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HomeMy Public PortalAbout07-0337 Nelson r/ CITY OF TYBEE ISLAND BUILDING PERMIT DATE ISSUED: 07-31-2007 PERMIT#: 070337 WORK DESCRIPTION: RESIDENTIAL DOCK WORK LOCATION: 1409 CHATHAM AVE OWNER NAME KIM&FRANK NELSON ADDRESS 1414 SEVENTH AVE CITY,ST,ZIP TYBEE ISLAND GA 31328 PHONE NUMBER 404-405-0655 CONTRACTOR NAME JOHNSON MARINE CONST CO INC ADDRESS 607 E 54TH ST CITY STATE ZIP SAVANNAH GA 31405 FLOOD ZONE BUILDING VALUATION SQUARE FOOTAGE OCCUPANCY TYPE P TOTAL FEE'S CHARGED $ 50.00 PROPERTY IDENTIFICATION# PROJECT VALUATION $26,072.00 TOTAL BALANCE DUE: $ 50.00 It is understood that if this permit is granted the builder will at all times comply with the zoning,subdivision,flood control,building,fire, soil and sedimentation,wetlands,marshlands protection and shore protection ordinances and codes whether local,state or federal,including all environmental laws and regulations when applicable,subsequent owners should be informed that any alterations to the property must be approved by the issuance of another building permit. Permit holder agrees to hold the City of Tybee Island harmless on any construction covered by this permit. This permit must be posted in a conspicuous location in the front of building and protected from the weather. If this permit is not posted work will be stopped. The building contractor will replace curb paving and gutter broken during construction. This permit will he voided unless work has begun within sih months of the date of issuance. cr:jieLtivsit) Signature of Building Inspector or Authorized Agent: P.O.Box 2749-403 Butler Avenue,Tybee Island,Georgia 31328 (912)786-4573-FAX(912)786-5737 www.cityoftybee.org CITY OF TYBEE ISLAND, GEORGIA APPLICATION FOR BUILDING PERMIT D • lZ/D te A.47 . Location: I tp I VA 1.1E PIN# NAME ADDRESS TELEPHONE Owner t2ANk. ( (o 13114 LA-14G N�l,San.1 Architect or Engineer N r• Building To►ar.�soN M'kg Ne 0.7$ ctANst-Ft LAIGE et7. .��.5,'� Contractor C TQ JJ-11 ON GO. t,,l t!7 K+D<.�4 4'A 3 13 a `�IZ 364•to2�}� V���, (Check all that apply) [2. New Construction ❑ Renovation ❑ Minor Addition ❑ Duplex ® Single Family ❑ Substantial Addition Residential ❑ Commercial ❑ Multi-Family . ❑ Footprint Changes ❑ Repairs ❑ Demolition [l Other toctz Estimated cost of Construction: $ 2(a , D11 , 00 Construction Type ti (Enter appropriate number) (I) Wood Frame (4) Masonry (6) Other(please specify) (2) Wood&Masonry (5) Steel &Masonry (3) Brick Veneer Proposed use: poGIG Remarks: PoC- - Mdi2lN &Q-M,c wooD ATTACH A COPY OF THE CERTIFIED ELEVATION SURVEY OF LOTS and complete the following information based on the construction drawings and site plan: #Units _ #B•u oo #Bathrooms Lot Area Li '' sp . e(to sq. ft #Off-street parking spaces Trees located&listed on site plan A Access: Driveway (ft) W !vert? With swale? ) Setbacks: Front Rear Sides (L) (R) #Stories Height Vertical distance measured from the average adjacent grade of the building to the extreme high point of the building, exclusive of chimneys, heating units, ventilation ducts, air conditioning units, elevators, and similar appurtances. b0/20'd 62G6 98L 2i6 '�1SI '9HJ,1 AO 1,I1 9T:2T 9802-2,ti-2ld3 During construction: On-site restroom facilities will be provided through Ow On-site waste and debris containers will be provided by N/Pc • Construction debris will be disposed by Gontiy .at NO by means of WJM,.--w tot rmA-noes I understand that I must comply with zoning, flood damage control,building, fire, shore protections and wetlands ordinances,FEMA regulations and all applicable codes and regulations. I understand that the lot must be staked out and that the stakes will be inspected to ensure that the setback requirements are met. I understand also that a certified plot plan showing elevation must be attached to this application and that an as-built elevation certification is due as soon as the habitable floor level is established. Drainage: I realize that I must ensure the adequacy of drainage of this property so that surrounding property is in no way adversely affected. I accept responsibility for any corrective action that may be necessary to restore drainage impaired by this permitted construction. Date: 1121 01 Signature of Applicant: ,,.