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1989-800 CERTIFICATE OF OCCUPANCY TOWN OF QUEENSSURY WARREN COUNTY, NEW YORK Date �-- " t9 This is to certify that worts requested to be done as shown by Permit No, 89- 800 has been completed. This structure may be occupied as a One Fai 1 y Dwelling, Z a.,adon L G- 5 k Tree Circle MIdden Hills ner Martin Mosher Ow By Order Town Board TOWN OF QUE£NSBURY Director of Bldg. & Cade Enfo cement BUILDING PERMIT TC)VNN OF QUEENSBURY No. 89~800 WARREN COUNTY, NEW YORK c� PERMISSION is hereby granted to Martin Mosher e>a w OWNER of property located at 121 Oak Tree Circle HIdden Hills Street, Road or Ave. t.� in the Town of Queensbury, To Constructor place a One Family Dwelling_ at the above location in accordance to application together with plot plans and other information hereto filed and approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. [3. CONTR EROS Address is 26 Sugar Pine Rd . Queensbury , Nw Y . 12804 m r. TRACTOR or BU1 LDE R'S Name Martin Mosher ;n ro ACTOR or BUILDERS Address Same 4, ARCHITECT'S Name t� €�c 5. ARCHITECT'S Address ro ro =s 6- TYPE of Construction — (Please indicate by x) n SU I ,X1 Wood Frame I I Masonry I } Steel I l 7 PLANS and Specifications No. 26 x 52 single family dwelling as per plat plan , specifications 0 and application including septic application , driveway permit and 2 car ro s. Proposed use garage , One Family Dwelling t7 ro $ 235oOO PERMIT FEE PAID — THIS PERMIT EXPIRES hiaY 1 19 90 (lf a longer period is required an application for an extension must be made to the Building and Zoning inspector of the aq town of Gueensbury before the expiration date.) Dated at the Town of Queensbury this 12 Day of Oct ` 19 89 SIGNED 13Y THY for the Town of Queensbury —"' Building and 7aaning Inspector TOWN OF �,iCJEEr.'SL3L' RY rr� r TC T F `r -1. Tr �' ' Nn � � v •, n rr. ? 41IT F a Gteu t i C" `cM O 0i_TwENSRURY F+, OCT 1 f iggq Fee f'a-c -� l;UILDINC .uJI} CODES l�i .l 'AItTr T Date I.6,4ued € ®C,. °_ ; �^ '`; ' DFEE T. tiY and HAVILANO ROADS RD 1 Liox 98 nUEENs BURY , NEli YORK 12 d o -i PC�tnui.t No R Tel , ( 518 ) 792 - 5832 Exc 204 A 11EIMIT NIUS'r DO OBTAINED BE ORE aEGINNING CONSTRUCTION NO INSPECTIONS VILL BE MADE UNTIL APPLICANT HAS p,.I; CLIVED A VALID 13CILDINC PERMIT . All aprilicabla spaces on this application must be conipletcd and the ear on the reverse sick of this sheet , +0poature of the applicant must app * rl) e owner of this property is : ajaj__'a� '""' l' , O , Address rt TEL . $ .► `PAX MAP NO * iroperty loeatiork i<A'a Z' /.:4 / Lyr' -k I + as there been any split of this property since October yes no If yes , Planning Board Review is necessary . ! � LOT NO * �. UBDIVISION 14AME , IF APPLTCADLE s The person responsible for su }aa: rVjslon of work as regards Building Codes is , NAME Tel . O * ADD C 8 TEL. NF] . Address Tel Name at builderwoo, Tel ttame of Plumber T.ddrass Tel Name of MiaSon A�idro� s [ �.1TURt CIF I'RC]i'4`.LC3 L.l1Rr`, . . 