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HomeMy WebLinkAbout0152 BREEDS HILL ROAD a Treed Ni 1 I ` - o LL.n� 5 3 �� oa N �S v �1 " �oa�Hero o CPQ.mplaint C,aII�Report p Pnnt dOn 1 1/26/2019 - eenrtsreai.e. ., 3' y -4, 1M 59. 1`52 UNIT 5`BREEDS RILL ROAD; ° �, Case# � C 1.9-4,36 � d, r M� BARNST 4RLE � �3 , Case#: C-19-436 Address: 152 UNIT 5 BREED'S HILL Date: 5/22/2019 ROAD, BARNSTABLE Owner Info: Property Info: MBL: Owner Notified?: Complaint Details: Type of Complaint Classification of Complaint Method of Complaint Building Code, Medium Priority Dept Referral Complaint Summary: been compromised per email from DC now Chief) Pulsifer Fire separation between every two units has ee p p ( � and confirmed again by current DC Pfautz. Action History: Action Taken Date Description Fee Inspector Close Case 11/26/2019 doors between units $0.00 bowerse were created with building permits Inspector Assigned to Complaint. bowerse Filed by. andersor Comments: Comment Date Commenter Comment §` ,,x Townof Barnstable.: � Date:' 11/26/2019 „e r �p�THETp,�, Town of Barnstable 0 Inspectional Services &ARNSAB& Brian Florence,CBO %639:. ,0 Building Commissioner ATfb MA'S° 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us INSPECTION REPORT Address : 152 UNIT 5 BREED'S HILL ROAD, BARNSTABLE Case # C-19-436 Inspection Type : Violation Inspector: bowerse Description ��Date IUnit Status Comment Violation 11/26/2019 'PASS Doors between units were created with a building permit no violation present Inspection Type : Violation Inspector: bowerse ---- ------ -...-- ---- .. .............. .......... ..................................... ......-................_.. ----.. Description Date UnitStatus Comment i Violation 06/07/2019 i Via concerns from Barnstable Fire Department. This complaint was created. I have contacted owners of all Units Requesting a walk through inspection ( Please see attached Document r I Violation 06/07/2019 i FAIL Via concerns from Barnstable Fire Department. This complaint was created. I have contacted owners of all Units Requesting a walk through inspection I Please see attached Document YOU WISH TO OPEN A BUSINESS? For Your Information: Busitiess certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which.you must do by M.G.L.-it does not give you permission to operate.) You must first,obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to he Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. h,: DATE: �0//� t Fill in please: APPLICANT'S YOUR NAME/S: x f 0. USINES YOUR HOME ADDRESS: © IC o a Vf 60 TELEPHONE # Home Telephone Number 7701— i-1 S7� GI y NAME'OF CORPORATION:'. rsct0 G r(9.5 NAME OF.NEW BUSINESS TYPE OF BUSINESS:. IS THIS A HOME OCC NO ADDRESS OF-BUSINES�S'1*11.:;; >..Y.2 eTS :�� t 05 [Assessing] } When starting a new busineE s there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is inte ided to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to makE sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM 1 SIO ER'S OFFI This individuate i• n nor o y rmi requi rem e is that pertain to this type of business. \\\ th rize Si nat re* COMMENTS: W 2. BOARD OF HEALTH i This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: /Engineering Dept.(3rd floor) Map Parcel O Permit# House# Date Issued ;/ Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) ee Conservation Office(4th floor)(8:30,- 9:30/1:00-2:00) G UJ k n 1 - Planning Dept..(1st floor/School Admin. Bldg.) ,►� Definitive Plan Approved by Planning Board 19 t679• V � f TOWN OF BARNSTABLE /�� Building Permit ApplicationA J Protect Street Address o2 /� � ►2� �,�,t1.6 � ��� /Village � p 311 M��� ;/6wner ,�FV s7-A a�� /jS, 1b A � Ltl� � Address , elephone r r Permit Request L 9 �.6pe ' First Floor . square feet Second Floor square feet Construction Type ✓Estimated Project Cost.$ paQ 6.0 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No D i Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existin tructure Historic House ❑Yes ❑No On Old King's Highwa Yes ❑No Basement Type: ❑Fu ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Ar sq.ft) Number of Baths: Full: Existing ew Hal • xisting New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑El c ❑Other Central Air ❑Yes ❑No Fir ces: Existing New Ex' 'ng wood/coal stove ❑Yes ❑No Garage: ❑Detached(siz Other Detached Structures: ❑Pool . e) a ❑Att d(size) ❑Barn(size) None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# QQ$ -9 - Current Use Proposed Use / Builder Inforjnation 1 � v Name d Telephone Number S Address License# -� !