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HomeMy WebLinkAbout0154 LONGVIEW DRIVE h�Or1QvlPa �'ivlL. Town of BarnstableBuilding Post This Car,:d So That rt is Visible.From the Str.,eet Approved;Plans Must be,,Reta�n'ed on Job and this CardMu'st be�Kept . Permit Knsa Posted Until Final Inspectun Has Been Made y -' +� Where a Cert�ficate,of Occupancy,;s Requ red,such 8u�ldmg shall Not be Occup�e�d until a�Final Inspection has been made Permit No.. B-17-4178 Applicant Name: Craig Bishop _ Approvals Date Issued: 12/21/2017 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 06/21/2018 Foundation: Location: 154 LONGVIEW DRIVE, HYANNIS Map/Lot 251-076 Zoning District: RC-1 Sheathing: �. Owner on Record: CLOUTIER,ALLISON Contractor Name Craig P Bishop Framing: 1 S, Address: 154 LONGVIEW DR Contracto( icense CS409777 2 CENTERVILLE, MA 02632 Est Project Cost: $2,191.00 Chimneys Description: Air Sealing&Weatherization Permit Fee: $85.00 Insulation: Project Review Req: Fee Peed $85.00 Final: r� 12/21/2017 r � Plumbing/Gas zr as Rough Plumbing: Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afte rissuance. g All work authorized by this permit shall conform to the approved application and the approved construction documents for whiehAhis permit has been granted. All construction,alterations and changes of use of any building and structuresl" shal be in compliance with the local zoning by laws=and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or.road and shall be maintained open for public uispeetion for the entire duration of the work until the completion of the same. Electrical Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Buildmgaand FireOfficials are provided on this permit. 01 Minimum of Five Call Inspections Required for All Construction Work:,, xe rs< Rough: 1.Foundation or Footing �•`� 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: ON t-s4dE All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT I j to het b ,►,� Town of Barnstable *Permit# Building Department Services Expires 6moVthsfrom issue date saaxsr,+srrs, _ Brian Florence,CBO >a� - s 16s� ��' Building Commissioner S c suet" 200 Main Street,Hyannis,MA 02601 www.town barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY D 16 Not Valid without Red X-Press Imprint Map/parcel Number = Property Address V t _ a iL v j)°e �-sC Residential Value of Work$ 3,(7V6 a, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address eA)w", C 6a,��eA Contractor's Name . .aae,) plyte"U1 Telephone Number Home Improvement Contractor License#(if applicable) ��� 3�- Email: r—AJCK-L I-{�(4(, C YV C (DM Construction Supervisor's License#(if applicable) C'5 ®9 TETI ❑Workman's Compensation Insurance Ch ck one: am a sole proprietor a . I am the Homeowner ❑ I have Worker's Compensation Insurance TO OCT,l 2417 Insurance Company Name � Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) a Re roof(hurricane nailed)(stripping old shingles) All construction debris will be to G S� 2�- Re-roof(hurricane nailed not❑ (h )( stripping: Going over existing layers of roof) Re-side -� Replacement Windows/doors/sliders.U-Va1ueAJ,,scV% (maximum.32)#of windows .� c{p® dies #of doors: '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. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: ' QAWPFILESTORMbuilding permit formslEXPRESS.doc 08/16/17 i The Cormmomveakh ref1fassackusetts Department cif Industrial Acc idim& r Office oftigafions 600 Washington,S`Met Boston,MA 0111 nwmmasLgovfdia Workers' Campensat an Insurance Affidavit Btdlders/ContractarslEIectdciansd%mbers A licant Information Please Print Name nciirp' �bSnIZaii� /'/�C/(G�Q� /l�IPwJYLJ City/tat : 5, ygtgt"C&rr# AW Phoneme 2R. '97 Zf Are you an employer?theckthe appropriate bom ' Tyke of project(required)- I.