2 (ltJI ;JC I1VI C7lLi`1.ti '1' iC1N ( c) rtsce use canlVl ✓ r:on � cructior4 of a nuw buildi.rh.7 ZONING DESIGNATION OF PROPERTY �AdsicLon to :a IsuilJinq PERMITTED PRINCIPAL PERMITTED ACCESSORY +AILur aLion to L" ildLnq - REVIEW REQUIRED PLANNING BOARD. ?.ONING fiOARD� ( F;Q clk-r + .i1 � to 4'xc + rLor cl1=nQnL- Lana ) . . Ucls,ar work SITE PLAN REVIEW S APPROVED DATE iH055 AkLh C7l' Yf2i3I' OSL' G3, rI= UL: TuR " VARIANCE # APPROVED DATE 15 -/ t Floor 10 � 44 sq ft . Remarks : 2 nd Floor 7zs'' D sq f t . �, * CotyPl.l:'l'L: Irt!'Gil rKA'1`LO l:u11t4 G7 lsL Lf.+W . ` 3� Sira of lxrol,urty 3i , 4g4c" +� •l . rc ct XYCo2 _ fc . Other Floors sq ft . * Lxi .tii �cl L' uillic +.] ( :+ ) iaa: IL x rt . ( not cellar or b :is .:m+ancl TOTAL FLOOR AREA //4fZcl f t . fi Lxi «.GLntJ L7ui1alli�aJ ( :. } Usu � i : u tir new ::cructura eft X .5 '..z ft Luauad:atLon-pier/ t;13L/Crawl/Iyatts..al Lull ' Yropo::ca builsing . dr :. c:►nr� u trQau I,r�i+urcy ttnu y Le ' pM . 0��(cirelu one ) + ' Front yµrd_, s S' r' z Itcar y:►rd ft Noo of ztoriarz (h"Lic:.blc &4)4cc ) Sida y"rdu wwwwwo, p rc and l Apr lj :jghc ( yradQ to ridge : ) a � ft . Ir on cQrna: r . from sitlu :; cr. uc fc If res:iduncialo now of famili.e5 / ' OCCuPANLY INFORMATION No . of rOom.&4 ( cxClu`diinal b"thu) '7 %lo . Of budroocns p��.i~4T.ILY uL1ILDINL� woo No . Qf b:.zlxraoiu : ' a Ono fan"ly dwelling l'riuury dwelling 'rypu of full htultirala: a]waclling / Number of units woo of firuplac"s; tea 4" in::z:allud � rr� a - � sya�nL1iz occupwicy Nill :a wuw.i x►:Qvu t,a.: ins: t:. 11+:.lt���'��r..x� 1'r:an::i.:nt Ci a:Qui?;,ataf:f Lcnzrrl Air Cal 4+ iti� onickg?i * Llusin4ss BUILDING STYLE, PRIMARY STRUCTURE . Inwustrial oehaer suuC#L CQnt.w�lc�r..ty Loon, C;aliila w It .addiction • w16.►t will u;.iu boa? 1:..ais�:d rarnClti M:an�sit.a� DuY,l.:x 1�.---- Q1314t luv*sl old styl" ULAAhLj,alQw i% d CQLz"q%: Otl,.-r ; ACCeSSOItY UUILQXHG^ G:oLoni..l luaw 1'Owi4 House ' U"tached y.ar.•gQ/pnu cur/ two a;ar/ c:sr ( CIRCLL: O L:, PLUALE. ) * =Atc " t-%4j l tj"rragu/o,Yaz Cur/ LwQ c:+r/ - saa •' • t s ■ * fi is a t F a fi st.or"ga b"ilaing USTIMATI-* 0 MARxcoj* VALUE: of ' ❑char 1NFORHATTON ON BUILDINC SPC:CIFrCATIONS . ON REVERS £ a.IDI: OF TYlIS S.kILET. 'I'o Be COMPLC'I"L'A ! Form BPA 10/98 V1 E12I -.01N0 PEPJMI'T.' APPLICAT eCN C= *iliL❑ - OUILDING SPECIFICATIONS : type cf con = truction , wood frame , fire safe , etc . Will any second- hand or ungraded jumper be used ? Ir sa , for what ? Faunda. tion wall material p Thickness Depth of foundation below grade ( to bottom of footing ) �, Q ., Will there be a cellar ? L Heated or unheated .'] Floor sq . footage ,gyp �sq ft Will there be a basement ? Will any portion be used as living space ? ( If so , what portion? sq . ft . - - Type of use ? ype of roof - slcs ed flat/shed/other Material of roof Q � ,6 �, d � y ,�^r,�Y1 �;,� i e , wood studs " x ( spacing _"" o . c , length 01 ft , Joists ( floor beams ) 1st . floor D '" X je " spacinG_l I�"a . c . span 13 £ t . joists ( floor beams ) 2nd . floor W�2- " x le '" spacing -" o . c . span 3 ft . verlays ( ceiling beams ) cwR " k 6 spacing / Z„ _"n , c , span l�ft . Roof rafters "?c spacingo . c . span ft . P,00f trusses ( pre- engineered) spacing " C . c . span ft . Exterior wall .fini h Of what material ? Interior wall finish '" If a garage is to be attached , describe materials to be used for FIRE SEPARATION : Is there to be an opening between garage and dwelling ? If so will, a Fire - rated door , enclosure , and self-closing device be provided ? Zq� Will a flue-lined chimney be installer.)