/'Iiome Improvement Contractor# orker'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 DATE —6, -92 BUILDING PERMIT DENIED FOR T E FOLLOWING R ON(S) FOR OFFICIAL USE ONLY PERMIT NO.. DATE ISSUED � t MAP/PARCEL NO. - ADDRESS VILLAGE s . OWNER DATE OF INSPECTION: ' FOUNDATION ' FRAME ' w r - INSUL'ATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: FINAL GAS: FINAL n FINAL,BUILDING 6 4 /`cu r DATE CLOSED OUT 4 ` 2-0 g ASSOCIATION PLA � I L 1 • I S T7 d' 6- _1i1� LL- I�Qe L� or S� 3� ful;! The Town of Barnstable Department of Health Safety and'Environmental Services 1. Building Division 367 Main Street,Hyannis MA 02601 NlIke: 508-790-6227 Ralph M.Crossen ax: 508-79"230 Building Cammissiam+er February 20, 1997 Janet Parker and Sondra Toolin 10E Seashore Park drive PO Box 708 Provincetown,MA 02657 RE: SPR-008-97 Mama's Laundry, 152 Breeds Hill-Road,Hyannis (314/24• . 4). Proposal: Commercial laundry not open to general public. Vehicles will transport the laundry to and from the site approximately 2 to 4 trips per day. Dear Ms. Parker and Ms.Toolin The above referenced site plan was reviewed at the February 20, 1997 meeting of Site Plan Review and deemed approvable with the following condition. 4 • Contact DEP and either obtain the necessary permit or obtain a letter stating a permit is not necessary. Please be informed that a building permit is necessary prior to any construction. Upon completion of all work,the letter of certification required by Section 4.7.8 (7)of the Town of Barnstable Zoning Ordinances must be submitted. Also, all signage must be discussed with Gloria Urenas of this Department. Should you have any questions,please feel free to call. Respectfully, ptiCrossea� Building Commissioner r 4,nna MAR. -04' 97(TUE) 13:51 OEF / SERO TEL:50g9 ?655? p. ooa PUBLT C NOTICE PROTECTION MASS.kMSETTS DEPARTMRN`"1 OF EIr7VIRL)N4EWT14L KW OF WASTE INDUS AL WAST PREVENTION Ot+T R Southeast Regional Office 20 Riverside Drive Lakeville, MP. 02347 Pursuant to Chapter 21, Section 43 of the General Laws. and 3I4 CMR 7.a0 licatians for sewer extension and 2 . 06. notice iCSiand proposed ven Of the pactions llowin whereon: or connection pe CITY/TOWN OF: BARNSTABLE FROacT NAME: ' S Laundry ppPI,ICANT Janet L. Parker, Co-owner LOCATION.- Hyannis.Breed' s Hill Road Hyannis. 14A 02601 PURPOSS: Sewer Connection Permit TRANSMITTAL rYo. : 131106 pgoPoSED ACTION: Tentative Determination to issue � livable laws, regulations and procedcixes The above applications, and app ro osed available for inspection at the above address. must be sent are wows public hearing on P actions or requests for a p da S of this notiee - to the above address within thirty (34) Y John K. Winkler, Chief Permit Section Bureau of Waste Prevention r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC ION soL7ubmTr RwioNAL or-mcB WHIM F. WII' M TRUDY C'm Goomr swam" ARM PAUL CELLUCCI PAM D. STRUHS J.t. QDrtR1Qr ConuMosinmr March 4, 1997 Janet L. Parker RE: BARNSTABLE--Industrial Wastewater Post Office Box 708 Branch BWB--Pgblic Comment Re LMieW Provincetown, Massachusetts Perjod, Industrial Sewer Connection 02657 Permit (aWP;W33) Transmittal No. 131106 Dear Ms. Parker: Enclosed herewith is a public notice, the fact sheet, and a draft of special conditions for your sewer system extension or connection permit application. The Department of Environmental Protection has completed its Technical Review of the permit application listed above and determined that on the basis of information now in the record, the Department shall complete the public comment review period and issue the permit within 90 days following the close of the period for public comment. The Department may request additional information during the course of such review. in the absence of significant public comment which would, on its face, appear to constitute grounds for the Department to deny the