HomeMy WebLinkAbout0078 FRANKLIN AVENUE
jJ
16
.b- A414-,
I,N7
Assessors map and lot number ... `.1. ............... .7�
SEPTIC SYSTEM MUST 13E
INSTALLED IN COMPLIANCE
Sewage Permit number % ............................................. V!ITH ARTICLE II STATE
SANITARY CODE AND TOWN
�QyoF7MEro�°o� TOWN OF BARIV"OASLE
Z BABHSTODLS, i '
"69 H-1 DI` INSPECTOR
APPLICATION FOR PERMIT TO ./� 1. ...... ....... ............ ....................: .....................................................
TYPE OF CONSTRUCTION .......................... "" ................ .............................
1..v� .19.)
TO THE INSPECTOR OF BUILDINGS: r ^^-
The undersigned hereby applies for a permit according to the following information:
— v ..ff :.1.......... ......... /.
Location ..L-..d..�"'........ � �- !1/ '�� 1�. ./L ✓ .5..................................
........... ......... .. ..........
ProposedUse ...................................................................................................................................................
Zoning- District ........................................................................Fire District // .....;111 11%S
�E�$' ,3/?.../e.... ... .��lx�.� ��1�..Address ,��1/ .. `..........r?r, �-ll.�ll�l�l.s..............
Name of Owne ............ ...
Name of Builder ...........................Address
Nameof Architect ..................................................................Address .....................................................................................
Numberof Rooms ......" .......................................................Foundation >.v c.................................................
7-�..L ..
Exterior ...�.:�.���.�..L:L.........................:...................Roofing �..:�� - ...........................................
Floors .Interior .!� ...
y......................................................_..........
Heating7`,/�. ....... TI/ .:.......................a......,........:..:Plumbing � .L.. 7............... .. ...� .���.y�..
Fireplace ... L... ................................................................Approximate Cost . . ... 1..�....................................n.�........
4,Definitive Plan Approved by. Planning Board ________________________________19________. Area ....... ® .... ........
Diagram of Lot and Building with Dimensions Fee le................ .. . ........................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ............ ............
Coughlin, Joseph H.
No A§788.... Permit for .... ... ......... ......
........... .... A..;4 1YAWPIling...................
r76Y
Location"I-9--..-Fr-ank1inALv.e.........................
..........................Ay-anni-s.....................................
Owner ..............Joseph F. Coughlin
....................................................
Type of Construction .........frame......................
................................................................................
Plot ............................ Lot ..........#107.............
A-01
Permit Granted ... December 121................................... 19 73
-Date of Inspection ....�-%in....!7!..1 9"P
A4
.,Date Completed
A—
PERMIT REFUSED
a..............................................................
................................................................. .............
I................................................................../...........
.....................-***--***-1......
...............................................................................
`',Approved ................................................. 19
..............................................................................
...............................................................................
Engineering Dept. (3rd floor) Map Parcel 'a�77 F= Permit# 3
House# `�8 Date Issued Q
a PM
Board of Health(3rd floor)(8:15 -9:30 0:00-* O) 7
Conservation Office(4th floor)(8:30- 9:30/1:00 2:00)
SEPTIC SYST
Planning Dept.(1st floor/School Admin. Bldg.) r ST SE
IPJSTALLED I NCE
De ' ti a Ian Approved by Planning Board 19 WIT
EN,VIRON E �
TOWN OYBARNSTABLE
Building Permit Application
Project Street Address
Village lA.
Owner Address /l/,4&�:
p
Telephone 7G�✓ �7d
Permit Request
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family (J Multi-Family units)
Age of Existing Structure Historic House ❑Yes � o On Old King's Highway ❑Yes 10
g Y
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil. ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name 1. � R"� Telephone Numberl�
Address J9"A) (lUeZ License#
h Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE �c DATE
BUILDING PERMIT DENIED FOR THE FOLL ING REASON(S)
FOR OFFICIAL USE ONLY _f
PERMIT NO.
