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HomeMy WebLinkAbout0045 MAPLE AVE �' �� � `� �� �� � i i i i 1�� �� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 Parcel BS Application # r;�D/S d � Health Division Date Issued 12-7-- r S P� Conservation Division Application Fee (2 Planning Dept. Permit Fee A Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner 0 P Address vCLMO, Telephone RX II II '' nn II Permit Request ftdd �3 8 ce l lu0 oSC i-T E c�-CT-r c, (A I to- A't x I ':ti --+[�e, P lane 2il Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation n 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No 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 Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Roorn_Count ' Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Otherr - ' 52 Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/e-6al stove:.-W Yesr43 No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ Rew Vie_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Y.a CD UJ rrs Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes )�(No If yes, site plan review# Current Use Proposed Use - APPLICANT INFORMATION - - (BUILDER OR HOMEOWNER) Name r II MCCIIJ1 Q o �c Telephone Number 50 '899 Address �L Ans"lwo 14V 4- License # b Home Improvement Contractor# Email Worker's Compensation # W I/f c 313 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L SIGNATURE DATE Aw L FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP%PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING y } DATE CLOSED OUT ASSOCIATION PLAN NO. J V x ~z e Commonwealth ofMassachuse a '� •` ''= Depart»teitt of_LndusttQAMd,0 its -1 Congress Street;Suite 100 r,-j, ,, �:�: .E �,,�.. • r,, .= a�> 'Boston,MA D2I14=2017,", www.mass.gov uz Workers'Comp ensition Insurance-Affidavit:Buildeis/Confrictocs/Electricians/Plumbers, ¢,....-TO BE FILED WITH THE•PERMITTINGAUTHORITY. _ = Applicant Information 1 Please Print Legibly r ; t Name(Business/OrganizatioiAndividual):Cape Save Inc { Address:7-D Huntington Avenue _ 1� l City/State/Zip:South Yarmouttl, MA 02664 ,. phone#:508-398-0398 t Are you an employer? y y r?Check the appropriate hog: _ _ + Type of project(required).. =k 1.E✓ I am a employer with.20 t w-employees(full and/or part-time) 5 i - .. 7 New con strucrion D - 2.❑I am asole:pmpnetorbr partnershrp and have no employees working forme m <. , - g Remodeling,-•a. rr•F` �T`} ; an capacity. o workers co insurance re uved . ;s o Y P h•IN mp• q r r . € ( }!. , r J Demolition), t• , IM I.am a homeowner doing all work myself.[No,workers comp..insurance requtred.]t. -.• ! k ,+; )-• .+10 Q Building addition A.❑'I am a homeowner and will be hiring contractors to conduct all work on my property'I will`""`- ' f - " ensure that all contractors.either have workers'compensation insurancesor are sole 11.❑Electrical repairs Or additions proprietors with no employees. 12,❑Plumbing repairs.or additions 5.�I am it general contractor and I have hired the suV.-contractors listed on the attached sheet. 13:❑ROof repairs These sub contractors have employees and:have workers'comp,insurance • 14.[Dot her - r 6.Q We area corporation and its officers have exercised their right of.exempuon per MGL c: ��her Insulation , IL 152,§1(4),and we have no employees.[No workers'comp.insurance required.] '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. , -. •` 'Contractors'that:cheek this box musrattached 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,'theymust provide their workers'comp:policgnumber.• I a,an employer that;is roviding workers'compensation insurance for my employees. Below is the policy and job site - -- ~ in ormation: y p _-_ . Insurance Company, Insurance Company Name: P Y . Policy#or Self-ins Lid.