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10-10628
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10-10628
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Last modified
2/3/2011 10:02:52 AM
Creation date
2/3/2011 10:02:52 AM
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Building Department
Company Name
ARBY'S
Building Department - Doc Type
Permit
Permit #
10-10628
Building Department - Name
SYBEA,INC. (ARBY'S)
Address
7446 GALL BLVD
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�, '. v / <br /> .74,s j CI GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> .� o 0 g, frerage Part consists of this Declarations Form, the Common Policy Conditions, the Commercial General Liability <br /> r o ,,fiend the Endorsements indicated as applicable. (See "COMMON POLICY DECLARATIONS" for Items 1 and 2) <br /> , LICY NO. GL 3679182 <br /> NAMED INSURED FIRE PREVENTION SYSTEMS <br /> DWIGHT R. TEATER, JR. DBA <br /> 3. LIMITS OF INSURANCE <br /> General Aggregate Limit (Other Than Products - Completed Operations) $ 2,000,000 <br /> Products Completed Operations Aggregate Limit $ INCLUDED <br /> Personal & Advertising Injury Limit <br /> $ 1,000,000 <br /> Each Occurrence Limit $1,000,000 <br /> Damage To Premises Rented To You Limit $ 100,000 Any One Premises <br /> Medical Expense Limit $ 5,000 <br /> Any One Person <br /> RETROACTIVE DATE (CG 00 02 only) - Coverage A of this insurance does not apply to "bodily injury" c r "property <br /> damage" which occurs before the Retroactive Dae, if any, shown below. <br /> Retroactive Date: NONE (Enter Date or "None" if no Retroactive Date applies.) <br /> Location of All Premises You Own, Rent or Occupy (Same as Item 1 unless shown below): <br /> CLASSIFICATION CODE NO. PREMIUM BASIS RATE PR / C ADVANCE PREMIU OTHER <br /> JANITORIAL SERVICES 334 96816 P 16,700 64.29 1074 <br /> (P) PAYROLL 336 96816 INCLUDED <br /> PRESSURE APII'NARATUS 334 96816 "IF ANY" <br /> 336 INCLUDED <br /> I R41NG�P(BMW <br /> EGA? LIMI ' <br /> ADDITIONAL INSURED (1) 100 <br /> 4. FORMS / ENDORSEMENTS APPLICABLE: TOTAL PREMIUM <br /> SEE SCHEDULE OF FORMS AND ENDORSEMENTS - FORM 0001 FOR THIS $ 1,174.00 <br /> COVERAGE PART I <br /> 5 J=ORM OF BUSINESS: n Individual ❑Joint Venture Partnershi ❑ Organization ❑ P g (Other than Partnership or Joirt Venture) ❑ Corporation <br /> Audit riod: Annual unless otherwise stated: <br /> DCJ6553 (07 -02) Includes Copyright material of Insurance Services Office, Inc. with its permission. <br /> Copyright, Insurance Senrices Office, Inc., 1984 <br /> Insured <br />
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