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DRVA2018-0001
See I w ina evenueCoc . -- GEM Df/JIDESERT - - DRIVEWAY APPROACH / E7o18/ PUBLIC WORKS CONSTRUCTION For the construction of public or private curbs, driveways, pavements, sidewal ks, parking lots, sewers, wat ' r mains and other like public wc improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 2/7/2018 LOCATION OF CONSTRUCTION(Street address or Description): 77250 CALLE NOGALES PURPOSE OF-CONSTRUCTION: PTION OF CONSTRUCTION: KINCAID / RES dRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: APPROXIMATE TIME WHEN WORK WILL BEGIN:.TIME OF COMPLETION: ESTIMATED CONSTRUCTION COST: _____(Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) S COMMENTS: 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 at (760) 777-7097. To submit an inspection request, leave a message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four (24) hours prior to the anticipated inspection. Comply with all applicable city Ordinances, the terms and conditions of the permit and all applicable rules and/egulations of the Ci ty of an to pay for.any additional replacement necessary as the result of this work. // of Applicant or Agent WILLIAM MORRIS DEVELOPMENT INC DBA W M B 52-520 AVENIDA NAVARRO LA QUINTA, CA 92253 (760)688-2608 Name of Applicant (please print) Business Address Telephone No. WILLIAM MORRIS DEVELOPMENT INC DBA W.M B 52-520 AVENIDA NAVARRO LA QUINTA, CA 92253 (760)688-2608 Name of Contractor and Job Foreman Business Address • Telephone No. 945496 • • LIC-0100420 Contractor's License No. • City Business License No. NAUTILUS INSURANCE COMPANY • •. NN714647 Applicant's Insurance Company Policy Number Finance RevenUe Code PERMIT INSPECTION • • DRIVEWAY RESIDENTIAL $156.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: • $161.00 PERMIT NO: DRVA2018-0001 DATE ISSUED:)--/7(I S EXN DATEW7/cq BYC"4) WORK INSPECTED BY.*: S PERMIT COMPLETION DATE*: • *If the work is covered by a Subdivision ImroemenAg'reement, Subdivider shall request final acceptance of improvements from the City Council. ta Qa~fra - CM.f,t)ISERT DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: S Applicant/Owner (please pjjat name here): N- (3 -Pc1D S Applicant Address:¶2Z- Number Street City State Zip Code Address or Parcel No. of work location, if different from applicant's address above: Number •Street City State Zip Code Date: //J 97 Appli Phone No: (7h0)77I Applicant's Signature: Approximate Start Date: _iJj..4 Approximate Completion Date: Contractor Information: . . Address: Th7 &L-1 Iki'(Z— L,,iTc C4- Number Street S City. State Zip Code Phone Number: (7$ 1 Z!Z;U-25 Contractors License Number: t, 57LJ 9' 2 1 City Business License Number: General Liability Insurance Company: /1J ]/t1$ 4c1Jra1C? t'oLicy No. t' W 7/.L/ q 7 Request for Inspection - Please call (760) 777-7097 before 1:30pm to. request an inspection at least 24 hours prior to your requested inspection date. The Hub Counter (760) 777-7125 Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm Permit Fee $156 + $5 Technology Enhancement Fee = $161 Total Fee Permit No. OkuA-Uo / - OD4 Ex ir tion 0 Permit Issued b, Date • Issued I?IJj istrative Authority Work Inspected by: Permit Completion Date: __I__I. Inspector's Signature Comments: Note: Driyeway approach must.be constructed per C!ty at ia iwuinta stanciara zi]. WILLMOR-01 ONIELSEP DATMMIODMYYY) 1 02J06/2018 CERTIFICATE OF LIABILITY -INSURANCE THIS CERTIFICATE IS 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 REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(Ies) must have ADDITIONAL INSURED provisions 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # 0F09643 C2ACT_Diane Nielsen tN°k!): (760) 360-4700 I . No):(lSO) 2009706 Desert Empire Ins Services, 775" Country CUD Inc. Suite 401 Palm Desert, CA 92211 - &SS: diane.nielsen@desertemplreins.com INSURER(SJ AFFORDING COVERAGE NAIC U INSURER A:Nautilus Insurance Company 17370 INSURED INSURER :State Compensation Insurance Fund 35076 William Morris Development, Inc. DBA: W. M. Builders INSURER C- 52520 Avenida Navarro INSURER 0: INSURER E: La Qulnta, CA 92253 INSURER F: CflVPRACFS (FPTIFI(ATF N1IMRFR RFVISIflIJ PJtIMRFP THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF I - ADDL UBR POLICY NUMBER POLICY EFP (MMJDOIYYYYI POLICY EXP MMIDOIYYYYI LIMITh_______________ rA - COMMERCIAL GENERAL LIABILITY CLAIMS-MADE [] OCCUR j NN714647 0611712017 0611712018 EACH