❑ I am a employer with 4. F]I am a general contractar and I 6. ❑New c:oastruction employees(full and/or part-time).* have hiredthe sub-contractors 2. am a sole proprietor orpartuer- listed onthe attached sheet 7. Q Remodeling sip and have no.emplayees. These sub-conlractam have g.,Q Demolition -waiL^ing far me in any capacity. employees and have wodome [No worlcers'comp.insurance comp.insluagce I 9. ❑Building addition 5. We are a corporati on and its 10.❑Electrical repairs or addAions 3.❑ I am a homeowner doing all work officers have exercised their IL[:]Plumbing repairs or additioms O wailers' _ of a tiou per MGL i [No required.]1 c.152,§I(4h and we have no 17 Roof employees.[No o�ess' �-El other w comp.iusarance requires!-] 'fYrty agplicm&diwt chedmbox p1 mast also fin oxtthe secdonbelow showing fie wodere compeasatiaupoTicyinf3nDRdam. Ffomeoolnem who submit ilsis affidmir iedxating they are doing all weak gm&=lute Gumde=bMam—st 5nbffilt a new affidavit indi��SnCIL TCoitnsctgrs ff=,b--7r figs btta mmt attached as addili®at sheet s owing thename of fe s ab-ccatm teas s net state whether or nor these elides have empltryees.Ifthe dh-r rs have empicym%they amsrprovide their workEn'gyp.policy n meber l ant art etnployer fftatispranadirtg ivarkers'compensagaii iamirance f or m.y oarp[Dlwes Hetoov is i fie paficy and job sac hzfbrnza6Dm Insurance CompatzyName: Policy 9 or Self-ins.Lic.A Expiration Date: Job Site Address City/Statelzip: Attach a copy of the work-ere compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL a 1572 can lead to the imposition of criminal penalties of a fine up to$1,50a OD and/or one-year imprisonmeut,as well as cive penalties.in the fazm of a STOP STORK ORDER and a fine of up to$250.DO a day against the violator. Be advised that a copy of this statemomt maybe forwarded to the Office of Irrvestigations of the DIA for insurance coverage verifisatic a- I do hersby cerfif3,a n-dfr t s 4mdpeaiaMes afpeefury that Aa infont a&mprm drd abmre is bare art carrect Sittattrre: Date: '17 Phone ik Offidat use only. Do not errita in this area,to be arinpfeted by taffy vrtoirn Official City or Tern: Permit/I,icense Issuing Authority(circle one): L Board of Health I Building Department 3.drown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Eaformation, and Instructions MaSS WIMSetts Gets-A Laws chapter I52 regal=all employers to provide wows'compensation far theg erPIoyees. e Pmsaantto this stye,an.employee is defined as.c:soup person in tits service of another tinder a¢y contract ofhn-e, express or implied,and or 71iftcaf An.employer is defined as"an i a f�iau pamtaershi p.associeli6 arrporaii0 or other legal enthy,or any two or more of the foregoing engaged is a joint eateaprim,and inchidmg fife legal represmfatives of a deceased employer,or the renewer or t mste,--of an individual,partaership,associafion or other Iegal entity,employing employees, However the owner of a dwelling house having not more than three apartments and 7ho resides therein,or fhe o=43aat of the - dwuffi g house of anoher who employs persons to do mace,construction or repair work-on such dweILing house or on the grounds or buddmg shOnotbecanse of such employmentbe deemetitn be an employer." MGL cbaptnr 152,§25C(6)also states that'every state or local Rcensiug agency shag withhold fine issuance or renewal of a license or permit to operate a business or to construct bmuldings in the commonwealth for any applicantw•ho has not produced acceptable evidence of cdmpZiauce with the insurance.coverage required." Additionally,MGM