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2 RAYMOND TER - BUILDING INSPECTION a The Commonwealth of Massachusetts Board of Building Regulations and StandardsRECEIVEU. g CITY OF Massachusetts State Building Code, 7� ' 10HA� SERVICE'k t SALEM evised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling. Z815 FEB 12 A ID 2 2 .4 This Section For Official Use Only Building Permit Number: Dat Applied: T _ `Building Official(Print Name) - Signature - Da SECTION 1:SITE INFORMATION , 1.1 Prope Address: 1.2 Assessors Map&Parcel Numbers IA]a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.Z,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes[] SECTION PRO PERTY 2.1 Owner of Record: fio_h��lcwe Sot l e tin Name(Print) City,State,ZIP a �aN, .fll Tee . -9i-?1�-9'7G7 No.and Street ' Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 A eration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other pecify: JVV ark 4'� Brief Description of used WorkZ: C e Vell,11 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 5-Z�V 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier_ ' `'' x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ 6.Total Project Cost: $ l 5UV Check No. Check Amount: Cash Amount: 0Paid in Full 0 Outstanding Balance Due: -SECTION 5: CONSTRUCTION SERVICES "- 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder Eric W.Palm List CSL Type(see below) No.and Street 3 H1Dil11CC( Type`' Description Salem MA 01970 U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 7�,//,� (, 2 SF Solid Fuel Burning Appliances "1"! �b�y J I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 'i rzv �- l 3�1Z HIC Co HIC Registration Number Expiration Date t e No.and Street ,Wem lA 01970 Email address City/Town,State,ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance3fAhe building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize (Fr-,-c ecat ri to act on 1 � m\y behalf,in all matters matters relative to work authorized by this building permit application. �A1Ju ny4t)R I'I Print Owner's Narhk(Electronic Signature) Date SECTION 7b:OWNEW OR'AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained innn this application is true acc to the best of my knowledge and understanding. f( G iit1Nt t- � /3�� Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at 3D w.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" �Iassaelallsetts�onae gna nttrom roveffientSa� le Contract bfa�sxda m�rota�ho�meaeao�pa s��'drosrate>;Hometmptarmpem CAmatlwl.ew �Weans Comt®erGtddoroAome tgal addceffa�roa�atl.AaYPtama (adQ.uhapterly�q)•aatdoesaotiadedes»odard OrficeofConsomerggyrs�B PIaA®Bbemeimprottnteatsdtoyda a Homeonaertutbrmabo sue° j"fO1O'h® edieaot66le dan a7 17 l-B MI Mayabtainafree �YoFA 7-Dna7 er 88-?g3-sr»or sthe cont -- Surt,tdd�rl4s(dons men ast OBrenmr¢d � ' cinyrioll i Canoaetm/gy . J sma �Dcads Y�p��_`pr q 9minea;Add=bm,n u `T ny�Ile Da}time PhGane ^�:�'O1• �' /! n'.7 mlpacag� 101 70 I - �IO i � r�I Pfime Gtr?om �J�i1II1se33tt11 77 97 O ,flailing AddrestNdifFnmt � � SmC 'T+D Code tmmalmsTy Bmineapbppe ��PtarzrIDars$}s�bQ The Contmttora-11M to do tlmfononrogaork ,NaH I'/�0�� 3/�Z �p rOmtnbein derail the twd:rocpm�p�y�mT}do9ma aroeamnInt trP_bmodeed4adeaf MeacientabtaKaL Itie�tI Required Permits-Thefolloum, v�.