1989-001 y . a ... a ^�!'•d:. '-,.-rA' v• - _ .. ii.,.R.iryrv+v—p.• '[ .• r a • �Tr _.. N
CERTIFICATE OF OCCU'PAN .0
i
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
I
February 2, 19 $S
i
5-r - [q
This is to aertifp that work requested to be done as shown by Pe. .. it No. 39-01
has been completed.
This structure may be occupied as a Xio:>i ] ia Home
I ocatio � szlnde:us Road
�� Itoi�c�rt:. Clark.
I
I
By Order Town Board
TOWN OF QUEEN3SBURY
Director of Bldg. & Code Enforcement
I�
BUILDING PERMIT
TOWN OF QUEENSSURY �
No. 89 - 01
WARREN COUNTY, NEW YORK '
zt
C
PERMISSION is hereby granted to Robert Clark +
OWNER of property located at Sanders Roar] Street, Road or Ave. �
a
in the Town of Queensbury, To Construct or place a Mnhi 1 e� Hnmr�
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.
1 , OWNER'S Address is
VanDusen Road
Queensbury , New York 12504
fi=
2. CONTRACTOR or BUILDER 'S Name
9
Fairhaven Affordable Homes -�
3. CONTRACTOR or BUILDER'S Address
Rte . 4
Whitehall , New York
4. ARCHCTECT's Name
5. ARCHITECT"S Address i✓
Z
t�
S. TYPE of Construction — {Please indicate by Xi v�
( ) Wood Frame { ) Masonry { ) steel
7_ PLANS and Specifications
28 ' x 44 ' mobile home as per plot plan , and application ,
N-ncluding septic and driveway .
8. Proposed Use
Mobile Horne.
25 . 00 c/o
$ 72 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES August 1 1989
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.) p
6
Dated at the Town of Queensbury this _ lst Day of January 19 $ ^
SIGNED BY
far the Town of Queensbury
Building and Zoning I ctor
TOWN OF OUEEN89URY
cc-��■ / To BE . COMPLETED JAY ni.rkG . DE.PT. RECEIVED
_Juia+ri ra as"a�ns�rrr Application No.
BUILDING anu 20NiNG DEPARTra NT PaarmwLt issued DEC 2 9 1988
E3ay and Hu Road. Ft.D. 1 8ax 48 Zo a
n1wn9 Domign Paaac�ait -Eupireatio�+ 19
0uaaunStr6ArY. Now York 12Bo1 V.ariau►ce Now. _-�/,'Z"O� BLDG* 0005 DEFT„
Sit* Flan Uavi4aw No .
APPLICATION FOR Approv"51
MOBILE DOME
PUILDING AND ZONING PERMIT
r► ar w • w w r w M ♦ w w w w vw • s ar � +r ♦ +r rr mo w , r +r w • w r r wr r w ar :: r
A PERMIT MUST BE OBTAINED BEFORE BECIN ING CONSTRUCTION* ANSWER ALL OF THE FOLLOWING .
The undaruigned hereby applies for a Building Permit to do the following work which will
tau done Ica accordance with the doucriptiono plan& and arnuCifia:atiaaaraa uulrauittud , and - such
ujleci:al conditions Am away be indicated on the Permit ,
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Ttw owner of this property is :
P . ra , hd iraua + f Tel
Property Location ; -LA e.. 7`ax Map tlo.ias�f —err L3.0
Struet l.uauluur or building /lot nwr nr
SuLdivision name (if applicable)
1'111i YI.IZ:ON ritESAr4r'lsxH/E FOR SUPERVISIONaF WORK AS FIUG.hJ" UUIl&DING CODES IS : ------'
erz
ra.aa�w P [1��.._Address Tel . No .
N:,ern» crf Installer 0VCe ,J A5rryjf; "hddreaa ,/Z: Tel .wwww
N.aFtL ui` I.lun►luer Addroua „1e1 . II . . . _._
aeuuon Vic,.-� " Addretaa t,.
