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HomeMy WebLinkAboutLSSP-06-2021-152372.tif L$SP- O .DO l-iSD3 if;iik .05.20)J -3 71 7 q fc'',v STATf w7;,� 4'r ,, °�">s. ROY COOPER • Governor '�., R [�'. NC DEPARTMENT OF <,�• ;J- iOI HEALTH A N Q MANDY COHEN, MD, MPH • Secretary _ HUMAN SERVICES !' MARK T. BENTON • Assistant Secretary for Public Health "� •F Division of Public Health COMMON FORM FOR LICENSED SOIL SCIENTIST COVID-19 PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See Instructions for Use in Appendix A Except for"Date received",this Section to be completed by the 155 in accordance with S.C.2020-97,Section 3.19 and G.S. 130A-336.2 LHD USE ONLY: Initial submittal of this NOI received: u 'u - 7.( by ' Date Initials PART 1:Notice of Intent to Construct(NOI) S New ❑ Expansion El Repair—LHD Permit Number ❑Repair—EOP/LSS Permit Number 1. Facility Owner's name:(Owner, Company Name, Utility, Partnership, Individual,etc.): Scott Marks Mailing address: 129 Live Oak Ln City: Mooresville State: NC Zip: 28115 Telephone number: (704) 622-9256 E-mail Address: scott@synlawncarolina.com 2. Licensed Soil Scientist(LSS)name: Caroline J. Edwards LSS License number: 1220 Mailing address: 991 Duncan Rd City: Rutherfordton State: NC Zip:28139 Telephone number: 828)289-0122 E-mail Address: ciedwards234PRmali.com 3. Licensed Geologist(LG)(If applicable)name: NA License Number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 4. Proof of Errors and Omissions or other appropriate liability insurance for the following persons is attached that includes the name of the insurer, name of the insured and the effective dates of coverage: U LSS ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot, block number of the property to be permitted):_Lot 2 5863 Sherrills Ford Rd NC 6. County Name: Catawba 7. Type of facility: M Place of residence No.Bedrooms: 3 No. Occupants: 4 Place of business Basis for flow calculation: n Place of public assembly Basis for flow calculation: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION 5605 Six Forks Road, Raleigh,NC 27609 MAILING ADDRESS.1642 Mail Service Center,Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5854 • FAX 919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER State of NC LSS Permit Option COVID-19 LHD Reference: LS>P-Dt-2-021- I5237` 8. Factors that would affect the wastewater load: None 9. Type,location,and classification(per Rule.1961)of wastewater system: Type Wiz;front side of house looking from street Single family residence 10. Design wastewater flow: 360 gpd Design wastewater strength: U domestic ❑high strength ❑ industrial process(For high strength and industrial process wastewater,a Professional Engineer licensed in accordance with G.5.89C shall design the on-site wastewater system.) 11. A plat as defined in G.S.130A-334(7a)Is attached: ❑Yesn�I ® No 12. A site plan as defined in G.S.130A-334(13a)is attached: UGI Yes ❑ No In accordance with G.S.130A-335(f),an LSS COVID-19 Permit with a plat is valid without expiration and an LS5 COVID-19 Permit with a site plan is valid for five years. 13. Owner meets requirements of ownership or control of the system per 154 NCAC 18A.1938(i): Yes® No❑ 14. Easement,right of way or encroachment agreement required per 15A NCAC 18A.1938(j): Yes❑ No lid If yes,documentation filed in_^ County Register of Deeds in Deed book Page 15. Multi-party agreements required,as applicable,pursuant to 15A NCAC 18A.1937(h): ❑Yes Q No If yes,agreements filed in County Register of Deeds in Deed book Page 16. Location of proposed or existing wells(drinking water,irrigation,geothermal,groundwater monitoring,sampling,etc.) and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 15A NCAC 18A.1950: Q Yes ❑ No This is a saprollte system. ❑Yes ® No 17. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(al)signed and sealed by a LSS is attached: EYes ❑No 18. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes © NA 19. Proposed landscape,site,drainage,or soil modifications are attached: 0 Yes 111 NA Attestation by LSS pursuant to S.L.2020-3,Section 4.18 and G.S. 130A-336.2 I, Caroline J.Edwards hereby attest that the information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations,rules and ordinances,and that the proposed system does not require a Professional Engineer,licensed in accordance with G.S.89C, and in accordance with 1SA NCAC 18A.1938 and activities determined to be engineering as determined by the North Carolina Board of Examinersfor Engineers and Surveyors." 