DATE ISSUED• .. `
MAP/PARCEL NO.
ADDRESS r r VILLAGE
.YY
i P .
OWNER
DATE OF INSPECTION:
FOUNDATION -
FRAME` - t
INSULATION
FIREPLACE
ELECTRICAL: ROUGH '` ` FINAL
71 PLUMBING: -
1 ROUGH. FINAL -
GAS: 12-.OUGH r FINAL
i-
FINAL BUILDI G
DATE CLOSED OUT,
ASSOCIATION PUAN.NO. } !'
r
r
The Town of Barnstable
• m►srrsrwma: •
9� 1 9. ,,�' Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commission:
For office use only
Permit no.
a ,
Date }
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization.
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: Vr Nil, --4r14 Est. Cost
9? P_4 4UA) jl e
Address of Work•
Owner's Name 4�4 � �S
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under SI,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED .
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
agent of a
I hereby apply for a pe m a g
�owner:l� lbw
Date ontractor Name Registration No.
OR
Date Owner's Name
" s
The Commonwealth of Massachusetts
Department of Industrial Accidents
_
- Office 0ffalv95#98ti0ns
J ._ i� 600 Washington Street
+i Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name: Uv�
location:
city phone#
❑ I am a homeowner performing all work myself.
❑ I am a sole pro rietor and have no one workin in any ca acity
❑ I am an employer providing workers' compensation for my employees working on this job.
company name:
address.
city:: _. phone#.
insurance co. ohcv#
❑ I am a sole proprietor er-al contractor homeowner(circle one)and have hired the contractors listed below who
have
the following wo compensation polices:
coin ativ name:
ciyyi1 �G /y[ phone
insurance co. oltcv#
-..
company name:
address.
city phone#.
iocv4nsarance co. #
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby certi r h pains and i/es of erju that the information provided above is truo and correct
Signature �" Date
Print name Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
;::OOHe
Licensing Board
❑check if immediate response is required ❑Selectmen's Office
alth Department
contact person: phone#; ❑Other
(revised 9/95 PJA) -
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewai
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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street _.
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
F.I.D.No. 11-2320449 L\�/�/�+/�\ ME Lic.No.DD00001893
Job# �665 -3 v I/,w NH Lic.No.
7� MA Lic.No.120456
HomeCerrtral' New York Department of
SALES: FOR ALL Consumer Affairs Lic.No.730686
New York: SERVICE/REPAIRS The Service Side of Sears" Nassau Lic.No. 50000
800-942-6111 Suffolk Lic.No.2964HI
64HI
PLEASE CALL Yonkers 654
Boston: 800-942-6111 SIDING Westchester WC 613H87
New Jersey Lic.No.097578
800 SEARS 31
CONTRACT Connecticut Department of
Springfield/Hartford: Consumer Affairs Lic.No.532774
800-SEARS-56 VT Lic.No.
RI Lic.No.
SOLD TO JE, DATE
�
ADDRESS 36)—I4MD RD. PHONE(Home)
CITY 'DI N8Jg�I p STATECTZIP L!PHONE )SOS 7 0O — Zq.?
JOB SITE ADDRESS(if different) �/l ER r yf Nya r Apr O.a�0
APPLIED VINYL & ALUMINUM SIDING
Sold,Furnished 8 Installed by Bil-Ray Aluminum Siding Corp.of Queens,Inc.