MOBILE HOME INFORMATION : r ZONING INFORMATION ;
New llama:: placement ra I"LIOi• PLANSl1UsT DE PREPARED' AND SUBMITTED,,
drrawn r.aasonably to scabs and attacl%ad hereto.
R.era l ac i ng existing Home _ , " uhowing clearly and diat3.nctly all bu13.4109s ,
Size of new Rome ft x V ft * whether exist3.ng or proposad and lndicatu all
meL " scat-back diwa:na� ions from property linuu . Give
single w ` !e Double wide V * utreat and nwnlaur or lot nuuLLaex and inaicata:
No . of rooms texcluding baths ) whether interior or corner lot . Snow location
of water supply and location and conftqur" Lion
Now of bedrooms .,j " of auptic disposal area .
No , of bathrooms
* C014PLETE INFORMATION REQUIRED I3ELDW
Fircpluce?.. Wood stove? New " Size of property / ft. x $-� 0 ft .
Foundation style and • siza: * " Exinting buildingku) Site ft x ft .
■
Piers- No . of. Size- it x ft . * "Luting building ( :: ) aia3
Depth below grade ft. r
" i"ro a3ud buildirae diULance frunn property FOUNDATION Faatin+g site " X " r p� � ' P IwrCy line
r Front yard / z�o ��it hear yard c �^G it
Wall material „ Side yards „/� ft and it
wall thickness." Height ft. . If on coiner , sotb:ack froau aide utruat ft
Total depth below grade ft. ~ OCCUPANCY INFORMATICN
Grade to Hoops floor level it. r PRIM"Y BUILDING w
■ +. y • w w w w w w w w w w • ea r One family dwelling
Frope7sed date of placement /5' r Two family dwwll inel
p �/_/ , ,, Multiple: dwollIeng / Number of units
Aprox . Value. of Home $
r Pearin:ana:nt occuncy
* 'Transient ocaul7.zncy
-water supply Well municipal �sa
* Dusinuss
. Industrial
Septic Permit required? „ other
* if additioat, wlatac will usa b.r't waft
FURTHER INFORMATION REQUESTED * ACCESSORY l3CIILDiNG--
ON THE REVERSE SIDE OF THIS SHEET . * Detached gar"go/one car/ two car/ car
It Attached garage/one car/ two car car
o 'rrivato storage building
* Other
w .
Farm M111a 5 / 06 encl - vl
r
APPLICATION FOR MOBILE HOME PERMIT, ( CONTINUED)
State of New York Division of Housing and Comxnunity Renewal
INSIGNIA OF APPROVAL OF THE STATE BUILDING CODE
I * INSIGNIA SERIAL NUMBER
7 • NAME OF MANUFACTURER
3 . PLAN APPROVAL NUMBER
'+ . MODEL OR COMPONENT DESIGNATION ;
rLe
5 . MANUFACTURER ' S • SERIAL NUMBER
G . DATE OF MANUFACTURE _--1 ` "e?q
r
A 2 t the above tnformaxti on sa to be found on a pxate ar atsaker tehi.a3x
shoes ld be afflIxed to the Mobi. Ee liome . Complete..above trz:th Hutt %nfokez* h
ne
Tawas i71` Q4ae3nabury
County of Warren A F F I D A V I T STATE OF NEW YORK
Y swear that to the best of my knowledge And belief the atatements contained
in this application, together with the glans and specifications submitted , are a true and
complete stataeenent or all prapased work to be done on the described premiaers and that all
pravisionu Of the SUMDUAG CODE,, THE ZONING ORDINANCE* and all other laws Partaining to
the Proposed work shall be complied with, %ohath,er spocifled or not, and that such work is
.authorized by the owner.