1, Signature of Licensed Soil Sc,: Date NOTES: OHHS/ENS/OSWPB—L55 COV!O-19 COMMON FORM Effective May 5,2020 Page 2 of 6 • State of NC LSS Permit Option COVID-19 LHD Reference:1SsP_.l/t `LuN - 1-04-> LIABILITY: The Department, the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed, constructed,and installed pursuant to an LSS COVID-19 Permit Option[Si.20203, Section 4,18(d)and G.S. 130A-336.2] RIGHT OF ENTRY: The submittal of this Notice of Intent to Construct grants right of entry to the Local Health Department and the State to the referenced property. ISSUANCE OF BUILDING PERMIT: Once the LHD deems that the Notice of Intent to Construct is complete via signature in the section below,the owner may apply to the local permitting agency for a permit for electrical, plumbing, heating,air conditioning or other construction, location or relocation activity under any provision of general or special law pursuant to G.S. 130A-338. DHHS/EHS/OSWPB—L55 COVIO-19 COMMON FORM Effective May 5,2020 Page 3 of 6 • State of NC LSS Permit Option COVID-19 LHD Reference:LSS UL 15 372 This section for Local Health Department use only. PART 2: LHD Completeness Review of the Notice of intent to Construct "(c) Completeness Review for Notice of intent to Construct.—The local health department shall determine whether the notice of intent to construct required pursuant to subsection(b)of this section is complete within five business days after receiving the notice of intent to construct.A determination of completeness means that the notice of intent to construct includes all of the required components.If the local health department determines that the notice of intent to construct is incomplete, the local health deportment shall notify the owner and list the information needed to complete the notice. The owner may then submit additional information to the local health department to cure the deficiencies in the initial notice.The local health department shall make a final determination as to whether the notice of intent to construct Is complete within five business days after the department receives the additional information.If the local health department fails to act within any time period set out in this subsection, the owner may treat the failure to act os a determination of completeness. The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of intent by the local health department or if the local health deportment fails to act within the five business day time period." The review for completeness of this Notice of Intent was conducted in accordance with G.S. 130A-336.2(c). This NOI is determined to be: ❑ INCOMPLETE(If box is checked,Information in this section is required.) Based upon review of information submitted in Part 1,the following items are missing: Copies of this form listing missing items were sent to the LSS and the Owner on Dote via with directions to re-submit missing items using Page 5 of this form. Email,FAX,LISPS,hand-delivered Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date ❑ COMPLETE(If box is checked,information in this section is required.) Based upon review of information submitted in Part 1 of this form,this NOI is deemed COMPLETE. Copies of this signed form were sent to the LSS and the Owner on via Date Email,FAX,LISPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Date Email,FAX,LISPS,hand-delivered /AA./ 714,4--- I D-2( Print Name of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date DHH5/EH5/OSWPB—L55 COVi0-19 COMMON FORM Effective May 5,2020 Page 4 of 6 COVID-19 Permit Option Common Form LHO Reference: L P"b.' 20)1 '15237) Re-submittal of NOI with missing items included This Section is for use by owner to submit items noted as missing during LHD Completeness Review above. Resubmittals must be accompanied by a cover letter from the LSS. LHD USE ONLY: This NOI resubmittal received: by Dote Initials Item#from initial NOI Resubmittal description Attestation by[SS pursuant to S.L.2020-97,Section 3.19 hereby attest that the information required to be included with Licensed Soil Scientist(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws, regulations, rules, and ordinances. Signature of Licensed Sail Scientist Date The section below is for Local Health Department use after submittal of items noted as missing above. LHD Follow-up Completeness Review of Notice of Intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G.S. 130A- 336.2(c). This NOI is determined to be: ❑ INCOMPLETE Based upon review of information submitted in the RESUBMITTAL above,this Notice of Intent remains INCOMPETE because the following items from Part 1 of this form remain missing: Copies of this signed form were sent to the LSS and the Owner on via Date Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ❑ COMPLETE Based upon review of information submitted in the RESUBMITTAL above in addition to information provided in Part 1 of this form,this NOI is deemed complete. Copies of this signed form were sent to the LSS and the Owner on via Date Email,FAX,USPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Date Email,FAX,USPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date DHHS/ENS/OSWP-L55 C-19 COMMON FORM Updated April 2022 Page 5 of 6 - State of NC LSS Permit Option COVID-19 LHD Reference: '`5S� �� 2!- �, �� �C PART 3: Authorization to Operate (ATO) Except for date received,the Section below is to te completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: 1 I1 Z7 by -2 Lot Initials Date of Post-construction Conference: 4 i 1 ? 2- The following items are included in this submittal for an AutIhorization to Operate under an LSS COVID-19 permit: 1. Signed and sealed copy of the LSS's report that includes: a. Signed and sealed evaluation of soil conditions and site features 2 Yes ❑ No b- Drawings,specifications, plans L Yes ❑ No c. Reports on special inspections and final inspection Yes ❑ No d. Management Program manual,including ORC contract,when applicable L Yes ❑ No e. On-site Wastewater Contractor's signed statement r_A0(' Yes ❑ No 2. Fee(as applicable) ! Yes ❑ No 3. Notarized letter documenting Owner's acceptance of the system from the LSS 11 Yes ❑ No 4. 4. On-site Wastewater Contractor name: (b\A`C2� 1 ik, � 4ct Number: 1(-AI Mailing address: -2ul 't ,U 1,-.1-1S3 ` City:` 131 $yki„),_. Stta�te: Zip:2.g 4as Telephone number: j G c4 Ci (,:) 1S1?, E-mail Address: \ 'c1�r Y-CAp� 15 ► t V\ Wits_t wa er b � 5. Proof of Errors and Omissions or other appropriate liability insurance for the On-site wa er ntra or is atta ed and includes the name of the insurer, name of the insured,and the effective dates of coverage. Yes ❑ No Attestation by the Owner for Authorization to Operate I, t om' �OJ`)ic c hereby attest that all items indicated above have been provided to the Print name of`,Owner ( C71 E3�}- )�`/.sc+\ County LHD and the system shall meet applicable federal,State,and local laws, regulations,rubs and g #i �ces. / � �� 4 i - 7 Signature of Owner Dote This section for WO Use Only. LHD Review of required information for the ATO ❑INCOMPLETE Based upon review of information submitted by the Owner in the Section above, the following items are missing from the information required for an Authorization to Operate for an LSS COVID-19 permit: Copies of this signed form were sent to the LSS and the Owner on via Dote Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date QCOMPLETE Based upon review of information submitted by the Owner in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.2(m). A copy of this complete NOVATO with tracking information was sent to the State on 5 {7 J2-via £fit l I . Date mail,FAX,USPS,Hond-delivered %) — li ' L- L1/4/21 Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the ATO submission,the owner may apply to the local permitting agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S.130A-339. DHHS/EHS/OSWPB-LSS COVID-19 COMMON FORM Effective May 5,2020 Page 6 of 6 LSS COVID-19 Permit Option Tracking information The LHD completes this form for each NOI/ATO submitted to their offices. The LHD updates this information and re- sends it throughout the process as appropriate. The Department will use this data to answer any questions on the implementation of the LSS COVID-19 permitting process. Tracking information