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HomeMy WebLinkAboutIndianapolis Stage and Sales - $83,610 Disbursement Instructions (PAC Stage Equipment) Regions Bank hereby is instructed to make a disbursement of Loan Proceeds from the Borrower Loan Account to(or for the account of)Borrower in (a)the amount of the"Total Authorized Disbursement"line in the "Amount of Authorized Disbursement"column below;and (b)accordance with the terms and conditions of the Agreement, the other Loan Documents, and the Disbursement instructions. Purpose of Authorized Disbursement Amount of Authorized Disbursement Atnoun s fo ie paid 6,y Fingno41 i L C App3 (Indit�tnna(is 5fi►9r-) Aojt 20/6 - I' Z/o. 00 App. �Thditth,j nlir -51,0 f) SehlrAkr2OJD -P 63,9()0..00 Total Authorized Dlsbuisomont Y -6/trt QD ^ All terms used in these Disbursement Instructions without definition shall have the meanings ascribed thereto in that certain Loan Agreement(PAC Stage Equipment),dated January 28,2010,by and between Lender and Village Financial, LLC. Dated: 12I/bo CITY OF CARMEL REDEVELOPMENT COMMIS ION glipvBy . Printed L- e5 S. Olds Title L. X e Ci,fi"Ve D1r.e ( 1-0r Draft PAC Stage Equipment (Indianapolis Stage and Sales) December 2009(application 1) Total Contract Amounts for application 1 Completed and Stored to date $ 45,000.00 Retention held $ 4,500.00 To be paid $ 40,500.00 Paid by Village Financial $ 40,500.00 March 2010 (application 2) Paid by Village Financial $ 70,740.00 August 2010 Amount to be paid by Village Financial $ 19,710.00 September 2010 Amount to be paid by Village Financial $ 63,900.00 .4.74 AZAIA Document G7©2/C. a = 1992 & z Application and`Certificate for Payment Construction Manager-Adviser Edition TO OWNER: PROJECT: APPLICATION NO: 3 Distribution to: Carmel Redevelopment Commission Parcel 7A PERIOD TO: August 15,2010 OWNER ❑ One Civic Square Regional Performing Arts Center Carmel, IN 46032 CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: VIA CONSTRUCTION MANAGER: CONTRACT DATE: February 17, 2009 ARCHITECT ❑ Indianapolis Stage Shiel-Sexton Sexton PROJECT NOS: 2695 ( 6010 / CONTRACTOR ❑ 905 Massachusetts Ave. Indianapolis, IN 46202 VIA ARCHITECT: CSO Architects FIELD ❑ CONTRACT FOR: • Bid Package#6010-Production Lighting ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and Application is made for payment,as shown below,in connection with the Contract. belief the Work covered by this Application for Payment has been completed in accordance with the Continuation Sheet,AIA Document G703,is attached. 818,334.00 Documents,that all amounts have been paid I ,le Contractor for Work for which previous 818,334.00 Certificates f• ment were isst ed and pa en ••ceived from the Owner• and that current 1.ORIGINAL CONTRACT SUM $ payment sh vn he ein is no e. 2.Net change by Change Orders s -50,300.00 CONTRAC re R: i`��, �f / 3.CONTRACT SUM TO DATE(Line I t 2) 768,034.00 By. �rr1(ei Id i I,L4a.,/.fL,1.� Date: e • a ` . /t) 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) $ 14S,SUO.0U State of: 1 ND tf\tJ1 / ..`" y. 5.RETAINAGE: County c ': _ EtAR R!.�,®,I�'yG®tM1 Q y MCI h 1 p i\ =my reSYTlti' t 4 a. %of Completed Work Subscribed'and sworn to before (Column D+Eon G703) $ 14,550.00 me this I h S4 li o el It ]l t. a� day of P UGU , �.D 1 My CrsS'watosion Gagtroo Jan 20,2010 in b. i'a of Stored Material Notary Publi -- �u1/}7 ,J` (Column F on G703) $ My Commission ,pires: i/ Total Retainage(Lines 5a+Sb or Total in Column I of 0703). $ 14,550.00 CERTIFICATE FOR PAYMENT 6.TOTAL EARNED LESS RETAINAGE 130,950.00 In accordance with the Contract Documents, based on on-site observations and the data comprising this application,the Construction Manager and Architect certify to the Owner that to the best of their (Line 4 Less Line 5 Total) 111 240.00 knowledge,information and belief the Work has progressed as indicated,the quality of the Work is in 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT CERTIFIED. 