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DRVA2018-0031 ta Qai,da - GEofSeDESEM DRIVEWAY APPROACH I.- PUBLIC WORKS CONSTRUCTION See below for Finance Revenue Codes 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. DATE: 11/26/2018 LOCATION OF CONSTRUCTION(Street address or Description): 51855 AVENIDAJUAREZ PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: STEMMER / DRIVEWAY APPROACH . DIMENSION OF INSTALLATION OR REMOVAL: 040SQ FT APPROXIMATE TIME WHEN WORK WILL BEGIN: 11/26/2018 TIME OF COMPLETION: 11/30/2019 ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) 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 pay for any additional replacement necessary as the result of this work. - City of and to JOE W STEMMER JR Name of Applicant (please print) JOE W STEMMER JR Name of Contractor and Job Foreman 42215 WASHINGTON ST #355 PALM DESERT, CA 92211 (760)880-3525 Business Address Telephone No. 42215 WASHINGTON ST #355 PALM DESERT, CA 92211 (760)880-3525 Business Address . . -Telephone No. 605857 . LIC-763387 Contractor's License No. - City Business License No. Policy Number PERMIT NO: DRVA2018-0031 DATE ISSUED:lUjØ I Irb EXPIRATION DATE: BY W041'NSPECTED BY: PERMIT COMPLETION DATE*: *If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. Applicant's Insurance Company Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL TECHNOLOGY ENHANCEMENT FEE TOTAL: I ta Qaigra — GEM o/theDESERT - DRIVEWAY APPROACH PERMIT APPLICATION. Applicant Information: Applicant/Owner (please pEtt name here): Applicant Address: '?2 21 S (A)cc CA Number Street City tate Zip Code Address or Parcel No. of work location, if different from applicant's address above: ) Number Street City State Zip Code Date: i.L'jjjJ Ap lica Applicant's signature Approximate Start Date: j1..../20/i' Approximate Completion Date: j.LiiJ Contractor Information: Address: 7,2V 1-L Rfo'' tciJ C'r i Number StreetlJ 0 City State Zip Code Phone Number: (l/J)) Contractors License Number: U os 8S '7 City Business License Number: R, 33 General Liability Insurance Com at 56j C Policy No. 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 MondOy through Friday between 8am and 4pm I Permit Fee $156 + $5 Technology Enhancement Fee = $161 Total Fee I Permit j 0. amy;oif"A Expiration Date JLL51L/......L Permit Issued by: Signature of Administrative Authority Work Inspected by: Inspector's Signature Comments: Note: Driveway approach must bate Issued t/2-0$ Permit Completion Date: _I_I per City of La Qu C ' I DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP O N T H E C E R T I F I C A T E H O L D E R . T H I S CERTIFICATE ()OES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COV E R A G E A F F O R D E D B Y T H E P O L I C I E S BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE I S S U I N G I N S U R E R ( S ) , A U T H O R I Z E D REPRESEN'TArIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(Ies) 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 holdcr In lieu of such endorsement(s). PRODUCER cONTAUT Customer Service Department Target Insur.nce Services IPHONE 800 )4 5 -8013 FAX - F (NC,NoExt):_ IA/c, No): (866) 2273052 eCert E-MAIL -6630 '1ander Drive - - INSURER(S) AFFORDING COVERAGE - - -- NAIC# San Diego CA 92121 INSURER A Allied World Surplus Lines Ins Co - 24319 INSURED INSURER 6: Joe W stemmew Jr INSURER C: 42335 Washingt0fl St #355 INSURERD: INSURER E: Palm Desert CA 92211 I INSURER F IFflTlFI(AT N1IIARFRCL 18-19 ouiev,.i U1 1"neffs. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INS U R E D N A M E D A B O V E F O R T H E P O L I C Y P E R I O D 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 AL L T H E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR OF INSURANCE WYG POLICY NUMBER ..LTR -- - -- - - - TYPE INSD LIMITS (MMIDDIYYYY) (MMIDD/YYYTI X COMMERCIAL- GENEMLUABII.ITY EACH OCCURRENCE $ 11 000,000 -. A - - CLAIMSMAOC X OCCUR -- DMAGE1OAENrth - -- - PREMISE$ (Ea occwrence) - $ - 50,000 X 5057054801 1/27/2018 1/27 /2 019 ylre $ - 5,000 1,000 GENL AGGREGAT E LIMIT APPLIES PER: PRO- X POLICY JECT - - LOC PRODUCTS -CaMP/OP AGG $ - 2,000,000 OTHER: $ AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT - a aceden) - - $ ANY AUTO -. - BODILY INJURY (Per person) $ - 'AU. OWNED SCHEDULED AUTOS - AUTOS - - - -- - - - BODILY INJURY (Per accident) $ - -- NON-OWNED - PROPERTY DAMAGE - $ -- HIRED AUTOS - - AUTOS (Peraccident)_ - - $ UMBRELLA LIAB - OCCUR EACHOCURENC $ - EXCESS UAB - CLAIMS-MADE AGGREGATE - -. - DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER 0TH- _STATUTE ER - - - ANY PROPRIETOWPARThEXECUTIVE - - EL EACH ACCIDENT $ N/A- OFFICER/MEMBER EXCLUDED? .- - (Mandatory In NH)E.L. EA EMPLOYEE -$ If yes, descrIbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be iltached If more Specs Is required) Certificate Holder is named as Additional Insured per the attached Endorsement, *Additional insured status is subject to all policy terms, exclusions and conditions* sswanstrom@laquintca .gov City of La Quinta 78-495 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 *Account Carl/MSTEV ' IOO-UJq MI.,VI1L I.UMVUHAIIUN. All tI9fl1S reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY NUMBER: 5057-0548-01 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Any person or organization to whom the Named Insured Where specified by fully executed written contract. has agreed by a fully executed written contract that such person or organization be added as an Additional Insured, but only with respect to operations performed by or on behalf of the Named Insured and only with respect to occurrences subsequent to the making of such fully executed written contract otherwise covered by this insurance. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but 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(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (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 CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2 POLICY NUMBER: 5057-0548-01 2. 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. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: Required by the contract or agreement; 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2