#:WWC3136274` -� -�'" 4;"; ;.:Expiration Date- Job - . ... Job Site Address: 45 Maple ity/State/Zip: Hyannis Ave,.:,� . } Attach a copy of the worker's'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,tbe.Office.of Investigations of the DIA for.insurance ., coverage verification._ '�` - -•' • - � r' f- � ' 1 do hereby certify under th pains and penalties of perjury that the information provided above is true and.correct, ' Sip-nature: Date: 11/20/15 Phone#:508-398 0398 'Official use.only.-Do'notwrite:in this area;.to be completed by city or town"o004 "` "" - ""' `' ""�. ,•a City or Town. m Mrs• •.� x -�, +: Permit/License » Issuing Authority(circle one).+' ;: 1.Board of Health 2.Buildi_n e _ar.tm_-ent 3 C�i /Town Clerk 4.Electrical Inspector 5.Plumbing Inspector, y i 6.Other 1 Contact Person: Phone#: a` t .Aco V CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) k. , 10/14/2015 THIS CERTIFICATE 13 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(les)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 not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT COME: Colleen Crowley Risk Strategies Company PWCiN E : (781) FA 986-4400 C NO):(781)963-4420 15 Pacella Park Drive _ AD�SS:.ccrowley@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAICi Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INSURER Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc INSURER C:Wesco Insurance Company 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth. MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER:CL15101402127 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. LTR TYPE OF INSURANCE POLICY NUMBER MMIDD YY POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMStviADE X❑OCCUR _ PREDAMAGE TO RENTED MISES Ea occurrence $ 100,000 S1994480 10/16/2015 10/16/2016 MEDEXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY��Cf FxI LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED Ea accident SINGLE $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL TOS E AUTOS SCHEDULEDAU AVBA46796600 11/6/2015 11/6/2016 BODILYINJURY(Peraccident) $ XHIRED AUTOSAUTOS (Per ecci entI DAMAGE $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A ExcessLIA13 CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION Nil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION Officers Included for X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE Coverage E.L EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? FNJ NIA (Mandatory In NH) BBC31362?4 4/9/2015 ,4/9/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 Ardescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Michael Christian/CLC O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT.HOMEOWNER. , I M+cck e 1 l�cr��c�c161 hereby consent to and agree that weatherization work may be done by the Weatherization.Program of Housing Assistance Corporation on the property 'i located at: k nn�s o The weatheriz ion work done will be based on programmatic priorities and availability of funding may and it include all or some of the following.measures: Y 9 Weather stripping; air sealing; attic &basement insulation; exterior wall insulation;ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill-for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) Home Owner email: Date: 1�b& t5 Agent:(signature) < Date: Weatherization Contractors: Adam T Inc Cape Save All Cape Energy gy Solutions Alternative Weatherization Lohr Home Improvement Building Science Construction Resolution Energy Cape Cod Insulation Tupper Construction G9�e W��W" 0/vI, Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 - Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation w 4, i Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM McCLUSKEY - 7-D HUNTINGTON AVENUEa: SOUTH YARMOUTH, MA 02664 ----------T----�----- w „ " K Update Address and return card.Mark reason for change. SCA 1 0 20M-05/11 Address Renewal E] Employment Lost Card O�Tr`V�ii�nureufNulG��ff{:ll��J;�ur�l ie.,et/4 " • Office of Consumer Affairs&Business Regulation License or registration valid for individul use only VExpiration:;�.