Loading...
HomeMy WebLinkAbout37848-Z tyt+~S~~~fC Town of Southold Annex 6/28/2013 ~,`tt~tTT P.O. Box 1179 ~ 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36322 Date: 6/28/2013 THIS CERTIFIES that the building HVAC Location of Property: 68530 CR 48, Greenport, SCTM 473889 Sec/Block/Lot: 33.-5-21 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 2/28/2013 pursuant to which Building Permit No. 37848 dated 3/6/2013 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: heating system and hot water heater as anylied for The certificate is issued to Galanis Realty LLC (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 6/6/13 Peter K nakoulio Auth ized Signatu"re TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 'ts ~ SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit 37848 Date: 3/6/2013 Permission is hereby granted to: Galanis Realty LLC 56-27 East Hampton Blvd Oakland Gardens, NY 11364 To: convert a heating system as applied for At premises located at: 68530 CR 48, Greenport SCTM # 473889 Sec/Block/Lot # 33.-5-21 Pursuant to application dated 2/28/2013 and approved by the Building Inspector. To expire on 9/5/2014. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector Form No. 6 TOWN OF SOUTHOLD. BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new buildipg or new use: 1. Fi~l survey of property with accurate 9ocation of all buildings, property lines, streets, and unusual nature} or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 fotm). 3". Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than Zl10 of 1% lead. 5. Commercial building, industrial building, mtiItip[e residences and similar buildings and installations, a certificate of Code Compliance'from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to Apri19, 1957) rion-conforming uses, or buildings and pre-existing" land uses: I . Accurate survey of property showing all property lines, streets, building and unusual natural or topographic Features. 2. A property spmpleted application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees I. Certificate of Occupancy -New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions [o accessory building $50:00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $:25 4. Updated Certificate of Occupancy - $50.00 5- Temporary Certificate of Occupancy -Residential $15.00, Commercial $I5.n00 Date a~~~ao/'3 New Construction: Old or Pre-existing Building: (check one) - Location of Property( S ~ ~ i 5~ S'l' GR-~~-fi //9 ~jt~ House No. Street Hamlet Owner or Owners of Property: ~~AYh S Suffolk County Tax Map No 1000, Section 33 Block 'S Lot a-~ Subdivision p Filed Map. Lot: Permit No. ~ ~ g O Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Finale Certificate: (check one) Fee Submitted: $ 5p .tro, A leant Signature CERTIFICATION bate: ~ixic G ~ 20~~. Building Permit No. ((~~37~~/~ Owner: ~i~lf 1ni5 ~~1~ LLC_ p (Pleas print) Plumber: P~~ ~Yna~ou ~ ia'S (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. umbers Signature Sworn to before me this day of ~~iP~, 20~~ ~~i i j~~ JUN 2i 2013 Notary Public, County Ll ~ SUSA NOTARY PUBLIC-STATE OF NEW YORK No. OtCA6192082 7n ~ ~ ~ i~,mp Qualltl®tl In Nassau Cou~n1~/~ MY CommuUan 6>rp~r4i 3~`~ ~ ~o~,~OFSOpr~o6 TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ )ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL) REMARKS: L'~~ DATE ©3 ~r~ INSPECTOR ~ > ~1 FIELD IlHSPECT.[ON REPORT DATE COMMENTS . ~ ~ FOUNDATION (1ST) ~ .L FOUNDATION (2ND) ~ O J~~~ ROUGH FRAM'!NG & ~ y PLUMBING r- INSULATION PER N. Y. STATE ENERGY CODE . ~ c ~ t~1 u ~ ~ h. FINAL U~ ADDITIONAL COMMENTS ~ r, r. ~ m z - o ~z e TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following, before applyin«' TOWN HALL Board of Health SOUTHOLD, NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. 