� V� ead"Illbeseaved 6y'rheaaaactor�asl Ptrmi6a2axpmad TomPosetl Smrtaod ..(Owners n'hoseWratheirowe b0IDCannee"11 t b ldt,erW tbomesC��OD�'eaata-nmtogonia xb esclUded from the Pertnrtsnill be & ed&wilt en`n°wzaasbcYoad the blGLchopter742AG.)etantpFundproDislonsof o2 lTareniten tooaattofstaaoolanse toatmmo arm bI mnaamedamd• Total Cotmatt Priceaotl --'�++LDazenfien caoaamed tmrl:n�116e The ConoMaw,l mes ro PoYmmt$chedale - �A3'emnpleted. }mrlo®me.mdr:fmnv4 Neatatcial and tabor PeIments aUl ba madeaecettling �eci6edaboteforthe romlmo of rothefo0mvinSs6edule s f Woo sipdaFaaaaaa(aotroexcced 1!3 oftherodl Wntractp fco g the omrofspeew oadmitemq nhiobecais completion of ---�� ) . -_or Won coaWledmt of •{•�-{� 3 —mil T11+ —�-�•�(L:�Wan compledon oFthemnnen.(tawfotbids �n -, , Thefalloxiagmy '__%� fWl twal mntmttis ram IL atlered hlomrhecmtup�ered�mwmostbespacmr P7 m boN panya mr;.med� romst me '�belimman� 5 roE6Paid )mmpledoosehedule(••} S NOTES;t•11ndudingab fmznee bpa m ttaed thegn_-.tQ )(°onethirdoRfthatasrdep�tmdo�.pgmvn f _ srS m- herywol mdaedmadmseeromerttaeuumpleyao Nsdmfide r� }?Danml egoiPmemmmmo�bt + Submntmttms:- •`a m Party/suh �°ennA°mOfa mnnattorfmthq desenbed mntramoruuliaed by �tO��el3'respotmble far �❑�`e A r e te' dmmnaxttor. nm remDletioe ofWeuyry- r r ContrectAccepmoce- �robIDlelYraspooablefor�e$afWearaoasofmythud conrrect shall oo[impl l+poa apmng,the:domment - Paymeaes to ell mhrontratt Ythat�tratt rerlmrsecodtybt�esa b,'p�trmsaoaaaumdclm,: U tLmnim ors For careFWlrheFom si _ ° Dea'[be lTmll thm � Ptattd ao themideoa.ltaviewWefollmiiagn �mdno�odmcea the ° � Ptesaaed inrosiHlia§the tvaUa¢T tkeamerorwdaad fWlyundtsataodit 9 oat ifsomet6m snbceetra i e em reasaananp mMgrojy do.Mhe DtteawofHotne lmProtfficot Co nn �'egidtesmoubome-Sis®dear. ° Don the tnohamor »treerorm l0]°mCptA�(�mili Re-.wanMmd ° seeampyofa'pmoforiosmu!!dAns'the CoabactorforhisianaaoR cep' 116 ar . Cal, -1 87WTIU-et7 I: 01""wdShtsand tomeat WmPan•'iatonnadan so r5atyvo tao confirm Guide to tbeHome tatPonstbitidei Readthehn emVI oratI lmprotenno ContractoriaR P°AAAtlnfmmman on Nemtxae9deoftbisfmm and Yau may emeol this - @ttaeW)'oftbe COMM, wrd busres4qu bisMmtmyao&ceoryaa�mocumby dt�thao naaaran third businessdayfollmtingrhesia_,wing ofWis o8acb_o-ethe -Mall paned,byleleI IMm or h��'PmiidedyvaaadiyWe DO MOT SIGNTIiiSCpantseedtaetmd`edDO°ceofnencellaudnfotm �t�'Aoetmv,ban®r��troftya o°— a°raemms��b e�NTRACTIFTB$g�AREaNYB tobofft'lltht• ' amcaaUgamWa v>y„_ LANK SPACES!!! mDFabYd hatspt hr tb saao-�mc