4060,e -
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private 'curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class II I
DATE: January 8, 2004 i Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Fritz Burns( Park, 78-550 Saguaro Rd., City Playground at West
eud of Saguaro Rd., Saguaro Rd., Hiking 'Trail near Coave Oasis & Ave. Madero, Calle Tecate
(Street address or Description of Location) & Ave. 52 just past Citrus entrance
PURPOSE OF CONSTRUCTION TV Cormrcial Production Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION pickup shots of *Sea attached special conditions*
La Quints► scenery
1) Leonard St. Sauver's cell phone #
DIMENSION OF INSTALLATION OR REMOVAL is (760) 275-2143 to request key
to gate.
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 1/12/04
APPROXIMATE TIME OF COMPLETION 1/13/04
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this w rk.
,r�
Signature of Aplplicant or Agent/�
Green Dot Films 1554 16th Street Santa Monica CA 99fiO4 805 1-2982 - John Gomez
Name of Applicant (please print) Business Address Telephone No.
Green Dot Films, 1554 16th Street, Santa Monica, CA 90404 (803) 587-2982 — John Gomez
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
Fireman's; Fund Ins.
Applicant's Insurance Company
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction
Private improvements: 3% of estimated construction
Minor Improvement Permit — Class IV: See attached scl
Inspection Fee $ 0.00
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL
100.00
0.00
0.00
$ 100.00
Receipt No.
Received by Date
City Business License No.
XXC80401762
P lto . Number
JAN 12 2504
r,l ;'y ()f LA QUiNTA
PERMIT NO.
4060
PERMIT VALIDATION
4060
DATE APPROVED 1/12/04
61
EXPIRATION DATE 1/14/04
DATE ISShJ�ED
gy .�
Administrative Authority
Recorded by
Telephone: (760) 777-7075
J
PERMIT NO. � O 4 O
Green Dot Films/The Cove/Commercial
In addition to the standard permit conditions, the following shall apply:
Pursuant to Section 14.16.320 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), all
work shall be performed in accordance with the latest edition of the Standard Specifications For Public
Works Construction (SSPWC) and as directed by and to the satisfaction of the City Engineer.
2. Green Dot Films, hereinafter referred to as "Permittee", shall be responsible for providing continuous
dust and erosion control.
3. Streets shall be kept clean. They shall be completely cleaned at the end of each working day and more
frequently, if required.
4. Pursuant to Section 6.08.050 of the La Quinta Municipal Code (Ordinance 18 § 1, 1982), throughout the
work site, the Permittee shall comply with City regulated work hours. Operation and maintenance of
equipment within one-half mile of human occupancy shall be performed only during the following time
periods:
October 1st to April 30: Monday -Friday 7:00 a.m. to 5:30 p.m.
Saturday 8:00 a.m. to 5:00 p.m.
May 1st to September 30: Monday -Friday 6:00 a.m. to 7:00 p.m.
Saturday 8:00 a.m. to 5:00 p.m.
Work shall be prohibited on legal holidays and Sundays.
5. Work within 500 feet of a signalized intersection shall be performed between the hours of 9 a.m. - 3
p.m. Traffic control shall be set up after 9 a.m. and removed before 3 p.m. The Permittee shall contact
the Riverside Country Traffic Signal Maintenance Department at (909) 275-6894 if signal operation at
the intersection is to be altered in any way.
6. Pursuant to Section 14.16.250 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982),
advance warning signs and traffic control shall be installed and maintained in accordance with Cal
Trans Standards or the Work Area Traffic Control Handbook (WATCH Manual). A traffic control
plan shall be prepared in accordance with the WATCH Manual and submitted to the City for
review and approval one (1) week prior to starting any construction. It shall be the Permittee's
responsibility to appropriately detour and barricade all construction sites.
Pursuant to Section 14.16.290 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), street
closures shall not be permitted. A minimum of one (1) travel lane of paved surface shall be
maintained at all times.
7. All landscaping, irrigation, decorative rock, decorative concrete, lighting, etc., shall be replaced to its:
original condition.
Special Conditions
Page 1 of 2
PERMIT NO.