3~~`~ ~ Check Septic Form N.Y.S.D.E.C. Trustees C.O. Application Flood Permit Eramined_ , 20~ Single & Separate Storm-Water Assessment Fonn ~ ~ Contact: Approved of 1/J, 20_~ Mail to: Disapproved a~c~~" rr n Phone: a~-I 1O-1 F:~piration , 30~ i 1 f 7 r Building Tnspector I ~,ll~ ~ I IS ~ PLICAT[ON FOR BUILDING PERMIT I~I! Ll' FEB 28 2013 Date , ~0 - INSTRUCTIONS ~ ,n nimD -i-hisappircatrrnr letely filled in by typewriter or in ink and submitted to the Building htspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on prcmiscs_ relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application. the Building Inspector will issue a Building Permit to the applicant Such a permit shall be kept on the premises available for inspection throughout the work. e. No building: shall be occupied or used in whole or in part for any pwpose what so ever until the Building Inspector issues a Certificate of Occupaneti. £ Every building permit shall expire if the work authorized has not commenced within 12 motrths after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim. the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall he required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, far the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. Chncs a ~ ~t~;n,, 1w,~ (Signature of applicant or me, if a corporation) ~91k1 Groff ~x- (Selln,.~ i~t Y I I7W (Mailin a applicant) APPROVED A~ State whether applicant is owner, lessee. agent, architect, engineer. general c tr tp~r, ele~cct 'ci~~~ber or builder DATE J B.F'. PI~m1~ ~rz 6Y~~~_-.- pllTIFY BUIL~NG D?P~ " Name of owner of premises ~lafl~ s ~ Ll-C 302 8 E f~' ~ ' ' - (As on the tax rollF~lt~~~'(~~ r If~ica ~~~,j~~a~corpo tion signattyrgirsE^dukyaut}tprazedrohfcer t FOUNDA 10~' t~^~C' YG(.!/L %~~wl'r._"'~ I L. ,~,?I`~ FOR POURED C, 2 ROUGH -FRAMING. P'- e ~ i e ofcotporateic~Ei`t~er) ; ~;i rlti~i4 ~ STRAPPING, ELECTF.~~ ~ & Builders License No. INSULATION Plumbers License No. S'pp~'~ ~ C„ i~ ^t T 4 FINAL- CONSTRUCTION ~ ELEC'~ ~ J Electricians License No. , ~ ~ ~ MUST BE C0~1P1_ETE FO~~ 0 _ 13 ALL CONSTRUCTION SHF, L [L ~ THc Other Trade's License No. REQUIREMENTS OF ThE G,~cS OF NEB"J YORK STATE. NOT RESPOy31LLE FOR I . Location of laMnd on which proposed work will be done: DESIGN OR CONSTRUCTiJN ERRORS. ,f /'/Qd , ~ S~-trc-f G*~cn~" N Y 119 yy House Number Street Hamlet County Tax Map No. 1000 Section 03'3 •oJ Block ~•QO Lot p9.1. o0 Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~S ~prw~l"a~on b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work ~~5 ~u2(`Si«I (Description) 4. Estimated Cost cmo Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear ~D~pth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner 1 1. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 13. Will lot be re-graded? YES ~1 NO Will excess till be removed from premises? YES NO 14. Names of Owner ofpremises V inh~tj r+La~an~ 5 Address ~ (SOn 5~- Phone No. G't'16-76/-33~~ Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? *YES NO * IF YGS, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNT"Y~OFy ) ~~i~,{ 4.y('~q~(pV~~q} being duly sworn, deposes and sa}~s that (s)he is the applicant (Name of inpdividual signing contract) above named, (S)He is the 1 l rm~i s ph~~~ (Contractor. Agent, Corporate Ofticer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me th' L day of %~G(A/' 20 g CARMAN NOTARY PUBLIC-BTATE OF NEW Y No. OtCA67928g2 Notary Public Gfuallflaa In Nassau County ure of Applicant My Commlbion E%plres ~ ffi SO(/jyl Town