. .. '• �Z
Signatures
er, • owner • a agent , aranit"ect, cantraator
t
• w w w w w w w w w w w +w w w w w s +� ei , � w sti w rt r w w w w rt w r rt w " w tr w w w w w w w w ' ■
SPECIAL CONDITIONS OF TILE PERMITe
• + ' • •.. . �yrwrrrrY�T..•...r..r�rr.+r r..�r rriir.r�..rNwr�rr
TOWN OF QUEENS13LYRZY
APPLICATION FOR
SEPTIC DISPOSAL PERMIT
r
DATE
LOCATION OF PROPERTY
,,�FOR
' INSTALLATION
Owner's Name:-���^�'' �- . / Telephone: W ' /r /
Address:
installer's Name: A/Telephone:
Number of bedrooms (residential only)
Total daily flow (compute (d 150 gal per bedroom)
Topography: Circle on - Fla Rolling Steep Slope % of Slope
Soil Nature: Circle o . Sand Loam Clay Other. /Depth: Feet
Ground Water. At what dept#i? Z2 Feet
Bedrock or Impervious Material: At what depth? ��'L4 nJ� Feet
Percolation test: Circle one: not required required rate min. inch.
Domestic water supply: circle or
Municipa Well Other
If domestic water supply is a
Separation: 'Water supply from septic absorption feet
PROPOSED SYSTEM: Septic Tank JIF gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench feet/'Total system length feet
SEEPAGE PIT(S): Number of ar ^/ Size each G 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 S wage Disposal Ordinance.
SIGNATURE OJF RESP NSIBLE PERSON: J ' . /j7' �
DATE: G
OVER
Septic System Inspectionsc
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
2 . ) location and distance to lot lines
3 . ) location and distance to -structures
4 . ) location and distance to any water supply
5 . ) size and dimensions of all ranks , distribution boxes ,
tile fields and /or drywells
B . No system shall be covered before inspection and approval by the
Building Inspector . Failure to comply with this requirement may
rusult 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
r. usult in an immediate work stoppage .
D . Should unforeseen problems during construction prevent proper installa—
tion , alteration or repair of an approved system , a new proposal must
b� submitted to the Quvensbury Building Department before further
construction .
Town of Queensbury
BUILDING and CODES DEPARTMENT
Bay and Haviland ]toads
Queensbury , New York 12804
r'
ALTH ELECTRICAL i EI,EC"I R
COMMOI3WE Mauheim. YA ;75A5
Main Office 357 Elwyn Terry ICAL PIPPP'OVAL Y
MUNICIPAL CEItOVIEICATE
0
36590 Ctst.in Card NO. . . .. . ....... ..
Cert.
c1.
' Panel f3cxard N ............... ... .............. .. .. ..... . .. . .. .
� .. .,- .. .G . .- ..
owner -.. .... .occup
ant / /f✓ . .. -* � yi 4t .t ?` _ 9...
. r l '�,.. ... . .
lnstaliatic�n consisting LJ
/ C._. _...-.-..... _. .. _.
tic . #._ . rcvioualy
,r ,s an ;CSt1114'at�`
__.. . . , . ... . L L . ,Q - ati date. Upon
C�,•verned the issuaricx of this ccviificatc, and Y
Installed MY conditions as made tur
folfosv'inR R tnt and installation ramptSY
The can -elleds ii. 4ts
electrical e9urpm ' . 5icatic,n shal4 time, and
issued is Cane at yonfY covers the �>r ahcrsuons, aPp ns at any
[iris cduct'cateof addit`sonai equipment
inspe
the introduction shall have the p
T iY i1�G1'e �f Makin);gi Cttl �
iinspection. this Company have the right to revoke
inspectors of any sha11 ha ,� . .-
rules are violated. the Comp INSPFCTOE . ....t".• .- ..emhe■ r4.F.P•A•• ti-A.F'•�.