Green Dot Films/The Cove/Commercial
8. Access and egress to all local properties shall be maintained at all times.
9. Permittee shall permanently stabilize any and all soil that was disturbed as a result of work performed
under this permit with an approved dust control treatment. Soil stabilization shall be done immediately
after completing the operation.
10. The City of La Quinta reserves the right to revoke, suspend or void this permit at any time.
11. The permittee shall indemnify, hold harmless and assume the defense of the City from all damages,
delay costs, costs or expenses in law or equity that may arise out of work under this permit.
Special Conditions Page 2 of 2
., City of La Quinta
The following General and Special Provisions are attached to and made a part of
Permit Number
The following shall always apply:
UNIM
ENCROACHMENT ON PRIVATE PROPERTY: This permit authorizes work to be accomplished within the City of La Quinta's right of way
ONLY. Whenever construction extends within private property, it is the,responsibility of the permittee for his contractors to secure permission
from abutting property owners. Such authorization must be secured by the permittee prior to starting work.
TRACK -LAYING CONSTRUCTION EQUIPMENT: Cleated track -laying construction equipment shall not be permitted to operate on any paved
surface unless fitted with smoother -faced street pads. All mechanical outriggers shall be fitted with. rubber street shoes to protect the paving
during excavations. Rubber -tired equipment only shall be used in backfill operation in paved areas." If the existing pavement is scarred, spalled,
or broken during the term of this contract or if the pavement is marred, City of La Quinta shall request that these portions of road be resurfaced
over their entire width. Resurfacing shall consist of one coat of two inches (2") of A.C. surfacing plus appropriate seal coat as specified above.
PROTECTION OF TRAFFIC: All excavations and work areas shall be properly lighted and barricaded as deemed necessary by the City
Engineer or City of La Quinta Public Works Inspectors. Suitable detours and detour signs shall be placed and maintained for the duration of the
project. The City shall be notified twenty-four hours (24) in advance of any traffic detours or delineation.
CARE OF DRAINAGE STRUCTURES: Any drainage structure to include corrugated metal pipe, concrete pipe, steel culvert and concrete
structures encountered during excavation which necessitate removal shall be replaced in kind. In the event it becomes necessary to remove or
cut existing drainage structures, City of La Quinta shall be notified prior to commencement of this work. Drainage structures and open drains
shall be kept free of debris at all times for proper drainage.
RIGHT-OF-WAY CLEANUP: Any surplus material resulting from excavation and backfill operations shall be removed from the right of way. All
paved surfaces shall be broomed clean of earth and other objectionable materials immediately after backfill and compaction. Existing gutter line
and drainage ditches shall be replaced to their original standard or better. All excess material shall be removed prior to paving. Water tanker
shall be used, as required, to sprinkle the job site to keep down dust conditions and shall be used immediately after backfill.
DE -WATER OPERTATIONS: If de -watering operations are required and pumps are forcing water on City of La Quinta roads, it shall be the
responsibility of the permittee (contractor) to control this water and to provide off-street barricades when necessary.
CLOSING STREETS: No street shall be closed. A minimum of one lane of traffic shall be maintained at all times to provide limited access for
the adjoining property owners and emergency vehicles. In the event it is felt by the permittee that he must close a street for any length of time,
permittee shall contact this office to obtain the necessary permission.
SPECIAL PROVISIONS
The following shall apply when indicated:
® R1 NOTIFICATION: Permittee shall be notified the City at (760) 777 - 7097 at least forty-eight hours (48) in advance of starting
construction. .
❑ R2 UTILITY CLEARANCE: (Substructures) Prior to making any excavations within the City of La Quinta right-of-way authorized
by permit, the permittee shall contact all concerned utility companies relative. to the location of existing substructures.
Damage to existing substructures resulting from operations conducted under this permit shall be the sole responsibility of the
permittee.
❑ R3 UTILITY CLEARANCE (Surface Structures) No work shall be done under this permit until all utilities are clear of the
proposed work site. The permittee shall notify all concerned utility companies of the proposed work.
