DRVA2019-0004ta Quigr
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DRIVEWAY APPROACH
PUBLIC WORKS CONSTRUCTION
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CITY OF LAQUINTA
DESIGN & DEVELOPMENT DEPARTMENT
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: 2/11/2019 11
LOCATION OF CONSTRUCTION(Street address or Description): 53095 AVENIDA VELASCO
PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH
DESCRIPTION OF CONSTRUCTION: STEMMER /_DRIVEWAY APPROACH
DIMENSION OF INSTALLATION OR REMOVAL: @405F
APPROXIMATE TIME WHEN WORK WILL BEGIN: 2/11/2019 TIME OF COMPLETION: 2/14/2019
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 210 1-
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules
pay for any additional replacement necessary as the result of this work.
JOE W STEMMER JR 42215 WASHINGTON ST #355 PALM DESERT, CA 92211
Name of Applicant (please print) Business Address
JOE W STEMMER JR 42215 WASHINGTON ST #355 PALM DESERT, CA 92211
Name of Contractor and Job Foreman Business Address
of the City of and to
of Applicant or Agent
-
(760)880-3525
Telephone No.
-
(760)880-3525
Telephone No.
LIC-763387
City Business License No.
5057054801
Policy Number
PERMIT NO: DRyA019-0004
DATE ISSUED: .2/ls' fzos
EXPON DATE: J4161201 C)
BY: OM
WORK INSPECTED BY*:
PERMIT COMPLETION DATES:
1f the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council.
605857
Contractor's License No.
TARGET INSURANCE SERVICES
Applicant's Insurance Company
Finance Revenue Code
PERMIT INSPECTION
DRIVEWAY RESIDENTIAL
TOTAL:
4 td&
wtv t0 I
- GEM of rl!r DESERT
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (p/ease print name here,k & r-) r\41\
Applicant Address: & Q.2J2JJ
Number Street ty State Zip Code
Address or Parcel No rk location, if different from appli s adJress above:
Number Street ity State Zip Code
No: ('4)) Date: ,jj...Lij..!t
Applicant's Signature
Approximate Start Date: /A Approximate Completion Date: _iJLiJS
Contractor Information:
R44 luml Address:
Num er Street City State Zip Code
Phone Number: (?t) ) ?& 3 3-3ZJ Contractors License Number:
City Business License Number: 1'
General Liability Insurance ComPan:i1+ 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 Monday through Friday between 8am and 4pm
Permit Fee $160 + $5 Technology Enhancement Fee= $165 Total Fee
t2JP-2o1 —000tj
Permit No.t*')A Wt'I Date _/jjpj Z
Permit Issued by: Date Issued -2 / 1/ /201.
Signa&fe'fAdministrative Authority
Work Inspected by: Permit Completion Date:
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221
REV: 11/27/2018
ACHJ CERTIFICATE OF LIABILITY INSURANCE
OATE(MMIDDIYYYY)
1 02/12/2019
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: It the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) 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 T Customer Service Department
Target Insurance Services (A C. EA:(80w 450-8013 I i
AX . No): (866) 227-3052
6630 Flanders Drive -
ADDRE SS: Certfficates@premieragencyservlces.com
INSURER(S) AFFORDING COVERAGE NAIC I
San Diego CA 92121 INSURER A: Allied World Surplus Lines Ins Co 24319
INSURED INSURER B:
Joe W Stemmer Jr INSURER C:
42335 Washington St #355 INSURER D:
INSURER E:
IN5URERF: Palm Desert CA 92211
COVERAGES CERTIFICATE NUMBER: GL 19-20 - REVISION NUMBER:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
INSR
LTR - TYPE OF INSURANCE AIJULISUOK POLICY NUMBER POLICY EFF IMMIDDIYYYY) POUCYEXP (MMIDDIYYYY) LIMITS
COMMERCIAL GENERAL I lABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE 19 OCCUR DAMAGE TO RENTED
PREMISES (Es occurrence) $ 50,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1.000,000 A V 5057054802 01/27/2019 01/27/2020
GEN'LAGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE 2.000,000
POLICY fl PRO-
LOC PRODUCTS. COMP/OP AGG s 2.000.000
$
- OTHER:*
AUTOMOBILE LIABILITY COMOINCO SINGLE LIMIT Me accident) s
BODILY INJURY (Per person) S ANY AUTO =A
OWNED
UTOS ONLY El SCHEDULED
AUTOS BODILY INJURY (Pet accident) $
PROPERTY DAMAGE
(Pet accident)
$ HIRED NON-OWNED
- AUTOS ONLY AUTOS ONLY
$
-
UMBRELLA LIAS L_J OCCUR EACH OCCURRENCE $
-
AGGREGATE S . EXCESS LIAB I CLAIMS-MADE
DEC) I I RETENTION S _______ S -
WORKERS COMPENSATION
ANDEMPLOYERSLIABILITY YIN
PER 0Th-
STATUTE ER
ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? Li N IA
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE S
If yes. describe under
- DESCRIPTION OF OPERATIONS below - -
. E.L. DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, my be attached If more apace 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'
IFRTIFIATF I1fltflFR CANCIFILLATInN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE ThEREOF, NOTICE WILL BE DELIVERED IN
City of La Quinta .
ACCORDANCE WITH THE POLICY PROVISIONS.
78-495 Calls Tampico
AUTHORIZED REPRESENTATIVE
La Quinta CA 92253
@1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
ITITARGET
FINANCIAL & INSURANCE SERVICES
January 23, 2019
Joe W Stemmer Jr
42335 Washington St #355
Palm Desert, CA 92211
Regarding: Carrier Name: Allied World Surplus Lines Ins Co
Policy Type: General Liability
Policy Number: 5057054802
Policy Period: 1/27/2019 to 1/27/2020
Target Financial & Insurance Services would like to thank you for allowing us the opportunity to provide insurance
products and services to you and your company. Please review the attached documents and advise us immediately
if any information is incorrect or changes need to be made.
Included:
Proof of Insurance (Certificate of Liability Insurance) - This is for your files.
Certificate Request Form - This form must be used to request any third-party-specific certificates which
you may need throughout the policy year. This form will allow us to respond to your certificate requests
quickly & accurately. Please send this request form to certificates@tgfis.com or Fax to (866) 227-3052.
All requests will be processed within 24 hours.
Afullcopy of your policy will be delivered to the address(es) we have on file, within 2-4 weeks, or, as soon as we
have received your policy from the carrier. Note, however, that the carrier may only send a full copy of your policy
to you directly, so please notify our office if you have not received within the above time-frame. Additionally, it is
very likely your carrier will conduct a phone inspection to confirm specific details about your operations that was
provided on the policy application. If you have any questions concerning the inspection, please contact your
broker.
Remember, Target Financial & Insurance Service is a full-service agency capable of handling all your commercial
insurance needs. Our focus is primarily with building and trade contractors to provide all varieties of coverage's
specific to the construction industry. We work closely with more than 20 different insurance markets so that we
can satisfy your specific coverage needs, including but not limited to:
General Liability • Builders Risk (COC)
Property / Inland Marine Insurance • Workers Compensation
Excess Liability • Bonds
Commercial Auto (including Fleet) • Businessowners Policies (BOP)
We pride ourselves in our ability to provide timely and responsive customer service. Feel free to contact our office if you
have any questions about your coverage or other insurance products that you may need.
Thank You;,
Customer Service Department
Target Financial & Insurance Services, Inc. 16630 Flanders Drive San Diego, CA 92121
Tel: (800) 450-8013 Fax: (800) 434-8053 Info@targetinsuranceservices.com