chapter 152,§25C(7)stairs-Neither the c=n mwealth nor ray ofits political subdivisions shall entfz- into any contract for the performance ofpobho work until acceptable evidence of compliance with the iwm7anc6._ retnrrr-elnemt s of this chapter,have been presented fn the con�author" Please fill Dirt the wmicers'compensation affidavit completely;by checking the boxes that apply to your sitoation aud,if necessary,supply sob-contractor(s)name(s), addresses)and phone mmmbea(s)along wish their cert rficate(s)of m ara ce. Limited Liability Comparmes(LLC)or Lmnited LiabBity-Partnerships(LLP)with no employees other than the members or partners,are not ceded to cant'workers'compensation insurance- If au LLC or LLP does have employees,a policy is mgmfted. Be advisedthaf this affidayitmaybe submitted to the Department of Industrial Accidents for confamaiion of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be rstomed to the city or town that the application for the permit or license is being requested,not the Department of . Industrial Accidents. Shoddyou have ray questions regarding the law or ifyou.are requmrd to obtain a workers' compensation policy,please call the.Department at the mmmber listed below. Self-insnred companies should ear their s eIf-n,�,T�*,ce license number an the appivgiiatm:line. City or Town Officials Please be sure that tie affidavit is complebY and prim t d legib y. The Department has provided a space at the bottom of the affidavit for you in fill out in the event the Office ofInvesfigatiom has to contact You regarding the applicant Please be sure to fill in the pennit/licemse number which will.be used as a reference number. In.addition,an applicant that must submit muhiple perm tllicense applications in any given year,need only submit one affidavit indicating rr117Ent policy information(if necessary)and under`Job Site Address"the applicant should write"all locations in (may or town)-"A copy of the-affidavit that has been officially stamped r or aked by the city or town may be provided to the ' applicant as proof that a valid affidavit is on file for fntare-per permits or licenses A new affidavit must be fiIled out each year.Whew a home owner or citizen is obtaining a license or permit not related to any btts�s or commercial vemtue (i-e. a dog license orpermit to bran leaves etc.)said person is NOT required to complete this.affidavit The Of of Iuvestigations would Imke to thank You is advance for your cooperation and should you have any questions, please do not hesitate to give vs a calL The Department's address,telephone and fax nm=ber. - t Degartraenfi of 1u&igftiak Accidents. Q�e�of�.�e�fightio� T(,-L 4 617-727-4900 cxt 4€6 or 1477 lvi A SAFE Revised4-24.07 ,M gqgfdhL �WE Town of Barnstable 4 Building Department Services B" ' ` Brian Florence,CBo &63 ►``� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us • 1 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1 I, �u>S��✓ �ic� �;� ,� as Owner of the subject 1 property hereby authorize ,fhx2r 17IM6'/7rw to act on my bebA in all matters relative to work authorized by this building permit application for. (�iYlS�t C /ye /� Q � cZ (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. �2 2z- � Signature of Owner Signature of Applicant Print Name Print Name w•rZ•17 Date Q:FORM&OWNWERMISSIONPOOL9 Rer.0&116t17 Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner J= 200 Main Street, Hyannis,MA 02601BARNSTA ram. www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE ExEAIPTION Please Print DATE: %e I Z•I 10B LOCATION: /3• ,Gr;xow i"Ve /m//�mber street t village ER" "HOMEOWN : / U64".) le Y''�=/C name home phone# work phone# CURRENT MAILING