Hall Annex ,y~~ Telephone (631) 765-I H02 54375 Main Road ~ T Fax (631) 765-9502 P.O. Box 1179 G C Southold, NY 11971-0959 ~ ~ i~ OIyCOU~ 0 June 3, 2013 BUILDING DEPARTMENT TOWN OF SOUTHOLD Galanis Realty 56-27 East Hampton Blvd Oakland Gardens, NY 11364 Re: 68530 Route 48, Greenport TO WHOM IT MAY CONCERN: The Following Items (if Checked) Are Needed To Complete Your Certificate of Occupancy: **Need to amend application to include Hot Water Heater. Provide O`c , ~ot,''Y' ~f7 specifications for Hot Water Heater and Boiler. Application for Certificate of Occup nc . (Enclosed) Electrical Underwriters Certificate. (contact your electrician) b~~ A fee of $50.00. ~F nal Health Department Approval. Plumbers Solder Certificate. (AU permits involvin / '~/~/'j~~~~~~ g plumbing after 4N 184) ~r(,-' y~ Trustees Certificate of Compliance. (Town Trustees # ass-~ssz) Final Planning Board Approval. (Planning # ~s5-~s38) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept BUILDING PERMIT: 37848 -Heating System Conversion Chris & Son Plumbing Inc. 2841 Grand Avenue Bellmore, NY 11710 (516) 322-5583 June 12, 2013 Town Of Southold Building Department Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 RE: Building Permit #37848 Dear Sir or Madam, I am forwarding this letter in response to the letter received on June 3rd requesting additional information for the new boiler installed at 5 Madison Street Greenport, NY 11944. Along with this letter please find my Solder Certificate signed and notarized. There was no electrical work performed other than the disconnection of the existing junction box from the old boiler which was reconnected to the new boiler. Any new wiring that may appear is from the boiler which is a packaged system and is low voltage. Also I would like to request that the hot water heater installed be incorporated into the permit application. Water Heater is a 50 Gallon Bradford White Model Number MI503S6FBN337. Additionally I would also like to state that all of the metal chimney breaching installed was done to both manufacturer's specifications as well as any state and municipality regulations. If you need any further information please feel free to contact me. Sincerely r i ~ ~i, ` h ~ 'i / ~ U ~.l JUN 2 2013 t Peter i koulios tr~~~,~'c,~ :o~ i,~o~n SUFFOLK COUNTY DEPARTMENT OF COiN3iMAER AFFAIRS ER PLUMBER PETER KYRIAKOULIOS , This osrliRes that the °1"`° CHRIS 1 SON PLUMBING INC Ixwer IS duly licensed by the o..~. County of Suffolk 04/26~pt Z .P.?..rR 9N „ 50058-MP FEB-27-2013 11:27 From:JOMJ ROSSI 5167850559 To:516 221 6929 P.4~5 STATE OF NEW YORK WORKERS' CO[~ENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name & Address of Insured (Uu street address only) 1 b. Business Tcicpboae Number of insured Work Lontba of insured (Doty rcgw/rtd !f tavaagt Lt 516-231-6929 spec~caRy lhnhed to cerlahr locerJnns in New YorA State, f.e., a NYS Unemployment Inwreace Employer Wrap-Up Palley Registration Numlxr n(lasured CHRIS & SON PLUMBING INC 28x1 GRAND AVE. BELLMORE, NY 11710 ld. FMenl Empbyer Idenllllcatfon Number of Ibsurcd or Social Secority Number 2, Name and Address of the Entity Requesting Proof of 3a. Name of Insurance CarNcr Coverage (Entity Being Listed as the CertJcate Holder) STATL FARM FIRE i CASUALTY INS. CO. TOWN OF SOUTHOLA 3b. Polley Number of entky listed In bax "la" 84375 RTE. 25 9bBS-U189-9 F SOUTHOLD, NY I'1971 3c. Policy cifectlve period 01 /113/13 TO 01/03/14 d. The Proprietor, Partnen nr Rxeeative OfQcers are included. (Only eaeek Mn if sll psrtscrsrolllun lad Wed) XX all a:eluded or certain partners/officen excluded. This certifies that the insurance carrier utdipted ebovt in box "3" insures