❑ R4 PAVEMENT WIDENING: Area between the proposed concrete gutter line and the existing road pavement shall be surfaced
with ( 4 ) inches of A.C. paving placed on ( 6 ) inches of ( crushed ) aggregate sub -base course having an "R" value of not
less than ( ** N/A ") and in conformance with the City of La Quinta Road Improvement Standards and Specifications,
Ordinance #461.
❑ R5 PARKWAY GRADING: Area between the property line and top of the proposed concrete curb shall be graded to a slope of
one-fourth inch ('/4") to one foot (1').
❑ R6 GRADE CHECKING: City of La Quinta shall check grades upon receipt of plan and profile and/or grades as established by
a licensed engineer.
❑ R7 CURB REMOVAL FOR DRIVEWAYS: A portion of the existing concrete curb and/or curb and gutter (" N/A ") feet shall
be removed. Curb and/or curb and gutter shall be saw cut prior to removal. Depressed curb, matching concrete gutter and
concrete driveway approach shall be constructed in conformance with City of La Quinta Standard #207.
❑ R8 DRIVEWAYS: A.C. driveways shall be constructed as not to alter existing drainage pattern. Surfacing between the property
line and the existing road paving shall be two and a half inches (2 Y2') of A.C. paving on (`* N/A ") of class (" N/A " )
aggregate base.
® R9 SIGHT CLEARANCE: Sight Clearance of six` -hundred feet (600') in all directions shall be assured and maintained at all
times.
❑ R10 SOIL STERILIZER: The area to be surfaced shall be treated with soil strerilizer. Rate of application shall comply with the
manufacturer's specifications.
City of La Quinta
® R11 COORDINATE WORK: The proposed work shall be subordinated to any operation, which the State of California or City of
La Quinta may conduct in this area during the period of this permit. Work shall be coordinated with the State or City of La
Quinta forces to preclude delay or interference with State or City of La Quinta projects.
❑ R12 SURVEY MONUMENTS: Prior to excavation or beginning of construction, all survey monuments which exist on the
centerline of all streets or property lines when included shall be completely tied out so they may be readily and correctly,
replaced by a licensed civil engineer or surveyor at the expense of the permittee.. A complete set of notes showing the ties
to these monuments shall be furnished to the City Engineer prior to the removal of any monuments. This office shall be
notified upon completion or replacement of all survey monuments for proper clearance.
❑ R13 PAVEMENT CUTTING: Pavement will be mechanically saw cut to a straight edge prior to excavation. Method of pavement
cutting shall be approved through the office of the City Engineer. (Under no circumstances shall excavating equipment be
used to excavate prior to cutting or pavement.) Excavation material shall be placed in such a position as to best facilitate the
general flow traffic. Prior to final paving operations, any damage to pavement straight edges shall be corrected.
❑ R14 LIMIT OF EXCAVATIONS: Excavations shall be limited to one -thousand feet (1000') of open trench before backfill
operations must begin. All excavations shall be properly barricaded with lights overnight, on weekends and holidays for the
protection of the traveling public. The Public Works Inspector shall determine the suitability of excavation barricading in
each case. No excavation shall remain open for a period exceeding five (5) days. No excavation shall be made unless the
construction material is actually on the work site.
❑ R15 BACKFILL MATERIAL: Backfill shall be free of brush, roots or other organic substance detrimental to its use for purposes
of producing and adequately consolidated backfill. Ant material which the City of La Quinta deems unsuitable (spongy or
saturated material) which is encountered during excavation shall not be used for backfill, but shall be supplemented or
replaced by an approved sand or gravel.
❑ R16 BACKFILL SAND: Backfill shall be approved transit -mix sand or equivalent and shall be placed on lifts not greater than
three feet (3') and vibrated using vibrostamper or equivalent equipment. Alternate methods may be substituted, but in' any
case, a relative compaction of ninety-five percent (95%) shall be maintained with the structural section of the roadway.