pate . . . . .-
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW PORK 22800E%
TELEPHONE (5I8 ) 792--5832
BUILDING INSPECTOR' S RE o gr
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION {
DATE It q .PERMIT �� r
APPROVED
A &L ,L I YES NO
x
FOOTINGIPIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACICFILL APPROVAL
ROUGH P.LUMBIN
FRAMING
ELECTRICAL ROU -IN
IWSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
,* FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PO CFIESIST P2LS
SSTAXRS-CLE RANCE G
PLUMBING IXTURES/RE XEF VALVE
INTERXO TRIM/PRIVAC DOORS
FINISH FLOORS
GARAGE FIREPROOFING
DOOR LOSERS)
SMOK DETECTORS
FINAL ELECTRICAL INSPECTION --
_FINAL. APPROVAL OF CONSTRUCTION���
OK T4 ISSUE C/o OR C/C
A SIGNED CERTFICATE OF OCCUPANCY MUST BE
I
OBTAINED FROM THE ,BUILDING DEPARTMENT .BEFORE
THESE PREMISES ARE OCCUPIED!'
REMARKS : 5,<, j'T+ .r rto Qpwn
ARRIVE, �
OEPAR'�� IN PECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 2280& -
TELEPHONE ( 518) 792- 5832
BUILDING INSPECTOR' S REPORT
REQUESTFOR INSPECTION RECEIVED
NAME ,�LOCATION
PERMIT
!�_ PERMIT ,E4 CJ I
DATE
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL RO GH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
f�p ��R CEILING
�' XAAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESISTE
STAIRS-CLEARANCE & RA --
PLUMBING FIXTURESJRELIE'F' VALVE
INTERIOR TRIM/PRIVACY I7C�QRS_^��-.
FINISHED FLOORS
ppp
GARAGE FXREPROOFXNG
DOOR CLOSER (s)
SMOKE DETECTORS-
FINAL ELECTRICALlINSPECTION
FINAL APPROVAL OF CONSTRUCTION
r
i
A SIGNED CERTkF.TCATE OF OCCUPANCY MUST BE
OBTAINED PROO THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:eO /
k; 101
INSPECTOR
MIDDLE DEPARTMENT INSPECTION AGENCY, INC. ( �}
aino H lag �+
�sT� s. ' ' " " # iS � ••. oat�f January 9 , 19 89
Ctirtif ie$ that It ectrji0eil equipment listed has been exarAned a approved as being in accord
with the National ElectricaY GQcle; applicable governmental, utility and. ency as.
C7wner: Robert MarIV
k
upa B it d
occupant-
Location:
j ;. f 't``;a „y t
Location: Sanders Road, Qila$n8bLltCy� �GBrrtE 14 ''�+UB7,' al aLt an�fica5e thr flecdrie uiAmant and Ina[anation inspected this
tlatB. If atld�lYonal uipiNaM fsh be introduced of alterahons made to
existing aycteui lhid cc�rM1rficis be null and voltl: and application for
200 Am SP,x H 3 CB' inspection should oe ao6ra fitted pr fly to this Agency.
Equipment: P ; : Mader of tn,a eannie■te at+od+d nt cams to hle property insurance carnar
..r '" " . (agent
specifedmpany9 as av+Wfnc rtitlaat ion of alactr lcal eq ui pnvent approved
as specified,
r Robert+ c lark ,71
Apptfcant: Sanders Road :{ " o . 15 -028938
LQueensbury , NY 12804' ar
fi �EenS -/n"eT `e3."!tfi'�ii`.e "AIIEnR`30{'.r'r "'"...ri'- 'r„L •'as,�w�a�s5�.�su5? a1a/'�ss.�.na ..
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12801-
TELEPHONE (518) 792-58.32
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION
RECEIVED
NAME
LOCATION
DATE - �J /�_ f PERMIT # `
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAME' PROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
INSULATION.