permit or significantly modify the proposed permit, the Department will complete a public comment review within thirty days of the close of the public comment period. You are, therefore, encouraged to review and comment on the permit and the draft of special conditions. Please have this notice Published in a newspaper of general circulation in the municipality where the project is proposed. This notice shall be published once only at the applicantts or permittee's expense in accordance with the requirements of 314 CMR 2 .06 as amended. It is the applicant jpermitteeIa responsibility to forward proof of publication to: Department of Environmental Protection Southeast Regional Office Bureau of Waste Prevention 20 Riverside Drive Lakeville, MA 02347 ATTM. June Mahala 20 Ri eriide 1hive . Lakw0b, MMKhW*1b 02347 • RAXIM) 9474aO • Tekphope (M) 9r6-�7�A Y The mandatory thirty (26) day public comment period will commence with the date of publication of the public notice. It is in the permi.ttes's best interest to publish this notice upon receipt and forward the proof of publication to the above address as so6n as possible to avoid delays in processing your application. Should you have any questions pertaining to this: matter please contact June Mahala at the Reaional Office at (508) 946-2822 . very truly yours, �L a', Lly�, Winkler, Chief Permit Section Bureau of Waste Prevention W/JMM/re httachment CC. Barnstable WPCD 617 Bearse ' s Way Hyannis, MA 02601 ATTN: Peter Doyle, Superintendent I (J I I i I I r i i FACT SHEET DRAFT SEWER CONNECTION PERM TO DISCHARGE TO BARNSTABLE WASTEWATER TREATMENT PLANT PERMIT NO. 131106/S97CIOOX NAME AND ADDRESS OF APPLICANT: Jan L. Parker P.O. Rox 708 Provincetown, MA 02657 NAME AND ADDRESS OF FACILITY WHERE. DISCHARGE OCCURS! MA,N`,A I a Lau 152 Breed's Hill Road, nit 5 (314/24-4) Hyannis, MA RECEIVING POTW: BARNSTABLE WASTEWATER TREATMENT PLANT I . Proposed Action and Type of Facility: The above-named applicant has applied to the Department of Environmental Protection, Bureau of Waste Prevention, for a sewer connection permit to discharge into the Barnstable POTW' s sewer systeM. mAMA's Laundry is proposed as a small commercial laundry which would not be open to the general public but would be receiving two (2) to four (4) vehicle trips of transported laundry per day. IT. Description of Discharge: The discharge consists of approximately 8,496 gallons per day (GPD) of industrial wastewaters and 120 GPD of sanitary wastewaters . III . Limitations and Conditions : The effluent limitations and the monitoring requirements of the draft permit may be found in the attached draft of special conditions. IV. Comment Period, Bearing Requests, and Procedures for Final Decisions: All persons including the applicant, who believe any condition of the draft permit is inappropriate must raise all issues and submit all available arguments and all supporting material for their arguments to the DEP, Bureau of Waste Prevention, Industrial Wastewater Branch BWP, 20 Riverside ,prive, Lakeville, MA 02347 by the close of the thirty (30) day public comment period. In reaching a final decision on the permit, the Bureau of Waste Prevention, Permit Section Chief, will respond to the significant comments and make these available to the public at the Department of Environmental Protection, Southeast Regional Office. Following the close of the comment period, the Bureau of Waste Prevention, Permit Section Chief, will issue a final determination and forward I -04' 97(TUE) I3:50 DEP / SERQ TEL 5069 '655 P, 00? a copy of the final permit or requesto the ed Withant and each inr30ndays submitted written comments r q interested any following the issuance of the final determination, reconsider or person may submit a request for a formal hearing contest the f final deC1e of•M GRLquChtS3 0A and 319for 1 hearings mugt Ct�1R 1 00 of the satisfy the requirements Departments Rule$ for Adjudicat:ory Proceeding. V. Department Contact: Additional information concerning this draft permit may be obtained from: June M. Mahala DEP/BWP/Industrial wastewater Branch 20 Riverside Drive Lake-Ville, MA 02347 (508) 946-2022 f MASSACHUSETTS DEP SEWER CONNECTION 22) SPECIAL CONDITIONS (DRAFT) PERMIT N0.111106/897CIoox I , � S La ndr is autharized to discharge industrial wastewater to the Town of Barnstable rawer system, located at: MAMA' s Laundry 152 Breed' s Hill Road, Unit 5 Hyannis, MA 02601 2 . This permit authorizing the discharge expires five (5) years from the date of issuance. The permittee shall apply for a renewal of this permit ninety (90) days p to the exprracontinu d lawful Cordance dischargeswith 7 .astsb) �o beyond � the expiration date . 