❑ R17 BACKFILL PLACEMENT: Backfill shall be applied in layers of not more than fifty percent (50%) of the total depth of the
trench before flooding or a maximum of five feet (5) lifts where trenches are of excessive depths. Care is to be exercised
that the backfill material is not subjected to extreme swell by flooding operations.. Backfill material shall be placed so that the
resulting compaction shall not be less than ninety percent (90%) or equivalent to the surrounding ground, whichever is the
greater compaction. Where ponding or flooding is used for a maximum settlement, adequate dikes will be constructed to
retain the water. Where jetting is used, the jets shall be of sufficient length to reach the bottom of each layer and the water
supply shall be continuos.
❑ R18 COMPACTION TESTS: If so required by the inspector, compaction test shall be made at intervals of not more than one -
thousand (1000') feet and a maximum of one (1) test on each road. One (1) copy of each test shall be forwarded tot the City
Engineer for approval and filed prior to making permanent repairs. Compaction tests shall be made as outlined in Section
6.3.01 of the Standard Specifications, Division of Highways, State of California, dated January 1973.
❑ R19 COMPACTION TESTS: If so required by the Inspector, compaction tests shall be made for each crossing or service line.
One (1) copy of each test shall be forwarded to the City Engineer for approval and filed prior to making permanent repairs.
Compaction tests shall be made as outlined in Sections 6.3.001 of the Standard Specifications, Division of Highways, State
of California, dated January 1973.
❑ R20 TEMPORARY PAVEMENT REPAIRS: After completion of backfill and compaction operations, a temporary patch consisting
of two inches (2") of SC-800 shall be placed on a prepared sub -grade. The SC-800 temporary paving shall be placed after
a maximum of three -thousand linear feet (3000') or trench has been excavated and backfill operations completed, but in no
case shall the placement of the temporary pavement exceed a five (5) day limit.
❑ R21 PERMANENT PAVEMENT REPAIR: After backfill and compaction have been completed, a temporary patch consisting of
two inches (2") of SC-800 shall be placed immediately. A permanent patch of ( 3 ) inches of A.0 surfacing placed on a ( 6 )
inch ( crushed ) aggregate base shall be placed no later than ( 7 ) days after completion of temporary road repair.
❑ R22. FOG SEAL: A fog seal coat consisting of an application of asphaltic emulsion shall be applied over all patch areas as
determined by the City Engineer.
❑ R23 STREET RESTRIPING: Where street striping is still visible on street to be excavated, such striping shall be replaced upon
completion of permanent repairs.
❑ R24 TREE RELOCATION OR REMOVAL: Tree relocation within the City of La Quinta road right-of-way shall be accomplished
by a licensed, bonded and insured tree service, and handled safely without interference or hazard to the traveling public. It
shall be the responsibility of the permitte to maintain the tree'in a vigorous growing condition at its new location.
Trees to be removed shall be in. sections, which can be handled safely without interference or hazard to highway traffic. The
entire width of the tree stump, shall be removed and disposed of so that no debris remains in view of the highway. The
stump hole shall be backfilled and thoroughly compacted as specified in the following paragraph. Where it becomes
necessary to restrict traffic, the work shall be restricted to a maximum of five -hundred feet (500') at any one time. Adequate
signs, flagmen and or barricades shall be provided to protect the traveling public at all times.
Large holes resulting from tree removal shall be backfilled and compacted to not less than ninety percent (90%) or
equivalent tot the surrounding ground, whichever is the greater compaction as determined by the impact or field method.
Compaction tests shall comply with Section 6.3.01 of the Standard Specifications, Division of Highways, State of California,
dated January 1973.
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Date
Location of Construction:.