Homemmer'sSigmtum ,? / - ° ,.F�}� a.13 I S Coo°saor's 4mmma eret' `. I Date ContractorArbitratioa hmaeo\vcarswiththeright,mmlt"'m2narbitrationactiontasan The Home Wmvemem Cc they h Lawprovrdes antomaticelly aMrded to a alternativemCc=nation)ifdtryhavead�spum.viWaeaeanydi utehThe emethas g43 contraeror,however. The cootsactorwould have totesolveanydisputehe/shehas\vdhahomeo.werincouRnnlass both parties agree to the optional clTm provided below.Taus clam would gtvethe cooMW the on 1*110 arbitration as is afforded to the homeowner by the Home improvement Contractor IA%.. The contramor and the homemvuerhereby mutuaOY ar ree in advance that in the event the contractor has a dispute con conme his contract the cmitractpr pray submitrhe dispute to aprivate arbitration f mu\rich has been approved by the Secretary of theExecutiveOfficepft_pagrow ffairsxndBrsinessRegulationandthecoasmner shall berequved tosubmittosuchatbitrationast�tidMI° usettsGenumlIan%ela,,terld2A. ;�r t�=y ,� t ^M Contractor's Simamre Homeowner s Sigo 1\only to the agreement of the parties to alternative dispute OTICE:7hesignaturesofthapardesaboveapp; Y � tersolutionevenwherethis resolution initiated by the contractor. The homeownermay initiate altemative dispu section isaotseparatatYsi ed thepariies• . Homeowner's Rights A homeowner's rights wider the Home improvement Comactor Law(MGL chapter 142A)and other consumer protection laws C e.MM chapter 93A)may not be waived in any way.even by agreement However homeowners may be a\eluded from cedabr rights ifthe contractor they choose is not properly registered as proscribed by law- Homeowners who secure their o\va bur7ding permits are aammaticelly excluded firm all Guaranty Fumdpr cliin ns of the Boma Improvement Contractor Law. The contractor is responsible for completing the work as described in a timely and wrorimmul lx manner• Homeowners may be entitled to other specific legal rights if the contactor guaraatees orprovides an cypress werrantY for tvodminuship or materials. in addition to guarantees Orwarraaties invided by the contractor_all goods sold in Massachusetts carry an impGedNvwrmq of murcbantability and fitness for aparticularpurpose. Anwumerationofothermaaerson.VhichthehomeowttarandContractorlatvfullyagreemaybe added to the terms ofthe contract as long as they do not restrict a homeowner's basic consumer light. If You have questions about your consurnm*Otaeownerngbs,Contact the Consumer Information Hotline(listed below}. Execution of Contract ` The contract must be executed in duplicate and should notbe signed until a copy of all exhibits and referenced documents have been attached. Parties ate also advsednotto sign the document until� Mwect ons have aaaehmmbss to filled in ormarked as void,deleted,or not applicable. One original signed copy mrttractmust be nt writing be given to the owner and the otherlspt by the contactor..Any