18 Lyman St.,Suite M1 A Sears Authorized Contractor
Westborough,MA 01581 40 Elmont Rd. Elmont,NY 11003
General Description of Work at Above Address:'. Approx.Start Date: SEr 1
Type of House�_- &fflme ❑Masonry Approx.Completion Date:
SPECIFICATIONS
Sears approved materials will be furnished and inst to these specifications:
YES NO PLEASE READ CAREFUL HE ITEMS CHECKED"YES"ARE INCLUDED IN YOUR ORDER. 1
1. ❑ SOLID VINYLSIDING-covero II flax' atedfor i in tthoseareasd at d I w S'e
Color�a�flf�rn Package Nstom corner posts color 191VT RCH
to ❑ SIDING will be applied to the following areas only:
❑Front Elevation ❑Right Elevation ;Cntire i, Details:'
❑Rear Elevation ❑Left Elevation ❑Partial(SEE DETAILS)
❑Other ❑(SEE DETAILS)
2. ❑ INSULATION-cover only flatwall areas designated for siding with 31 y inch insulation.
o: ❑ Use Sears approved GALVANIZED STEEL STARTER STRIP where contractor deems necessary.(Not available with Nailite.)
4. ❑ Siding to be applied over existing foundation.
5.;t ❑ Use Sears approved PERMA TABS AND FINISH STRIP where contractor deems necessary in same color as siding.(Not v'ab e i Ite.)
6cCh ❑ WINDOW OPENINGS �p
J� �4ustom wrap with Sears approved vinyl clad aluminum# Q Color
❑Jump over castings with siding and'J'channel# Color
❑Channel existing window only leg.Andersen type or previously wrapped)# Color T�
Details �
7._X ❑ CAULK-all sills with rubberized color co-ordinated caulking
8. ❑ DOORS-custom wrap with SEARS approved VINYL CLAD ALUMINUM.#of Doors 3 —.Color M(
9. ❑ �GARAGEDOORFRAMES-custom wrap with SEARS approved VINYL CLAD ALUMINUM.Co r
❑Single L]Double With Mull ❑Double No Mull
10. ❑ FASCIA-custom wrap with SEARS approved VINYL CLAD ALUMINUM.Color
1.1 ❑ SOFFIT-(eaves/overhangs)cover with SEARS approved SOLID VINYL SOFFIT SYSTEM.Except area noted below.thVented.Color '
12.; �,_❑ ROTTEN WOOD-Will only be repaired or replaced where specified online item#27listed below.Any additional areas needing a repair will be estimated upon
their discovery and priced accordingly.(Does not include wood studs,or exterior sheathing).
13. ❑ �temove existing material on exterior of house.
❑Vinyl ❑Aluminum O Wood Shingle ❑Wood Siding ❑Other
nDoes not include any asbestos removal.
14. ❑ //f7ZPORCH CEILINGS-cover with SEARS approved SOLID VINYL CEILING MATERIAL in the following areas
15. ElJ"CAMS/COLUMNS-wrap with SEARS approved VINYL CLAD ALUMINUM(No circular or round columns).Color
16. ElXJGUTTERS/LEADERS-remove existing and replace with new custom seamless gutters and leaders.White Brown
17. ❑ SQ SHUTTERS-provide
18. j andinstall�pairSEARSapprovedpolystyreneshutters.Color
—MASTER MOUNTS exteri I' resinstallfor
1 ❑ GABLE VENTS-provide and install vents.Color No circular or triangle vents.
20.t&171 CLEAN UP property at completion of work. cc
21.1ii< ❑ INSURANCE-all required WORKMANS COMP.and LIABILITY to be maintained. L�-A11 Discounts Have Been Applied.
22 ❑ WARRANTY-mail to customer after completion and full payment is received. r�
23. ❑ PAYMENTS-on NON-FINANCED orders installer is authorized to collect progressive payments. Deferred Payment,Interest Will Accrue.
24.�tlZ ❑ ALL DISCOUNTS APPLIED. MU! /O F rV C
GL-
25 ❑ ADDITIONAL WORK-not speci ied ab ve.
Job Total$ Less de oslt 25% —� Balance 1�6 Start/2 F
NAN ED$- C_does not includ i r st Completion 1/2-
If financed,balance payable n monthly Installments of approximately$ per month,payable by'Owner'to ontractor
but if financed by Owner then Owner will pay sa' mount to the lending institution plus such interest an credit service ch of said lending institution payable directly
to.the lending institution loaning such monies 'Owner'and will execute a Retail Installment obligation and any documents required by such lending institution in
connection with such loan.