OCCURRENCE DAMAGE TO RENTED EEMiSE$(EacuIye,jce)_ one pe MED EXP (Any rscn)_ S 1,000,000 100,000 $ $ 5.000 PERSONAL & ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY [] ita [j LOC - _!OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS PAGG S Included S ANY AUTO - OYNED r—i SCHEDULED - AUTOS ONLY I I AUTOS A ONLY- RAWMK9 . COMBINED SINGLE LIMITAUTOMOBILELIABILITY(Es aeddenil $ BODILY INJURY (P') $_____________ I BODILY INJURY (Per aiden1' S UMBRELLA UAB EXCESS LIAB I I OCCUR CLAIMS-MADE - EACH OCCURRENCE $ AGGREGATE $ - DED I I RETENTION B - WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE fli fa.IRIMM EXCLUDED? If yes describe under ESRIPTlON OF OPERATIONS below N IA. - - 9157107-17 0411612017 04I16I2018 X PER I 0TH- .J_SLSTLJLE_L1ER_ E.L. ACCIDENT $ E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $______________ $ DESCRIPTION OF OPERATIONS! LOCATIONS /VEHICLES (ACORD 101. AddItional Remarks Schedule, nay be attached It mo,e space Is required) RE: 77-250 CaIle Nogales, La Quinta, CA City of La Quinta Is named as additional insured per attached endorsement City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WiLl. BE DELIVERED IN ACCORDANCE WiTh THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .t4vt ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy #NN701587 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARTISAN CONTRACTOR EXTENSION ENDORSEMENT ADDITIONAL INSURED - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT AND WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement moifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. ADDITIONAL INSURED - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT 1. Section II - Who .Is An Insured is amended. to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for bodily injury", "property damage' or "personal and advertising injury' caused, in whole or in part, by: Your acts or omissions; or . The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: Only applies to the extent permitted by law; and Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. This insurance shall not apply to claims, "suits" or damages arising out of the acts, omissions or negligence of the additional insured(s). 3. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to render, any professional architectural, engineering or surveying services, including: The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or Supervisory, inspection, architectural or engineering activities. 4. The following is added to 4.a. of Other Insurance of Section IV - Commercial General Liability Conditions: The insurance afforded to the additional insured will be Primary Insurance and Noncontributory, but only if such claims, "suits' or damages arise out of the sole negligence of the Named Insured. 1815 (02115) Includes copyrighted material from Insurance Services Office, Inc., with its permission. Page 1 of 2 5. With respect to the insurance afforded to the additional insured, the following exclusions apply: This insurance does not apply to "bodily injury' or "property damage" occurring after All work on this project, including materials, parts, or equipment furnished in connection with such work (other than service, maintenance, or repairs), to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 6. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: Required by the contract br agreement you have entered into with the additional insured; or Available under the applicable Limits of Insurance shown in the Declarations; whichever is less: This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. B. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US The following is added to S. Transfer Of Rights Of Recovery Against Others. To Us of Section IV - Commercial General Liability Conditions: We waive any right of recovery we may have against those who are added as additional insureds by this endorsement because of payments.we make for injury or damage arising out of your ongoing operations or your work' performed under a contract with them. This waiver applies only when you are solely negligent. This waiver shall not apply to claims, suits" or damages arising in whole or in part out of the acts, omissions, or negligence of those added as additional insureds by this endorsement. All other terms and conditions remain unchanged. 1-815 (02115) Includes copyrighted material from Insurance Services Office, Inc.. with its permission. Page 2 of 2