for LSS COVID-19 permits(Required) County Ca-awba LHD Reference Number LSSP—CA— 2021 - 15523 /2 Permitting backlog as of date of NOI submittal(#$days) 35 Number of days to process the NOI(#I days) 4 Number of days to process re-submitted NOI(ft days ys') NA Facility type 3 s'Ck1DOiv. +10 )se' Domestic,High Strength or IPWW f)UMesft C, Design Daily Flow 3‘,d T cl Residential or Commercial ReS+di,KI-lal System type(per Rule.1961) ELL Date of Post-construction conference 1.1I ZZ Date Authorization to Operate issued l�1_1 22 Fee charged for LSS COVID-19 310 @0 11 Is fee sufficient to cover LHD costs? tS Date LHD notified of LSS COVID-19 malfunction I Date LHD notified of Owner complaint DNNS/ENS/USWP-COVID-19 Appendix A Updated February 2022 Page 4 of 4 To: t .4) County Department of Public Health Re: Signed Statement of Verification of Installed Septic System Address: ,$ 7 2 k" 4 , ��3 rzxsS r-ocLc(S �� L y My signature below hereby attests acceptance of this system from Caroline_1 Edwards NC Licensed Soil Scientist #1220 EARTHWISE DESIGNS 991 Duncan Rd Rutherfordton, NC 28139 I submit that this Authorization to Operate (ATO) is accurate and complete to the best of my knowledge and that the constructed system shall meet applicable federal, State, and local laws, regulations, and ordinances. Sign with NOTARY present, not iz below. Owner Signature: Date /I orOZZ North Carolina (\()A0430b,. County ADKek-t rewir a Notary Public for \ County, North Carolina, do Hereby certify that . ��� I kfUr-k(-S personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the I day of ,Apn I , Notary public: {� .\2f4S1)-\ My commission expires: - 11- 9OT .�`� ...... Q,Q q: Y :4. _ • :Z= pVBUC 7a'' •iici COUP 00i 1/1111 0 Installer Name _ * I Y 0.i.,S `C- 4'`C Address: 2_i) l ur ,� U i��J 2e) Le2S To: Catawba County Department of Public Health Re: Signed Statement of Verification of Installed Septic System Address: S' 1. < Ckrt* My signature below hereby attests that the installation is installed as designed with any as-builts/changes as attached; and I submit that this Authorization to Operate (ATO) is accurate and complete to the best of my knowledge and that the constructed system shall meet applicable federal, State, and local laws, regulations, rules and ordinances. Installer Signature: ram_ A , Date LI - i1- as '12 'k,'' Earth wise Designs Sitean for Lot 2 AFL1 , CT Sails& Land Evaluation ' ' Si.. Iiy, ub�dsioli q \ i, Z t ,c, 5r_;r '. , ; , _ t , : sm '4_1> 04 RreA S4ed 45, CAr \:,4):, ' f :' SIFT it * a oil 04 REBAR (NI I CAPPED) Ln) 2. . " N r+ _ 4 ' Irf��31`� i 111. r 4:11,, W 42":1. 45 ..r) SIP r#4 z t. Dralnfield lines marked as Follows: corm .....44.1 Y Y.yellow flagging stakes,B blue,P--pink. d \ Double stakes mark the ends of lines- ok v• .ea '` House marked with wooden stakes and — Z \ L " orange flagging tape. -' v.voU y , { l ' The trees noted are the only ones next r t - . t .t Q �i the house and pasture. IlliN it I I-- . ZD 0 �� IZ Other measurements from fixed points: Pit 1:46'from closest hardwood to house; n 0 I 99'from 3i0 hardwood. h Pit 2:52'from 3'0 hardwood; .: M° 130'from 4'hardwood LC Pit 3:100'from 3rd hardwood; 112'from 4'hardwood ^ EN tk I CAPPED) ' - ' l '" .."' **Iii BANDY'S CROSS RDA. 1 - e Erie CERTIFICATE OF INSURANCE DATE ISSUED(MWDD1 ) Insurance" —THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— Home Office • 100 Erie Insurance Place • arie,Pennsylvania 16530 • 814.8702000 Toll free 1.800.458.0811 • Fax 814.870.3126 • www.erieinsurance.com NAME AND ADDRESS OF AGENCY SNIDER INSURANCE GROUP LLC AGENTS NO. ERitE COCN� G COVERAGE 1438 Wr,KESBORO HWY JJ2072 jig..:-R_ERfNSURIIN"IE(NSURANC RO AN" CAS COMPANY NC 28625 Co.:E EERIE INSURANC CHAN otAppIIcabIa STATE9VILLE Erle Ilndemni .Attome -in-Fact _. .a,,`" CAGS This certificate is issued for Information purposes only and confers NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder. It does not affirmatively or negatively amend,extend,or otherwise alter the terms,exclusions GROUNDBREAKERS GRADING INC and conditions of Insurance coverage contained in the policyfies) 207 MOUNTAIN VIEW RD indicated below.The terms and conditions of the policy(iesi govern the insurance coverage as applied to any given situation.Limits STATESVILLE,NC 