the business referenced above is box "la" for workers' compensation under the Ncw York State Worken' Compensation Law. (To rse this form, New York (NY) roust be listed under heat SA on the INFORMA170N PAGE of flee worken' compenxatlon insunoce policy} The Insurance Carrier or its licenud agent will send this Cerificete of Insurance to the entity listed above as the certificate holder in hox "2". The lnrtu•dnce Carrier wdl also notify the ahnvs cerr~catt holder within JU days !F a policy ft canceled due to nonpayment of premiums or within 30 dayr !F there are rtasou olhn Chun mmpaymen! ojpremlunu the! cuncal tho policy M eliminate the lrxtured jrom the coverage indicmed on this Cerr~cate. f7hese notices may be sent hY regulor mall.) Othnwhe, this CertrJicafe is valid jot one eor aJki thlt jotvn lr approved by the lnswrance carrin or !tr Beensed a;ens, nr waNl the paUcy expirafton dale Ilcted !n hox 3c ,whichever it radier. Please Note: Upon the cancelhtion of the worken' eoropensatioa policy indicated on this form, if the btr.~iaexs continuos to be named on a permit, Ikense or cnntraet tuned hY a eertifierte holder, the business moat provide that certifcate holder will a new Certificate of Warkenr' Competsation Coverage or otker anthotTCCd proof that the business is coroplyiag with the mandatory coverage rcqulrcmeots of tMC New York State Workers' Compensation Law. Under penalty o[perjury, l certify that 1 am ao authorized representative or Hccaaed agent of the insurance carrier referenced above and that eke named inanr-ed~has the coverage as depicted oo this form. Aplm+ved by: D wJ ~o .-S ~S 1 ~ ~~C °(P~rint name otauthoriae:l rpcwtative or licensed anent o[ insuronce comer) Approved by: y~ft/ ~ ~a 7 ~,E jt (U Title: A ENT Telephone Number of authorized representative or licensed agent of insurance carrier: _5 I (x785-2526 Please Notc: Only ituurance carriers and their licetued ugcnlr are awrhortzed to lssar Form C-JUS.I. Inrrtrance brokers are NOT awthorlred ro issue rt. C-105.2 (9-07) www.wcb.state.ny.tts Workers' Compensation Law Crrrinn L7 Reu.:"r:........:.....,.r....~.:....w.r. FEB-27-2013 11:26 From:JDFtJROSSI 5167850559 To:516 221 6929 P.5~5 STATE OF NF.W YORK WORKERS' COMPCNSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be com red b Di9abili Beeefits Carrier or Liccased loaaraace ant of that Carrier 1 a. Legal Name and Address of Insured (Use street address only) I b. eusmrta Telephone Number of Insured 516-221.6929 CHRIS & SON PLUMBING INC. Ic. NYS UanoPloymrnt Insurance Employer Regisvation 2841 GRAND AVE Nulnbex of Iasured BELLMORE, NY 11710 I d. Federel Employer Identification Number of Ensured or Social Security Number 2. Name and Address of the Gorily Requesting Proof of 3a. Name of tnsurancc Carrier Coverage (Entity Being Listed as the Certificate Holder) STATE FARM FIRE & CASUALTY CO. TOWN OF SOUTHOLD 36. Polity Number ofentiry listed in box "la": 54375 RTE. 25 92-CY-%75-0-F SOUTHOLD, NY 11971 3c. Policy effective period: 04/Ol/lT TO 04/01/13 4. Policy rovers: a. X All of the employer's employees eligible under the New York Disability Benefia Law b. ~ Only the following Class orclasses oflhc cmploya's employees: Under penalty of perjury, l certify that I am m aulhnrized rtpre5entative or licensed agent of the insurence carrier referenced above and that the ntutltA insured has NYS Disability BeneSts insurance coveDrage as descn'bed above. L.~ _ DalcSigncd__12~~ AY.