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11-11369
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2011
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11-11369
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Last modified
10/17/2011 9:17:08 AM
Creation date
10/17/2011 9:17:06 AM
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Building Department
Company Name
ARBY'S
Building Department - Doc Type
Permit
Permit #
11-11369
Building Department - Name
SYBEA,INC (ARBY'S)
Address
7446 GALL BLVD
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co <br /> ? ui 3 .R CIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> m <br /> o ;overage Part consists of this Declarations Form, the Common Policy Conditions, the 0 0 = � ,h and the Endorsements indicated as applicable. (See "COMMON POLICY DECLARATIONS" for to sGeneral <br /> t and Liability <br /> POLICY 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 1 1 IP <br /> Personal & Advertising Injury Limit $ 1,000,000 <br /> Each Occurrence Limit <br /> $ 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" or 'property <br /> damage" which occurs before the Retroactive Date, 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 1 PR / CO ANC1 i REMiAL1 OTHER <br /> JANITORIAL SERVICES 334 96816 P 16,700 64.29 1074 <br /> (P) PAYROLL 336 96816 INCLUDED <br /> PR S0URE APPARATUS 334 96816 "IF ANY" <br /> 336 INCLUDED <br /> •I D SA Dd <br /> E M <br /> ADDITIONAL INSURED (1) 100 <br /> 4. FORMS / ENDORSEMENTS APPLICABLE: TOTAL PREMIUM <br /> SEE SCHEDULE OF FORMS AND ENDORSEMENTS - FORM U001 FOR THIS I $ 1,174.00 <br /> COVERAGE PART <br /> 5. FORM OF BUSINESS: © Individual LjJoint Venture OPartnership Organization (Other han Partnership or Joint Ventral n Corporation <br /> Audit Period: Annual unless otherwise stated: <br /> DCJ6553 (07 -02) Includes Copyright material of Insurance Services Office, Inc. with its permission. <br /> Copyright, Insurance Services Office, Inc., 1984 <br /> Insured <br />
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