modification to have received a ftrih executed i tom•of and agreedlo by both parties.Contracted work-may notbegin parties the contract,and the three day rescission period has eaptred Accelerated Payments A contractor may not demand payments in advance of the dates specified on, a payment schedule in cases where e homeowner deems bimllterself to be finencia0y insecure. Howeve,in instances where a contractor clam him/herself to befivanciafiyinsecure the contractor mayrequirethatthebalanceoffundsnot)atduebeplacedinaiointescrow account as a prerequisite tocon[umdngthe contractedwork. Witt Mvaloffunds from s aidaccountwronldrequiratbe sianatuces ofboth parties. Additional information vement Contractor Law or other Iflou have general quet4onsor need additional informationabomtheH C�vemoer idetoHoctorLame trvrother consumerrighs,or if You wish to obtain a free copy of oA Massachusetts meuV contact Cousumerinformation Hotline Office pfConsumer Affairs mod Business Regulation 10 ParkplaM Rome 5170,Bosnia MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at i:ne:;s\"c.rKI; .er._o'- ": If you want to var*the resismidon of a contractor orifyon have questions or need additional information specifically about the contractor r*gttrabon componem of the Home Improvement Contractor i.aw,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regtdanon 10 park pLM Room 5170,Bosm16MA02116 617A73-8787,888 383 3757 or visit the MC t\xlsite at i-r :\:��r" uoviotab' Go online to view the stems of a Home improvement Contractors Registration: =t�-`'d' 4 'RIa.LL4bpm`tri77nw2'nSVti�1'aa:l�a�: For assistance with Mfotrnai mediation of disputes or to register fomurl complaints against a business call: Cods®ter Complaint Section Off_itiatheAtromeY General 617117-8400 AL9)/OR Better Business Buren 5086324SO ,5o8-755-2548or4l3-734-3114 Ved: I ,eta COmmMixaM IfMazsackasgm B€ 0)4 IMF €2124-20..77 q ! Y�`2Fae�§ y CoripeaspJFS �cufFJu.s®Pa/ELa{L "��„ 9`�xlptII�Hat �tzz® LPLe Affidavit �§§�o7�as/�cai� ekmrs/�H >Ifl� mot§HcH $)Plumbers e REG RElat Legiblyblyupi a(3usines "antic WeatheuatiuHg nizationladi : L 6 ULeless: Oily/"1cate/Gip: emg3oyer?resit employer tlxe O rhoi��#: 1. 9 qq- 8i y 3 �g taa�p�:ate h��: ployer with Tyft employees -�=— `2 ® I am 8 general contractor and T of paraeeE I ii4)ogees(fill!and/orpart time}.= have hired the 5. ( ): 2.❑ .am a sole proprietor or sub-contractors ❑New construction Ship and have no Pai'tuar listed on the attached sheet 7. Remodeling employees These sub-co F'vOrkI a r sub-contractors have workers, coil any urance emnlo S- ❑Demolition ��+o VJOr�,-e1,>imp-insurance Yees and have wortrers, r e�*ed.] comp.insw-anceJ 9. ®Building addition am a homeowner doing all work ® We an a corPoraBon and its 10. cars have �Electrical repair's or additions rnYseLF{�=o workers exercised than insurance required]t camp. r�it ofexemption pe• GL 21.