1��� (Line 6 from prior Certificate) ge r 8.CURRENT PAYMENT DUE $ 19,/10.00 AMOUNT CERTIFIED $ 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach explanation if mount certified differs ft- le amount applied.Initial all f figures on this Application and on he Continuation S 'et th t are hanged to conform with the unworn certified.) (Line 3 less Line 6) $ 637,084.00 CON - •UCTI S L Lit AG - rr By: ,1•:1 ►-':4_ =..._ . i. ! Date: Df3(21/10 ADDITIONS DEDUCTIONS •' ' 111 CHANGE ORDER SUMMARY ARC T: Total changes approved in previous months by Owner $ $ 5U,3UU.OU By: _� Date: be Jbef Total approved this Month $ $ This Certificate '. not n• ble. The AMOUNT CERTIFIED is payable only to the Contractor TOTALS $ 0.00 $ 50,300.00 named herein. :suanc• payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $ -50,300.00 the Owner or onus or under this Contract. `CAUTION::You should`s)gnan originetAIA,Coniract,Docurrtent,on whicti this text appears in RED..An or iginahassures,that,changes;will notbe;obscured. AIA Document G702/CMaTM—1992.Copyright ©1992 by The American Institute of Architects.All rights reserved.-WARNING This AIA",Document.is protected by.p.S..COPyright Law and•International Treatles. Unauthorized re roductionordistributionof this AIA0 Document;or an .,p, , yportfon'of it,may result in sevore;civil'and crimnappeneltles;and will be prosecuted'to;the maximum extent possible under the taw: Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright @aia.org. P'/4 Document G703ma ° 1992 Continuation Sheet AIA Document G702.APPLICATION AND CERTIFICATION FOR PAYMENT. APPLICATION NO: 3 containing Contractor's signed certification is attached. APPLICATION DATE: $/15/1010 In tabulations below.amounts are stated to the nearest dollar. Use Column I on Contracts where variable retaina_e lot line items may apply. PERIOD TO: $/1$/2010 ARCHITECT'S PROJECT NO: 2695/6070 A 13 C D I E F G H 1 WORK COMPLETED MATERIALS 1'O I'AI_ BALANCE PRESENTLY COMPLETED RETAINAGE 1 CAI DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS `; CO SPORED AND STORED HP VARIABLE NO. VALUE APPLICATION 1HISPERIOD (NOT IN 1'O DATE iG=C) FINISH R41L"1 (D+E) DORE) tD+E+FI (C-GI 1 Mobilization&Submittals 45,000.00 45,000.00 45,000.00 100% 2 Shipment of back boxes&racks 84,500.00 78,600.00 5,900.00 84,500.00 100% - 3 Shipment of Electronic Components 217,500.00 16,000.00 16,000.00 7% 201,500.00 4 Shipment of Fixtures 250,000.00 - 250,000.00 5 Installation of light fixtures&equipment 15,000.00 - 15,000.00 6 System energization 95,000.00 - 95,000.00 7 Training&Completion 6,334.00 - 6,334.00 8 General Allowance 100,000.00 - 100,000.00 9 CAD Allowance 5,000.00 - 5,000.00 818,334.00 123,600.00 21,900.00 - 145,500.00 672,834.00 - CAUTION:You should sign an original AIA Contract Document;on which this text appears in RED.An original assures that_changes will not be'obscured:. AIA Document.G703T1•I—1992.Copyright©1963,1965,1966,.1967,1970,1978,.1983 and.1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA°Document is protected.by U.S.Copyright Law and International.Treaties.,Unauthorized reproduction or distribution of this+AlA°-Document or any portion of It,may.result In severe civil and criminal penalties;and will be,prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright @aia.org. CONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT From: Indianapolis Stage Sales and Rental, Inc. Reference Payment Application # 3 Dated: August 15, 2010 Upon receipt by the undersigned of a check in the amount of $ 19.,710.00 payable to Indianapolis Stage Sales and Rental, Inc. and when the check has been properly endorsed and has been paid by the bank on which it is drawn, this document shall become effective to release any mechanic's lien, stop notice, or bond right the undersigned has on the of Carmel Regional Performing Arts Center located at 773 3`d Avenue SW, Carmel, IN 46032 to the following extent. This release covers a progress payment for labor, services, equipment, or material furnished to the above referenced project through [enter date of payment application] only and does not cover any retentions retained before or after the release date; extras furnished before the release date for which