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HomeMy WebLinkAbout3809 EDITH LNENCROACHMENT PERMIT l�l! CrrY OF BAKERSFIELD PUBLIC WORKS DEPARTMENT 1501 TRUXTUN AVE ........... ��`` BAKERSFIELD CA 93301 , 10 (661) 326-3724 TO THE CITY ENGINEER OF THE CITY OF BAKERSFIELD CALIFORNIA: Pursuant to the provisions of Chapter 12.20 of the Bakersfield Municipal Code, the undersigned applies for a permit to place, erect, use and maintain an encroachment on public property or right of way as therein defined. Application Number . . . . . Property Address . . . . . . Application type description Owner -= ---------------------- AYALA JULIAN & VICTORIA 3809 EDITH LN BAKERSFIELD CA 93304 08- 30000034 Date 4/08/08 3809 EDITH LN PW - ENCROACHMENT PERMIT Contractor ------------------ - -- - -- OWNER Permit . . . . . . ENCROACHMENT PERMIT Additional desc Phone Access Code 193653 Permit Fee . . . . 200.00 Issue Date . . . . 4/08/08 Valuation . . . . 0 Qty Unit Charge Per Extension 1.00 200.0000 EA PW ENCROACHMENT 200.00 ---------------------------------------------------------------------------- Special Notes and Comments Build chain link fence behind sidewalk not over 4' high. this fence is already built. --------------------------------------------------------- ------------- - - - - -- Fee summary Charged Paid Credited Due - --- ------- - - - - -- ---- - - - - -- - - = -- - - -- ---- - - - - -- ---- - - - --- Permit Fee Total 200.00 200.00 .00 .00 Grand Total 200.00 200.00 .00 .00 Applicant acknowledges. the right of the City Engineer, pursuant to the Bakersfield Municipal Code Chapter 12.20 to revoke the pern7t any time. Y� " 4 "4 /z--� 1 Si ature of Applicant Owner /Agent) Print Name I HEREBY CERTIFY THAT I HAVE MADE AN INVESTIGATION OF THE FACTS STATED IN THE FOREGOING APPLICATION AND FIND THAT THE MAINTENANCE OF. SAID ENCROACHMENT . (1) WILL (NOT) SUBSTANTIALLY INTERFERE WITH THE USE OF THE PLACE WHERE THE SAME IS TO BE LOCATED AND (2) WILL (NOT) CONSTITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE; SAID APPLICATION IS TPMREFORE (GRANTED) (DENIED). Said permit shall expire on date stated above. 'gnature of Cio Engineer Additional Terms on the Back o�/- s 4 R A K E R S F I E I- I� PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Raul M. Rojas, Public Works Director FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: June 2, 2008 SUBJECT: Encroachment Permit Application for: 3809 Edith Ln. Name of Applicant. Ayala Julian & Victoria Description of Encroachment: Build chain link fence behind sidewalk not over 4' high. This fence is already built. Engineering and Traffic staff has reviewed the attached encroachment permit to allow the installation of description of encroachment. The site is located at address of encroachment. The applicant has provided proof of appropriate insurance coverage to Risk Management, and has provided signatures of all immediate neighbors stating that they have no objection to the proposed construction. Based on their review, staff recommends approval of the permit. SAPERMIMENCROACK3809 Edith Ln.doc B A K E R S F I E L U PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Ryan Starbuck, Civil Engineer III FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: May 2, 2008 SUBJECT: Encroachment Permit Application for: 3809 Edith Ln. Name of Applicant: Ayala Julian & Victoria Description of Encroachment: Build chain link fence behind sidewalk not over 4' high. This fence is already built. Please review the attached encroachment permit and return to me at your earliest convenience. 