-. _ . Note: A permit normally takes 7 to 10 days to process. • The following is to be completed by City personnel: Zoning certification NFIP Flood Zone Approved rezoning/variance? Street address and number:New Existing Is it in compliance with City map? If not,has street name and/or number been reported to MPC? FEMA Certification attached State Energy Code Affidavit attached Utilities and Public Works: Describe any unusual finding(s) Access to building site Distance to water main tap site Distance to sewer stub site Water meter size Storm drainage Approvals: Signature Date FEES o� Zoning Administrator .r►r - Permit ✓ V1 Code Enforcement Officer �'� �„' ,_ Inspections Water/Sewer Water Tap Storm/Drainage Sewer Stub Inspections — '' Aid to Const. City Manager TOTAL ,5OV- b0/20"d 62S6 98L �ti6 " 1SI 3SSrll JO J,lI9 8T:2T 9002-6ti-ddd JUL-2-2007 03:28P FROM:J H MRRINE CONSTRUCT 9123543982 TO:7869539 P.1'2 'DUI '.op uopon.nsuo3 auiieN uosuyo( uosuyof we11PM -AlaJaDu1S 11ea e aw aniS aseaid suollsanb Cue aney noA�I (213AOD JNIanDNI) amend weyleyD 60171 Z :S3Jbd 3O # U1wlad s,uoslaN �uea3 :3j 6£56'99L :X73 uosu4o(wei11IM :Nom pueisl aacA1 p A j LO/ /L :31Va ouo auueio :01 Z86E'6S£'Z16 (d)/L6Z9'65E'716(d) 50O Lc e1SJoao 'qeu uenes PanS mijS ise3 109 DNI 'ANVdWO) (4) NO11)111211SNOD TI II -a7-7P27 1 R:GIFT Q1 7Z�I1ZQf=Y7 Q7V P (.l1 FEB 0 2 2007 CoastcroNaTA al Resources Division Frank L. &Kim Z. Nelson 16 13th Lane Tybee Island, GA 31328 RE: Revocable License - Modification of an existing Private Residence Dock Facility, Tybee River, Chatham County, Georgia (GPS-31.59766°N/80.51277°W) Dear Mr. &Ms. Nelson: In response to your application for a Department of the Army Programmatic General Permit PGP0083 (960009050) for a private, single-family residence, recreational dock facility, please find enclosed a fully executed Revocable License for the modification and maintenance of a private, single-family residence, recreational dock facility. This license serves as authorization to utilize state-owned tidal water bottoms for your dock facility as per the location,dimensions,and configuration depicted in your application for such license. Your proposed structure will consist of reconfiguring an existing dock facility to include a 6' x 24' walkway to an 18' x 23' covered fixed deck with a 6' x 6' platform with a ramp to a 6' x 24' floating dock, a 12' x 24' boat hoist and another 6' x 18' floating dock. The dock will be constructed approximately 4' from the extended property line to the left and approximately 11' from the extended property line to the right of the structure. The entire project extends approximately 40' into the waterway at a point where the waterway is approximately 1000'wide at mean low water. The height of any covered area cannot exceed 12' from the lowest part of the decking on the facility. Any change in the use, location, dimensions, or configuration of the approved facility, without prior notification and approval from this office,could result in the revocation of this license and in required removal of the facility. Based on the information and plans submitted with your application,it has been determined that the proposed dock facility complies with the terms and requirements outlined in the PGP0083. All activities performed under this permit must meet the conditions stated in the enclosed copy of the PGP0083. This dock facility must be constructed precisely to the approved location, dimension,and configuration as depicted in the drawings and description provided. If dock corridors exist,please ensure that this dock