-.�.r.3i44i2046 OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 171380 Type: Office of Consumer Affairs and Business Regulation Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE SAVE INC. k Ix - WILLIAM McCLUSKEA�- � 7-D HUNTINGTON AVENUE" � � , SOUTH YARMOUTH,MA 02664 Undersecretary Not vali tthout signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards '1.11111i1 Ulill/il JIl f1C�7-V)1111`Si�e�ibn�" �aw7oexaa,rwys License: CSSL 102776 37 NAUSET ROAD Obip West Yarmouth IRA ✓,,�,,. Ar,N` Expiration Commissioner 06/28/2017 5 �oF1HE ram, Town of Barnstable *Permit# 9 P �p� Expires 6 months from issue date sexxsrnsLe. : Regulatory Services Fee /-50 MAS S. Thomas F.Geiler,Director ArEp�,Ip� Building DivisionX-PRESS R Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 JUN 2 1 2005 Office: 508-862-4038 Fax: 508-790-6230 TOWN! OF SARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 3070 Property Address 41 k /7'jG 0 ft-Ite'sidenitial Value of Work /`S�!/t*D. a Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address s et Contractor's Name Telephone Number ' Home Improvement Contractor License#(if applicable) 3®fy q7 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Lam the Homeowner rg i nhave Worker's Compensation Insurance Insurance Company Name 4!°mot /4IOfv. Workman's Comp.Policy# L —1 -26 t Copy of Insurance Compliance Certificate must be on file. x; Permit Request(check box) C:) rz Re-roof(stripping old shingles) All construction debris will be taken to V Co €t ❑Re-roof(not stripping..Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum.44) \ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise063004 x r - g Regpfalos and Standards . HOME IJyI,PROVEMf_NT 1 License or registration valid for mdwidul'use only ` ��T(QR before the expiration date. R �St .30447 y If found return to` I-- Board of Building Regulations and Standards I _ 3/4;0/20© r One Ashburton Place Rm 1301 'TYPe rxdividual Boston i 1 Ma.0210$ S4 ..DANIEL C.McSV/fl _jn DANIEL McSWE�NE 1� 1 ' 66 BOG RIVER:BE�l�1[ MASHPEE,.MA 02649 ✓ - Administrator; ' -- No- " t valid how: gnature 1 he (;ommonweairn of lvluasucnusec&s Department of Industrial Accidents ' Office of Investigations 600 Washington Street t Boston,MA 02111 �w www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): :1 1M 0o etjl e m em+ Address:�a City/State/Zip: Phone#: Are you an employer?Check the appropriate bob: Type of project(required): 1.(f I am a employer with -3 4. LL'YT am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.Q'I000f repairs insurance required.] employees. [No workers' �1 ].t 13.❑ Other comp.insurance required.] *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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: _ — 1 y kJtA r Policy#or Self-ins. Lic.