5-1r16 APO 22 w M-q�� S: \PERMITS \ENCROACH \TRAFFIC \3809 Edith Ln.doc 40 O L D A K E R S F I E L D PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Ralph Korn, Risk Manager FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: April 24, 2008 SUBJECT: Encroachment Permit Application for: 3809 Edith Ln. Name of Applicant. Ayala Julian & Victoria Description of Encroachment. Build chain link fence behind sidewalk, not over 4' high. This fence is already built. Please review the insurance certificate with the attached encroachment permit and return to me at your earliest convenience. 00) S: \PERMITS \ENCROACH \INSURANC \3809 Edith Ln.doc SAM APPLICATION FOR ENCROACHMENT PERMIT IM 3 i TO THE CITY ENGINEER OF THE CITY OF BAKERSFIELD, CALIFORNIA: Pursuant to the provisions of Chapter 12.20 of the Bakersfield Municipal Code, the undersigned applies for a permit to place, erect, use and maintain an encroachment on public property or tight -of -way as therein defined 1. Full name of applicant and comnlete address including phone number. Jul/ tV_ ' �iC a �._. ��� fry � �®9 �,�1 i�h � � 60&ye re'(, �.� q � '3 Q q 2. Nature or description of the encroachment for which this . application is made: &M� ��r aro p /v ? 3. Location of the proposed encroachment: fi - - ,� e z 51d e w��� 4. Period of time for which the encroachment is to be maintained:���_ _ Applicant agrees that if this application is. granted, applicant shall indemnify, defend and hold harmless City, its o cars, ageau and employees against any and all liabu tt�►, claims, actions, causes of action or demands, whatsoever against them, orany ofthem, beforeadministrative, quasi-judicial, orjudicial tribunals ofanykind whatsoever, ansin out of, connected with, or caused by applicant's placement, erection, use (by applicant or any other person'or eatittyy) or maintenance of said encroachment. The applicant further agrees to maintain the aforesaid encroachment during the life of said encroachment or until such time that this permit is revoked. AppIicanf further agrees that upon•the expiration of the permit for which this application is made, if granted, or •yM nrooerty or right of way where the same is located, and restore said public property or right of way to the condition as nay as that in which it was before the placing, erection, maintenance or existence of said encroachment. Applicant fw ther agrees to obtain and keep all liability insurance required by the City feel is full force and effect for however long the encroachment remains. Applicant shall furnish the City Risk Manager with a Certificate of Insurance evidencing sufficient coverage for bodily inj or property damage liability or both and required endorsements evidencing the insurance required. The type(s) and amount(s) of insurance-coverage is: Applicant acknowledges the right of the City Enginc revoke the permit at any time. Date :_, _ .PERMIT I HEREBY CERTIFY THAT I HAVE MADE AY INVESTIGATION OF THE FACTS STATED IN THE FOREGOING APPLICATION AND FIND THAT THE MARTMANCE OF SAID ENCROACHMENT (1) WILL (N SUBSTANTIALLY INTERFERE WITH THE USE OF THE PUBLIC PLACE WHERE THE SAME IS TO BE LOCATED AND (2) WILL (NOT) CONSTITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE; SAID APPLICATION IS THEREFORE (GRANTED) (DENIED). SAID PERIMIT SHALL EXPIRE Date: Signature of ity Engineer No. 08- 3000063Y - CITY QA 8AKERSFIELD �L)EPAPZTMENT OF PUBLIC WORKS TO WHOM IT MAY CONCERN: We the undersigned, have no objection to the construction of a fence beside the sidewalk within the public right of way. (Street for puposed encroachment) (Owners Name) of ago% ..:. .