facility is constructed in such a fashion that the entire structure fits between the extended property lines. The facility,for which these authorizations are issued, shall not be used at any time for business or commercial purposes. Prohibited uses include,but are not limited to,leasing of the permitted dock space; docking a commercial fishing vessel of any type; and utilization of the dock facility in any tour or charter boat fishing activities. The use of this facility for other than private,single family residence, recreational purposes will result in the immediate revocation of the license and in required removal of the entire facility from state-owned property, and possible criminal and civil penalties as provided by law. This agreement is not transferable with ownership interest in the upland Georgia Department or Natural Resources * Coastal Resources Division One Conservation Wav * Brunswick, Georgia 31520 TEL: (912) 264-7218 * FAX: (912) 262-3143 * WEB: http://crd.dnr.state.ga.us Npromi Dock Modification thd 0 2 2007 Page 2 property. These authorizations do not relieve you from obtaining any other required federal, state, or local permits. You must obtain a county or municipal building permit prior to beginning construction of the dock facility. The tidal water bottoms and marshlands of coastal Georgia are public trust lands controlled by the state, except over such lands where a validated Crown or State Grant exists. This license authorizes use of lands assumed to be under the control of the state. You may proceed with construction of this project with the knowledge and understanding that this license agreement could be rendered invalid should another person produce a validated Crown Grant or State Grant. Please contact the undersigned should you require more information. Sincerely, Brad Gane Assistant Director Ecological Services Enclosure Cc: U.S. Army COE-PGP0083 Local County Building Inspector Oct 11 06 02: 15p Frank L. Nelson an4_948_9779 p. 2 Oct 10 06 04:29p KIM @DOCkUt 9. t p-3 i ,i..--`.S`-k.v, t.i.li"?•lei::f}•!)tl,'S' in_:-•iif.'.it.:t ti•ii lr a::T'u.i r-wale i 1:_23.: rri._.c{2irS -'.At13i?5;:. -.__ k.....,..... ......2-. .Y . rc.,traic.... .L. ,. W. I.St2n...0:11-d•;; ... . .. . .... T `H AufrlatSS: 1lQ 13 LA.0..r.. l _ i D . — 7I �8 – , -_ ._ .._ .._. . _ Susan Shipman.Director t.ierwais Department of l'itdaral 1:' rnh:er: guaiayien}-Services•nr neh One Conservation Way BouasistickAelargia 11.21.14A27 Dear Ms.Shipman: 1 sturnatttiopoppliestientfersiteets4441441o,ti..S Dnp' astatsorstlw-At4wyrE;erpset,b= Detw..tit ?hoist Fonticesteniktbas issuance of suers a penult...yin not relieve m Of'the obligation 10 oblein authorizstioo from the State of Georgic since the proposed poect iou1 castit as oaeJxnatstoa tae b oe€thdeetatmtssebt,h s>•.Starr.um,.d rrnppm_ lirgly,S.tt,„4,3,satriwaFt3Mtp stomed er„v4voble lieerre front the Sint*.of Georgia.Attacked hereto and rookie a puma this sootiest is a copy oflhe Nam anti description of tine project which will be the sub ecl-o Biro s\ t onjer tand drat fIwrrra sirtn.1lunathc--SDnt iev.•rtet,it.+•i_t1 be a re..n.nbt4lit...eu a'licexnse coupled-with nrt� huerest. I further acknowledge tdbst such a Iicenae would relate only sop the�proper y interests of the State and would not obviate the necessity of obtuittim ..t other State kM1c transit[X'Y�'vegnt t -. a-lasts I recognize last I waive my right of expectitlion of prtvxey and I do trot have the permission of the Stave o t•Gcorgit:to proceed with each project wails t:olty.uf this regaatdn:s been si.gpet1 tty.Conuttissihter Ilutairb. By: F L- P,ti_s_u (Applicant):tilts ifmpptio bib.. l r•.. Z - /Sit'_(s..