#: _&U of -701 t7 110 ' Expiration Date: 3Z7.Z0 Job Site Address: e1�g City/State/Zip: file, 0,)60 0 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 15.2 caii lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an alties of perjury that the information provided above is true and correct: Signature. Dater Z� 6 Phone M ^ �- 4eO 70 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#: 1 De pasi4 i r u 7007 AfCeDtan&of Estimate The above prices, specifications and'conditions are :z t moty ad are hereby accepted. MCSweeney&Son Borne Improvement is authonzed to do-tin;vvmk as specified- Payment will be made as such: =Depposi1/3 when half complete and 113 upon,substantial completion. All progress and final payments to be made to Foreman,at aWopriate time. If any concerns, foreman to call office. DO NOT SM UM CONTRACT W THERE ARE.AINY K:E4M SPACW Date: Signatures: Note: No work shall begirt prior to the sigmng of the contract and transmittal.to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. Seethe attached notice of cancellation for an explanation of-this right. �hn �,tsee 46 Maple male IMnio, MN OVA 307095 6 :?.`t,j.= `'�`as"`fir,-r'i+�it rt` `%r,=.2 :Y�'r1G:';,{•. - .s t< __ _ ___. n285 y{t '' }�4���m '44 . i, ,ii tY{ ,�'" }.�:Sr Sy{?: i# .:.,,. tc. !<}f �' ' '� r. t ��y. �`>F �� 3/THIS CERTIFICATE IS ISSUED ASA MATTER OF INFOONLV ANTD CtONF-"ISNO RIG-141S UP= Tim C RI: �`R RISi� SPECIALISTS HOLE?ER• THIS CERTIFICATE DOES NOT AMENiD, EX ALTER THE COVERAGE AFFORDED 8Y THE F`OLICIES 8ELOW. IN, Z;RANCB AGENCY. INC,,. P + ..BOX 115 -Ii�1l�PAI1tiES AFFORDWG COVERAGE , COMPANY t7N[E NIA 02 53 4—0 2.15 A, E3�3zDEIRWR T ERS AT !Wx-DS LNSURW 14csw8 SON c s A MUTUAL 1:�tSiLrTRMiCE T_ T Y T tst 'COMPANY DANIEL MCSWEENEY D/B/A 66 BOG RIVER BEND COMPANY C MASHPEE, MA 0264.9 COMPANY S '! '+, Tyre v-e�- -.�.\ xyr •w.t a'`:it... D Tf :t.4•r+:..ti;`a;,;:;.-. a\c.- .....:.-.,,; :.-..:..-:;.\::a«:.:':;,:,Z!',`-:.�'Yr•.:. �Y.. �i.t,cvaf�.:<,?:.y;;�>:.:,. •'�.u..:=.+•-.�•," �`�C- -': f '�. IN i #S ED CERTIFY THAT TFIE POLICIES OF INSURANCE.LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD \} !N' CAT ,NOTWITkISTA[VL]II�It,"y wcru o�,,ENT TM A O:�Cv?vDlTiviv 23F AIV�t C%f�L+ITkiACT OR OTHEf)DCICUMER)T WITH RESPECT TO WHICH THIS 1 T�ATE'MAY BE ISSUED OR MAY T"E�AIN, THE INSURANCE AFFORDED BY irlE POLICIES DESCRIBED HEREIN IS SUB IECT TO ALL THE TERMS, E} IS)ONS AAIR?CONDITEOHIS OF SUCH POLfC)ES LudiTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ._ L� TYPEOF UMMANCE POLICY NUMBER POLICY 6FECTIVE POLICY EXPIRATION DATE(MMfDD1YY) iY`)tF LATE(bRmmlyY) LIMITS ..r. C:t 1 ltAMItTV [ .PRODu _ O�I ERCIAL GENEAAL UAMUTY tRNRAL AGMIEGATE 2,0 0 0,000 CO�IPpat a1, 000,000�i CLaus nnsnc��. A I;WNER'S&CONTRACTOR' PROT LGL 0 4 6 8 6 6 PERSONAL&.AOV iM IttRY A, 000, 060 3/7/05 3/?./06 EACH OCCURRENCE sl—, OflO, 00 I.RRE DAMAGE IAmT one fireL $5 0,0 0 0 Al OIaO1ALE UA�TrY EXP ors peasw�I $5,0 0 0 IXY AUTO COMBINED SINGLE UMIT e$ 1:LL OWNED AUTOS — _ n'HEDULED AUTOS BODILYOtr�onl 3 kid AUTOS A 7N OWNED AUTOS BOD11Y IN $ (Per acddtmtl PROPERTY'DAMAGE S GI umuAsum ANY AUTO AUTO ONLY-.EA ACCIDENT 3 j OTHER THAN AUTO ONLY- EACH ACCIDENT .-EX- :S.S.tlAMIITY AGGREGATE S ,. EACH OCCURRENCE $ AGGREGATE 5 il I-HEA THAN UM&RELLA FORM 4W.L _°BS COAiRi�iQAT",AsM ENOYEAS`LIABIUTY k �•�-•`�+:•T'w` vtco- :��, r $ TH 'OPRLETORr EL EACH ACCLOENT sll0 0 0 0 0 aNtx.:�.WC' 7:0?559101 �� � � r� _ TIV6 �/ ,/i,' , 3/3/too ELo+sEA -R�1319CYuMrT s500,0i9U OF: MUM X EXCt OT A EL DISEASE-EA EMPLOYEE $10 0, 0 0 0 DESCRLPT R OFOPDiAT1OWILOCATIONSMENtCLES1SPECIAL ITEMS nn _�', ,:: < _• ,.l'r':+••.trt!"�:;a,poir:;::-��£:�?;,,'g. v��'t?.::::::.v ,✓`-:.rt: -':..-.:.ti.,:%1....v ....4�;..:_ <r.>s: v.' .rt d:..v:>.. f ::fi,• ...,,::. ..•.,..r:ar::r. G'iu::.::..+".-.,t4. ,.,......,xt..,..v;c:;.xtk,•- Mr.;} a?, ♦ •• :�xS}� ? v.• � �.k.: Wit` SHOULD ANY OF THE ABOYE POLICIES BE CANCE IIED BEFORE THE DAN EMRAATION DATE TtE$DF,.THE ISIAM COMPANY WILL ENDEAVOR TO MAIL 1_0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDHL NAMED TO THE LEFT. BUT FAILURE TO HALAL,SUCH NOTICE SHALL IMPOSE NO OSLIGAT[ON OR LIABILITY OF ANY tLmo COIAPA6. 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