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HomeMy WebLinkAbout0003 WOLLEY ROAD 4"Jo lGc� Rd $�)-q- ..Application numbe .. ..........5. .. ..�......... Fee4► .............................. ............................ MOM Lv— �, Building Inspectors Initials..... . s639. Awe I b 39. Date Issued.....I t.).$)I. ........................................... Map/Parcel. w� .. .... ........................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVE S/WEATHERIZATION PROPERTY INFORMATION Address of Project: 0,16 O/ NUMBER f STf&ET VIL AGE Owner's Name: � i�0 Phone Number506'- '7?1--5''/gs' Email Address: R6198 S k-'j 1Ajg)yAgoo. e-pyi Cell Phone Number 5-0r--Y "- VYJ O Project cost$ �i V 5-0r or/ Check one Residential mercia OWNER'S AUTHORIZATION v, _ As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR z Owner Signature: Date: TYPE OF WORK 0 Siding F-1 Windows(no header change)# F-1 Insulation/Weatherization 0 oors(no header change)# Commercial Doors require an inspector's review U Roof(not applying more than 1 layer of shingles) Construction Debris will be going to o CONTRACTOR'S INFORMATION Contractor's name 91 Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# /d'V"f (attach copy) Email of Contractor 3f P-J®/0H,1 4WI-cf¢ecoAte4yf, N E.I-- Phone number .h©S= 2, Z ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. The.Coinmonwealth of Massachusetts Department.oflndustrialAccidents . I Congress Street, Suite 100 Boston,MA 02114-2017 tiM e` www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. . Applicant Information Please Print Leeibly Name (Business/Organization/Individual): P/f eA-" Al 11 2!:Z te-k Address:- /0 " f<l f3 A)City/State/Zip: ��R IV IC-H1,40, 191 P`r� Phone Are you an employer?Check the.appropriate box: Type of project(required): l.Q I a employer with employees(full and/or part-time):* 7. New construction 2. 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.]t - 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 1.1.EJ Electrical repairs or.additionst proprietors with no employees. 12TQ Plumbing repairs or additions .5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet: 13 �Roof repairs These sub-contractors have employees and have workers'comp.•insurance.t . • 6. We are a corporation and its officers have exercised their right,of exemption per MGL c. 14.®OtheC 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. 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: Policy#or Self:ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 a. 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 iri 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: ,-0 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#: • � I 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. Anew 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 F A-NC3819/T3850-3-part carbonless contractors Proposal Page q�_ ..._._. m - - Rages Stephen P.Mauur 0 10 Mark Lane . Harwich.'MA'02645 (508)737 9212 PROPOSAL TTEDTD: t JOB WE JDe; ADDRESS JDBLDCAIM - 6(94YwI DATE DATE OF PLANS PHM it rAx �n'1w iy e e We hereby submit specifications ald estimates for. / /QVCl�/d t,0 all lour wiles a://_<av_S /f its, _5 1�` 44w/s. ;=n4624_f7e_LJ_-f.