? "2 Q... Height ab6ve roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft . in . Water supply or ,private well SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties ft . ( A separate application is necessary for any repair or new installation of septic system) D E C L A R A T I O N To the best of my knowledge and belief the statements contained in this application, together with the plans and specifications submitted , are a true and complete statement of all proposed work to be done on the described premises and that all provisions of the BUILDING CODE, THE ZONING ORDINANCE, and all other laws pertaining to the proposed wort; shalt be complied with , whether specified or not , and that such work is authorized by the owner . Signature 'keL.,a,.,s Owner, owner's agent , architect , contractor SPECIAL CONDITIONS OF THE PERMIT : HY- --- -- - -------,_--..--- __ --- --- TOWN OF QUEENSBURY WARREN COUNTY , NEW YORK Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVATION CODE A permit must be obtained before beginning work . ANSWER ALL of the following : / 1 . Gross floor areaC!� 2 . Type of heat _ c} — lr 14 3 . Is the building mechanically^ cooled ? d 4 . Percentage of area of windows and doors `10- 2- A . Over 16 % only 1 . Uo value of gross area of walls , roof / ceiling and floors exposed to ambient conditions 2 . Floor over heated spaces YES NO a . Are foundation walls insulated ? YES NO 1 . If YES , what is the R value ? 3 . Slab on grade YES NO a . If YES , what is the R value of insulation around perimeter of floor ? 4 . Is basement heated ? YES NO a . R value of insulation 5 . Type of insulation B . Under 16 % Only 1 . R value of roof and floors exposed to ambient conditions_ ,._ !L 2 . R value of exterior walls 3 . R value of glazed area �+ < C) 4 . R value of doors 1%A 5 . R value of floors over heated spaces 6 . R value of slab edge insulation - unheated slab 7 . R value of slab insulation - heated slab S . R valve of heated basement / cellar walls ( above grade ) 9 . R value of heated basement / cellar {walls ( below grade ) _ 10 . Type of insulation .. 1Is`^ sL C . Controls 1 . 'Thermostat maximum heat setting D . Duct Systems 10 Is duct system installed in unheated spaces ? YES NO a . If YES , R value of duct installation b . R value of duct in other areas E . Pijaln2 Insulation 1 . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulation F . Service Water Heating 1 . Performance efficiency 2 . Temperature control setting maximum G . For Swimming Pool Only 1 . Maximum heating Telephone No . ( applicant ' s signature TOWN OF QUEE- NSBURY C. L APPLICATION FOR TOWN OF QUEENSBURY RECEIVED SEPTIC DISPOSAL PERMIT DEC 1 i; 1989 BLDG. & CODE DEPT. DATE /� ,z - / j7 p LOCATION OF PROPERTY FOR INSTALLATION J ,;x Owner's Name; Telephone: 7 ;Z- Address: ctr_ c ._ e?