3 . R opener Clause: The Department reserves the right to make appropriate revisions to this Permit in order to establish any appropriate effluent limitations or other provisions which may be authorized under the clean Water Act in order to bring a12 dischaY'ges into compliance with the Clean Water Act . A. The process wastewater discharges from K*%1 s Laundry shall be in compliance with the Town of Barnstable Industrial Pretreatment thereunder as wellaslthe Town' sPP) and c al m sewer use established ordinance. 5, r�eral A oh'bitions. No person shall discharge or cause to be discharged to the POTW any substances, materials, or wastewaters that can harm the sewers, wastewater treatment process, or equipment; have an adverse affect an the rece�.ving waters or can otherwise endanger life, limb, public propertyr or constitute a nuisance . h the Introduced t c d e TW ll not ss POTW or inter ere through with the aoperation a pollutants or throug performance of the works. 6. a„�•c; f iC pxoh'bitio - ]27t od eed into the POTWn addition, the 11owi:►g pollutants shall not be {a) pollutants which create a fire or explosion hazard in the POTW; (b) Pollutants which will cause corrosive structural damage to the POTW, but in no case unless the dischargesis with pH ecificweritha neS . works s specifically desigd to accommodate such discharges; r I 22Y Special CoAditions - page 2 MAMA' s Laundry p Permit No. 231106/S97CI0OX (c) Solid or viscous pollutants in amounts which will cause obstruction to the flow in the PGTW resulting in interference; (d) Any pollutant, including oxygen demanding pollutants, released in a discharge at a flow rate and/or pollutant concentration which will cause interference with the POTW; and (e) Heat in amounts which will inhibit biological activity in the POTW resulting in interference, but in no case heat in such quantities that the temperature at the POTW treatment plant exceeds 40 degrees Centigrade (104 degrees ;wahrenheit) unless the Division, upon request of the ppTW, approves alternate temperature limits. � f The Conintonivealth of Massac•husctts Departntcnt of Inrlustrial.4ccirlutts 'y ^t�Ir1 officeo/inveW921/ons •\_,:;..:.'_r 600 11 ashin ton Street Boston, Mass. 02111 Worlurs' Compensation Insurance Affidavit IA licant information• Please PRINT le-&_......� name: Inc•ttion• sit• nhont:# I am a homeowner performing all work myself. k-ra—m a sole proprietor d have no one working to any capacity _ • T .•w.�.�7MVY..YVf:.l'T"'�..AT.•"l7�ll.:,wyTT1wT+.".�f���..��,,.,�:�wT�.A...wM'�'.'�_..�?�•'.M++.w•._. r.�.�.�..�•-..__.. •.. 1 am an emplover providing workers' compensation for my employees working on this-job. contonny name• '4�e$-15 2T address: cit_ oA l W/U i M-a l'9 i M I phnne#: I'SM 9`S Z-log L; insurnnce M. &"y �nlic� !! ?Jle7 OR-004 �7 — (r�/ Cj 1 am a sole proprietor, beneral contractor, or homeowner(circle ate) and have hired the contractors listed below who have the followin_ workers' compensation'poIices: comnanv name- address: cirv: Rhone#: insurnnce co Holier # 1 •i.::•+.. '�"• - _ .-�,..t...:...-:� _- _2r^�_•L�.:�•"Zt;�.•.r!1w�ry ^-:T.T•., _ __._....-ram"_'t'...i__.r_ _..__._.... _._ ._.__—....._. _�_r.....a.r..._._-- -....r�:aw..+....1�. - - — _.il. .Lam• - .._a��.o•-'-. compnny nntne: address: rity• phnne#• insurance co Roiiev# 77 .Attach additional sheet if ncccssary_.�•'- Fr —i Ji tJ •- __-_ "•".ir.