410 WALNUT ST-CERT OF INS (3).pdf� � 018
CERTIFC TE OF LIABILITY INSURANCE
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THIS CER (FICA., ,.
TIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVER _ _ ER AND THE CERTIFICATE AT_E_HOLDER. _
IMPORTANT: If the OR
holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURE provisions � ...r
PRODUCER, _
N O D or be endorsed.
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 r3gl"tl^ holders to the cerfitlholder in lieu of such a�ndorem n_ ,.�___._ . ......�_ _...— �.... .....—
INSURANCE SERVICES GROUP INC/PHS
811422 P: (866) 467-8730 F: (888)
PO BOX 33015
SAN ANTONIO TX 78265
c _ 6) ( 467-8730
4 4 3- 6112 ADDRESS: u. 8 6
INSURED
WALNUT ST COFFEE LLCw��
19304 21ST AVE NW''
SHORELINE WA 98177
No): (888) 443-6112
NAIL#
VERAGES
COWS
.
CERTIFICATE
NUMBER:
NUMBER: �.-
iANY ES
OF
BELOW HAVE
_
BEEN ISSUED
THE
POLICY PERIOD
To CERTIFY
NOTWITHSTANDING REQUIRE REQUIRECE
MTED
ENT,
CONDITION
OF ANY CONTRACTOOR
OTHER DOCUMENT
T TO WHICH THIS
WITH RESPECT
INDICATED.
CERTIFICATE
MAY BE ISSUED OR MAY
PERTAIN,
THE INSURANCE AFFORDED
BY THE
POLICIES DESCRIBED
HEREIN IS SUBJECT TO ALL THE
EXCLUSIONS AND CONDITIONS
SUCH
POLICIES.
SHOWN MAY
LIMITS S 0....
REDUCED
HAVE BEEN RED�tJ_1104
BY PAID CLAIMS,
TERMS
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T� EOFINSURANCE
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EACH OCCURRENCE 2 000, 000
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COMMERCIAL GENERAL LIABILITY
CLAMS -MADE X OCCUR
UAM
PREMI 5 10 RENTEDO O, 000
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—.....
X Generlal Liab
52 SBA IX0766
02/24/2016
02/24/2019
MEDAEXP(Any°one person) Q 0 00 _
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PERSONAL&ADVINJURY °,2, 000, 000"
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GENERALAGGREGATEs4,000,000
(A.'W1AWR UA} LIMIT APPLIES O
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PRO-
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PRODUCTS COMP/OP AGG 4000,000OGI..
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OTHER:
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4 1,)MBpNLI'.I IW�G&, G G, LIMIT
2 0 0 0 0 00
AUTOMOBILE LIABILITY
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ANY AUTO
BODILY INJURY Perperson)
A
OWNEDSCHEDULED
52 SBA IX0768
02/24/2018
02/24/2019
BODILY INJURY (Per accident)
)
AUTOS ONLY , AUTOS
X HIRED X NON -OWNED
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UMBRELLA LWB OCCUR
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EXCESS LIAR MS -MADE
AGGREGATE
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ANY PROPRIETORIPARTNER/EXECUTIVE
H ACCIDENT i 1° O00000
EL EACH 0
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OFFICERIMEMBEREXCLUDED? •--
(Mandatory in NH)
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5Z SBA IX0768
02/24/2016
02/24/2019
E^L DISEASE- EA EMPLOYEE
If es, describe under
y
-POLICY LIMIT $ 0
E.L, DISEASE LIMIT1 , 0 0 0 , 0 0
DESCRIPTION OF OPERATIONS below
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d7ESCIiII�IPC7N
ONS/LOCATIONS/VEHICNOMRD
OFOPERATI �
101,
Additional Remarks Schedule
m be attached if more
may
p e is required)
space is
Those
usual to the Insured's
Operations. Re:
Wall Mount
Sign,
Flower Box and
Seasonal
Outdoor Charis
located
in the City
right of
way; 410
Walnut St
Edmonds,
WA as per street
use
permit # eng
20060145 and
encroachment
permit #
eng
20110308_ Certificate
Holder
is an Additional
Insured
per
the Business
Liability
Coverage Form
SS0008
attached to
this policy.
CER`I°IFICA°
City of Edmonds
Engineering Division
121 5TH AVE N
EDMONDS, WA 98020
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
.DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
DNS.
.....................mm,_ —
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