_rL ' _ Installer's Name: " y� � ��� Telephone : Number of bedrooms (residential only) Total daily flow (compute (t7 150 gal per bedroom ) Topography : Circle one: Fla Rolling Steep Slope % of Slope Soil Nature: Circle one: and Loam Clay Other /Depth : Feet Ground Water . At what depth ? Feet Bedrock or Impervious 'Material: At what depth ? Feet Percolation test : Circle one: not required required rate min . inch. Domestic water supply : circle one blunici aI Well Other If domestic water supply is a well: Separation : Water supply from septic absorption feet PROPOSED SYSTEikI : Septic Tank 1 , gal. ( minimum size: 1 . 000 gal. ) TILE FIELD : Each Trench feet/Total system length feet SEEPAGE PIT(S) : Number of 0; L / Size each feet by _feet Size of stone to be used # _/Depth or Thickness feet I have read the regulation on the reverse side of this sheet and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. SIGNATURE OF RESPONSIBLE PERSON: , DATE : / ;L OVER Septic System Inspections : A . All applications for septic system installation , alteration or repair , as required by the Town of Queensbury Sanitary Sewage Ordinance , shall be submitted to the Building Department at least 24 hours before start of construction and shall include a plot plan showing : 1 . ) the proposed location of the system .� . ) location and distance to loc lines 3 . ) location and distance to structures 4 . ) location and distance to any water supply 5 . ) size and dimensions of all tanks , distribution boxes , tile fields and / or drywells B . Nu system shall be covered before inspection and approval by the Building Inspector . Failure to comply with this requirement may result in the uncovering; of the system by the installer and a fine of up to $ 250 . 00 . C . An approved copy of the plot plan shall be available on the construction site . 'Failure to produce said plot plan at time of inspection may result in an immediate work stoppage . D . Should unforeseen problems during construction prevent proper installa— tior'I , alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further coxiStruction . Town of Queensbury BUILDTNC and CODES DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 Kt nLs r kz� TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY 6 HAVILAND ROADS QUEEN.SBURY, NEW YORK .I2804- TELEPHONE (5I8 ) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR Ns RECEIVED NAME LOCATION ✓ �j 7 DATE PERMIT ,�j� '-�(L�,r APPROVED YES NO FOOTING/PIERS MONOLITHIC POUV MS_ �. FOUNDATION/DAMOFINGBACKFILL APPRO ROUGH PLUMBING FRAMING ELECTRICAL ROUGH N INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES ST PS STAIRS--CLEARANC & ILS PLUMBING FIXTUR S/RE EF VALVE _ INTERIOR TRIM/ IVAC DOORS FINISHED FLOOR - GARAGE FIREPR FING DOOR CLOSERS SMOKE DETECTO S FINAL ELECTRIC INSPECTI FINAL APPROVAL OF CONSTRU ION OK TO ISSUE C OR C/C A SIGNED CERT FICATE OF OCC ANCY MUST BE OBTAINED FRO THE BUILDING PARTMENT BEFORE THESE PREMIS S ARE OCCUPIEDI F REMARKS.- ARRIVE DEPART. NSPECTOR _Down o� �itrzen36eertat � � BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 9 Oueensbury, Newyork 12801 SEPTIC DISPOSAL SYSTEM INSP TION N,E LOCAT I CAN DATE PERMIT NO . (7 SOIL TYP E - S and - Loam ~ Cla - Percolation T St Required? Y S - NO Percolation r to - Min/inch TYPE Of SYSTEM , Absorption fie] , total le th Length of each ench Depth of trench s Size of t1ravel SEEPAGE i7 S4N ex Of) Size- ft . 