—� +"^-• � w; R o"" Failure to secure coverage as required under Section Z5A of NIGL 152 can lead to the imposition of criminal penalties ol'a line up to S1.500.00 andiur une%cars' imprisonment as%%ell as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement mac be forwarded to the omcc of Investigations of the DIA for coverage verification. I do herebi• Ifi ut der t! p nd pert hies of perjun•that the information provided above is true and correct Sienatum Date Print name Phone# ,official use unlc do not write in this area to be completed by city or town official r� r it city or town: permit/license# r'tlluilding Department foLicensing Board check if immediate response is required Selectmen's Office f_ [311ealth Department contact person: P hone#: r•lOthcr is f Information • Instructions st uctions ion and Massacliusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their emplrn c S` As quoted from the -law-. an emptvree is defined as every person in the service of another under any contract of hire, express or implied. oral or written. An enrp/arer is defined as an individual, partnership, association. corporation or other legal entity, or ally two or more . 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 dwcllin�g house of another who employs persons to do maintenance , construction or repair work on such dwelling hour or o►i 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 even,state or local licensing agency sliall withhold the issuance of- al of a license or permit to operate a business or to construct buildings in the commoirwealth 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 anv contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha 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 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. Pleas be sure to fill in the perm it/license number which will be used as a reference number. 171e affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investi=atioils 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. r..w.,.•.+ ....- ..�www•.....•.. s��.+..........++�,+rw!*+^�n�+e..._.wwrw+. w._,+•..+w�•.w.ro.ter-7r+•Tvn��•wao..........�n The Department's address. telephone and fax number: The Commonwealth Of Massachusetts r Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 est. 406, 409 or 375 t fICOMPANY EastGUARDmA SubsidiaryMof GUARD Insurance Group %INSURANCE 190 Main Street-P.O.Box 537 •Saco, Maine 04072-0537 CX4VM Iev Payment Plan ,%R=200477 — NOV A ARTISANS POLICY DECLARATIONS Agency Bill Direct Bill F:ene wal of Number Policy No.ART 0200477 .NOV B Na id Insured and Mailing Address(No.,Street,Town or City,County,state,Zip Code) R:obert Grimala L`26 Leicester Street Amburn, MA 01501 Police Period: From 11-7-96 to 11-7-97 at 12:01 A.M.* Standard Time at your mailing address shown above.*Exceptions:12:00 noon in New Hampshire. The Named Insured is: X Individual Partnership Corporation Joint Venture Other: Occ>:rpation: Carpenter Loc. Street City or Town County State Zip Code L 426 Leicester Street Auburn Worcester MA 01501 ..: :.. .:.. Nap Applicant Interest: ] Owner-Occupant ❑ Tenant ❑ Buildings: ❑ Replacement Cost ❑ Actual Cash Value $ IX 3usiness Personal Property including Tools: ❑ Replacement Cost 23 Actual Cash Value $ Premises Off 00 Loss of Income: 20%of Building Limit and/or 100% of Business Personal Property Limit Included De, tlble;° ❑ $100 ❑ $500 ❑ $1,000 ❑ Other :<S:::u...,.:. avXie•fo)pb�``t2..^•.`w:'iWSJ'�SSa'Gv���,2'tY.v.i,vTy..W. Applicable only if an"X"is shown in the boxes below ❑ _accounts Receivable: (AP300) ❑ Money&Securities: (AP304) ❑ Employee Dishonesty: (AP308) ❑ Valuable Papers& Records: (AP328) C Theft Exclusion: (AP348) ❑ Other: Limits of Insurance Liability Bodily Injury and Property Damage $ 300,000 per occurrence 600,000 general aggregate Medical Payments $ 11000 per person Fire Damage Legal Liability $ 50,000 any one fire or explosion S Applicable only if an"X"is shown in the boxes below: Cad Contractual Liability Coverage (GL-104) Property Damage Deductible (AP222) ($250 included) ❑ Non-Owned&Hired Auto Liability(GL-122) ❑ Other FORMS AND ENDORSEMENTS Forms and endorsements made part of this policy at time of issue: A 432 CP 21 MORTGAGEE/LOSS PAYEE ? None Agency: 3049 Northeast Agcy. JANNUAL PREMIUM $ 351. Auburn, MA 10-9-96 Countersigned By lm Authorized Repro cam6ve THESE DECLARATIONS,TOGETHER WITH THE COVERAGE FORM(S),COMMON POLICY CONDITIONS AND FORMS, AND ENDORSEMENTS,IF ANY,ISSUED TO FORMA PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.' = E►c•ARTDEC•E.D W-95 -- —> z=