmed) before me this Sub�s_c�ri�be�d� and sworp.�{oyaffirme�) bgfor� by - `� �.P-' /,(/C Who Is/are personally known to me or has/have produced Who is/are personally known to me or ha as iden fication. as identlflcadon. _ ' ,� � Notary Public _ ary Public Commission No. Commissfon No. ,,,��,,,, ,••'s�� BOBBIE S. SWETLA Name of Notary typed, printed or stamped Name of No � =•;� Explres February 22, 2012 ,o< ,, , eondW7lwTroyfalnlMUmorAW�36&7oto :� � �! �r ��s ��; � ��, � �,, � ��. � � ____-_ ,r, _ � I -,,: � Y ��,...., _...�.. .__. SNIP `_ � /' ' i r _ ', r ltiT� < i ? 1 i r i - 9 (; , t i ._„+.._.�.-. - _ ✓ �.�—' i � t J �. . ' �1, a j ! / ��_75„�_._._. �'s___ � ��.�. ��. J " J � , � w : .---��T ��°-- / - y y . i � ��:_ ' 'l,/ i �� n b �(//,,�_ � 1 .e.__.._..._.t--°�' � e � � � +, y.. (y.—,i X --- '�'r —'T'�"^�� ,_. �__..._.._.e.� ! 1.{� � , _ v ' ��r��T :1,tA?i�� %` � '� �� ,* r �.--�e--T--_L,�_ �.O.B. ,e DATE � �,.,. M,__-.._.., i TEnPlIS � � I �'r;;W° Ca •L ��'� bOtU EY � � � ' � . °` PRt�E n UNI� A i�UNT � •R Q�S1��t1�Y9Uh � ;; OF�ER°_i� ��5*��'� _.._.i_, --; , ��—� a � � --------�-�- ; �' � . - . — _ r_--�-�_ . -- � - -- , �-�-.---------�-�:� _ , � , t.� ; ----��, . '�' R ' i � --�-M�;. _ • r � �� -___-___-�� „�. r ,__._-________--- '� ��..'� �" � �, �.� i � � y . _ v..._._ �� 'R"" � - --- , � ___ _,_.� _;—._ � __� —�T!! �, : �: � , �, � � -�- , ; , � __.__ _ _ �__ ; t __.� � _ '� ��__..._ ... ..�. _ _. � .er ; ` � ____ - �.�.__._______._.�.____�_.._�_�._ ff�.--�--�-�,�;-��,,'�,°��'_ �, .',t � �r"�� - � , ; , r �--=— �t. p4•i9 4--_ __ __.____q_�. _._._ _�.�. — — — ;� m� t'` , t ` �'; 'll�. .�.- ,.. : � - -- �, a.-±.i �:� ... ,.; nr,...r; ^�.�_a.�� Mpo�e s �<,�s �""/�� P..3 t P�' 3� � ��.� f ar <�t� �- S � � oo - �t o��T4 ��. Qo f=T. Lea� r o �4�c% I� �� s� P� i�� . zeiii0�iaa ` NOTICE OF COMMENCEMENT \' ��. .� Rept:1377544 Rec: 10.00 PermitNo DS: 0.00 IT: 0.00 07/12/11 K. Gareia, Dp{,y Clerk Property Identification No f�'�(p - 2 f-� o f O_ p ! g� -�� O ( THE UNDERSIGNED hereby gives not�ce that improvements will be made to certain real property, and in accordance with Sect�on 713.13 of the Florida Statutes, the following mformation is provided m this NOTICE OF COMMENCEMENT ___._----'° 1 Description of property (legal description :) �_ a) Street Address• �t"-� ' m D 2 General description of improvements. 3 ' ? Z o v � � �/.a D N N 3 Owner Information � � o a) Name and address. ! `z m , b) Name and address of fee simple titleholder (if other than owner) 3 � Z ' ��' r c) Interest in property (f;'� S Contractor Information � o a) Name and address: N D b) Telephone No • _ � /`?°�tie C � 3SL� � � a 5 Surety Informat�on Fax No. (Opt.) � � � a) Name and address• � � b) Amount of Bond �� c) Telephone No � c , 6 Lender Fax No (Opt.) � � a) Name and address � o r r 7 Identity of person within the State of Florida designated by owner upon whom noti es or other documents may be served. A a) Name and address: b) Telephone No.. 8 In addition to himself, owner designates the following person to receive a opy ofthe Notice as provided in Sectimn 713 13(1) (b), Florida Statutes. a) Name and address. b) Telephone No 9 Expiration date of Notice of Commencement (the expiration date is one year from thO date of recording unless a different date is Specified). WARNING TO OWNER: ANY PAyMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEIVIENT ARE CONSIDERED IMPROPER PAYMENTS UND�R CHAPTER 713, FLORIDA STATUTES AND