[I Plumbing r pairs or additions e. 152, §1(d),and we have no 12 0 Roofrepairs employees.[AIa workers, 13.0�<er iySr t/a ""Any applicant that clteck;boxatmust conto.mstsancerequired-] �Hameatvners umo submie this �o fill out thesectioa below shonin tCantractors that affidavit iadipdag they are doing g theirtvor§ers'compensation oli check this box as wodt P cy information,rmatioa employees. iFrhe sub-contraemss atthched an addi4oget Sheet stpr t5e t o de �aors m submit a new afndawt indicating tbO$O enti hate employers, ties havea they must g ttame o£the suo-conbzctos�d statewbetherornot Provide their tvodters°coma policy number �vo,a�,czer��plcyert,3PG+t'�SAYOYaG'drlgWAFTeet;aG0�8rZR41Y/Jr'aZ'r�Sl(P _arzcej©: y1,ea;_Dtt yee� Below is Flas pflfY ruae fab sire 'nsurauce Company 2�lame: 2 u rrc�, Policy 9 or Seo.ins.Lit r: S6227019 1 Job Site Address: _ ExPiration]ate: a tae_k ayn'er, r.� I _.C✓ v Failure syoft-heWorken ity/StateJZrp: h re to a a compensation n pntscy duration na @(olio ectrre aaverage as reclnsad render section 25A ofrLIGL c 52 can w&gto the it Polley number&Erfi Fne up to SI,500.00 an oIIe yea o� ezpkaulos r of u to position of o iminai srej. F o25o.00 a day against the violator: B tzar as weal as civil paIIalties in the form n1a STOP penalties of a tavestzgations es the DIA for insur a advised that a copy of this s WORIt ORDER and a fine ante coverage verincation statement may be forwarded to the toe of dfl rae:�gy cer�i , aea the 'as¢nKIM citrr :t R F fI. � b'Cli Gb©TJ2 i5 e e r�acj s©rfeeC Phone�: —,J.•CEf<1t 2:s^E 3iEji� 'DO 12.3r W7Ft Ett 1 4 J2 Cd33W:F.:•P.8 by tLjl 0?:Or1, fl :125II?===F:iirther1LJ{Cs""CIe 6IIE}; Pes'ss_.i✓I,ieenS s�'r Eeai d of__ar-. 2.Bui9d' ! f.O"taeS ias tS$ep-.tom 7aeah 3.`iiy/^ofva�iarix Ccr ai e2 Persoru: e.?Rs§estsSsr§gs�p��s 5.Piumbsng laspectur $t i TRIS CC '� � �0 99L� u Y p�fl HOIOERR�FlCAFE IS ISSUED L n 41 ��g r� ��' °ATE THIS CERTIFICATE DOES NOT AEFtIRt AFNEIYAORF, ONLY AND CONFERS AFFORDED BY THE POLICIES - t2 2014 j FHEtSSU1NGINSURER(gj A BORE THIS CERTIhTCAIe OF i NEGATIVELY A(HEND No RIGHTS UPON THE CERFIFICATE� UFHOR2ED REPRESENTATIVE OR Pp URANCE DOE E^IEND OR ALTER THE COI! I IMPORTAI'1 F: Ifthe certiEcak, RODUCER ANDS NOT CONSTfiITE A CONi ER AGE i sub)ecttDthetar anti 0.7 IderLsanADOti(O THECER7IFlCAFEHOLDER RACTBEt'{grEENI natcortferr;ahts onsofthe Mi tNSURED,theooGcy(esjmustbe t0 the�ltificata;colder in��eit cr car�in P°ucies may 7 stdorsed, if SUBRO OGjc� oGhendorsernamis).Quiraanaid;sEm�itAstlai EZt GATtoN1.8"V Ep 16AS'ER'1 INS GROuP LLC on this Cerhgmia.doas 33"AI CENTRAL 51 'ek`^cr NA71CK,(yA 017fiG 'i"CN= ' _,ti= �. rA,G •,. 