(Address of purposed encroachment ) Phone: SIGNED: ----`f 1) Name: Address: 3) Name: !address: 3) Name: Address: 4) Name: Address: 3) Name: Address: $) Name: Address: 111=4A ff I WA i r: a 3"15'cyo Date • pate: y33vL� v Qate• l `— PREVIOUS ADDRESS (If less than 3 years) OTHER STRUCTURES YRS AT AF HOMEOWNER DATE(MMIDDIYYYY) 4%_ , APPLICATION 04/02/2008 AGENCY HONE 661-322-1888 /C N�_EExtLJ APPLICANT'S NAME AND MAILING ADDRESS (include county &ZIP +4 BAKERSFIELD CA 93304 FAX �C'121C,Mo APPLICANT'S EMPLOYER NAME AND ADDRESS JULIAN AYALA NAIC CODE YEARS W/ FACILITY CODE MAR "L -__ - - " - -_- 3809 EDITH LANE SELF EMPLOYED LOCAL CURR OCC CHARPENTIER INSURANCE SERVICES RIOR EMPL STAT 18031 J13LIAN AYALA 525 H STREET _ _ _ ___ ✓ YES NO YES ✓ NO YES ✓ NO YES NO OPEN iNONE.__ - DWELLING LOCATION OCCUPANCY �/ DEADBOLT OIL STORAGE TANK LOCATION SWIMMING POOL YES ,/ NO WINDSTORM LOSS MITIGATION POLICY# DIVING ABOVE FIRE DIST TENANT VACANT NEIGHBORS MASONRY FLOOR GROUND BOARD ROUND M 05/06/1938 556993207 BAKERSFIELD CA 93304 CO- APPLICANT'S EMPLOYER NAME AND ADDRESS YEARS IN BAKERSFIELD CA 93304 -1317 MAR - DATE OF BIRTH — - SOCIAL SECURITY # SECURITY CURROCC CO /PLAN HOMEPHONE# STAT OFF PREMISES CURR RES �/ DAY PARTIAL -FAO Topa Insurance Company 661- 396 -8099- EVE. CODE: SUBCODE: EFFECTIVE DATE EXPIRATION DATE BUSINESS PHONE # - 565049242 HOW LONG HAVE YOU KNOWN THE APPLICANT? DATE AGENT LAST INSPECTED PROPERTY: UAY AGENCY CUSTOMER ID 04/02/2008 04/02/2009 _ EVE APPLICANT INFORMATION PREVIOUS ADDRESS (If less than 3 years) OTHER STRUCTURES YRS AT LOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP) PERSONAL LIABILITY MEDICAL PAYMENTS EST TOTAL,•, PREMIUM PREY ADDR 3809 EDITH LANE j 03 $ 151.000 $ 15100 $75500 $ 30200 BAKERSFIELD CA 93304 APPLICANT'S OCCUPATION (State nature of business if self - employed) APPLICANT'S EMPLOYER NAME AND ADDRESS DED T e &Amount ✓ ALL PERIL YEARS IN YEARS W/ YEARS WI MAR DATE OF BIRTH SOCIAL SECURITY # SELF EMPLOYED LOCAL CURR OCC CURR EMPL RIOR EMPL STAT Bakersfield II J13LIAN AYALA ___ DATE HEATING SYSTEM NUM CFSYST) CIRCUIT BREAKERS FUSES ALUMINUM WIRING CONDITION ANY KNOWN LEAKS- NDATION LAST SERVICED i CLOSED _ _ _ ___ ✓ YES NO YES ✓ NO YES ✓ NO YES NO OPEN iNONE.__ - DWELLING LOCATION OCCUPANCY �/ DEADBOLT OIL STORAGE TANK LOCATION SWIMMING POOL YES ,/ NO WINDSTORM LOSS MITIGATION 0 DIVING ABOVE FIRE DIST TENANT VACANT NEIGHBORS MASONRY FLOOR GROUND BOARD ROUND M 05/06/1938 556993207 CU "APPLICANT'S OCCUPATION (State nature of business if self-employed) CO- APPLICANT'S EMPLOYER NAME AND ADDRESS YEARS IN YEARS W/ YEARS W/ MAR - DATE OF BIRTH — - SOCIAL SECURITY # SECURITY CURROCC CURR EMPL PRIOR EMPL STAT OFF PREMISES SELF EMPLOYED �/ THEFT EXCL PARTIAL -FAO VICTORIA AYALA LIGHTNING PROTECTION _I FULL HEARTHS WOOD S IOVE INSERT M 05/12/1943 565049242 HOW LONG HAVE YOU KNOWN THE APPLICANT? DATE AGENT LAST INSPECTED PROPERTY: WaWrArlf --I � Am Irnoeiwimvicnuu, HO FORM DWELLING - OTHER STRUCTURES PERSONAL PROPERTY LOSS OF USE PERSONAL LIABILITY MEDICAL PAYMENTS EST TOTAL,•, PREMIUM $ 616.00 DEPOSIT j 03 $ 151.000 $ 15100 $75500 $ 30200 EACH OCCURRENCE i $ 300000 EACH PERSON $1000 _ $ $ 616 BALANCE DED T e &Amount ✓ ALL PERIL NNqq 500 WIND /HAIL THEFT HURRIDCANE' r_I14UUM0r_IVIGI4 1 17 .— m— PN—aulr In .� ✓- REPLACEMENT COST DWELLING ✓ REPLACEMENT COST CONTENTS ENTER OTHER ENDORSEMENT(S): PAYMENT PLAN J ACORD 610 Attached (NOT APPLICABLE IN NC) ACCOUNT #: MAIL POLICY TO: BILLING�II IF DIRECTBILL:; IF APPLICANT BILL: ✓__ AGENT DIRECT BILL ✓ BILL APPLICANT ✓ FULL PAY .