� eS a"- dXMI,Grp/% et i f Z'�rizl/.��,a•.�c� nc2�-K��� �i�� c�Sr� -u.e�J r���h, '1e�. 'C/ Alote �/� »c,�teri�s,; la6or,_�errrn�fis_ �c�. �.crn�.�cs fir t/� too kILn e z - r lacmi �.anaG/or i-e �-4 /s �i ': jnL'l uG �c / zteru�.ls� '�tul�-rYcec ."� [ r�I,.' f.�ld� ' /Y? l�sdo We propose hereby to-fumish material and Wimr—com in accordance with the above l �` 7 V r specifications for the sutra of t r vim payments to be made'as follows CIF � � �° r • f� � Myat ra it Vkdi ntrrsmabrve invoNirtgextracosts' Respectfully ' wilbe ercMo*4w wfimn adK and wiUbmameanextmdage submitted Ores aril above the es mate. AN agr Amts cmdrngeid uptm strikes a yr del2ys berand carrot / t'jOte—this proposal may be_withdrawn by us ifi not accepted vvithiita A. the a x¢ a Bpt of<abOn4 and ccadiam are story and are aitthOrted#ri do tits vmrk as specAted. ` yr!a eel be sttas otiati_trove. S gnature+ y // Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construes-h%iWrvisor ' ,f x CS-104459 :; Ek ires:09/02/2021 STEPHEN P&tAZZUR-. �� 4 10 MARK LANE HARWICH MA,42645 Commissioner .�� ✓/'!I7/�7C/lf/'!.'ll���/.'�:(�/liJ!/I/CfIJP.fIi Office of Consumer Affairs&Business Regulation. HOME IMPROVEMENT CONTRACTOR TYPEIndividual i Exoiration t47S34 _ 07/2412021 STEPHEN P MAa . 71Ff" far DB/A STEPHEN P h+ ; R ROOFlNG+SIDEWALL t :4- STEPHEN P.MAZZUR ; 10 MARK LANES<:•. ,�'CG•�ol(Jok HARWICH,MA 02645 Undersecretary Town of Barnstable *permit Expires 6 months from te . „RNSTABLE, . Regulatory Services Fee v 1639' Thomas F.Geiler,Director ED MA+ - -Building Division- -- Tom Perry;'.:Building Commissioner do 200 Main Street, Hyannis,MA 02601 01 900 Office: 508-862-4038 - Z 8 ti lbw Fax: 508-790-6230 _ 4'#94� EXPRESS PERMIT APPLICATION RESIDENTVR- d-)( (( ,^ Not Valid without Red X-Press Imprint Map/parcel Number Property Address 1j L.E c Residential / Value of Work Owner's Name&Address l J l 12 0 S 111 e-j 60ca -900--732;L- 7 7�31 Contractor's Name Bi 1-RAy Grp Telephone Number - Home.Improvement Contractor License#(if applicable) 120456 Consteuction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name American Workmen's Comp.Policy?. W C q 30 5-'it/3 Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going.over existing layers of roof) Replacement Windows. U-Value 31 (maximum.44) _ ❑ Other(specify) "Where required: TssuLe of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmr Revised1219G, SOLD, FURNISHED & INSTALLED BY Boston:800-SEARS-31 O Sit-Ray Aluminum SidingCorp. Hartford Area:BOO-SEARS-99 ffARS. y C®rpProvidence Area:888-SEARS-51 Home.Services of Queens, Inc. New Hampshire:800-829-2375 A SEARS AUTHORIZED CONTRACTOR JOB# L121 113 Cedar Street, Unit S3 • Milford, MA 01757 F.I.D. No. 1 1-2320 449 MAINE LIC.NO.DD1893-NH LIC.N0. •MASSACHUSETTS LIC.No.120456•VERMONT LIC.N0. -RHODE ISLAND LIC.NO.13707 NEW YORK CITY DEPARTMENT OF CONSUMER AFFAIRS LIC.NO.0730686• NASSAU LIC.NO.H2704150000•SUFFOLK LIC.NO.21194HI •YONKERS 1397 •PUTNAM PC934 WESTCHESTER WC0613-1I87 • LONG BEACH GC2001.