FOUNDATION
FLOORS
WALLS
CEILING
-' XNAL .INSPECTION :
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCH#S/STEPS
STAIRS-CLEARAN E & RAILS ^-
PLUMBING FIXT RES/RELIEF LVE_
INTERIOR TRI / PRIVACY DOOR
FINISHED F RS
GARAGE FIRE OOFING
DOOR CLOSER S)
SMOKE DETEC ORS
FINAL ELECTRI AL INSPECTION
FINAL APPROV L OF CONSTRUCTION
A SIGNED CER IFICATE OF OCCUPANCY MUST BE
OBTAINED FRO THE BUILDING DEPARTMENT BEFORE
THESE PREMTS S ARE OCCUPIED!
REMARKS :
INSPECTOR
TOWN OF QUEENSBrURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 3280*
TELEPHONE (518 ) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR IN PECTION RECEIVED
NAME _ a
LOCATION
DATE _ t� PERMIT #��� �!
APPROVED
YES NO
FOOTING/PI
MONOLITHIC POUR`:FORMS - -....�
FOUNDATxoN/DAMP-Y3ROOFTNG_ _
BACKFILL APPROVAL _...
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-T
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCH S/STEPS
STAIRS-CLEARA E & RAILS _
PLUMBING FIX RES/RELIEF VALVE
INTERIOR TRI /PRIVACY DOORS
FINISHED F RS
GARAGE FIRE ROOFING
DOOR CLOSE (S)
SMOKE DETE TORS _
FINAL ELECT#ICAL INSPECTION
FINAL APPRO AL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
,'BAY & FIAVILAND ROADS
QUEENSBURYO NEW YORK I2S+04--
TELEPHONE (5I8) 792-5532
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION�RECEIVED__Z.% .�j
NAME
LOCATION so wf
DATE /`Q PERMIT # 9 -G7[
�T
APPRO � D
YES NO
TING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/D P-PROOFING
BACKFTLL APPRO AL
ROUGH PLUMBING Yrt,
FRAMING
ELECTRICAL ROUGH IN
INSULATION: 0
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING '
EXTERNAL PORCHES/S'IMPS.
STAIRS--CLEARANCE ,6 RAXZ,5
PLUMBING FIXTURI0�§/RELIEIK VALVE_
INTERIOR TRIM/ RTVACY DO6J?S
FINISHED F S
GARAGE FIRE OOFING
DOOR CLOSE {S)
SMOKE DE CTORS
FINAL E ICAL INSPECTION
FINAL APP�?OVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUS'V , BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
ffgg 1
6J11�4
it
IN PECTOR
fow,n of Q"ven .3hesry
BUILDING and ZONING DEPARTMENT
Bay and Haailand Road, R. D. 1 Box 9
Queensbury, New York 12E
SEPTIC DISPOSAL SYSTEM
INSPE,CCTTION
LOCAT I ONYX
DATE f PERMIT NO. ( - 6r
SOILTYPE - San - Loam - Clay
Percolation Test Required? YES- O
Percolation rate - Min/Inch _
TYPE of SYSTEM:
Absorption field , total length` '
Length of each trench a
Depth of trenches
size of gravel_ -:7
SEEPAGE PITS#'Number of)
Size- ft. Xft . .~
Gravel size
PIPING : Size Type
Bldg . to tank ,_
Tank to dirt . box
Dist. box to field pier Y `
openings sealed? ES No Partial
LGCATIDN/SEPARAr`iONs
Foundation to :tank yft-
Foundation tc�` absorpt3son 2,57 ft .
Absorption t6 lot line '%.
Separation rof pits
LOCATION SYSTEM f7I3 PRtPERTY (circle one)
r6rit 'r It ar - Left side =. Right side
CC[494ENTS
I
Y
SYSTEM USE APPROVED QXE � NO
I f Jf
Bui di g Inspector
ol/86 and vl
Id Zoo a 0
Zh
ISSUE DATE jMiVIIQQlYYT
e
' i'RCJDUCfcFi
. . , � Y 7NIS C£F174FiCATE IS 355UE0 A5 A IitATTER OF INFORMATION ONLY AND CONFERS
NO HiGH75 UPON TErE CIc'R7IFICA7E HOLDER- 3'H15 CERTIFICATE DOES NOT AMEND,
I"iAY�.,�}R � FR�.++�� � �.QaN � �ij� � E%TEND OR ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.