26. ❑ �WORK NOT tobedone.
27. ❑ Repair or replace the following woods
NOTICE:It onanced,any holder or this Consumer Credit Contract is subject to all claims and SALESMAN HAS NO AUTHORITY TO CHANGE ANY TERMS
defenses which the debtor could assert against the seller of goods or services obtained OR MAKE ANY REPRESENTATIONS OTHER THAN CON
-
pu.suant hereto or with the proceeds hereof.Recovery by the debtor shall not exceed TAINED IN THIS AGREEMENT AND"OWNER"REPRESENTS
amounts paid by the debtor hereunder. THAT NONE HAVE BEEN MADE TO OR RELIED UPON BY
"OWNER REPRESENTS TO HAVE READ AND "OWNER".YOU ARE ENTITLED TO A COMPLETELY FILLED
RECEIVED A DUPLICATE ORIGINAL OF THIS IN DUPLICATE ORIGINAL OF THIS AGREEMENT.
AGREEMENT AND TO BE THE AUTHORIZED "YOU,THE BUYER,MAY CANCEL THIS.TRANSACTION AT
AGENT OF ALL "OWNERS" OF THIS PROPERTY ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS
UPON WHICH THE WORK OR THE MATERIALS DAY AFTER THE DATE OF THIS TRANSACTION. SEE
ARE TO BE SUPPLIED. ATTACHED NOT'CE OF CANCELLATION FORM FOR AN
S4GUARANTOR S, EXPLANATION Of THIS RIGHT. ALL ORDERS B-
NOTICE TO THE HOME OWNER
( ( ) LED AFTER THE RECISION PERIOD,
WILL D,CUSTOMERS WILL BE
LESSEE(S),CO-SIGNER(S). RESPONSIBLE FOR A 20% ADMINISTRATIVE AND RE-
STOCKING FEE.
«.Contractor. at the expense of owner, shall procure all permits THE COMPAuv WFILL DEPOSIT ALL MONIES RECEIVED _
required by law as follows: FROM
1. Owners who secure their own permits will be excluded from the
guaranty fund provisions of MSL Chapter 142A. IN AN ESCROW ACCOUNT AT CHASE MANHATTAN BANK
2. Any person who shall have co-signed,guaranteed or signed #105-1-062089, WITHIN FIVE BUSINESS DAYS OF ITS
any credit application or note relating to this agreement hereby RECEIPT.
accepts to be bound by this agreement. Date
3. Owner(s)represents that the contents on the back of this agree-
mentsignthisyou is a true part hereof and has been read and accepted by 9 9 Y
Owner. it contains any blank space or if it does not contain
4. ALL INSTALLATION LABOR GUARANTEED 1 (ONE)YEAR. everything agreed upon.
Air
Print J! ,1
Salesman's Name �Signature
ustomer Sig Here)
Salesman's
License No. V ' Signatu
E3riE REVERSE DE FORJADDITIONAL TERMS AND CONDITIONS
is
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM BOOR
QUALITY ORIGINAL (S)
m F�C&' -IL
DATA
�- •tip
71e.il«Ci'L(.L:�.u;,
a 4 HOME- ^ Boar a otMPROY�MN+ CONTRACTORS RECIS T RATION
Bu= e_ns R..guyak- ariaNiW
Sta,darCs
- O
_ ne Ashbur tc m Place Rccn 1301
Boston, Massachusetts 02108 ----
_ HOME IMPRO'VE1ENIT CON►RACTOR
Resistraticn 1204=6 ;r
= Type - PRIG/ <-- cxp anon 0i 01/90
_ BIL-RA.Y ALUM . SIDING: CORP
123-10 ATLAN'=C AV=
R ' CLMCND H=:.'_ NY 114_S
J 1 _
A
ACOROt, CERTIFICATE OF LIABILITY INSURANCE DATE(naM/DD/YY)
as/os/9s
PRotlucm T�IlS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
COUNTRY INN INSURANCE AGENCY, ONLY AND CI)NFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
217 MERRICK .ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SUITE 212
NSURERS AFFORDING COVERAGE
AMITYVII' :.�, NY 11701 __.