• NEW JERSEY LIC. NO. 9949269 • CONNECTICUT DEPARTMENT OF CONSUMER AFFAIRS LIC.NO. 00532774 "N OW CONTRACT SOLD 1 G ) DATE A TO CITY t � G9, C' STATEMig ADDRESS PHONE HOME roz) Z 71 1 7 -WORK,(,: . ) EMAIL,' .. JOB SITE ADDRESS (IF DIFFERENT) APPLIED VINYL WINDOW SYSTEMS General Description of Work at Above Address: Type of Ho RAME Date which work is scheduled to begin: 6 °-g Date which work is scheduled to be substantially completed: u(Nc t Sears approved materials will be furnished and installed to these specifications. PLEASE READ CAREFULLY:ONLY ITEMS CHECKED"YESI"ARE INCLUDED IN YOUR ORDER. YES NQQ�� YES NO 1. LEMOVE WINDOWS from opening where they now exist on: 22. ❑ SPECIAL ORDER Windows(in Addition to Above) 2. FIRST LEVEL #Openings #New Window Units 3. ❑(]SECOND LEVEL. #Openings #New Window Units 4. ❑BASIRD LEVEL #Openings #New Window Units p p5. ❑ EMENT #Openings #New Window Units 23. CLEAN UP-All job related debris will be removed from property e 6. (1 QER #Openings #New Window Units on completion of work;REMOVE AND DISPOSE of existing windows d/or storm windows 7. ❑C"WOVAL OF METAL or other units requiring modified installation 24 INSURANCE-All workman's compensation and liability is maintained #Openings #ofUnils 25. RRANTY=Maiedto customer upon compldionand full paymentisnxrived 8. ❑[rrstall new PAINTABLE MOULDINGS 26. PAYMENTS-(On non-financed orders)Is payable to installer on Inside Stops #of Openings day of installation Parrishell or Casing #of Openings 27. ❑❑ Additional Information � 9. ❑Urinstall new MASTER FRAME #of Openings 10. U316 New window units to have FUSION WELDED SASH # Ct' i y Tv 11. oew ew window units to have FUSION WELDED FRAME # G 12. window units include Insulated Glass 7/8"total thickness tlh the following INSULATED GLASS OPTIONS: ❑I!f 2a.) Triple Glaze Double Low E Krypton filled R-10 rating 28. ❑❑ Work Not to Be Done Cndudes injected foam insulated sashes&trames) #Of Units ❑ 12b.) Triple Glaze Single Low E Argon/Krypton filled R-6 rating Cmdudes injected foam instiatedsashes&frames) #ofUnits 12c.) Double Glaze Single Low E Argon/Krypton filled Cndudesinjectedfoamins Wad sashes&homes) #of Units 14 11 ❑�12d.) Double Glaze Single Low E Argon filled #of Units ❑ 2e.) Sun Clean Glass(an adedor) #of Units �1 13. 010 New window units to have CAM LOCK(s)or LATCH LOCK(s) _ TOtaI Safe �f lie 14. UU New window units to have NIGHTNENT LATCHES INDICATE FORM OF PAYMENT 15. ❑Xfew window unitsto h OBSCURED GLASS Deposit With Order t �a . 3� $ # ' have ❑Full 012 16. � New window unitsto have HALF(1/2)SCREEN Payment On 1 03 (uscreen On casement We WOW) Measure or Start -' 3 $ 17. [i p Wind sto have GRIDS Colonial - Diamond Balance Due on , 3 / uI ❑1/2 Additional info wa 4Q�t h Substantial Completion 34 $ 18. fJ❑ Install PVC COATED"MINUM to window frames ' / Total Amount of -r Color LA k7 e #of Openings t LL Balance to be Financed $ 19. gGAULKANDSEALwindowswith3pointsystem Wm d �AIig If financed, balance payable in monthly installments of 20. COLOR OF WINDOWS to be ❑White ❑Timbertone ❑Sandtone approximately $ per month, payable by 'Owner' to contractor, 21. UM Total#Double Hungs 3 Total#Two Lite Sliders but if financed by Owner then Owner will pay said amount to the lending plus such Total#Casements Total#Three Lite Sliders /w interest and credit service charge of said lending institu bn payable Total#H `^ Total#Dead Lite/Pictures directly to the lending institution loaning.such