750 JAMES STREET _ -- COMPANIES AFFORDING COVERAGE
sY �,cvs NY 32C�3 —_— - I .
' COMPANY
# LETTER AI.L.CITY INSURANCE CO
+.'or :g COMPANY
INSURED LE1"IER
ICs OUTLET Y3 COMPANYPA IiiAVE3 APFCR7AiLE IQISF C
LETTER
BOX 29A RTC: • 22A —
COMPANY
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HAMPTON O NY 12837 LETTER
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COMPA
:! ETTERNY
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THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERidO INDICATED.
i4 NOTWITHSTANDING ANY REOUIPREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY I
BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED F3Y 7Ht POLICIES DESCRIBED *-I IS SUBJECT TO ALL THE TERMS, E%CLUSIONS, AND CONDI-
"RONS OF SUCH POLICIES.
' •'s r'.i�:�+ nxl�1 LJI P11i,ICv Ex.'4IiA hGN LIABILITY LIMITS IN THOUSANDS
^-.,: L'U TYPE OF INSURANCE. POLICY NUMBER GATE (F.IM±ODr IVy DATE fMA,Sr I]a),"YYl EACri AGGREGATE
LTR _ i1C:('li4_�iiLraCF
GENERAL LIABILITY BODILY
COMPREHENSIVE FORM INJURY
P RE l,14SE S/OP E RAT I DNS PROP LR T Y
�F UNUERGROUlrD DAMAGE y
f XPLOSION d COLLAPSE HAZAAL)
PRODUCT&CON PLLTEU OPERATIOiIS -
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CONTHACIUAL COMUINELa $
INDEPENDENT CONTRACTORS
BROAD FOWA PROPERTY DAMAGE
P PERSONAL INJURY
PERSONAL INJURY
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" -+ AUTOMOBILE LIABILITY rt,.Wrir z
ANY AUTO II't f5 i'!n5(iNI ',$ �T
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-r i;' OTHER THA.^I AdLk Y
ALL OWNED AUTOS ,✓ln ALwNll.fr
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HIRED AUTOS PROPERTY
NON OWNEDAUTOS []AlfaciE
• id
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GARAGE LIABILITY UI & PD `
COMBINED $
EXCESS LIABILITY no a PO
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UMDRELLA FOWA
"E OTHER THAN Ula16RELLA FOHNI — •• ---
'E' '-• Idd
STATUTLIHYf ".
WORKERS' COMPENSATION FACH ACCIDFNTI
`'• A ANo 251 0066219-00 U5-31 -8E3 U5--31 -89 104
',' rj0[j (UISFASE4AGLICY LIMIT)
EMPLOYERS' LIABILITY 1 �(� IDISEASL-EACH EI:,'IPLOVEf y •'
OTHER
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TOWN QU ., �RY s SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%-
PIRATJON GATE THEREOF, TFIE IS5UING COMP NY WILL ENDEAVOR TO
MAIL 7 L} QAYS WRITTE NOTICE T CERTIFI TE HOLDER NAMED TO THE
;- :I�y $LOG • L)E7� • LEFI•, BUT FAILURE TO MAltI NOTI IIN OBLIGATION OR LIABILITY
Ax OF ANY KIND UPON THNY, IT N S -PAESENTATlVE5.
LBAY ROAD AUTHORIZED REPRESENT
YOU ARE HEREBY REQUESTED TO
INSPECT AND ISSUE CER ATES
TIFIC
G ELECTRICAL
FOR THE FOLL INSTALLED SY .
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