Purpose of Construction: I1% Caw,�e.-cr� �Uefia%,
Description of Construction: p i<�!j . s L-off
Dimension of Installation or Removal:
Approximate Construction Start Date: . 711 z '- 1 13 / e-y
Approximate Construction Completion Date
Estimated Construction Cost: $
Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back -filling, compaction and
placing permanent resurfacing and or replacing improvements
Name of Applicant:
Applicant.Address: Sl- S4,, A 16,; cR (�4 90�o
Applicant Telephone Number: • %ti,, 6ewrP_a7 eQ • -5-37 • _,�, 9Pa re.,/
Name of Contractor:
Contractor Address:
Contractor Telephone Number:
Contractor State License Number:
Contractor City Business License Number:
Applicant or Contractor General Liability Insurance Company:
Applicant or Contractor General Liability Insurance Policy Number:
Office Use Only:
Inspection Fee:
Permit Fee:
As -Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DU 0 0. l)
Office Use Only:
Assigned Permit Number:
Approval Date:
Expiration
Date:
Issue
Date:
Administrative Authority
Page 1 of 1
James Lindsey
From: Tony Colarossi
Sent: 'Thursday, January 08, 2004 11:15 AM
To: Tim Jonasson
Cc: Steve Speer; Leonard St Sauver; Raoul -Martinez; John Freeland; James Lindsey; Joseph Glowitz;
Brian Ching
Subject: TV Commercial at La Quinta
I obtained a permit application today for a TV commercial, which is planned to be taken at Fritz Burns Park. The
shooting is to include the following locations:
1. Kids in Tennis Courts, park area, possibly rec center pool
2. 78-550 Saguaro Road Residence, which is the Jody & Christine Jones House�-
3. City Playground at west end of Saguaro Road
4. Children riding non -motorized scooter down Saguaro Raod on Sidewalk
5. Family hiking on trail near Cove Oasis and Avenida Madero°
6. Mini van driving on Calle Tecate (Camera in curb lane on Calle Tecate @ Avenida Diaz)
7. Mini van driving on Ave 52 past intersection at entrance of Citrus (camera will be on south side road
shoulder Ave 52)
(says picture of van driving in traffic).
Please submit any questions to me as soon as possible.
Thanks, Tony
1/8/2004
Green Dot Films
Wal-Mart Job #H31257
Location: Fritz Bums Park, La Quinta
Day: Monday 1/12 & Tuesday 1/13
Times: lam to 6pm
Posting: N/S Frances Hack Lane East of Bermuda to end of park
Action: Shot of kids on tennis court, in park area, possibly in rec center pool (awaiting
approval on pool from Coachella Valley Aquatic Coordinator/Sara Haas)
Special Requirements: None
Site Plan: .
we want THIS ennis court
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CD
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Q .a no parking 7a-6n
Frances Hack. Lane;,.
Green Dot Films
Wal-Mart Job 0131257
Location: Jody & Christine Jones House, 78550 Saguaro Road, La Quinta 92253 760.777.4149
Day: Monday i/12 and Tuesday 1113/04
Tunes: lam to 7pm
Posting: N/S_Saguaro Road from Date Palm W to end of cul-de-sac; also the entire cul-de-sac (clear for picture)
Action: INT' and EkT dialogue on private property;
ALSO EXT dialogue at city playground at West end of Saguaro cul-de-sac;
ALSO EXT shot of child riding non -motorized scooter down Saguaro Road on sidewalk.
Speciaf requirements: None
Site Plan:
post
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Saguaro Road
Green Dot Films
Wal-Mart Job #H31257
Location: Cove Oasis, La Quints
Day: Monday 1/12 & Tuesday 1/13
Times: 12p-6g
Posting: N/S Calle Tecate from Avenida Madero to Avenida Diaz, W/S Madero 200' N of Calle Tecate
Action: Shots of family hiking on trail;
ALSO shot of minivan driving on Calle Tecate, camera in curb lane on Calle Tecate C> Avenida Diaz (no ITC
required)
Special Requirements: Would like to be able to drive 2 pickup trucks with equipment necessary for filming up
the trail; would need key to trailhead gate prior to shoot or would need to coordinate with city personnel on
opening the gate.
Site Plan:
0
no parking 12p-6p
5
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as
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Calle Tecate
Green Dot Mims
Wal-Mart Job #H31257
Location: Avenue 52 @ entrance to Citrus, between Washington & Jefferson, La Quinta
Day: Tuesday 1/13
Times: 6a-94
Posting:. none
Action: Minivan driving on Avenue 52 past the intersection at entrance to Citrus, camera on city
property south of road shoulder. Picture vehicle driving with flow of traffic. NO ITC required.
Special Requirements: None, would like sheriff (1) with us.