monies �scaums Bye Hoppers to °Owner" and will execute a Retail in BeenApp��= Total#Awnings Total#Basement Sliders v" obligation and any documents required by such + Standard or Equal lending institution in connection with said ban. GAee3 accrue-. TOR IS NOT:RESPONSIBLE FOR ANTMSTING SECURITY=SYSTSRr�IS PI,EASE'FIE1410VLE'ALL S.HADES,:IlEt3TICALS, 1SLINDS, CURTAINS, DRAPES OR WINDOW MWNTED'AIR CONDfi7't NER% PRIG TO I3iE INSTAl4�6ATtON OF_.YOLiR WIND"Si'INSTALLERS ARE NOT RtmSPONSIBLE FOR T"E REMOVAL fJR INSTALLAT9ON®FPi9 SE - ....: .. Notice:If financed,any holder of this Consumer Credit Contract is subject to all CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE AWA.RRANTY PROBLEM. claims and defenses which the debtor could assert against the seller of goods or SALESMAN HAS NO AUTHORITY TO CHANGE ANY ITEMS OR MAKE ANY services obtained pursuant hereto or with the proceeds hereof. Recovery by the debtor shall not exceed amountspaid by debtor hereunder. REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMENT AND "OWNER REPRESENT S TO HAVE READ AND RECEIVED A DUPLICATE ORIGINAL OF "-OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR RELIEF)UPON THIS AGREEMENT AND TO BE THE AUTHORIZED AGENT OF ALL"OWNERS" OFTIIIS BY"OWNER".YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE PROPERTY UPON WHICH THE WORK OR THE MATERIALS ARE TO BE SUPPLIED. ORIGINAL OF THIS AGREEMENT. NOTICE TO THE HOME OWNER(S),GUARANTOR(S),LESSEE(S),CO-SIGNER(S)." "YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO Contractor,at the expense of owner,shall procure all permits required by law. MIDNIGHT�OV THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. 1.Do not sign this agreement before you read it or it It contains any blank spaces SEE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS or if it does not contain everything agreed upon. RIGHT.ON ALL ORDERS CANCELED AFTER THE RECESSION PERIOD,CUSTOMERS .2.Any person who shall have co-signed,guaranteed or signed any credit application WILL BE RESPONSIBLE FOR A 45%ADMINISTRATIVE AND RESTOCKING FEE" Of note relatingto this agreement hereby accepts to be bound by this agreement 3.Owner(s)represents that the contents on the back of this agreement is a true SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS.BY SIGNATURE part hereof and has been read and accepted by Owner. BELOW,CUSTOMER AGREES TO THE TERMS OUTLINED ON THE REVERSE OF THIS, 4.ALL INSTALLATION LABOR GUARANTEED 1(ONE)YEAR. CONTRACT. DATE 1-40 C 2- LCV, Contractor Accepted Print 1 / Salesman's Name tti f L`(l- Signature (Customer Sign H Saleman's .' License No. Signature > . - " (cubiomer Si n Here)-.. 02M IN Flay r+.V Al W ft FkSK d ago/ _ _ $oudofBwIdma$eanlai�nns:andtgndards License or registration aa11d for ind�ridul use only, HOI+1lE IMOV M=tIT CONTRACTOR, before the expirationA4fe If found return to.: Board of Building ge.Qulations and standards. ©ne 9.shbufton place RX130. 8 d POQB. Boston,Ma..02108 Y ptement Card - atur -� 3�u�a�alid�thent,si.ua . ' ' ,;,y— -tea;,:• - .. ... _- • .. i - The Coirzmanwaitla.ofMasachzseits Departmen o}`lndusii ial Acciaents 0 Wce,qf bnveszzgations d 6 00 Wczsha. .on':Sta^eet Boston, IYL4 02111 wwiw..mass gov/dia Workers'-Commensatio-n insurance_ -davit -B d(err/Copea--tors/Electriciam/Fluffibers ,knDi cant t�rmat om- Tease�riatt I e blv Naane(Business/Organization/Individual) '` i' '= f`C.