- APPLICANT AGENCY BILL BILL MORTGAGEE RATIN(,/I INrTFRWRITIMr. FRAME MFG HOME YR BUILT # ROOMS MARKET VALUE STRUCTURE TYPE USAGE TYPE FARM ✓ # FAM- # PURCHASE _ MASONRY VINYL SIDING 1984 $ �/ DWELLING TOWNHOUSE ✓ PRIMARY COC ILIES H D DATE /PRICE RES 01/01/1998 MASONRY ALUMINUM SOFT #APTS REPLACEMENTCOST COMP. DATE: VENEER SIDING APART ROWHOUSE SECONDARY 1 FIRE RES 1202 $ CONDO CO -OP SEASONAL - - - - - - RENOVATION TYPE PART�COA4P eEA1, - - NUMBER OF TERR PREM PROTECT DISTANCE TO PROTECTION DEVICE TYPE HEAT TYPE NONE CODE GROUP CLASS_. - - .1 —._, WIRING u FIRE UNITS IN FIRE DIVS TFIRE DIV HYDRANT STATION SYSTEM SMOKE TEMP BURGLAR PRIMARY: GAS PLUMBING 0 12 12 3 150 FT 1 MI CENTRAL SECONDARY: HEATING FIRE /EC RATE _ _ FIRE DISTRICTICODE NUMBER DIRECT HOUSEKEEPING CONDITION ROOFING LOCAL .. ___ - -. ._._ Bakersfield II EXTERIOR PAINT ___ DATE HEATING SYSTEM NUM CFSYST) CIRCUIT BREAKERS FUSES ALUMINUM WIRING CONDITION ANY KNOWN LEAKS- NDATION LAST SERVICED i CLOSED _ _ _ ___ ✓ YES NO YES ✓ NO YES ✓ NO YES NO OPEN iNONE.__ - DWELLING LOCATION OCCUPANCY �/ DEADBOLT OIL STORAGE TANK LOCATION SWIMMING POOL YES ,/ NO WINDSTORM LOSS MITIGATION I CITY J INDOORS OUTDOORS APPROVED FEATURES ✓ I CITY LIMITS ✓- OWNER UNOCC ✓ FIRE EXT FENCE WI THIN VISIBLE TO ABOVE GROUND ON ABOVE DIVING ABOVE FIRE DIST TENANT VACANT NEIGHBORS MASONRY FLOOR GROUND BOARD ROUND WITHIN PROT ABOVE GROUND NOT BELOW IN HON _-_ SUBURB -_ - SLIDE - MASONRY FLOOR GROUND GROUND .,_. BLDG CODE INSPECTED? TAX CODE RATING OCCUPIED DAILY? # WKS WIND CLASS SEMI- ROOF MATERIAL CONDITION OF ROOF GRADE RENTED RESISTIVE �- NO CLASS SPEC ✓ YES NO RESISTIVE OTHER COMP GOOD IF REPLACEM APPLIES, ACORD 42 ATTACHED: RATING CREDITS MANNED SPRINKLER FIREPLACES Number) - ---._ .-- -- L SECURITY (Enter BASE GARAGE BREEZEWAY NON - SMOKER OFF PREMISES __ CHIMNEYS PRE �/ THEFT EXCL PARTIAL -FAO — SO FT SO FT LIGHTNING PROTECTION _I FULL HEARTHS WOOD S IOVE INSERT RIOR COVERAGE LIOR CARRIER PRIOR POLICY NUMBER EXPIRATION DATE ,%,Ur"v OU tcvvzNUO) Page 1 Of 2 © ACORD CORPORATION 1981 -2005 GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS (Except question 15,16 and 17) YES, NO 1 1 . ANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES? (Including day /child care) _ BY ATOLINSUF THIS BINDER REPLACED NOON EDPO AY LILY, THE COMPANY IS ENTITLED TO CHARGE A ✓ 14. DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE — ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR 01 CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON - RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) L —_ . -- Vy j 2. ANY RESIDENCE EMPLOYEES? (Number and type of full and part time employees) SOLID FUEL SUPPLEMENT ✓ -3. ANY FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC? PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE V( 4. ANY OTHER RESIDENCE OWNED, OCCUPIED OR RENTED? INLAND MARINE APPLICATION ✓ 5. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON PILES AN APPLICATION FOR INSURANCE �/ 15. IS THERE A MANAGER ON THE PREMISES? _ CONDOS ONLY: 16. IS THERE A SECURITY ATTENDANT? 17. IS THE BUILDING ENTRANCE LOCKED? —' ✓ ✓ ✓ I ✓ l �/ it ✓ �/ ✓ —j - ✓ ,/ ✓ 6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? — - — REPLACEMENT COST ESTIMATE ✓ 7. ANY COVERAGE DECLINED, CANCELLED OR NON - RENEWED DURING THE LAST 3 YEARS? (Not applicable in MO) 8. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FI YEARS? DATEy, HOME BASED BUSINESS SUPP v( 18. 18. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS? 19. IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTIOW (Give estimated completion date and dollar value) 9. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES? (Note breed and bite history) ✓ 20. IS HOUSE FOR SALE? 21. IS PROPERTY W /IN 300 FT OF A COMMERCIAL OR NON - RESIDENTIAL PROPERTY? 