CAN RESULT IN YOUR PAYIN� TWICE FOR IMPROVEMEN S T� YdUR ROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BE�l�� TgE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT YOUR LENDER OR AN A�'TORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. STATE OF FLORIDA SHERRY WlDNER �`� COUNTY OF PASCO ��,.,,,' N Hotary Pub�c; State of Floride �' � i �� y �� ,�,,,�,,,`_- �n �� Si na re of Ow er's n ed Officer/Director/Pa Manager • ; 4Y111 � I�It011�71 JY� N �^ � � �. . • DD943�52 � / Print Name , �+ he foreg instrument was acknowledged before me this � day of �� Y 20 � b l� �/•l J� 1 �f 2 rt o c`E' as �� Y in fact) for � e of authori �' (name of party on be om 'nstrumen� f ��y as� ' Personally Known �pR Produced Identification - Notary Sig ature "`� � :` _�� . � �., � ;,`',r��',;s Type of Idenhfication Produced �� l � i ��, e � Name (prmt) �� Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that have read the forego�ng and that the facts stated in it are true to the best of my knowledge and belief. k FORMS/NOC,rvsd2007 Signature of Natural Person Signing Above STATE OF FLORlDA, COUN�'V''�•��` �'`� � THIS IS TO CER1'IFY 7HAT'fHE FOF��G IS A, TRUE AND CORRECT COPY OF ��CUMENT ON FILE OR OF PUBLIC RECORD IN THIS OFFICE , WITNESS MY HAND AND FICIAL SEA2 THIS '.�. � � � AY IL�CL K ` MRTF20� � . PAULA S - J + DEPUTY CI.E�tK BY i �� DATE(MM/DDlYYYY) �,,.,,.,-� CERTIFICATE OF LIABILITY INSURANCE 07113/11 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 be endorsed. N SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, eertain 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 Statewide Insurance LLC PHONE (352) 523-0800 ac No : (352) 521-5936 12214 US 301 E-MAIL Statewidelns�earihlink.net Dade City FL 33SZ5 � INSURER S AFFORDING COVERAOE NAIC # Phone (352) 523-0800 Fax (352) 521-5936 INSURERA. United SpeciaNylnsurance INSURED INSURER B . Widner Roofing INSURER C . 37506 Moore Dr INSURER D. Dade City, FL 335255635 (352) 567-1465 INSURER E: INSURER F . COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERT�FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TF1E 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 ADD UBR LTR TYPE OF INSURANCE PO�ICY NUMBER MMroD/YYYY MM%DWYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OOO.00 � COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED �� ' PREMISES Ea occunence S ❑❑ CLAIMS-MADE � OCCUR NS1 Z1009 �` � MED EXP (Any one person) $$,�.0� A ❑ 07/07/2011 07/07/2012 � ❑ PERSONAL & ADV INJURY S 'I.�OO,OOO.00 GENERAL AGGREGATE S Z,OOO,OOO.00 GEN'L AGGREGATE LIMR APPLIES PER. PRODUCTS - COMP/OP AGG 3 Z,OOO,OOO.00 POLICY ❑ PR �� ❑ LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident y � ANY AUTO BODILV INJURY (Per person) S ALL OWNED SCHEDULED ❑ AUTOS ❑ q�7ps BODILY INJURY (Par accident) $ ❑ HIRED AUTOS NON-OWNED ❑ AUTOS PROPERN DAMAGE $ � ❑ Per accident S a UMBRELLA LIAB Q �LAIMS-MADE EXCESS LIAB EACH OCCURRENCE S AGGREGATE y ❑ DED ❑ RETENTION $ WORKERS CAMPENSATION 3 AND EMP�OYERS' LIABILITY � WC STATU- � ORH- Y/N I T ANY PROPRIE70R/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/ A E.L. EACH ACCIDENT g (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYE S DESCRIPiION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Zephyrhills THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PO�ICY PROVISIONS. � AU7HORI2ED REPRESENTATIVE Mark Capes ACORD 25 (2010/05) QF O 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD