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Home My WebLink AboutB10-0059 � October 18, 2010 Martin Haeberle I Chief Building Official Town of Vail 75 South Frontage Road , Vail, CO 81657 � RE: Permit#B10-0059 Substitute Contractor for Landmark#116/TH5 Dear Martin, Due to significant delays and compliance issues, I am replacing New Century Builders LP as the contractor of record with: i, Creative Construction Solutions �' Eric Slagle 239 Dianna Drive n �� Littleton, CO 80124 ' �)�, � 303-552-1204 � eric.sla�le@comcast.net Enclosed is his license application along with his Certificate of Liability Insurance and Compensation Insurance Waivers. The substitute electrician will be: Creative Electrical Solutions Nathan J. Slagle �/� Q _�' 21582 Omaha Ave « C� Parker, CO 80138 I 402-414-0440 ' License#7944 State of Colorado �' The substitute plumber will be: Adam &Son's t � �� 1660 Wild Rye Ct �I 3 Castle Rock, CO 80109 � 303-653-3851 State#541 Master#189000 Please call me if you have any questions or concerns. Thanks! Sincerely, _ � _ - -_- �I � __ J � ; � � � . �� . , - � ( � �� <<,� � � , �� i � � � � , Richard Russ !'''��!�'�, OCT 2� 2U10 Landmark#116/TH5 '',i''� 303-841-6618 -�'pW�j QF VA�L richardruss@msn.com ,, � � z � NOTE: THIS PERMIT MUST BE POSTED ON JOBSITE AT ALL TIMES � � .� � �owxo�vn�• � Town of Vail, Community Development, 75 South Frontage Road,Vail, Colorado 81657 �, p. 970.479.2139, f. 970.479.2452, inpsections 970.479.2149 ¢ ADD/ALT MF BUILD PERMIT Permit #: B10-0059 � Project #: PRJ09-0136 � � <; Job Address: 610 W LIONSHEAD CIR VAIL Status. . : ISSUED ; ' Location......: UNIT 116 Applied . . : 04/21/2010 ' Ytl Parcel No....: 210106307005 Issued... : 10/27/2010 z' Expires. ..: 11/09/2010 OWNER RUSS,RICHARD A. 04/21/2010 6567 N SURRY PL PARKER `' CO 80134 CONTRACTOR CREATIVE CONSTRUCTION SOLUTI 10/27/2010 Phone: 303-552-1204 239 DIANNA DRIVE LONETREE ' CO 80214 License: 1083-B - APPLICANT NEW CENTURY BUILDERS LP 04/21l2010 Phone:303-380-3750 19402 E MAIN ST � PARKER CO 80138 License: 1045-B Description: COMPLETE FINISH OF INTERIOR REMODEL �` € i: Occupancy: R2 Valuation: $9,100.00 Type Construction:IllA Total Sq Ft Added: 0 F; ....................+..........,.......,..,,,,,,...............,,«...,........,.,. FEE SUMMARY ........,,,....,,,.,..........,.«.....................,........,.,..,.......,,, ',; Building Permit Fee----> $181.25 Will Cal Fee------------------> $4.00 Total Calculated Fees---------> $303.06 " � Plan Check-------------> $117.81 Use Tax Fee-------------> $0.00 Additional Fees----------------> $0.00 � . < ''x Add'I Plan Check Hours-> $0.00 Restuarant Plan Review-----> $0.00 TOTAL PERMIT FEES----------> 5303.06 � ;= Investigation-----------> $0.00 Recreation Fee-----------> $0.00 E` � ' Payments--------------------> a303.06 � "' Total Calculated Fees-------> $303.06 BALANCE DUE------------------------> 50.00 = � •rs.xwxwx+.t+�:�r�:��.�.x+w++wx�xrrxe«wrxv,a�ww�ti:+:,r:+xw�ww:www�w.x��x�w�wwwwwy�rixv.xv.wxr+t�t+�+��„ww�ws.xx�xxx,r,re,r��wv.s.wrr�+.+++��xx�wwox�xwww�n.xw,rwwxs.xyxrw�,rreraxrrr�r��rwrtrr,�w�+� DECLARATIONS �. 1 hereby acknowledge that I have read this application,filled out in full the information required,completed an accurate plot plan,and state that all the information g as required is correct. I agree to comply with the information and plot plan,to comply with all Town ordinances and state laws,and to build this structure � according to the towns zoning and subdivision codes,design review approved, International Building and Residential Codes and other ordinances of the Town � applicable thereta � � t REQUESTS FOR INSPECTION SHALL BE MADE TWENTY-FOUR HOURS IN ADVANCE BY TELEPHONE AT 970.479.2149 OR AT OUR OFFICE FROM � 8:00 AM-4:00 PM. � _ ., � .; ' --�==i�„-._.^.:/ �--�_%�,�,� .��' k; _ Signature f Owner or Contractor L� Date � l�l�r�r�� 7� Print Name E ; bld_alt construction_permit_041908 € � � f P [ � � •fe*ffff4fRlrtYYY�F4444fffrfefeRfi4rtYY(#*#fklf'Rf'x1f4Yf1�FtR1'fnldlrftYf•i�kfY'#�Y####f1rt4*1f V iRIIy'LY('k**tRRfef'frf'RV1rL4rt##�tfi#f#k1�1rfi�Rfrtf'kY�k#*#tR}1fRlrffkA'T4'kf*�lRkR##ffrVitRRMYi4fF WH#}fffR4ff'f'N1fYff'St'4ftft#fRf APPROVALS � Permit#: 610-0059 as of 10-27-2010 Status: ISSUED � •tYfY'rtrtiFlir�Rf**##RRff1fYY1MfR*A#11MfrRiRfrfrk�k'4fi4ft4fff'�tV V41rrtfYYeYtf#lJAipARRf'!R V1rRfYffk�i'k4kleffr}f`f'f'Af1YfLfYTM'fYf`1fRRitfiRRRtritf V Yeik�R+tY'k4RRR�RRAVitffikffi'k4##*41rM##ffiMffrtYeYfitY.##l+ttRtRf'4!f}wfR1f Item: 05100 BUILDING DEPARTMENT 05/04/2010 cg Action: AP ,: Item: 05600 FIRE DEPARTMENT 04/22/2010 drhoades Action: AP Contact the building's fire alarm and fire sprinkler companies to ensure that adequate coverage remains after changes are made. Also, contact the fire alarm company to change out smoke detectors, to heat detectors, in any areas impacted by demolition/construction to avoid false alarms. Bagging £ of detectors is prohibited! f�kRYYY`R4'4�R�f�ttf*itM4kf1r4kfrfrffR*RRYrktitiFkfiF�k'kf'RAMtlf44fR}f}�RX4V1rtRMfYfYiYA'A'rt4�k####fl4411`1�4f�l�lRfR#�fVf�lrlrfYYlf4ftiYfiY�k�kYit�tf*44+tffR4trR44RR1r1tff1rtk4A'iFR44Y#fYr'R'44'R#�fH#lkRf41RMlRflrlrRf'NHfR �.. t See the Conditions section of this Document for any that may apply. � i � t bld_alt_construction�e rm it_041908 � e � � � �R1rRlrrtVf'kfkffl4kRRfrVflrtiR4y'tfleklkfrfr1r14ffA'iF9'#ffffrfrfrVffr4frfrfty'�t�!\4Rk##�fff4rtLrtfrtY+Y###�444R41rRiRiRR4YrrtYR###A4ffhfMVrt44tf�k1r4444R4VfrYfiR�k1�*frlRfrfRitlriR4YrYririf/+t##frfrlriRfrtkf4Yt4i##A+HMffVttRRffr44iSf 3�. CONDITIONS OF APPROVAL Permit#: B10-0059 as of 10-27-2010 Status: ISSUED ..........................................................................,,.........,..,,...............,,..,.......,.....,..,..........,.....,..,,........,.,.....,,...........,,,.., � Cond: 12 � ; (BLDG.): FIELD INSPECTIONS ARE REQUIRED TO CHECK FOR CODE COMPLIANCE. ` Cond: 14 � : (BLDG.): ALL PENETRATIONS IN WALLS, CEILINGS, AND FLOORS TO ' BE SEALED WITH AN APPROVED FIRE MATERIAL. < Cond: 1 , (FIRE): FIRE DEPARTMENT APPROVAL IS REQUIRED BEFORE ANY ' WORK CAN BE STARTED. � ; ;.' � ; 5 bld_alt_construction_permit_041908 � # € s NOTE: TH/S PERM/T MUST BE POSTED ON JOBSITE AT ALL T/MES .• �nw�o�vn�' Town of Vail, Community Development, 75 South Frontage Road,Vail, Colorado 81657 p. 970.4792139, f. 970.479.2452, inpsections 970.479.2149 ADD/ALT MF BUILD PERMIT Permit #: B10-0059 Project #: PRJ09-0136 Job Address: 610 W LIONSHEAD CIR VAIL Status. . : ISSUED Location......: UNIT 5 Applied . . : 04/21/2010 Parcel No....: 210106307005 Issued. .. : 05/13/2010 Expires . ..: 11/09/2010 OWNER RUSS, RICHARD A. 04/21/2010 6567 N SURRY PL PARKER CO 80134 APPLICANT NEW CENTURY BUILDERS LP 04/21/2010 Phone: 303-380-3750 19402 E MAIN ST PARKER CO 80138 License: 1045-B CONTRACTOR NEW CENTURY BUILDERS LP 04/21/2010 Phone: 303-380-3750 19402 E MAIN ST PARKER CO 80138 License: 1045-B Description: COMPLETE FINISH OF INTERIOR REMODEL Occupancy: R2 Valuation: $9,100.00 Type Construction:IllA Total Sq Ft Added: 0 .......................................................................,,,.,.�..... FEE SUMMARY .......x,,...�.......,.....................,,..,....,,.,,....�..,,.,.......,,.... Building Permit Fee------> $181.25 Will Cal Fee---------------------> $4.00 Total Calculated Fees-------------> $303.06 Plan Check--------------------> $117.81 Use Tax Fee---------------------> $0.00 Additional Fees-----------------------> $0.00 Add'I Plan Check Hours-> $0.00 Restuarant Plan Review-----> $0.00 TOTAL PERMIT FEES--------------> $303.06 Investigation-----------------> $0.00 Recreation Fee-----------------> $0.00 Payments-------------------------------> 5303.06 Total Calculated Fees--------> $303.06 BALANCE DUE------------------------> $0.00 .............�,.,.,,,.�........,......,�........,........x..,..,,......,,,.,...,,...,....,..,..,..,...,,x...k.,+.......«..........,.......�......<..........,.............«,.,...,,,,,,,..,. DECLARATIONS I hereby acknowledge that I have read this application,filled out in full the information required,completed an accurate plot plan,and state that all the information as required is correct. I agree to comply with the information and plot plan,to comply with all Town ordinances and state laws, and to build this structure according to the towns zoning and subdivision codes,design review approved, International Building and Residential Codes and other ordinances of the Town applicable thereto. REQUESTS FOR INSPECTION SHALL BE MADE TWENTY-FOUR HOURS IN ADVANCE BY TELEPHONE AT 970.479.2149 OR AT OUR OFFICE FROM 8:00 AM-4:00 PM. � � � ,��=� �==�=-�:� y/��C�, ,� Signature of Owner or Contractor Date IZ VcG� �� Print Name bld_alt_construction_perm it_041908 •*Rwwwkw#ww#w*�*/**f**f*M*f*#***i�>##tR*ixt##wwwwwww+ww#f/wwff**f4ffA�*�****�f!!f�*+##*#��/#hwe+w#w#fiwwww*wwwww*f}f4**fxf*�**fffftf##f*�+***ff#k***!w*wwfiRw++t#Xwtw/#+�#t#wrtwwwwwww APPROVALS Permit#: 610-0059 as of 05-13-2010 Status: ISSUED ......,>...,>..,.x...........