ADDRESS: 6S� �i✓✓t;va'F ./ . city/town state zip code The current exemption for"homeowners"was extende\d to includ owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who doer nss sa license,tnovided that the owner acts as supervisor. D OF HOAIFOWNER Person(s)who owns a parcel of land on which he/she or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessuch use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a hner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall re onsible for all such work erformed under the boil ' ermit. (Section 109.1.1) The undersigned"homeowner"assume/reh y for complian with the State Building Code and other applicable codes, bylaws,rules and regulations. \ The undersigned"homeowner"certifienderstands the Town of Barnstable Building Department minimum inspection procedures and re epts and that ply with said procedures and requirements. Signature of Homeowner Approval of B/Codletes icial Noe- y dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127u on Control ' HOMEOWNER'S EXEMPTION Thtes that: "Any homeowner performing work for which a building permit is required shall be exempt from the pof this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a p for hire to do such work,that such Homeowner shall act as supervisor." Meowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appenules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q-\WPFII.BS\FORMS%uilding permit forms\EJWRESS.doc 08/16/17 nsumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Soston, Massachusetts 02116 aprovement C-61AL>actor Registration Registration: 151639 Type: DBA Expiration: 6/20/2018 Tr# 419291 NSTRU�rTtl�4 & Update Address and return card.Mark reason for change. -- � .Address Renewal Employment Lost Card ation License.{or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 ►ry Not va' thout signature �® Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-098881 Construction Supervis-or MICHAEL L PIMENTAL ` PO BOX 1286 j n SOUTH YARMOUTH MA bi&4' (AC aj , } 'V- (AWN a=; nn , • 1 -i CL 'c �°, . a) <n a o� �„�n l Expiration: o` 01 a M CD CSc Commissioner 11/0912017 c ca m ° M .. (D�. A p L c m T" 0 O j .. .. 3Ch O H i O ?y N n / N O = � Fic . 00. M (a 7 - Office of Consumer Affairs & Business Regulation- Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints I b Registration# 151639 Home Improvement Contractor Registrant MICHAEL L PIMENTAL CONSTRUCTION & REMODE Registration Home Page Name MICHAEL PIMENTAL Address 275 WEST YARMOUTH RD City, State Zip W. YARMOUTH, MA 02673 Expiration Date 06/20/2018 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. https:Hservices.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=52700 10/19/2017 " pFZ T Town of Barnstable *Permit# �' Expires 6 months from issue date STD = Regulatory Services Fee MASS.9� ,b� Thomas F.Geiler,Director Building Division ( � � Al End A (/�1t/4/6 7— Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w Office: 508-862-4038 Pax: 508-790-6230 EXPRESS PERMIT APPLICATION F Not Valid without Red X-Press Imprint Map/parcel Number v o� Property Address residential OR Commercial Value of Work g,Q10 . '� Owner's Name &Addres ^ `� if J s o n t hbrzdc � 1 .1�� ��f-i -ems IOM I a I is 0, Contractor's Name�/ �7'_� z r�� j.� ��n c Telephone Number��-U Home Improvement Contractor License#(if applicable) ice. �Z1 `z Construction Supervisor's License #(if applicable)_ [r Morkman's Compensation Insurance Check one: I am a.sole proprietor MLN*ForSS pER 1 ❑ I am the Homeowner o 2002 have Worker's Compensation Insurance SEP 1 Insurance Company Name=J nt�� c<.