7S ft. Gravel. s ze 1 e PIPING : T e ( Bldgv to tank Tank to d1st . box �- Dist.. boa. to field t Partial Openings sealed? S NO LOCATION/SEPARATIC7 CI! f t, Foundation to tan Foundation to ab tion JX.FXf t , f t. Absorption to to 11 e , Separation of p isft. LOCATION SY PROPERTY (circle one) Front - ear - Left ide - Right side - CENTS j / I I t SYSTEM USE APPROVED 5+ NO Bui g Inspector 01/86 and vl Martin • Mosher 26 Seer Pine 12804 TOWN OF OUEENSBURY ! Queens try, N.Y`• RECEIVED ,4 0 E C I L 1989 BLDG. & CODE DEPT, vv a �- $7=--- , TOWN QUEENSBURY HUILDI NAVILAN ORDS pVS DEPARTMENT �_ J BAY & NEW YORK QUE'ENSSU'RYr TELEPHONE ( 518 ) 792- 5832 BUILDING INSPECTOR" S REPORT r RESIUEST FOR INSPECT O RVC lvrp NAME LOCATION PERMIT # y �� DATE __-.__ + APPROVED YES NO FOOTING/PIE�UR FORM MONOLITHIC P-PROO NG FOUNDATION/DAM C,KFILL APPROVAL H PLUMSING FRA ING ELECTRICAL ROUGH-IN z rpFS`ULATION : L/' FOUNDATION FLOORS WALE CEILING FINAL INSPECTIO = CHIMNEY HEIGHT ROOFING SIDING ES/STEP EXTERNAL POR STAIRS-CLEA NCE & RA LS___�__-�--�- PLUMBING TR M/PRIVACY EIyCX]RSLVE VA INTERIOR FINISHED F RS GARAGE FIR PROOFING DOOR C LOS (S) SMOKE PET CTORS -. INSPE 'ON FINAL ELECT ICAOF CONS UC`TIO1V____,-- FINAL APPR AL OCCUPANCY MUST BF A SIGNED ERTTFT R O ING DEPARTMENT .BEFORE OBTAINED ROM THE THESE PR MISES ARE OCC PIED ! REMARKS : INSPECTOR TOWN OF QUEENSBURY )BUILDING AND CODES DEPARTMEN17 f� BAY & HAVILA D ROADS 0 QUEENSBURYJ Ew 79 228 YORK 128 TELEPHONE 832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPEC RECEIVED fM� �^------ NAME LOCATION / '�- / j PERMIT # '! DATE , APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PR O O F IN G BACKF'ILL APPROVAL RgUGH PLUMBING loo*pRAMING ELECTRICAL ROUGH-IN ` INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SXDING EXTERNAL PORCHE STE ��-- STAIRS-CLEARAIV & RA VALVE PLUMBING FIXTU ES/BELT S INTERIOR TRIM PRIVACY - FINISHED F S GARAGE FIREP OOFING DOOR CLOSER I SMOKE DETEC ORS FINAL ELECTR AL INSPECTION FINAL APPROV L OF CONSTRVIC'TION A SIGNED CER IFICATE OF OCCUPANCY MUST BE OBTAINED FRO THE BUILDING DEPARTMENT BEFORE THESE PREMISE ARE OCCUPIED ! REMARI4S : E IxsPECTOR ze TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROAMS QUEENSBURY, NEW YORK 12804- TELEPHONE { 51.8 ) 792-5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED _ NAME LOCATION DATE PERMIT #� --- APPROVED YE O L,�P''OOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION D4MP-PROOFING BACKFrLL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-IN INSULATION: Jr, FOUNDATION FLOORS WALLS R CEILrNG ` FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEPS.. -- STAIRS-CLEARANCE & RAILS - . . PLUMBING FIXTUR.tSIRELIE ' _ VALVE INTERIOR TRIMIjRIVACY DOORS FINISHED FLO04*S GARAGE FIREPOOOFING DOOR CLOSER {;) SMOKE DETECtORS FINAL ELECTRtAL INSPECTION FINAL APPROVAL OF CONSTRUCTION SIGNED CERTIFICATE RTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMI/S`ES ARE ,rOCCUPIED' REMARKS :Wj '2� S IN ECTOR ory Bell n1z �- -JVI Amoy cotes $U r DES