�..................x.................,..,......,.,,,.�....,.....,,.....,.,..,....,.....................,.,,.,,.,..,....>,...........,....,�,.>,.,....... Item: 05100 BUILDING DEPARTMENT 05/04/2010 cg Action: AP Item: 05600 FIRE DEPARTMENT 04/22/2010 drhoades Action: AP Contact the building's fire alarm and fire sprinkler companies to ensure that adequate coverage remains after changes are made. Also, contact the fire alarm company to change out smoke detectors, to heat detectors, in any areas impacted by demolition/construction to avoid false alarms. Bagging of detectors is prohibited! rt.......».............................<,......,......,....,....,..,.....,,,...........�.�.,.,,��...,.......,.,,......�..�.�x..........,..�.....,<..<.,....�........,.....,,.......... See the Conditions section of this Document for any that may apply. bld_alt_construction_perm it_041908 �www+��i��x:xwax�w�xx��wr>aerw��ww+�wwwwww�ww+wwww�w��rw��+��w��wx+��w+�ff�f��xxx��w�x��xxw�x++�wxwwwww�w+w�ewww�w+w�e�»www�xwwwxww�w+�+wwwr�r�ww�wxwwrx�xxxxw�x�rx� CONDITIONS OF APPROVAL Permit#: 610-0059 as of 05-13-2010 Status: ISSUED ...............................�...�.,....,,..,........�,........,,..,........,,.,...............,x�..,..,,,.,...,..,x,.,.....,...,...,.,,.x,�.......,,,.,�,...,x,....,.,............, Cond: 12 (BLDG.): FIELD INSPECTIONS ARE REQUIRED TO CHECK FOR CODE COMPLIANCE. Cond: 14 (BLDG.): ALL PENETRATIONS IN WALLS, CEILINGS, AND FLOORS TO BE SEALED WITH AN APPROVED FIRE MATERIAL. Cond: 1 (FIRE): FIRE DEPARTMENT APPROVAL IS REQUIRED BEFORE ANY WORK CAN BE STARTED. b I d_a I t_co n st r u ct i o n_pe rm it_041908 **�*******�********************************************************�************************ TOWN OF VAIL, COLORADO Statement **********�*******************************************************************+****+**+***** Statement Number: R100000458 Amount: $303 .06 05/13/201010:25 AM Payment Method: Check Init: SAB Notation: 2637-RICHARD RUSS ----------------------------------------------------------------------------- Permit No: B10-0059 Type: ADD/ALT MF BUILD PERMIT Parcel No: 2101-063-0700-5 Site Address: 610 W LIONSHEAD CIR VAIL Location: UNIT 5 Total Fees: $303 .06 This Payment: $303 .06 Total ALL Pmts: $303 .06 Balance: $0. 00 ************************************�*******�***�*********+***********************�********* ACCOUNT ITEM LIST: Account Code Description Current Pmts -------------------- ------------------------------ ------------ BP 00100003111100 BUILDING PERMIT FEES 181.25 PF 00100003112300 PLAN CHECK FEES 117.81 WC 00100003112800 WILL CALL INSPECTION FEE 4 . 00 ----------------------------------------------------------------------------- 11-18-2010 Inspection Request Reporting Page 11 7:05 am Vail, CO - Citv Of Requested Inspect Date: Thursday, November 18,2010 Inspection Area: CG Site Address: 610 W LIONSHEAD CIR VAIL UNIT 116 A/P/D Information Activity: B10-0059 Type: A-MF Sub Type: AMF Status: ISSUED Const Type: Occupancy: Use: IIIA Insp Area: CG Owner: RUSS, RICHARD A. Contractor: CREATIVE CONSTRUCTION SOLUTIONS Phone: 303-552-1204 Description: COMPLETE FINISH OF INTERIOR REMODEL Requested Inspection(s) Item: 90 BLDG-Final Requested Time: 02:30 PM Requestor: CREATIVE CONSTRUCTION SOLUTIONS Phone: 303-552-1204-eric Assigned To: CGUNION Entered By: SBELLM K Action: Time Ex Comment: ALARI�FINAL NOT DO� 2 ELECTRIC FINAL NOT DONE 3 PLUMBING FINAL NOT APPROVED 4 REPLACE GAS SHUT-OFF KEY AT FIREPLACE WITH LONGER ONE THAT WILL REACH VALVE _7r�;S�� I I (► �-I -� �� Inspection Historv Item: 226 FIRE DEPT. NOTIFICATION Item: 30 BLDG-Framing ""Approved"* 07/13/10 Inspector: CG Action: CR CORRECTION REQUIRED Comment: 1 MECHANICAL PERMIT IS REQUIRED FOR THE REPLACED BATH FANS � BATH FANS REQUIRE FIRE DAMPERS 3 N�T REW/NAtL PLATES MISSING ON MC CABLE,AND PLUMBING PIPES THROUGHOUT 4 FIRESTOP ALL PENETRATIONS IN FLOOR FROM PARKING GARAGE BELOW 5 FIRESTOP ALL HOLES IN TOP PLATES,AND WIRES/PIPES, GAPS AT DOUBLE WALL C. 6LDRYWALL BACKING MISSING THROUGHOUT. 2 LAYER ASSEMBLY REQUIRES 51AGGERED JOINTS 7 SOFFIT FRAMING IN BATHROOM NOT COMPLETED 8 BLOCK ALL 2X FRAMING WERE UNSUPPORTED BY SHOWER AND CMU WALL 9 FIREPLACE CLEARANCES TO NEW FRAMING REQUIRED PER FIREPLACE MANUAL. AINTAIN ACCESS TO GAS SHUT-OFF 07/26/10 Inspector: mdenney Action: DN DENIED Comment: Items 1,2,4,6,9 remain. Design professional shall address overboring�above master bath. 5"holes in joist. 08/05/10 Inspector: mdenney Action: PA PARTIAL APPROVAL Comment: item 2 and 6 remain, need to see bath fan fire damper and staggered joints for fire ceiling assembly. okay to sheetrock, call for inspection of each layer. Item: 50 BLDG-Insulation Item: 60 BLDG-Sheetrock Nail ""Approved*` 08/13/10 Inspector: nsc Action: DN DENIED Comment: no one onsite 08/16/10 Inspector: mdenney Action: NR NOT READY FOR INSPECTION Comment: provide fire-ceiling assembly. U.L. listing or GA. Sheetrock on-site is AGX-1.type X 08/19/10 Inspector: mdenney Action: PI PARTIAL INSPECTION Comment: 1 st layer on ceiling, assembly GA-FC5406 08/20/10 Inspector: sgremmer Action: AP APPROVED REPT131 Run Id: 12193 �� '� ,�a�-x a''��t r� � ,, ��'�t .�'s"' �..� ,. x} r�y, �.� � .; v g '., 3 s • :s=�� S'�f� � t �6 �� K � A � �� . h k�� y �t � � , ' � ,�;:� : ��`�;'�;� ` ; � � Department of�Cvmmun"rty De�elopmenfi�_ :- , ,.� � �� r � * a �� % �� °�,�� ,�F�, ; -� 7�5 South Frontage"�o �°�.� �k� ��,� ,�'�� >. �:� z � � �.;r• �, , �«,� � �� .��- -_� _ , � �� °Vatl,��ora� -�a 'ti -� °� z a �,, . � � � x � � �� '� °�' � � � � � *��, �� t 9 � ��' F ,�`a � �„ . y"�:�x�}.+a� � � P, c �d` ,�`Y ��.a"'`�� 'j ��!. j4g ,�'.�.« � f � s«", �j.� �,g. Z� 3 i`+xa'—„ ��g "�ra: .P.+��. .� a ".w�G � 9 `�" n �n Y� '`.� .,y� ,�� e� �, �e � ,� � � �� a. ^,n. r 4 �. � � �r... BUILDING PERMIT APPLICATION Separate permits are required for�ctrical, piumbing, mechanical, fireplace, etc. �P�roject Street Address:�� ', Office Use: ��0� �� I� / € ,� � Project#: �YJ 1,..) L�or.sl�.