10. DISTANCE TO TIDAL WATER: ❑ Miles El Feet 11. IS PR OPERTY SI TUATED ON MORE THAN FIVE ACRES? If ) ( yes, describe land use ✓ 22. IS THERE A TRAMPOLINE ON THE PREMISES? 23• WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? 12. DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOWMOBILES, DUNE B GGYS, MINI BIKES, ATVS, ETC)? (List year, type, make, model ✓ - - -- - - -- 24. ANY LEAD PAINT HAZARD? - - -- 25. IF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (Give First Party and limit, and Third Party and limit) 13. IS BUILDING RETROFITTED FOR EARTHQUAKE? (If applicable) 13. — ✓ 26. IF BUILDING IS UNDERCONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR? I ncrt UM NU I rAw esx INSUKANGt, UUHING �� I APPLICANT'S I nS.S' HIATORV THE LAST YEARS - AT THIS nR AT AMV nTHPOI n TInMO �..__ I _/ DATE TYPE DESCRIPTION OF LOSS CAT # AMOUNT INT # MORTG'E NAME AND ADDRESS LOAN NUMBER ADD L INT KcivuaKna tAttacn Haaltlonal sheets it More Space is Required) MIMI Jr Ml.1R; MA I IIMr INSURANCE BINDER IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONSI APPLY: ATTACHMENTS TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY. PHOTOGRAPH TIME COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER M 1z:o1 AM MAY BE CANCELLED BY THE COMPANY I RECREATIONAL VEHICLE APP BY ATOLINSUF THIS BINDER REPLACED NOON EDPO AY LILY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS COVERAGE IS BOUND SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY. STATESUPPLEMENT(S) (Ifapplicable) ISSUANCE OF THE INSURANCE POLICY. SOLID FUEL SUPPLEMENT OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WATERCRAFT APPLICATION PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR INLAND MARINE APPLICATION HOW TO SUBMIT A REQUEST TO US. PROTECTION DEVICE CERTIFICATE ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON PILES AN APPLICATION FOR INSURANCE LEAD FREE PAINT CERTIFICATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, MA, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied.) APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION IN THEM IS TRUE, REPLACEMENT COST ESTIMATE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. PERS EXCESS /UMBRELLA APP DATEy, HOME BASED BUSINESS SUPP PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER MIMI Jr Ml.1R; MA I IIMr INSURANCE BINDER IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONSI APPLY: _ EFFECTIVE DATE EXPIRATION DATE THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY. --BINDER OR BY WRITTEN NOTICE TO THE TIME COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER M 1z:o1 AM MAY BE CANCELLED BY THE COMPANY BY NOTICE ACCORDANCE T CONDITIONS. THIS BINDER IS CANCELLED WHEN BY ATOLINSUF THIS BINDER REPLACED NOON EDPO AY LILY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS COVERAGE IS BOUND SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY. APPLICABLE IN COLORADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OF COVERAGE, TO EVALUATE THE ISSUANCE OF THE INSURANCE POLICY. PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. ❑ Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not applicable in all states; consult your agent or broker for your state's requirements.) ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON PILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR; THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, MA, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied.) APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. APPLICANT' IGNATURE GG DATEy, � �� PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER .,, V_ — 1om,,., —.1 y rage z oT z - — - - - - - •- -- y t ` LY WWI-. l l fd. �.