� (Applicant),title if applicable Atincttn ens The State of Georgia hereby grants you a revocable liceose not coupled with an is-itereSt us pi rl.d in your request.This cues may wawa('in the t9 _ d..........a.....,di...kla sperF.bwitstwin,(,im: - . la its occupancy and use of the premises,bcensee shall not discrtnnvelc agnittst any person tan t r-basis of Luce,gander,tutor,uationei origin, retie:no 2:P rw h bility.j t c vrom,qm by Iir-nttf aUtry&i'ratr^echo„trnni,atinn of thie tj,vcj joy inkl.:tint:.Ya.I' b any ahar u msn3 :ry ailable at tai:-to The Department.The.project proposed for this literati.mutt be contpt tad wicltin 3 yours of the date of ismancc of the license. Ott>`•twi,::,.a..—Ion-onll-be.:itcnul:is.r~'v�th,: r. 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TD CXrENbE t r: RS 0 DoG i MLAI MIA�,f .. - .._ ()1A-t l --c VrtLv) (—� • 1 . E V tE iJ .s 1 uwidoul aA Chatham County Re",a/14)/1,-,Ved S - / 5 q . . n Jpb et of r,„ 1 . REVIEW FOR CODE COI[PLIANC Site at /411 TMost L1 �� � �me4.v riaa>./rrnoworala ur∎moua�r�s�pt rr_n�.a;ntI/ 7 -Fv z T p . r..F_ .-_., code violati.ns, no •)versigh by.r' t� — -- rev W .sha 'l be co strued . s-a th. �� .•=__ ML-4J "1-1-18 E pet\,159____ to violate, ' ancel, s -r or set asi; - any applicab e code . or or. :w- es J . review and permit should not be -co•:, as a warranty or guarantee., RECEIVED Reviewed By . Date.7— —c57 JAN 0 5 2007 BY: JUL-2 2007 03;28P 1.—j��M'�,� MARINE CONSTRUCT 9123543982 TO:7869539 1C704 4,� �a i C.2"4:4-c`:-X-7 t" '� a f - {.d r , sC(12) iiiiiiiii, ' Ai -ti 131 QCO7Of'�arc (�,,,,v Z I :1111111 SV. c3-eK a„,. .. ....... ...111,...._e . �'>. -0U of,r d 7fib' r1. / I `- f \ / N3v Si aINmv VtO O39 30 31VIS (INV 1' N ►1903 3Q00 0NI1'l3�fi0 A1l9�9 3 r aNY 3NO 39 3k1ONV+ �M - 911.5 '5 cnt�=>n� AN c po 0 ��\ 1 NlIM KU NO 1 9�9N N49S0I1�1 +l 3 1 v 7 \ 1 c) ry '1,',4.4,,,,3 l,, a , ....0 ,-. 0/0L c.., Nter`" - s 711 7 7 avo)o o < 4 co 1 ") lir 1-4 ri - 4 ‘4....._ ,,,,,,,„ t , 1/4„, v ,:,,,_ NI a ,...34..„1.16, .44 4- t3 4) i TI a _LTD_ 4i DZc'4Z4S�7 47:. A p7 '"F,-• G. 4V V r r V •,l rwrrr iYV. 711'7 I . I Chent#:15_ JHr `.IN ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE ro7D l PRaoucER This CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Savannah,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR I .O.Fax 9966 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 7 East Congress St.,Ste 1002 . Savannah,GA 31412 INSURERS AFFORDING COVERAGE NAIC# INSURED wsuRERA: Northern Assurance Co. 3$951 Johnson Marine Construction Co.,Inc. INSURER Ka: AIG through AUN 36567 607 E.54th SI NouRER c; Northern Assurance Co. 20621 Savannah,GA 31405 INSURER D: Safeco Insurance Company 1635 INSURER E: — — COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INstNRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF 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 OF SUCH POLICIES.AGGREGATE LIMrrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- '=''��• POLICY EFFECTIVE FOuGY eXPIRATION .• TYPE OF IN9uRANCE POLICY NUiEBER •. P.il, •.A. ... .....i. .....A. ! LIMiB A GENERAL LIABILITY CCP426965 10112/06 10112107 EACH OCCURRENCE f1,011QQ0 -. COMMERCIAL GENERAL LIABILITY OAMAQE TO RENTED S ., QQQ ■ CLAIMS MADE Lid OCCUR MED EXP(Any One Penal) :5 000 ---- PERSONAL 6 ADv INJURY i1,OQ0,000 LOENERAL ABOREGATE 32.000,00D GEM_AGr3REGATE OMIT APPLES PER: PRODUCTS•GDMPIOP AGG- 51,000000 FOLIGY PRO. LOC IIII I) AUTQMQmLE LABILITY 01C113397691 11/02/06 11102107 COMBINED SINGLE LIMIT ANY AUTO (Be accident) $1,000.000 ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (P9foaaMem) S r ' — PROPERTY DAMAGE S (Per etddenl) O RAGE LIA9ILKTY r_ AUTO ONLY-EA ACCIDENT i ANY AUTO OT1iER TFLgry EA ACC_S AUTO ONLY: AGG S EICQSSIUMBRELLA UADILITY EACH OCCURRENCE S OCCUR , {CLAIMS MADE AGGREGATE $ S S DEDUCTIBLE RETENTION $ s III WORXERSCQMP!NSATIONAND WG2859305 10f12/OG 10112/07 X WGSTATV- DIN- EMPLOYERS'LIADILfly E,L-EACH ACCIDENT $100,000 QFFICERIMEIM ER E7SCLUOED7""E E,L.DISEASE-EA EMPLOYEE s50D 000 II yam,deesdec under SPEC':. PROV13f0,-Celow - E•L.QIBEASE•POLICY LIMIT 5100,000 C OTHER N5JH23537 10/12/06 10/12/07 P&I Limit; Protection& $1,000,000 CSI indemnity $ 5,000 Deductible OH3CRIP ION OF OPERATIONS I LOCATIONS I VEHICLES I I.XCLLS/ONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION /MOULD ANY OF THE ABOVE DESCRIBED POLICIES DR CANCELLED BEFORE THE EXPIRATION City of Tybee Island PATE THEREOF,THE ISSUING INSURSA WILL ENDEAVOR TO MAIL _IA— DAYS INRI TEN 401 Butter Avenue NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Tybee Island,GA 31328 IMPDdENeo6UGATIoNoRuAl1LIiYOF ANY KINDUPON THE INSURER,ITS AGENTS DR REFRESENTATWES. I A�uTHH�ORsu REPRESENTATIVE L I f-+ ,. ‘ . ACORD 25(2001/06)1 of 2 #861820/M59225 KXS a ACQRD CORPORATION 1956 iY V, J f T J I . L IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the palicy(les)must be endorsed. A statement on this certificate does riot confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively emend, extend or alter the coverage afforded by the policies listed thereon- . ACORD 25.5(2001(05) 2 of 2 #5615201M59225 �� vet-• L. LVVI IV• Jlnivi Au, 7147 r, ] Client#:15'. Jig IN _ A �7R ,� CERTIFICATE OF LIABILITY INSURANCE DATE A4210� PRODUCER + - - i INFORMATION HRH of Savannah,Inc. , • • • + 1 - DOES + AMEND,� Y i P.O.Box 9966 . . POLICIES 7 East Congress St., Ste 1002 Savannah,GA 31412 + COVERAGE NAIL iF INSURED INSURER A; Northern Assurance Co. 36951 Johnson Marina Construction Co.,Inc, INSURERS; AIG through AUN ! 36587 , 607 E 54th St. INSURER C: Northern Assurance Co. 20621 Savannah,GA 31405 INauRER a: Safeca Insurance Company 1G35 MSURER E: —� COVERAGES i,� 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 BF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED DR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. _ - PCLICYEFFECTTVE POUCY EXPIRATION UNITS LTR •N$A� TYPE OF INSURANCE POCKY NUNBER ��1LX &.IIcDlYYI DATE IMMIDOfYY1 A GENERAL LIABIL Y CCP426965 10(12106 10/12/07 EACH OCCURRENCE '51,00D 000 X _COMMERCIAL DERMAL LIABILITY DAMAGE RENTED 550.000 ' (CLAIMS MADE , X1 OCCUR MEO EXPjAnyone Parao.I 55,000 PERSONAL S ADV INJURY 51 000 000 GENERALADOREGATE $2,000,000 GENtAGGREGATE LIMIT APPUESPER: PRODUCTS-COMPIOP AGO S1,00OL000 — POLICY 1 JdS F-1 LOC D roNeaan c LM9ILITY 01CH8997691 .11/02106 11/02/07 aBIINkEDQ SINGLE LIMIT s1,000,00Q (Ga X ANY AUTO ALL OWNED AUTOS BODILY INJURY S _ $OHEDULED AUTO$ (Ng person) . X HIRED AUTOS EMILY INJURY (Per Coalden1) X NON-OWNED AUTOS PROPERTY DAMAGE g (Paraatd t DARAOE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC ! AUTO ONLY; AGO S Ey(C!SSAIMHRELI.A LIABILITY . EACH OCCURRENCE S OCCUR .—CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE _ - $ — RETENTION 3 S MI-- - - WC STATU- B WORI4ERS COMPENSATION AND WC2959305 10/12/06 10/12/07 X ,: ,: EwPLOYERS•LIAOEITY E.L,EACH ACCIDENT s100,000 ANY PROP RIETOR/PARTNERSXECUTIYE DFFIOER,'4EMBER EXCLUDEOT E.L DISEASE-EA EMPLOYEE(5500000 - IfyYaa.A PLETOunder E.L.DISEASE-POLICY LIMIT 5100,000 PECUL�fiOVrSIGN3 DIIUw -. - --- C OTHER N5JH23537 10/12/06 10/12/41` P8,1 Limit: Protection& $1,000,000 CSL Indernn $ - 5,000 Deductible DESCRIPTWN OF OPERATIONS I LOCATIONS I VEHICLES f EXCLUS1QN$ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS w CERTIFICATE HOLDER CANGELLATI+N SHOULD ANY or THE ABOVE DEBCRIRED POLICIES BE CANCELLED BEFORE THE EXPIRATION I Attn:Mr,Frank Nelson DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO+MAL 10_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL NAME NO OBLIGATION OP LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES_ — AUTHORIZED REPROENTATIYE ACORD 25(2001/06)1 of 2 #$81821/M59225 KXS 0 ACORD CORPORATION 1985 L. L VV l I V. JVfl I 141.). ti ray r. 1+ IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policycres)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), DISCLAIMER The Certificate of Insurance on the reverse side of this farm does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does It affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORN 25-S(2001l0e} 2 of 2 #361521/M59225