�c�-� Gt-c 1 �(Number) (Street) . (Suite#) DRB#: �Building/Complex Name: '`^�� ' �uilding Permit#: IO" ��l �`,�....�_��,��, ��.._.�. �f�..�,��u��.�, `IcI,;( �-E�-( 3 "' Lot#:�Block#� Subdivision: J� (Contractor Information: �Company: �)A�t 1 \ ��Jliu�4 �,�r S � _� i 'Company Address:�4(`1�� F '�c..v� S� Detailed Scope and Location of Woric:r.r��s� �City:�.e State:�Zip: g� 1�3 � ��,.xL�� }�K h>c e , ��, -t�It ; � Contact Name: �r�� J ��.� � �1c..'t'� "F��.�r� s ., �r�) C�'�� r � � Contact Phone: '7�) - �C�R- '�C'�� (use additional sheet if necessary) � ! E-Mail t.��e-�p� n c' � �s:�c�v�-� C 0�"' � --�� 3 � i� I��j,r_ �� Work Class: ?, i Town of Vail Contractor Registration No.: �� ' New( ) Addition( ) Remodel(✓j Repair( ) Other( � �X Work Type i I � a � quired) �� Interior( .�J Exterior( ) Both ( ) � `Property Information Type of Building: ; Parcel#:�_� l�(� �f,� � Single-Family( ) Duplex( ) Multi-Family(� � (For parcel#,contact Eagle County Assessors Office at 970-328-8640 or Commercial O Other O ; �visit www.eaglecounty.us/patie) � �„��,��.,,,.�,„„ �.��. ��•e� �Tenant Name: � Does a Fire Alarm Exist? Yes( � No( ) _ Monitored Alarm? Yes O , No O j �Owner Name: ��c�c.._r�c) �„�s ; � Does a Sprinkler System Exist? Yes( � No O , ; >�..,.,�*.,�,,�,n...��,.,__..,.,_..��.�,.m�A�,. �,.,.�...m,�...,_..��,�,,�.�„ ..v..�...�,�,�s.�,,.m.�,�„a,,:� � � . � ;�.�..��,.�....�.u.��.....w.�..�,.�....._.�.. .o.�.�.,.,_�,. � � �#8�Type of Existing Fireplaces: Gas Appliances�_ (Valuations(Labor 8�Materials) � E;Q � � Gas Log Wood/Pellet Wood Buming 4 , �Building: $ ; E /�S O G �#&Type of Proposed Fireplaces: Gas Appliances ; 'Plumbing: $ �Gas Log Wood/Pellet Wood Buming . _ ' ; �_._...._._ _ _._._..._. __.... ___ __... _.._ _._: €Electrical: $ � � � � � � � r � Date R e e ;MechanicaL(including fireplace) $ � � .� � APR 2 0 2010 i Total: � { .__ ___. _..._ ____ __.._.. _..__� � TOWN OF VAtL O 1-Jan-10 October 18,2010 Martin Haeberle Chief Building Official Town of Vail 75 South Frontage Road Vail, CO 81657 RE: Permit#B10-0059 Substitute Contractor for Landmark#116/TH5 Dear Martin, Due to significant delays and compliance issues, I am replacing New Century Builders LP as the contractor of record with: Creative Construction Solutions Eric Slagle 239 Dianna Drive Littleton,CO 80124 303-552-1204 eric.sla�le@comcast.net Enclosed is his license application along with his Certificate of Liability Insurance and Compensation Insurance Waivers. The substitute electrician will be: Creative Electrical Solutions Nathan 1. Slagle 21582 Omaha Ave Parker, CO 80138 402-414-0440 License#7944 State of Colorado The substitute plumber will be: Adam &Son's 1660 Wild Rye Ct Castle Rock, CO 80109 303-653-3851 State#541 Master#189000 Please call me if you have any questions or concerns. Thanks! Sincerely, �, � � .......,. r. .,....� :`..