payment has not been received; extras or items furnished after the release date. Rights based on work performed or items furnished under a written change order which has been fully executed by the parties prior to the release date are covered by this release unless specifically reserved by the claimant in this release. This release of any mechanic's lien, stop notice, or bond right shall not otherwise affect the contract rights including rights between parties to the contract based upon a rescission, abandonment, or breach of the contract, or the right of the undersigned to recover compensation for the furnished labor, services, equipment, or material not compensated by the progress payment. Before any recipient of this document relies on it, said party should verify evidence of payment to the undersigned. Dated: August 15, 2010 Indianapolis tag: Sale..n11 ental, I► By: x,14,%,Aram J=me.s R. Herm sdorfer Title: "resident 1 *.AIA ocmit GTh21CNr — l992°"'` Application and Certificate for Payment Construction Manager-Adviser Edition TO OWNER: PROJECT: APPLICATION NO: 4 Distribution to: Carmel Redevelopment Commission Parcel 7A PERIOD TO: September 15, 2010 OWNER ❑ One Civic Square Regional Performing Arts Center Carmel, IN 46032 CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: VIA CONSTRUCTION MANAGER: CONTRACT DATE: February 17, 2009 ARCHITECT ❑ Indianapolis Stage Shiel-Sexton Sexton PROJECT NOS: 2695 , 6010 ) CONTRACTOR ❑ 905 Massachusetts Ave. Indianapolis, IN 46202 VIA ARCHITECT: CSO Architects FIELD ❑ CONTRACT FOR: Bid Package#6010-Production Lighting ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and Application is made for payment,as shown below,in connection with the Contract. belief the Work covered by this Application for Payment has been completed in accordance with the Continuation Sheet,AIA Document G703,is attached. Contract Documents,that all amounts have been • i by the Contractor for Work for which previous 818 334.00 Certificates for a) Went were i. ued and 'a' e is received from thi: Owner, and than current 1.ORIGINAL CONTRACT SUM $ payment sho here n is n v du 2.Net change by Change Orders $ -50,3UU.U0 CONTRACTOR: ' � 3.CONTRACT SUM TO DATE(Line I ±2) $ 768,034,00 By: I��i.�• . ). ' /i Date: CI - /S ]0 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) S 21b,5U0.00 State of: n• I OV`IV / 5.RETAIiJI�GE: County o )'pq P I M.• r _ a. U%of Completed Work Subscribe and sworn to before UMW G. ®�O 21,650.00 WOW p t- (Column D+Eon G703) $ me this I 'I-r\ day of .,S.Q. ;' t ©1 til0t0 09 @PisHOtiO b. %of Stored Material Notary Public: �. � am Io310n t npI(DS Jen 20.M®0O(Column F on G703) $ My Commission expires / — a fie- 6 . 21 650.00 - 4. Total Retainage(Lines 5a+5b or Total in Column i of G703). $ CERTIFICATE FOR PAYMENT 194,850.00 In accordance with the Contract Documents. based on on-site observations and the data comprising 6.TOTAL EARNED LESS RETAINAGE $ this application,the Construction Manager and Architect certify to the Owner that to the best of their (Line 4 Less Line 5 Total) knowledge,information and belief the Work has progressed as indicated,the quality of the Work is in 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 130,950.00 accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED. b3,9UU.OU et��f6_.) ====.8.CURRENT PAYMENT DUE $ AMOUNT CERTIFIED .. $ 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach e.+planation if amount certified differ front he amount applied.initial all figures on this Application and of e Continuation Sl t d.it are 'hanged to conJ'atan with the an ourit certified.) (Line 3 less Line 6) $ 573,184.00 CONSTRUCTION , By: \N._�y ii =.__ - Date: G.