97NTIC WGJtTH' - 1 -�cA, ZRICNRJSILRgNC- �eATI J-tee eRIZA"ONLLCNIA CrvaF ! I ;S,MA pj QSONAVE _ IASJREa6_ i "�SURMRC_ ' LSJn A D: I 1 f COVcRgC- ': sua� i { _ I msJaER F:THIS IS tti"CEP.TI.y t _ IC c 'BER• Ae'CI FOR.7iE' ` ' _I•!e FOUCI=S 0'r t CON„ ACT LtCr PeR10D INDICAicp_N�tp VCE USieD15 t �1'SURANCEOR OTHER OOCUIVE TWlTtt BELOW HAVE BEeN gr D N 6E NTLYITfI RESPE� ANOING AIRY RECUIRE�Y COHOI"10 c Ur SUCH CED BY T.yE POLICIES = IG N'HCH THIS C 10 THE INSURED NAM N�OF SUCH POLICIES.LIMITS D-SCRIBED HEREIN IS ERTIFICATE A ' BE I55 M OR CONORION OF ~0 7 trtsR _ 5H0 W, SUBJECT E OR M,AY? aHE I IL'^ %YFE aF V AiAY HAVE BEEN REDUCEDByC 1 AID CLAIA45. EXCLUSIONS•AN 6eNSiAL L/AsM RANCE ' L'sU6 P All !�C D POUCYNlRMER PoLICYrr� p�cra D 1 { ��C:ttEl-7AI.G1eR.:tl _ lTl7lDDryylyl ->p I I tom^ IO''.1' 'tADE uLURY I Uattrs �e OCL71R I RCHOCCUBRaw'E { Z1 I F°pJ...' - RE, D IS IUS rao_m. n , NLA Dc^cF r� 1 C'GAEG:.TaU1.tTAFPy1EspE� 0°IM 75 ?OUCYI� FRD. I 'Dr.ALaaovlN,IVRY AV;DMID JEC II Lac I GcNER,or-Reur- !S N"aUTO �Y I 1 FRODUCiS.CG[F,.7PAGO B i �vu DiY; D :CN- I t s I L.uwres� r:'�05.,•,�,�,N o � � I�I�wEosLVDL= Is �ec:.n SRJtT 1 1 AUTOS `° I j Ir*^D,IYD•JUaY[pe,,y�� 1 Is IUA166 I 11 I IEDDRV CJURY(Fp,aCGCn E I to^�C3=LiAB�j OL:IN$JJA I I 7 I�4 ��1Y�aG 1Is !OEDj j REirhPtONS OE I Is ! I IYlOA: RS CO1JFg,sATpj i IEACH CLNaiq V s I 1 AA1D E!A.0' R5LI4E1-TAR 1! I I 'u'C+••CvAT- Is trpRC?R I IE f �LU. Dc6? lu:u:A' � 1 :?C S7A7U- I 2 03 iTORYLL'73 IO'rr!•I 1 I°c` ar• D_O. AT ' , 082/0121 3ZR ''`0.2D 7� 03-20.201a Aco0:"I cN--O .OGO 1 t i El06FJ1y'--•��JFLOYEE OI`3GG.000 i I 5CBIFnON OF EL 06 �0= I -1'3,cruUrr jc.,.,t•00.000 1 1 ' FEAaaoNs,LocanoNs;VF1;1 CL:s(riitinhACORD t01, aaany,,,,A I i nn+mie stlsiauls,Nenp,aa,z isrpuGall Ce'R'7PILATE BOLDERI CITYOFSALE11A CAA ELLAFION ''A"— GFON ST ` ISNNCEL ANY SAL-'7;,,AiP.Dt970 OF HE ABOt/E DESCRIBED POLICIES LED BEFORE FHE EXPIRATION DATE T _BEi !NOTICE V?RL SE DEL 'He fAl iPOUCYPROVtS10NS. ACCORDANCE V?IFH C}JGI""PORnM A xr ACORD 23 `�• -'�' (20TON3) The ACo" 0 t9M2070 °arDe end lDgo z,e reg1612 dmerits CORPORAi70N.DPACORD All rightsrEsarved.l THIS CER 1�a aC � O LaAa�a�a� � ,� ERnFCATE 15 Issu BFLCELOI f ill2 Does As A It7R , OtR+ THf3 C R'T1FOT gFFjRIP19.rNELiY p OF iNFgRMAnoN ONLv "MISU ANCE I RAREBEIyTAIVE "GATE OF INSURANCE DOES ND CONFERg NO RIGH I�IPJIPORTANT OR ARODUCER AND THE G CONSn�IU q�D aR at ;UPON THE 3��0/ YYYyI ERT7FlCATEHOLDER. GERnFICATE HO SDI the terms and con dldons�M holder is CONTRACT 6 THE �VERAGE AFFORDED By THEO 11 certin'cate aft ADDIIONAL INSUPED, ha �JEEh THE ISIS 1NSUP IS PRODUCeR holder in tie,of such endoY�Qe>1 in policies Folic !es (S), AUTHpR1 D tsement(s maq 2quire an endorsamen£ be endorsed IP SUB 3aste,•n. Astafemant0n ROGAnIINIsyyA thfa certificate does not canfar,subjact to 233 crest,�u�Ce GrODP xyC co �cr 9hLs to the tral Street FHONE CDnsioa NEI an Aa (SD8)651-7T00 INSURED 01 �s FA"Na 760i ' 6*�a^ uvsu 61 Ee=c t, erizacon rssuRERA_ayb eA�DRDOls CoVERABE erson Avenue lens QRERe_alb I Protection a Ias. Co. Sate � NAlcx r INSQ Q ' �d�l Ins Co. I41360 MSI)RERDmu 1tS V2eRCe Co 10017 COVERAGES ' 01970 s ISBass. 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