—. �� c.-�__ � �_�—�' Richard Russ `� � Landmark#116/TH5 303-841-6618 richardruss@msn.com ACORDTM CERTIFICATE OF LIABILITY INSURANCE °"'�`"'�'°°"'""' 10/14/2010 � Phone:(303)660-0470 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A ex Insurance Services,LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9000 E Nichols Ave Suite 705 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Centennial,CO 80112 INSURERS AFFORDING COVERAGE NAIC# ��D �NS�R�a A: Colorado Casua Insurance Com n Creative Construction Solutions,Inc Eric Slagle �"S"R�B. 239 Dianna Dr INSURER C: Littleton,CO 80124 �NSURER D: INSURER E COVERAGES THE POlIC1ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TF�tNSURED NAMEO ABOVE FOR THE POLICY PERIOD It�ICATED.NO7IMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHtCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURAI�E AFFOROED BY THE POLICIES DESCRIBED I-�REIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGC-�2EGATE UMITS SHOWN MAY HAVE BEEN REWCED BY PAID CLAIMS. INSR ADD' ��Y�M� POLICY EFFECTIVE POLICY EXPIRATION U�� A �une�uTr 3007127796 04/01/2010 04/01/2011 EACHOCCURRENCE a 1 000 000 X COMMERCIAL GENERAI LIABILITY DAMA E T RENTED PREMISES Ea occurence $ CLAIMS MADE �OCCUR MEp p(p(pny pne persan) $ PERSONAL 8 ADV INJURY S c,�N�aLACCRECnre E 2 OOO OOO GEN'LAGGREGATELIMITAPPLIESPER: I�2pDUCTS-COMPlOPAGG S Z OOO OOO �( POLICY PRO- LOC I AUT�MO��E L.��UTM i COM&NED SINGLE LIMIT ANY AUTO «�t� $ ALL OWNEO AUT0.S �DILY INJURY � SCHEDULED AUTOS (Pg�� HIRED AUTOS BODIIY IN,IURY a NON-OWNED AUTOS ��) i PROPERTY DAMAGE $ � (Per accident) ��1�' , AUTO ONLY-FA ACCIDENT b ANY AUTO OTHER TFiNN �A� S AUTO ONLY: q� a ��F��°V��' EACH OCCURRENCE $ OCCUR �CLAIMS MADE �I AGGREGATE $ I b oeoucne� � s RETENTiON a a �C��n��p I � VrC STATU- OTH- EMPLOYERS'LIABILITY ANV PROPRIEfOR/PARTNERIEXECUTNE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUOED? E.L.DISEASE-EA EMPLOYE 3 If yes,desaibe under , SPECIAL PROVISIONS below E.L DISEASE-POIICV lJM1T b OTHER i � ' � DESCRIP710N OF OPERA710NS/LOCATIONS i VElYCLES I EXCLUSIONS AODED BY ENDORSEMENT/SPEC�AL PROVISIONS CERTIFICATE HOLDER CANCELLATION SFiOIR.D ANY OF THE ABOVE DESCR��POLICtE3 BE CANCELLED BEFORE THE D�6tAT10N a�,e�,n��ssue�c rosu�wiu.e�►v�oa ro rnn. 15 wrs wwr�N RIC HARD A RUSS r.,once To n�c�n�,e Ho�w„�n ro,r��,BUi ppRURE Tp pp gp SHp�y 6567 N SU RRY PL �r�nb oeuc,ntron ort unewrr oF aNV�cwo uroa n�i�su�a,irs acorTS ort Parker,CO 80134 �s�rA,,,,ES. AU7HORIZED REPRESENTATVE CG ACORD 25(2001l08) O ACORD CORPORATION 1988 Printed by CGY on October 14,2010 at 02:46PM Compensation Insurance Waiver 8/16/2008 Creative Construction Solutions Eric Siagle 239 Dianna Drive Littleton, CO 80124 303-552-1204 PLEASE READ THEN SIGN BELOW Declaration: With respect to the above-mentioned business, I herby warrant that the business has no employees other than the owners, oifrcers, directors, partners or other principals who have elected to be exempt from Worker's Compensation coverage in accordance with Colorado law and as a result ! shall not have any cause of action of any kind under Article 40-47 of Title 8 of the GRS. I further warrant that I understand the requirements of the Workers Compensation Act of Colorado CRS 8-40-101 et seq with respect to providing Worker's Gompensation coverage for any employees of the above mentioned business. 