�i -� ` e ago-� .r4SAUbInE BARNST BCE Workman's Comp. Policy Permit Request(check box) 6L-roof(stripping old shingles) V K-N r ��•�,� gars. 3Gos, G .Q. !. ! Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value (maximum.44) 0 Other(specify) 'Where required:. Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Consen•ation,etc. Signature expmtrg ICA ►-ie Ash burtont"V�,-,;j oston i0 .. MaG._1 C.� 1 G-I rvS-1'1-:UCT10N :;UPD1 viSol{ i_ICr_Nsl.: 0?G;:?j L I;irllltl;llt: it xpir,": 10/�U/:_00�r Ilk;i A''/.I:.A I l I. i 1,10 ,.: tlr Ivlr Ir.f i,:l., ilrl .ultl r.i,.lni ti .uLlir.. '. nulill,..rluin. 110ARP,0F DUILUINt Itl_GUI_i1TlOId;;Liconsu: C(DJVL'"fI:UC i'IOIJ :;UI'IiI:VI:;c.rl( Uicl4ld�:u:.i�Q121)/I U'0 Expiru,,:::10l20/;'00,, Ilustrictud:,00 MAUL J CALt_.AuUr 1505 MAIN 'F OSTERVILLL', MA 0ZG55 ('� ':;i!��•. } .% V Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2004 PAUL J. CAZEAULT & SONS, INC. Paul Cazeault P.O. Box 2781 --- --- - ----- - - - _.-_. __ Orleans, MA 02653 ----- Update Address and return card. Mark reason for change. Address 1 . 1 Renewal I j Employment I,osl Card Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 103714 Board of Building Regulations and Standards Expiration: 7/9/2004 One Ashburton Place Rm 1301 Type: Private Corporation Boston,Ma.02108 CAZEAULT&SONS,INC. eault h Rd. C.G-� ru✓ MA02653 - -..:--. - -- - — ... .----- - Administrator Not valid without signature MAR-06-02 WED 09:56 AM MASTORS:& :SERVAN•1' FAX NO. 11018b9235 ACORD. CERTIFICATE OF LIABILITY @i�.��l��ANCE _.._.....__ -- -.---._.. Pn�oucL:r, .._ THIS CEHTIFICATE IS ISSUED AS A MAITE�+s ei:-vaI:l:, I,t:C3 . ONLY AND CJNFLHS NO RIGHTS UFOI, 5700 Do 3 t Road HOLDER, THIS CC-HTIFICATE DOES NOT P.n. 1-.1'_i� ALTER THE COVERAGE AFFORDED UY T-ri 2'a s 1: Cre oilw i ch, RI 0 2 l;i 1 INSURERS AFFL`HDING COVJ Paid.). CazQault 2>r Sons Roofinz IINS UFILHA._Cont.i.nOntal Cj.t:;U,')lt-� P.O. Box930 �INfuHoiLI TT.an;apc>rtatio:>, 7nOu:: I - -- — KIr$tOi) �u i K11i� MA 026- N.unrRC. NI THE POL ICIES GF INWP.ANCC LISTED 13F:LOW HAVL: UEEN ISSUED TO THE; INSURED NAMED ADOVE FOFl TI iE POLICY PERIOD INOIC ANY FiEI]UIREMF.fJT, lffitlt OH CUIJGITb�tJ OF ANY CONTRACT OR OTHER DOCUMEN.r WITH RE:il`ECT TO WHICH THIS Ci:RTIF MAY PERTAIN. THE RJ URANCG ArfUY,UEO f;Y TFIr POLICII" -11 S DF"CRIL3ED HEREIN IS SUl)JI: MAYCT TO ALL THE TERM$•Ei:CLUSIOAi I''OLICICS. AGGREGATE LIMITS FIOVlN MAY HAVE JCEIJ flEDUCED 6Y PAID CLAIMS. LTt7 TYf•C OF INSU(1gNCIi I _ F'UI.I(:Y Nl1AM1G C(1 IPOLICYCFFEGTIVf POLIc'Y I°7(FI piInN -----" 1f1ATs- Y r, G1141IIAL UAOILITY 0 ni 104/30/02 04/30/03 EAcho.culAn�Lc= A GUMW,Cf1CIAI(;f NF(1nl.(•I,1UIl-I l i I ----- -_ CLAIM,';MADC X I FIRF DAMAGE(Any or X TIT) Ded: 1 0 U 0 hILD t- (Any one pa, PERSONAL A ADV IN,1' G_Frdl ACC nf--C:A1t LIIJ ITAP('LICS r•GIi: GF_NERAL AGGR(C\I. PC ucy I X PqP - PRODUCTS •COMP,CI _ AIJTCiMOFiJLF-li,\CILIt Y --•- -- - -- __ __ • I Af•JY AUTCi GOMIIINFO^SGJG�L=Li (Ea ncclCarnl SIiF11 DULLD I,UTO r� fff UOUII.Y INJURY (Par pmxolq uIRFDAutJS _ _ ,,10:J•!7."1h1;[1 AU l i 1$ GOWN INJURY [Per acc4lanq - — P1101ERTY DAMAcc- (MACE LIACtLI1Y - - --- I War esilau.Iq ANY Au'I0 AUTO ONO;•CA ACC. J •-_I I OTFIFR THANA(jT0 ONLY I: • 6XCF:!sS UARILITY .—..�...-` _ I n run I I CLAIMS MADE EnCHOCCUHAE�C E --- -- i AGGREGATE_ •nCTr•NTInN !i I3 Wonl(i-:nSCCRhr[NSATIONAND 037 4 _-_ LJnrLoYl ns uAD1uTv I O 8/0 9/01 0 8/0�l/0? -JZ'7nsiJATCi -- I E CACNACcifKNT J. E.L.OIS[ASE_CAl-�.r DCSC:i11p'fI0 1" Of OJ'F.FlAl10NVL0CATIONG'VF:IIIOUf°,!LACLIJ:IOrl3 ADDED DY Eta DOFiSEMCINTISPCCIgI PROVISIONS ----_._I...._..... C_E;R71FlCA7C HOLOt A�1��Apnnx n tV3URLD.F>JtiuHr Rl rrrFr• CANCFIlATION SHOULDANYOFIliCAOOVEO SCRIDCDPOI-I;I!?$bECA;lC! SMIPle Cefdricate DATC-THEREOF, TNr_ISSUING INSURra wI, I-