� •CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHI C , �i ' tti�tt IV Total changes approved in previous months by Owner $ $ 50,300 OC1— By: %4 — Date: tr)� aC1 Total approved this Month $ $ This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor TOTALS $ 0.00 $ 50,300.00 named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $ -50,300.00 the Owner or Contractor under this Contract. •.CAUTION::You°should sign an'original.AIAContract Documente:on which this textiappears'in.RED:Ai.original assuresthat'changes°vvII not be obsctired: AIA Document G7021CMa. - 1992.,Copyright ©1992 by,The American Institute of Architects.All rights reserved:WARNING:'This:AlA®•Document Is protected.by U.S Copyright Law and International Treaties. na_ Unauthorized,reproduction ordistribution of this Ale:nocument;or any of,It;'mayresult'insevere.civil and criminal penalties,and will be prosecuted'to'(he mewmum extent possibteaunder the'law: Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mailThe American Institute of Architects'legal counsel.copyright @aia.org. AlA f Document �Jtl O `V'T61 0 1992 Continuation Sheet AIA Document G702,APPLICATION AND CERTIFICATION FOR PAYMENT. APPLICATION NO: 4 containing Contractor's signed certification IS attached. APPLICATION DATE: 9/15/1010 In tabulations below.amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: 9/15/2010 ARCHITECT'S PROJECT NO: 2695/6010 A B C D I E I= G H I WORK COMPLETED MATERIALS TOTAL PRESENTLY COMPLETED BALANCE SCHEDULED FROM PREVIOUS q{, TO RETAINAGC i't13M DESCRIPTION OF WORK STORED AND STORED (IP VARIABLE NO (NOT IN VALUE APPLICATION THIS PERIOD 1'0 DATE (G+C1 FINISH RATE) ID+E) DORE) ID+E+F) (C-G) 1 Mobilization&Submittals 45,000.00 45,000.00 45,000.00 100% ,- 2 Shipment of back boxes&racks 84,500.00 84,500.00 84,500.00 100% - 3 Shipment of Electronic Components 217,500.00 16,000.00 6,000.00 22,000.00 10% 195,500.00 4 Shipment of Fixtures 250,000.00 65,000.00 65,000.00 26% 185,000.00 5 Installation of light fixtures&equipment 15,000.00 - 15,000.00 6 System energlzation 95,000.00 - 95,000.00 7 Training&Completion 6,334.00 - 6,334.00 8 General Allowance 100,000.00 - 100,000.00 9 CAD Allowance 5,000.00 - 5,000.00 818,334.00 145,500.00 6,000.00 65,000.00 216,500.00 601,834.00 - CAUTION:You should.sign an original AIA,'Contract Document,•on which this text:appears:in RED;An original'assures that changes will not be_obscured.. AIA Document G703Tu-1992.Copyright©1963.,1965,1966.1967,1970,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.:WARNING:,This AlA®.Document is protected by U.S,.Copyright Law and International Treaties.:Unauthorized'reproduction or:distributron,of this°AIA;Document;or any.portion.of it May result in severe civil and criminal"penalties;and will be prosecuted to the maximum,extent 'possible under:theaaw.Purchasers are permitted to reproduce ten(10)copies ol this document when completed.To report copyright violations ol AIA Contract Documents,e-mail The American Institute of Architects'legal counsel.copyright @aia.org. } CONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT From: Indianapolis Stage Sales and Rental, Inc. Reference Payment Application # 4 Dated: September 15, 2010 Upon receipt by the undersigned of a check in the amount of$ 63,900.00 payable to Indianapolis Stage Sales,and Rental, Inc. and when the check has been properly endorsed and has been paid by the bank on which it is drawn,this document shall become effective to release any mechanic's lien, stop notice, or bond right the undersigned has on the of Carmel Regional Performing Arts Center located at 773 3rd Avenue SW, Carmel, IN 46032 to the following extent. This release covers a progress payment for labor, services, equipment, or material furnished to the above referenced project through [enter date of payment application] only and does not cover any retentions retained before or after the release date; extras furnished before.the release date for which payment has not been received; extras or items furnished after the release date. Rights based on work performed or items furnished under a written change order which has been fully executed by the parties prior to the release date are covered by this release unless specifically reserved by'the claimant in this release. This release of any mechanic's lien, stop notice, or bond right shall not otherwise affect the contract rights including rights between parties to the contract based upon a rescission, abandonment,or breach