1 agree to comply with the code requirement and all other applicable laws and regulation regarding woricers compensation. I understand that as a 10% owner of the business { am waiving my rights to have workers' compensatior�. An independent contractor is not entitled to workers' compensation benefits and the independent contractor is obligated to pay federal and state income tax on any moneys eamed pursuant to the contract relationship. I further agree to hold Douglas County harmless from loss or liabitifiy which may arise from the failure of the above-mentioned business to comply with such laws or regulation. I therefore request that Douglas County waive its requirement for evidence of Workers' Compensation insurance. � ., . � ,� �,��; _ ,� � �� SIGNATUR F OWNER OR AUTHORIZED AGENT DAT TITLE , ' �_' �S� _J(,;--,�c7U � ��' '`` . �__..�.-_.__.._..__._ , �� , Nick Buck DATE Gompensation Insurance Waiver 10/5/2010 Creative Construction Solutions Eric Siagle 239 Dianna Drive �ittleton, CQ 80124 303-552-1204 PLEASE READ THEN SlGN BELOW Declaration: With respect to the above-mentioned business, I herby warrant that the business has no employees other than the owners, officers, directors, partners or other principals who have elected to be exempt from Worker's Compensation coverage in accordance with Colorado law and as a result I shall not have any cause of action of any kind under Article 40-47 of Title 8 of the CRS. I further warrant that I understand the requirements of the Wo�lcers Compensation Act of Colorado CRS 8-40-101 et seq with respect to providing Worker's Compensation coverage for any employees of the above mentioned business. I agree to comply with the code requirement and alt other applicable laws and regufation regarding w4rkers compensation. I understand that as a 10% owner of the business I am waiving my rights to haue workers' compensation. An independent contractor is not entitled to workers' compensation benefits and the independent contractor is obligated to pay federal and state income tax on any moneys earned pur�uant to the contract relationship. I further agree to hold Douglas County harmless from loss or iiability which may arise from the failure of the above-mentioned business to comply with such laws or regulation. I therefore request that Douglas County waive afis requirement for evidence of Workers' Compensation insurance. � , �� -- � �, , ��. . .. SlGNATURE OF UWNER OR AUTNORIZED AGENT DATE TIT�.E ,., /' ';;: i' : �; . . r , / - -� �, ,{__ `� =�°� I��/ 4v , - �,;�- ,�---.�- Ryan Buck DATE