r NAN R rN.snECp�DN R S �pQjy�2 r Z-OCA ol Errs arc PO woveD rN Fr A x xruc CAliz Rio-rNC C&P + ��ED `�aPRI1`cvv xEP �ILy*DOOR C*� .!L �N A S CQNS-Tj?vc 'lpaV 2 fps rN�z7 �ORx�,rc 2, S'KSpREe§rI S s E • E�4RTrtp `� DE � �CAf I OF QUEENS BURY BU BUILDLD ING AND CODES DEPARTMENT BAY N& LAN ROADS �)UEENSBURYBURY� NEW W YORK 3280¢ TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED _ NAME �G 2,IZ LOCATION DATE / L�,/r PERMIT - © APPROVED YES TING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-,PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH IN INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: k CHIMNEY HEIGHT t ROOFING SIDING EXTERNAL PORCHE /ST S ,STAIRS-CLEARAN & LS PLUMBING FIXT ES/REL F VALVE INTERIOR TRIM PRIVACY RS _ FINISHED F RS GARAGE FIRE ROOFING DOOR CLOSE (S) SMOKE DR T TORS FINAL ELECT ICAL INSPECTION - FINAL APPR AL OF CONSTRUCTIO A SIGNED ERTIFICA TE OF OCCUPANCI' MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE TFIESE PR*XSES ARE OCCUPIED! REMARKS: ICE r 4 31 INSPECTOR u r ISSUE DATE (MM/QD'YY) FUa LTHIS CATE IS ISSUED AS A MATTER OF RMATION ONLY AND CONFERS NO RIGHTS UI PON THE CERTIIFICATE HOLDER. THSOCERTIFIICATNLY AND CONFERS E DOES NOT AMEND, yAte, �ncy, Ire! EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWk%x4 i►Igt0ft St+ceet F&"£ b, W 12801 COMPANIES AFFORDING COVERAGE COMPANY LETTER A +x - ;��.. p'0rSUIILCODE NatmS. L[nge MA u.4ft COMPANYLETTER It C. AlbAhtA COMPANY�71 ,�.�ILETTER �+six& P-I RoadCOMPANYabway. W 12904 LETTER COMPANY E LETTER 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 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 I OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE TN POLICY NUMBER CY EXPIRATION DATE (MMIDD/YYE DATE (I MMIDO/YY] ,IN T S N�IIAND3 } TE ALL LIMITS GENERAL LIABILITY x COMMERCIAL GENERAL L)ABIL)TY GENERAL AGGREGATE $ 1 . J 00 PRODUCTS-COMPIDpS AGGREGATE $ 1 t 0 0 CLAIMS MADE x. OCCUR. : �/�s �I 1 i ���r PERSONAL & ADVERTISING INJURY S. OWNER'S 8 CONTRACTOR'S PROT. wTI'" 091I4f '�'8'a9 and 0ra0... 11 09114189-#9114190 EACH OCCURRENCE $ S00 FIRE DAMAGE (Any one fire) y MEDICAL EXPENSE (Any one person) S � AUTOMOBILE LABILITY X ANY AUTO R7 p 1 11 �1'2 COMBINED I SINGLE $ +U * ALL OWNED AUTOS R7 09f 1418 !-99 w� LIMIT 300 09/ 14/ ai'� 09114190: rBn°luflv $ SCHEDULED AUTOS HIRED AUTOS (Per Pamon) NON-OWNED AUTOS INJURY, $ GARAGE LIABILITY (Per accident} PROPERTY EXCESS LIABILITY DAMAGE EACH AGGREGATE . 00CURRENCE OTHER THAN UMBRELLA FORM S $ WORKER'S COMPENSATION STATUTORY AND 10CLI, 11 772 as Ir / .r�0 sq y,�J�' aJ 9Y . $ tI A00' (EACH ACGI DENT) . EMPLOYERS, LIABILITY 0 (DISEASE—POLICY LIMIT) OTHER S 100 (DISEASE—EACH EMPLOYEE DESCRIPTION OF OPERATIONS'LC�C�`,ATIONSIVENICLE{wmEST/RTI..TC )"B/SPECIAL ITEMS CaApem.}. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE StEPhita Kettyr EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO 1 1fdittoW Rid� �� �� MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE n LEFT, T FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR L � } NV 12904 LIA ITI OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. A O O REPRESENTATIVE or 'ell;# 2&,s. (31") %OACOR=jwmm