18625-1269 shown may have been reduced by claims paid.This certificate of insurance does not constitute a contract between the issuing iosurer(s), authorized representative or producer and the certificate holder. Thish is to certify that policies,as indicated bathe Policy Number below are in force for�the iVNamed iInnsurre�dpat the time Certificate is being Issued. . ibal TYPE OF INSURANCE POUCY NUMBER ]TFMFurt1111YYf' I'WOW LIMITS E❑GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ❑X COMMERCIAL GFSIERALLIABIIITY Q41 0153420 5/1/21 Sr'1;'22 ❑CLAIMS MADE El OCCUR FIRE DAMAGE(My One Frei $ MED EXP(Any One Person) $ 5,000 ❑ PERSONAL&ADV.INJURY $ 1,000,000 ❑ _ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE UMfT APPLIES PER: PRODUCTS-COMP/OPAGG s 2,000,000 ®POUCY ❑PROJECT ❑LOC E ❑ AUTOMOBILE LIABILITY I BODILY INJURY ❑'ANYAUTO"(O NEO MIS Q05 0131816 5/1/21 5/1/22 PERSON) s El OWNED BODILY INJURY fEACHACCIDENf1 S ❑ HIRED PROPERTY DAMAGE $ ❑ NON-OWNED BODILY INJURY AND ❑GARAGE PROPECOMRTY GE $ 1,000,000 ❑EXCESS LIABILITY EACH OCCURRENCE I$ ❑ OCCURRENCE AGGREGATE $ ❑ RETENTION S S S I E WORKERS COMPENSATION& STATUTORY EMPLOYERS LIABILITY Q89 0102940 5/1/21 5/1/22 BODILY ACCIDENT S 500,000 EACH ACCIDENT INJURY DISEASE S 500,000 POUCYuMrr BY DISEASE $ 500,000 EACH EMPLOYEE OTiIER DESCRIPTION OF OPERATIONS/LOCATIONSAkHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IMPORTANT: If the certificate ho der is an ADDITIONAL INSURED,the policy(les)must 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 rights to the certificate holder in lieu of such endorsement(s). NAME AND ADDRESS OF CERTIFICATE HOLDER Earthwise Designs AUTH IZED RESE 724 Duncan Rd Rutherfordton,NC 28139 EIG6230 8/11 i Page 1of1 • Erie CERTIFICATE OF INSURANCE DATE ISSUED(MWDO/YY) Insurance' -Tills CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— 3/17/22 Horne Office • 100 Erie Insurance Place • Ertl.Pennsylvania 16530 • 814.870.2000 Toll free 1.800.458.0811 • Fax 814.670.3126 wrwv,erieineurance.00m NAME AND ADDRESS OF AGENCY SNIDER INSURANCE GROUP LLC AGENTS NO. s...I•: LI "1CO AN4 G COVERAOE o.: E• 'IA GUM'AN 1438 WILKESBORO HWY JJ2072 Co.:• n E•IE INS •U • CEEPROyERITI N CD pPPN(e STATESVILLE,NC 28625E EP�BEEIndemnl Ca. Anorni -In-Fact t AIn bl This certificate Is issued for information purposes only and confers NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder. It does not affirmatively or negatively amend,extend,or otherwise alter the terms,exclusions GROUNDBREAKERS :TRADING INC and conditions of insurance coverage contained in the policy(ies) 207 MOUNTAIN VIEW RD indicated below.The terms and conditions of the policy(ies)govern the insurance coverage as applied to any given situation.Limits STATESVILLE,NC 2I'625-1269 shown may have been reduced by claims paid.This certificate of insurance does not constitute a contract between the issuing Insurer(s), authorized representative or producer and the certificate holder. This is to certify that policies,as Indicated by tie Policy Number below,are in force for rEthe v ITATT Il�/{�+Named Insuredsured the time that_the_Certificate is being Issued. TYPE OF INSURANCE I POLICY NUMBER ti;;i ADM_ LIMITS E ❑GENERAL UABIUTIf Q41 0153420 5/1/22 5/1/23 II� EACH OCCURRENCE $ 1.000,000 ®COMitl L GENERAL LIABILITY FIRE DAMAGE(Any One Frei S ❑CLAIMS MADE ❑OCCUR MED EXP(Any One Person) s 5,000 PERSONAL&ADV.INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 GEWLAGGREGATELAEAPPIESPER: PRODUCTS-COMP/OPAGG$ 2,000,000 f POLICY ❑PRO.ECT ❑LOCH E❑ AUTOMOBILE UABILTTY BODILY INJURY .per, On tNOw oD E)D. Q05 0131816 5/1/22 5/1/23 (EACH PERSON) $ BODILY INJURY ❑OWNED IEACHACCIDENTI S ❑HIRED PROPERTY DAMAGE $ ❑ NON-OWNED BODILY INJURY AND El GARAGE PROPERTY BNE GE 1,000,000 COMED ❑EXCESS LIABILITY EACH OCCURRENCE S ❑ OCCURRENCE AGGREGATE $ S ❑ RETENTION S E WORKERS COMPENSATION& STANTON_ EMPLOYERSLIABILITY Q89 0102940 5/1/22 5/1/23 ACCIDENT $ $00,000 EACH ACCIDENT BODILY INJURY DISEASE S 500,000 POLICY LIMIT BY DISEASE S 500,000 EACH BAPLOYEE 0TH ER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditio 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). NAME AND ADDRESS OF CERTIFICA'E HOLDER Earthwise Designs aurHo I Es ;::2 724 Duncan Rd Rutherfordton,NC 28139 EIG6230 8/11 Page 1 of 1