INSURw BI:L- RAY ALUMINUM SIDING CORP` INSURERA:THE I:%TSURANCE�CORPORATION OF NY
134-10 ATLANTIC AVENUE INSUREaB:CIGNA INSURANCE COMPANY
RICHMOND HILL, NEW YORK 11419 INSURER CREALM INSURANCE COMPANY
INsuRER oGUARD IAN INSURANCE COMPANY
INSURER E•
COVERAGES
l THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE :OR THE POt ICY PERIOD INDICATED.NOTWITHSTANDING
l ANY REQUI!D.._MENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE:•PECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCF AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$;•E(CC=0"�'ID CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS•
INSR TYPE OF WStatANCE POLICY NUIM66t DATE IAWMQtM POUCY 9�ECTIVti POUC Y E(MATION ITS
GENERAL LIAMUTY EACH OCCURRENCE $l 0 0 0 0 0 0
X COMMERCJAL GENERAL LIABJUTY RRE DAMAGE Wn one Tad S 50,000
CLAIMS MADE a OCCUR MED EXP I"one pw2aN S J 0 O 0
A ICLOO6886 05/14/98 05/14/99 mtsONALs,ACV WJUAY $1,000, 000
GENERAL AGGREGATE a 2 O O a O O O
GEN L AGGREGATE LIMIT APPLIES POt: PRODUCTS-COMP/OP AGG S 1 0 O O O O O C
I POLIO( PRa hoc
AVTOMOItILE UABIllTY
COMBINED SINGLE LIMIT 8
ANY AUTO (Ea actidant)
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per parson) S
- HIRED AUTOS
BODILY INJURY 8
NON•OWNEO AUTOS (pa accident)
PROPERTY DAMAGE S
IPer accident)
I GARAGE LIABILITY AUTO ONLY.EA ACCIDENT s
ANY AUTO
OTHER THAN EA ACC 8
AUTO ONLY. AGG 8
EXCM UA13113TY EACH OCCURRENCE s 3 0 0 0 0 0 0
OCCUR ❑X CLAIMS MADE AGGREGATE s3,000, 000
B BINDER # 05/14/98 05:/14/99 $
i DEDUCTIBLE C I I 514 9 7
I s
R�ENTION s
a
WORKERS COMPOUATIDN ANo X WC STATU OTH-
C ewPLor»a'LIABILITY BINDER # 0 5/14/9 8 O 5/14/9 9 I=L EACH ACCIDENT $5 0 0 000
C I I 5 I4 9 8 E.L.DISEASE-EA EMPLOYEE s 5 0 0 0 a O
E.L.DISEASE-POLICY uMIT s500,000
OTH9t
D DISABILITY 'S BINDER # 06/01/98 UNTIL '
CII51499• CANCELED
DEBCFIIPMN OF OPMMONEADCATIONSrVfflCLE2M CW81pNG ADDED SY 21100RUMENT/S/ECIAL MWVMOUS a .
E
R �
CERTIFICATE HOLDER AMMONAL INSURM,INSUR9i I.E lBC CANCELLATION
1 SHOULD ANY OF THE'%BOVE DESCRIBED POLICIES BE CANCEI I En BEFORE THE EXPIRATION
DATE T/t9tBOF.THE I&=NO INStW=WILL ENDEAVOR TO MAIL 3 0 DAYS wmTT9e1 �
j
NOTICE TO THE CBM:ICATE HOLOrA NAMW TO THE LET,SUT FAsUjRE TO pO gO SHALL
1IMPOSE NO OBUGATMIN OR UANLITY OF ANY KIND UPON THE INWROL lTS AGENTS OR
ReR6BENiA '�
AUTHOR® •ATJ{/E
I /rCa_n�7rPt k