�L ('1 L gddr-ss: A. Are you an employer?`Check.the appropriate boat' Type of project(required): . s I.[ I am a emoloyer with ' . 4. ❑ I'am a general contractor and I = 146. El New,construction _employees(fixll and/orpat-time).* have hired the siib-contractors 2.7 i am a sole piopnetor orpartiier- listed onthe attached sheet t 7• 0.Remodeling ship andhave no.employees These sub=contractors:have $: Demolition wor3±mg for me in any capacity. workers' comp.insurance. 9. ❑Building addition jlvo wormers' comp_Fncr,rance 5. ❑ We.are a corporation.and its 1. reea] officers_have exercised their lO:Q Electrical repairs.or additions 3.❑ I am a homeowner doing all'work right of.exemption per M1.GL 1 l.r]Plumbing repairs or additions myself jNo warkers' comp.. c. 1�2,.,§:1(4);and we have no. 12.[]Roof!repairs b:Lsura-nce re quired-I t employees. UNci work=, U cep ;r_ cm-arce:seCP=ed.] 7 Other *Any applicant that checks-box Tl must also 5-1.1 outthe section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and.then hire outside contractors must submit a new a�idavit indicating such. Contracmr that check this bon must attached an additional sheer showing the name of the sub-ontractors and their workers'comn-policy mivrnarien Z am an employer that is providing workers'compensation insurance for my employees. Below is tFce policy and job site h Zormazioa_ Insm,ca Coma-m Narne:% oY, / a �. / -� policy#or Sel€ism Lim r .� F- at Date: Job Site Address .: C t./State/Zip: i�1 �` d �. Al tta6h a copy of the workers' compensation poRcyAeclaration page(showing-'the policy n�ber and eapaation date). Failure to secure coverage as rerniired under Section 25A of MGL c. 152 can 1 ad to the imposition ofl criminal penalties of a tine up to S1,500.00 and/or one-year impasonment, as.well as eivE penalties in the torn of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o tie DIA:for ins�nce coverage verification I do hereby der the pazns and penalties ofperjury thaf the in formation provided above is true and LDTr e-t - �,a*r,�P_- Dat Sia 32 Official use only. Do not write in this area, to.be completed by city or town o ciaL `�, OI 4 L` _ PermitfLicense#:. Isla rig Aidhorrty.(circle one) 1.Board of Health`Z:Buudmg iDepartment 3. ChtP/TovPn Clerk 4:Dlec#»cal Inspector 5.Plumbing Inspector 6.Other ; Contact Person_..: done '�gg 4i`25fl5 16:24 51.68.295957 5CS PAGE 02 r = DATE IMIIRIDNYYYYI �* 1D / -ft7s II mo+ Or U.31 1� � 1-4 c.rE. F 9 U. r _ Ndxi r R Or 1NrORMSF.T{ON _ THIS G:r k1=1GP"I`19 NO RIGS r UPDN Z H=C_RTiFICA i c ONLY AND CON-=R }iJ]LD=rZ.THis OcfCflrlChi ODES NOT 1USS-�1D =�'ND OR $C5 Rg�nry• =na• AL'irRTHE`COVEFt;4G:AFFL7RL1$D BYTg{ AOLlGl=S g�LDW. ?.D. Bax 22.D693 &L.a�I9 3D0 Nana Avpzlu� GOVcRAGE NAM G=n$t Neck ICY �3:D2:3-�Q�-�3 iNSIJ�ERs A'�OFtdiNu I �xDn0:51�-=ba-6(it77 x+ax:5�o�fl�5-7857 a xaaysasa� ctmo�v _ INSUFI�1� E.ffi;-tag IN5URFD 1 5UFIEREL smr_iean;f�• usur.=ao c.. I 1�305 INIURERCt StLLnL•�r►c==caa ytiau a�a Bii Pay zz= nL ding Carp. INSURErR¢ . . 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