AC No. 1991-07J4C ''I --a7
AMENDMENT TO AGREEMENT
This is to Amend the February 14, 1991 agreement between Asa Beehler and the Kodiak Island Borough by
granting an extension as requested by Asa Beehler on May 30, 1991.
This Amendment changes the date of condition 1 A from June 30, 1991 to October 15, 1991 for the construction
of the lower Apartment driveway to conform to the driveway permit requirements and the re -opening of the
drainage access to the existing Culvert under Tone Lane and the reconstruction of a drainage ditch to this catch
basin as shown on the original attached Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement the
the day and year
(first above written.
Asa Beeler, Owner
P. 0. Box 2645
Kodiak, AK 99615
STATE OF ALASKA
) SS
THIRD JUDICIAL DISTRICT
KODIAK ISLAND BOROUGH
By:
Jerorble M. Selby, Mayor
710 Mill Bay Road
Kodiak, Alaska 99615
THIS IS TO CERTIFY that on the �, day of 1991, before me, the undersigned, a Notary Public in
and for the State of Alaska, duly commissioned and swor as such, personally appeared Asa Beehler, Owner,
known to me to be the individual who executed the within Agreement and acknowledged to me that the same was
signed freely and voluntarily for the uses and purposes therein contained.
WITNESS my hand and Notarial Seal the day and year fir a ove written.
By:/ hJGYLi�t/
Notary Public in and for State of Alaska
My commission expires: v, 'J ! `J
STATE OF ALASKA I
) SS
THIRD JUDICIAL DISTRICT 1
THIS IS TO CERTIFY that on the ��day of(.tom f 991, before me, the undersigned, a Notary Public in
and for the State of Alaska, duly commissioned and worn as such, personally appeared Jerome M. Selby, to me
known to be the Mayor of the Kodiak Island Borough, a municipal corporation, known to me to be the individual
who executed the within Agreement and acknowledged to me that the same was signed freely and voluntarily for
the uses and purposes therein contained.
WITNESS my hand and Nntarial Rwal tha day and yanr firer
Notary Public in and for S to of Alaska
My commission expires: - 19x9
r'" G -7/- o l
>' a
INTERIM RETROSPECTIVE RETURN PREMIUM
ADJUSTMENT & REPAYMENT AGREEMENT
The undersigned insured hereby acknowledges receipt of payment from
Industrial Indemnity in the amount of
FORTY ONE THOUSAND TWO HUNDRED
FORTY TWO dollars ($ 41,242.00 ) as the 2ND & 3RD
restrospective premium adjustment payable to the undersigned under
the terms and provisions of the policy (policies) shown below.
The undersigned further acknowledges that further adjustments may
be made before the final restrospective premium is determined. In
consideration of such payment, the undersigned agrees that such
payment shall be charged against the amount of the final
restrospective premium and any excess of such payment over said
final retrospective premium determination shall be refunded by the
undersigned on demand.
COMPANY
INDUSTRIAL INDEMNITY OF ALASKA
INSURED
KODIAK ISLAND BOROUGH
SCHOOL DISTRICT & MENTAL HEALTH CENTER
CR 904-4408 CR 904-4410 CR 904-4411
CR 907-0405 CR 907-0406 CR 907-0407 CR 883-6186
Policy Number(s)
7
l Datb
Workers Compensation
Underwriting Manager
(A -WC -27)
By (Name & Title
41
Gr
SWEENEY INSURANCE
P 0 BOX 129
KODIAK AK
INC !1317060
99615
Industrial Indemnity
A Crum and Forster Organization
A XEROX Financial Services Company
RO Box 7808
San Francisco, California 94120
(415) 773-6000
Enclosed is our check in the amount of $41,242.00.
8836186CR
9044411CR
9044410CR
9070405CR
9070406CR
9070407CR
9044408CR
KODIAK ISL
KODIAK ISL
KODIAK ISL
KODIAK ISL
KODIAK ISL
KODIAK ISL
KODIAK ISL
MAY 6, 1991
4,464.00
286.00
4,922.00-
12,524.00-
4,929.00
45,754.00
3,255.00
If you have any questions please use reference 244-0000065
and contact PAT BONIFACIO at 4157736063.
KODIAK ISLAN
MENTAL
KODIAK ISLAN
KODIAK ISLAN
MENTAL
KODIAK ISLAN
KODIAK ISLAN