Site Plan:
Green
Fax Cover
Dot
Sheet
Total Pages. Including Cover
Date: U
Films
To: k Fax No. ?�O • 77 7, 71S'S
Phone No.
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1554 Sixteenth Street
Santa Monica. CA 90494
3le-6.56-49e9 Phone
310.656.0444 Main Fax
316.4S1.1632 Accounting Fax
www.greendotfilms.com
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Speare & Company
CA license #0697201
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15303 Ventura Blvd., 7th Floor
COMPANIES AFFORDING COVERAGE
Sherman Oaks, CA 91403
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THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TD THE INSURED NAMED ABOVE -FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
r OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YYI
POLICY EXPIRAYION
DATE IMM/DD/VVI
LIMITS
BILITY
FCIAL 4ENtHnI LLABuTYFRODIJCTS,
'-= & CONTR4_TOR'5 PFOT
XXC80401762
4/14/03
4/14/04
GENERAL AL3(�EG&T6
s 2000000
COMPIOP Ar,G
S 2000000PEf
YGENERAL
ONAL & ADV INJURY
0 1000000
EACH OCCURFENCE
e i 000000
_,
FIRE DAMAGE Any rr,e fire)
a 100000
ME0 FXF (Any ana Po(mr%l
5000
A
AUTOMOBILE-
LIABILITY
XXCO0401 762
4/14/03
4/14/04
COMOINED SINGLE LIMI1
d
IOOODDO
AN', AL ITC
. _••-
ALL. r)VOIED AIITC5
Z�CrIEDVLED AU fOS
BODILY INJURY
(Par pamn)
g
�.
X
BODILY INJURY
Per ea:,dantl
HIHhD o„TO5
NON•OwnIEU 4u'fOs
PHYSICAL
$125,000 PER VEH
DED: 1 O% OF LOSS,
$1,000 MIN
b
X
X
PROPERTY DAM_JE
8
_ _
DAMAGE
X
QARAGE LIABILITY
AI-1 TO ONI.Y -EA M_,.IDENr
S
OTHER THAN AUTO ONLY
'
6NN aLITO
..._--
E.ACH ACCIDENT
8
arC}EG4TE
e
A
EXCESS LIABIWTY
X ,JMERELLA r0aM
XYZ00075944
4114/03
4/14/04
EAf.H OCCURPENCE
4 4000000
AGGREGATE
a 4000000
nTHER THAN UMBRELLA FORM
A
WORKERS COMPFNrATION AND
XWC8081 3672
4/14/03
4/14/04
Ywy LIMITS IR
EL EACH ACCIDENT
s 1000000
EMPLOYERS' LIABILITY
EVIDENCE
EL DISEASE • POLIr_Y LbMIT
a 1000000
THE RROPPIETOM wrL
P&RTNEFQ-rt1 fI:UTIVE
CFFIi EF, APE
EL DISEASE - EA EMPLOYEE
Is 1000000
A
OTHER
RENTED EQUIPMENT
MPT07104215
4/14/03
4/14/04
LIMIT: $1,500,000 / $2,500 DIED
PROPS/SETS/WRDRBE
LIMIT: $1,000,000 / $2,000 DED
3RD PRTY PROP DMG
LIMIT: $1 ,000,000 / $1 ,500 DED
DFFCHI VI•IUN OF OPERA7IONSZDCATIDN6NEHICLES/SPECIAL ITEMS
THE CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED WITH RESPECT
TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED AND
AS LOSS PAYEE AS THEIR INTEREST MAY APPEAR,
CERTIFICATE HOLDER
CANCELLATION
E+ �SHOULD
ANY OF THE ABOVE DE6CHI0�E0 POLICIES .BE CANCELLED BEFORE THE
EXFIRAYION DATE THEREOF, FHt ISWING COMPANY "LL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE. TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Bur FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OH LIABILITY
OF ANY Wp UPON THE COMPAN ITS AGENT; OR REPRE6ENTATIVES.
t(�
,.nnan lr.c ,1/ocI R12 pt (?ICA
AUTHORUFn S IVEI
ACORD CoRPORATIOH
SEP-24-2003 11.5a
0.02