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' r ACORD,„ INSTALLATION/BUILDERS RISK SECTION °ATE `MW°°"Y"" <br /> 2 19 04 <br /> PRoDUC4R PHONE ( 9 a 7 ) 8 3 4 - 0 0 2 2 AP6LICANT <br /> ( 407 ) 260 - 1767 Barth Construction Inc . <br /> ' I Guignard Company PRDP45EDEFF. DATE PROPOSED ERP, DATE I BILLING PLAN I PATMENTPLAN PREM. ADJ, <br /> 1904 Boothe Circle 2 / 23 / 04 2 / 23 / 05 K AGENCY annual <br /> Longwood , FL 32750 DIRECT <br /> 4LINSTALLATION fOR QOIIPANY USE ONLY <br /> BUILDERS RISK <br /> ' OPEN REPORTING FORM <br /> COVERAGE CAUSES OF OSS & OEDUCTIBLE <br /> LIMIT AT ANY SINGLE LIMIT PER LIMIT AT TEMPgRARY TRANSIT CAUSES of LOMB SUB LIMIT DEDUCTIBLE <br /> LOCATION DISASTER LO�ATION LIMIT EARTHOUAKE $ <br /> FLOW <br /> S S <br /> sPEC1AL <br /> OAP BASIC <br /> ' <br /> TERRITORY r RECEIPTS <br /> sPMFY THE APPLICANTS OPERATING TEFI ITORYI ENTER THE GROSS INS{ALLATION RECEIPTS, <br /> PAST I MbFITNS NEXT 12 MONTHS T <br /> a � ' s <br /> JOBS/VALUES _ _ f <br /> ek <br /> ANNUAL s JOBB IN PROGpE86 MATERIAL COST <br /> COST OR VALVE OF EACH INSTMA.AMON (1` alTotBl) <br /> TYPE NUMBER 113URATION MAXIMUM AvERAGE MAXIMUM MINIMUM AVERAGE <br /> 1 <br /> RESID"HIAL $ S f . _ % <br /> ' COMMERCIAL $ S , • S % <br /> ADDITIONAL INTERESTS Attach a se sp to sheet, If necessary,)__ / <br /> NAME i ADDRESS — — r NAMES ADDRESS — <br /> f �rr <br /> dlF / <br /> r <br /> 1 <br /> INTERES ` / CERTIFICATION INTEREST CFOlTIFICATION <br /> REMMM <br /> NAME A ADDRESS /J NAME A ADDRESB <br /> i <br /> r <br /> ' jWMEAT CFRTMAT'ION WTEREST <br /> CERTIFICATION <br /> REgUIREO REQUIRED <br /> WGING TRANSPORTATIONISECURITY <br /> ' I OEBCRIBB AL OIBTING OR OTHER OPBpAT RggREgYIRIMC RIGGING. ESTIMATE % OF YAWS Of MATERIAL SHPPED TO JOB <br /> SIT! AT APPLICAKTB RISK, <br /> Y. <br /> j DESCRIBE JOB SITE SECURITY <br /> i <br /> REMARKS <br /> ACORD 147 (2001102) SPECIFIC .JOB ON REVERSE SIDE ® ACORD CORPORATION 2001 <br /> VIA ' rl J ,9J4ZG19p�J8Gtt+ kNHAwnn (TNHWnTnn VIM ! gT. t7SM7-9T —PqA <br />