of the contract, or the right of the undersigned to recover compensation for the furnished labor, services, equipment, or material not compensated by the progress payment. Before any recipient of this document relies on it, said party should verify evidence of payment to the undersigned. Dated: September 15, 2010 Indianapo ' ..ge Sa ,;Rental AP James R. errrmsdorfer Title: President i . ; DATE(MMIDDLYYYY)A,CORD TM, CERTIFICATE OF LIABILI P/ INSURANCE • 09!21!2010. PRODUCER Pfione: (317)'353-8000 Fax: (317)351-714B THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION WALKER&ASSOCIATES INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO BOX 19445. HOLDER. THIS CERTIFICATE.DOES NOT.AMEND, EXTEND OR 7364 EAST WASHINGTON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INDIANAPOLIS IN 46219 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Cincinnati Insurance Co. I 10677 INDIANAPOLIS STAGE SALES&RENTALS INC. INSURER B; Cincinnati Casualty Insurance Company I 28665 905,MASSACHUSETTS AVE. INSURER C: INDIANAPOLIS IN 46202 INSURER D: INSURER E: I COVERAGES THE POUCIES OF INSURANCE LISTED'BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR-THE POUCY 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS'AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE'BEEN-REDUCED BY PAID CLAIMS. rNSRIINSR TYPE OF INSURANCE POLICY NUMBER I POUCY EFFECTIVE I POUCY EXPIRATION LIMITS LTA INSRp', DATE(MM/DDIYY) DATE IMMIDOM') GENERAL LIABILITY CPP3658814 10123(09 10/23/10 EACH OCCURRENCE I5 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY ,PREMISES(Ea croak-me) IS 100,000. CLAIMS MADE I X I OCCUR. MED.EXP(Any one person) 15 5;000 - A PERSONAL BADV INJURY IS 1,000,000 GENERAL AGGREGATE I5. 2,000,000. GENT AGGREGATE.LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG IS- 2,000,000 I POLICY I X I JECT I ILOC I. AUTOMOBILE LIABILITY CPA3658814 10/23/09 10/23/10 COMBINED SINGLE LIMIT X. ANY AUTO (Ea accident) S 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per.person) $ SCHEDULED AUTOS A X I HIRED AUTOS BODILY INJURY IS I X I NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE 5 I (Per accident) GARAGE LIABILITY s AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN .EA ACC I AUTO ONLY: AGG,IS EXCESS I UMBRELLA LIABILITY CPP3658814 10/23/09 04/23/10 EACH OCCURRENCE IS 5,000,000 X I OCCUR CLAIMS MADE AGGREGATE Is 5,000,000 A 7 Is- DEDUCTIBLE is I X RETENTION, 10,000 IS WORKERS COMPENSATION AND WC2113734 10/23/09 10123110 X IrocZTLAATrrrs.I IoiiER I EMPLOYERS'LIABILITY EL EACH ACCIDENT 15 500,000 B ANY.PROPRIETOR/PARTNER/EXECUTIVE OFFICER1MEMBER:EXCLUDED?' E.L.DISEASE-EA EMPLOYEE Is 500,000 If yon,doncribn under - SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT 15 500,000 OTHER:Business Personal Property( CPP3658814 10/23/09 10/23/10 $300,000.Blanket Limit; A including stock) DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE:,CARMEL.PERFORMING ARTS CENTER CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL.ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOO THE LEFT,BUT FAILURE TO City of Carmel,,by and through its DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,TI'S` Redevelopment.Commission' AGENTS OR REPRESENTATIVES. One-Civic Square Carrnel'IN 46032 AUTHORIZED REPRESENTATIVE' 1,.0.2. j�-�-�— Attention: dburchard @shielsexton.com `- ,'eggy Armour ACORD 25(2001/08) Certificate# 38088 ©ACORD CORPORATION 1988 IMPORTANT • If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 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 amend, extend or alter the coverage afforded by the policies listed thereon. • CORD 25-5(2001/08) Certificate#38088 r°a f 's i ft Y- .•.. y. f•rt +�J "°' ... •�.-...ate. �a a d, q .-,^ -' �„ .x a t .,, .-, z o r- 1 y r. x • x i. '-f: 1 ,c. - *,- 1"II t.� t z ? ,, ,. r ,.fi •rxp a g .it t 3 .3e- Ip , rS i t,51+c t,k "q K tl Y E 3 ` -' f - ♦ '`'4 r 1. --.¢ 4--'"i c a '•• � ^'� {� 1 i Y ,<f a j _ !4r x r ^� � i ' Cis r 8. ','''':',.'11'1"..' .1 X'ryy 1 4f�,,'# a # ; -4 fir_ { �,f, 4`1.:-: `P . 1. t4 .f', . 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