-. efiaapana Cdtrlel sauthorlacd RpreS alive er NY5l.icprtrd lntwanee Agentorthn iasur.nce carrier) TekllhotleNtanber 516-785.2526 Titlo AGENT IMP(saTANT: Ir hna "4a" a eheehed, aad Mb rang b tlptrl by qe bwnaee eatAtr's aWhorlud roprtxantlvt or NYS Llaaxd lasuraaa Ageat orthat carrkr, thH tarttnute b COa1rLETE. M.a b dheetly [o the ternaeate holder. Irboa -4a" is theeked, MIS Krt~caN b NO'r COMPLETE firparpoter efCienloa ]3a, bated a olthe niwblNty Rpreap I Jw•, It meat bt maikd for lom lios b fhe Worhen' Cna Non a na A rk ' AIMa Vnrh 12!07 PART 2. To be com laced b NYS Worhtn' Com asatton Board Oo if bo: "4bn of Part l has been cheeped State Of New York Workers' CompcnsatIon Board According to information maintained by the NVfi Workeex' Compensation rieard, the above-Homed employer hat Wmplied with the NVS Disahiliry tienefitt I aw with respeu to all of hisAttr employees. Date Signed - _ By (Sigcawre of NYS Wnrken: Cnmpenvlirm nrand Gmployee) Telephone Nltmber _ Title P/[ase Note: Only insurance carriers licensed ro urire NYS disability benefits inrvranec policies and NYS /icenred inrurancc agents of those insurance carriers are authorized ro Issue Forts Dd-120.1. Insarrace hrokers ore NOT au/Aor$eAto Jaswe lltls form. DB-120. I (3-06) Additional Instructions for Form DB-120.1 v a.vnina eh i< i.,.n. v6n ina.,.a..n~ FEB-27-2013 WED 04,39 PM AARON GROBER FAX N0. 51681218]4 P. 02 pAre auVDDnrYrl ~Rd CERTIFICATE OF LIABILITY INSURANCE ~/27/zo13 I.ERTFl TTE DOE58N0T AFFIRMATIVELY OR NEGATI«VEALY AMCNDYE%T[ND~OR~TER THE QOVP6RAtlL' AFFORD DAISY TH[ pOLIC1E[ BELOW. TNIS CERTIFICATE OF INSURANCE DOES NITS CONSTITUTE A CONTRACT t1E11AIEEp THE 199UIN0 INBURtSR(S), AUTHORIZED REPRESENTATIVE lM PRODUCER, AND THE C[RTIFIt:ATE MOLD@R. IMPORTANT: N tM esK[Ieate hoMar en ADDITIONAL INeURBP, tM pallty(Iss) must M andorsnd. [SUBROGATION IS WAIVED, sublect to the farms and condRlOns of 1tN polkY, asKein poldes mar n4~a An fMdensmnlL A ststsmsnl on this eertifiab does not conhr dghts tD ttNl eeKElests IloMar In Ilan Ot auCh endorse s yam[ L PRODDCt71 P . (714 fTYlP91 n~c (51s)e7z-9,DD GROffiR-BEY AGENCY, ONE 60NAI8E PLAEA p001B436 VALLEY BTREAM, NY 11580 AtMOatNNOCOVE. e A•t7TIG 1rIA84: II490RANC[ C l4PAt4Y 26 atwRED PETER $yRTaICOI7I,YA31 CHR28 G SON PLDLfiSIN6r SNC. n: 2891 GRAND AVE3dtTE H151,Ii9URE, NY 1171D-3559 FN:A NU T[R_OB/2012 N~NUMBPJt: cOVERACEb THIS Is ro cERtTFYrHAT rHE POL~crEE OFrNSU cE LIeT®BELaw HAVE BEENN IeBUm TD TH[ msuRt9 NAMEDxtwvE~FOR THE POLICYPEWOD C~TIF~ NAY BE LSSUED OORR MIA PERTKAM TME~INSAURAHCE NAFFORDW B TH~POM URGES ~BCRIBEDD HEER ~N S 91UHBJECT Y~OTAl1 THE TES EXCLUSIONS ANO CONgRION3 OF SIIGi pOLIGE3. LBMTS tiHOWN MAY HAV[ BEEN REDUCED t!Y PAID OLVMB: uwr6 INSnR TneoF Plsuuxca 7 7B/iO1R 7 7a/E017 ~ f Sr000, 000 p, aeNeRALUAxm 12Ef3O90s 100,00 X CONNERC9LL oENERAL Luxor Am t~ s 5 000 cIWAL4MAOE ®OCCUR a I s 1,000 DO X Ps[eGSES DP[aarswls oo+enALA 2,000 000 PROP s-ooLwoPAOa s ~ 2 000,000 GBYLAG011EOATE LMfr APP PER: a X rouOY P LOC COAiNpO aNOUSLWff AVrDAnaaeLUUw.m tefaNNNW e 90DLr ptiuRY IFS Pm9Pl S ANY AUrO BODLY N411NlY D`S eraeNfl i ALL OWNED AUfOa SCNSDU{FD ANA PROPeRTV DFLUOE 1 IFS Lcitlafl NlplO AIlr09 1 NOKOwN30 AUTOS F uNaneLU uAa occ+ar ~ pJ(CWaLIAe CWMD#4ADE O®DGTxE a W TAT WORNFRS CONPQNWTN7N ~ . AND eNPLOTB1i'uAPXJrY YIN Q FACH a . ~i~~W~? NIA L4EAGE•PA a pF9eW ON OFS •POUCY LIME S PESCRIPnON OFaPH1ATIDN3I LDOATNNKI VeNICLlf (Afi~3 ACDIm107,AedNpPM W4e11e aPAANP4, ePINA iOSN N rieNrNl CffiTI82CaTa BOLO[R S9 INCLODLD 7.a ADDI'tI0l~. ssaaDRaD C IFICATt: HOLDER NC TION 6NOUL0 ANY OF THE ABOVE DBB IetA POU' ES BE CANCELLED BEFORE THE pNNGTgN OAT TII[R ~ P MDTIC MALL BE DELIVBRED IN ACCORDANCE WRN T~ OUCY VISION TOWN OF BOOTSOLD _ 54375 RDIITE 25 pumDRSm RaPRE7eNT SOVTHOLD, WY 11971 ACORD 25 (200BPoB) - D 1 Bb200B A OR ItPORATION. All Kghta nNSarved. rNe ACORD name and logo are nglstarsd mvks of wCOR~